David D. Oakes

Intestinal injuries missed by computed tomography

Isolated intestinal injuries are frequently difficult to diagnose using only physical examination and routine laboratory studies. Between 1980 and 1988, ten patients were identified who had intestinal injuries and had computed tomographic (CT) scans before operation. For none of these scans was the initial reading considered diagnostic of intestinal injury. All patients came to laparotomy from 2 hours to 3 days following injury, and no patient died because of missed intestinal injury. Retrospective review of the scans revealed two to be diagnostic of intestinal perforation with free intraperitoneal air or extravasated contrast. The remaining eight scans had findings suggestive of injury. However, six additional patients had similar suggestive findings and had no evidence of intestinal injury. One patient with missed duodenal injury had not been given gastrointestinal contrast. Computed tomographic findings of intestinal trauma may be subtle or nonspecific and require optimal technique and care in interpretation. The timely treatment of this injury continues to rely on a high index of clinical suspicion and serial examinations by an experienced surgeon.

Neurogenic Respiratory Failure: A 5-Year Experience Using Implantable Phrenic Nerve Stimulators

During the past 5 years, 20 phrenic nerve stimulators have been implanted in 11 patients who were ventilator dependent because of neurogenic respiratory failure. Ten patients had traumatic spinal cord lesions; the remaining patient suffered from a progressive demyelinating disease. There was no operative mortality. Complications included 1 stimulator malfunction and 1 pneumothorax. In spite of adjacent tracheostomies, there were no infections or wound complications. Of the 20 stimulators implanted, 13 initially produced good diaphragmatic function, 2 had fair function, and 5 had little or not function. Three patients became completely independent of their ventilators; 6 became partially independent, thus simplifying nursing care. There were no late complications. As of December, 1979, 7 patients had benefited or were continuing to benefit from phrenic nerve stimulation.

Intraportal splenic autotransplantation in rats: Feasibility and effectiveness

Abstract This experiment was designed to see whether or not normal host resistance to infection could be reestablished in splenectomized animals by intraportal autotransplantation of homogenized splenic tissue. Part I studied the feasibility of the technique. Within 1 hr of splenectomy, 16 adult Lewis rats received an intraportal injection of autogenous splenic tissue which had been passed through a 500-μm screen. Five rats died acutely from hemorrhage at the site of injection. The others tolerated the infusion well, both acutely and chronically. The animals developed only transient elevations in liver enzymes; chronic portal hypertension did not occur. Histologically, splenic tissue could be demonstrated within terminal portal venules. Part II assessed the effectiveness of intraportal splenic autotransplantation. Eight to twelve months after splenectomy, autotransplantation, or sham operation, 103 Sprague-Dawley rats were challenged with intravenous boluses of 10 5 to 10 8 pneumococci. Mortality was 91% for splenectomized animals, 88% for animals bearing autotransplants, and 59% for controls. Thus intraportal splenic autotransplantation is technically feasible in rats. The grafts are well tolerated by the liver, and splenic tissue is preserved in intimate contact with the blood stream. Even after 8 to 12 months, however, such autografts are not capable of providing normal protection against massive pneumococcemia.

Pyloric stenosis in a premature infant

Workup of a case of hypertrophic pyloric stenosis in a premature infant showed absence of ultrasonic criteria for diagnosis. Transpyloric intubation for enteral feeding may delay the diagnosis of this disorder and has been thought to play a role in its development.

Effect of hepatectomy on mitotic activity in the rat spleen

Abstract Mitotic activity in the rat spleen was studied in 60 animals by DNA uptake of [3H]thymidine and autoradiographic nuclear labeling. Sham operation did not affect these parameters. After partial splenectomy, there was a marked increase in DNA uptake of [3H]thymidine and nuclear labeling that was maximal at 48 hr and remained elevated throughout the first postoperative week. After 70% hepatectomy, there was a similar increase in DNA activity at 24 hr but this increase returned toward control values at 48 and 72 hr. The distribution of nuclear labeling was similar after splenectomy and hepatectomy. These studies suggest that common control mechanisms may regulate regenerative responses in both liver and spleen.

Esophagectomy in patients with polysplenia : Technical considerations

We report a case and discuss the special considerations necessary for safe treatment of patients with polysplenia who require esophagectomy for cancer or other conditions. Polysplenia is a form of abnormal arrangement of body organs intermediate between situs solitus and situs inversus, sometimes associated with cardiac abnormalities. Abdominal manifestations include multiple spleens, a preduodenal portal vein, an interrupted inferior vena with azygous continuation, a short pancreas, and intestinal malrotation and malformations with anomalous blood supply. Esophagectomy is complicated in such patients by possible cardiac abnormalities, risk of hemorrhage from the enlarged azygous vein (adjacent to distal esophagus), limited exposure via right thoracotomy because of the dilated azygous venous system, and possibly restricted availability of stomach and colon for esophageal replacement (constraints of mobility stemming from anomalous blood supply and malposition/malrotation).

Hepatorenal syndrome managed with hemodialysis, then reversed by peritoneovenous shunting

A patient with acute decompensated chronic liver disease developed acute tubular necrosis after an episode of hypotension. Renal failure was managed by hemodialysis for 11 weeks during which period hepatic function improved. Despite persistently severe oliguria, tubular function recovered as judged by a fall in urine sodium content and a rise in specific gravity, suggesting the development of the hepato-renal syndrome. Therefore, a peritoneovenous shunt was inserted. This was followed by a prompt diuresis; further dialysis was not required. This case suggests potential roles for hemodialysis and peritoneovenous shunting in patients with advanced, but potentially reversible hepatic and renal failure and draws attention to the need for formal evaluation of such a possibility.

Lateral Thoracotomy and One-Lung Anesthesia in Patients with Morbid Obesity

Between May, 1980, and October, 1981, 22 morbidly obese patients ranging in weight from 93.4 to 236.8 kg (average, 145.2 kg) underwent transthoracic gastric stapling. Fourteen of these operations were performed using endobronchial intubation and selective collapse of the left lung to facilitate surgical exposure. The patients were compared with 22 consecutive patients treated by trans-abdominal gastric stapling during the same period. None of the 44 patients had evidence of chronic alveolar hypoventilation (pickwickian syndrome). In terms of operating time, blood loss, duration of intubation, and hospital stay, the two groups did not differ significantly. Despite marked shunting during one-lung ventilation, satisfactory arterial oxygen tension (PaO2) could be demonstrated on 100% oxygen for all thoracotomy patients (PaO2 range, 67 to 230 torr; mean, 132.3 torr). In fact, except for a lower PaO2 during one-lung anesthesia, the thoracotomy patients were indistinguishable from the laparotomy patients in terms of perioperative respiratory function. Pain, sedation, and positioning led to significant decreases in vital capacity and one-second forced expiratory volume in both groups on the first post-operative day, and in the thoracotomy group on the second day. There were only two wound infections in the thoracotomy group, as opposed to six infections with two dehiscences in the laparotomy group. It is concluded that lateral thoracotomy with or without one-lung anesthesia can be performed safely in massively obese patients--at least in those without preexisting alveolar hypoventilation syndrome.

Repair of a post-traumatic common iliac arteriovenous fistula.

The management of a patient with a post-traumatic common iliac arteriovenous fistula which was repaired surgically is reported. The current use of less-invasive endoluminal techniques is reviewed.