Arthur B. Voorhees

Portasystemic shunting procedures for portal hypertension. Twenty-six year experience in adults with cirrhosis of the liver.

Abstract 1. 1. The results of the 404 cases of portal hypertension in adults with portal cirrhosis treated by portasystemic shunts are reviewed. 2. 2. The over-all operative mortality was 12 per cent. 3. 3. The five year survival rate was 58 per cent. 4. 4. Incidence of moderate and severe encephalopathy combined was 34 per cent in the follow-up period. 5. 5. Control of portasystemic encephalopathy is still imperfect but colon bypass offers hope when conservative therapy has failed. 6. 6. The incidence of shunt failure ranged between 5 and 50 per cent depending on the type of shunt performed. 7. 7. The most important factor in determining the clinical results of any shunting procedure is the underlying liver function status.

Aneurysm of the Aorta: a Review of 365 Cases:

* From the Department of Surgery of the Presbyterian Hospital and Columbia Univ. College of Physicians and Surgeons. Aneurysm of the aorta is a relatively rare but exceedingly important disease. There are few diseases the prevention and cure of which have presented a greater challenge to the profession, and no disease capable of causing more misery to a patient than aneurysm. In aneurysm of the aorta we are primarily concerned with two etiological agents; namely, syphilis, and arteriosclerosis. During the past decade in America there has been observed a distinct decline in the number of syphilitic aneurysms. But, discouraging to state, there has been both a relative and absolute increase in aneurysms due to arteriosclerosis. Figure 1 portrays well this trend at the Presbyterian Hospital in the City of New York in an analysis of 365 cases of aneurysm of the aorta during the years 1932 to June 1953 inclusive. Note the distinct preponderance of arteriosclerotic aneurysm over syphilitic aneurysm during the four year period, 1949-1952. It is gratifying to know that now with advances in the treatment of syphilis the prospects are good for eradicating this type of aneurysm. However, the great increase in the incidence of arteriosclerotic aneurysm presents a new challenge. For example, you will note in Figure 1 that there were more than six times as many arteriosclerotic aneurysms admitted in 1952 than were admitted in 1942. Furthermore, the number of arteriosclerotic aneurysms admitted in 1952 exceeded the greatest number of syphilitic aneurysms admitted any one year during the twenty year period. An important factor in the increased incidence of arteriosclerotic aneurysm in America is the increasing life span. It seems probable that the strong emphasis in recent years upon periodic medical examinations has contributed to the increased incidence of diagnosis of aneurysm. Particularly is this true with patients having arteriosclerotic aneurysm of the abdominal aorta who, so frequently, are asymptomatic until rupture of the aneurysm occurs. In recent years a high percentage of patients having aneurysm are being operated upon. This perhaps reflects an increasing confidence in the evolution of surgical techniques and advances in the surgical management of the geriatric patient. Figure 1 reveals that in the early thirties approximately 12 per cent of the

Simple methods for direct antibiotic protection of synthetic vascular grafts.

Two simple methods for direct antibacterial protection of synthetic vascular grafts were investigated. In the first protocol the highly protein-bound antibiotics nafcillin (90% protein bound), cefazolin (80%), and cefamandole (70%) were added directly to preclotting blood. Knitted Dacron grafts preclotted in the presence of one of these drugs absorbed significant amounts. Although at high concentrations these antibiotics exhibited anticoagulant effects, significant antibacterial protection was obtained at lower antibiotic levels. Washing treated grafts for 6 hours failed to eliminate the antibacterial activity. Antibiotics remained on the grafts for at least 96 hours. In the second protocol knitted Dacron grafts were soaked in a suspension of silver-pefloxacin, a silver-nalidixic acid analogue with intense antistaphylococcic activity. Using 110Ag-labeled complexes, significant antibiotic activity was documented on the graft after 19 days of washing. Four nafcillin-treated prostheses, six silver-pefloxacin-coated grafts, and 11 control grafts were interposed in the infrarenal aorta of dogs and immediately challenged with an intravenous infusion of 1 X 10(7) Staphylococcus aureus. None of the four nafcillin-treated grafts was infected at 3 weeks. One of the six silver-pefloxacin-coated grafts grew staphylococci, and 9 of 11 controls had positive graft cultures for Staphylococcus when harvested. These studies suggest that prosthetic grafts can be simply coated at the time of implantation with antibiotics selected for appropriate binding and antibacterial characteristics to obtain an infection-resistant prosthesis.

The role of factors of portal origin in modifying hepatic regeneration

Abstract 1. 1. Hepatic hyperplasia can occur in animals on total intravenous alimentation. 2. 2. In the total absence of splanchnic portal organs, partial hepatectomy produces a hyperplastic response of the liver which is significantly greater than that developed in the presence of those organs. 3. 3. The portal blood factors responsible for modifying the hyperplastic response of the liver to partial hepatectomy do not need to perfuse the liver directly. 4. 4. It is suggested that factors of portal origin have a role in the control of hepatic hypertrophy, and in their absence, there is increased hyperplasia after hepatic resection.

Clinical significance of intraluminal pH in intestinal ammonia transport

Abstract 1. 1. In the canine small intestine the ammonia furnished by the relatively alkaline ammonium acetate (pH 7.1) is absorbed at a faster rate than is ammonia from a comparable quantity of the relatively acid dibasic ammonium citrate (pH 4.8). 2. 2. In the canine and human colon ammonia can be dialyzed more efficiently by an acid medium (Impersol) than by saline and much more efficiently than by an alkaline medium (THAM). 3. 3. Passive non-ionic diffusion appears to be the mechanism of ammonia transport in the colon and canine small bowel. 4. 4. Acid dialysis by Impersol in the acute situation or by lactulose for chronic use is suggested for the management of portasystemic encephalopathy.

THE VALIDITY OF CHRONIC HEPATIC BLOOD FLOW MEASUREMENTS OBTAINED BY THE ELECTROMAGNETIC FLOW METER.

Summary Techniques of long term implantation of electromagnetic flow sensors on the canine ascending aorta, thoracic inferior vena cava, hepatic artery, superior mesenteric artery and portal vein are presented, with a method of obtaining zero flow in the vessels being monitored. Technical problems are discussed and solutions outlined. Hepatic blood flow was measured for periods up to 19 days in the unanesthetized animals. EHBF obtained by the BSP method through implanted catheters correlated well with values for hepatic blood flow obtained by the flow meter. Instantaneous cardiac output may be followed simultaneously with hepatic blood flow in the preparations described.

SURGICAL EXPERIENCES WITH THROMBOCYTOPENIC PATIENTS.

The surgeon approaches with trepidation a patient who has one or more abnormalities in the blood-coagulation mechanism. In his memory he retains a handful of experiences where bleeding a t operation presented a serious problem in which the causation all too often is established after the fact. There are few attempts in the recent literature which seek to correlate observed abnormal surgical bleeding with thrombocytopenia. It is the objective of this study to determine whether a patient with thrombocytopenia bleeds abnormally at operation, whether abnormal bleeding encountered a t surgery can be predicted on clinical grounds, and whether abnormal bleeding encountered a t surgery can be correlated with any clinical or laboratory data noted in the postoperative period.

Aneurysm of the aorta treated by wiring: case report of a 38-year survival.

A patient with a syphilitic aneurysm of the aorta treated by the insertion of wire is presented. The patient remained well Tar almost 40 years, but finally succumbed after rupture. The autopsy findings are discussed. To our knowledge, this represents the longest reported survival after treatment of an aortic aneurysm by wiring.