Dominic Albo

Indium 111-labeled leukocyte scanning for detection of prosthetic vascular graft infection

Recent animal and human studies have suggested that positive indium 111-labeled leukocyte scans may help establish the diagnosis of vascular graft infection; however, there is little information available about the predictive value of both positive and negative leukocyte scans in larger groups of patients. In this study 31 indium 111 leukocyte scans were performed prior to definitive treatment in 21 patients with suspected vascular graft infections. Patients with more than one leukocyte scan performed had either anatomically distinct sites of infection or rescanning of a potentially infected site after definitive treatment. Scans were performed according to the method of Baker et al., attaching 500 muCi of indium 111 to leukocytes with imaging 24 hours later. All patients with positive scans underwent surgical exploration of the area of leukocyte accumulation, with documentation of purulence and culture of the graft. Patients with negative scans were treated as if scan results were indeterminate and underwent surgical exploration for usual clinical indications; if no exploration was performed, the patient was followed up closely for at least 1 year. Twelve of 12 positive scans showed purulence or culture evidence of infection with three different organisms; in 15 instances of negative scans, two operations were performed with one infection noted, whereas no patient without surgery has had a graft infection at 10 months follow-up. In addition to localizing graft infections, two scans demonstrated a nonvascular site of infection. Positive scans also helped determine the extent of infection along the graft, allowing better planning of the surgical procedure. These results indicate that indium 111-labeled leukocyte scans help document and localize prosthetic vascular graft infections.

Gastrointestinal complications of collagen vascular diseases: Surgical implications

Abstract Life-endangering gastrointestinal complications in patients with collagen vascular disease often represent challenging problems to the surgeon in terms of early recognition, diagnosis, and treatment. The records of 122 patients with collagen vascular disease, documented either with a positive lupus erythematosis preparation or a positive muscle biopsy have been reviewed. Of these, major gastrointestinal complications developed in twenty-six patients (21.3 per cent). The majority of these patients were receiving steroid therapy, which often masked the severity of their complications. Gastrointestinal ulceration with hemorrhage was the most common complication observed, and represented 30 to 40 per cent of the complications. No patient with a surgically correctable lesion who was operated upon died. On the other hand, 60 per cent of those patients with gastrointestinal complications treated nonoperatively died. All but three of these patients had a potentially correctable lesion. Early diagnosis and properly timed and selected operation, if required, are necessary if this group of patients is to be managed successfully.

Spontaneous hepatic rupture in pregnancy

Abstract Hepatic rupture as a late complication of toxemic pregnancy is a rare yet lethal condition requiring rapid recognition and surgical management. The clinical triad of toxemia, right upper quadrant pain, and sudden hypotension is the diagnostic hallmark of presentation. Most patients present near the time of delivery and are found to have subcapsular hematomas of the right hepatic lobe with free rupture into the peritoneal cavity and resultant exsanguinating hemorrhage. The association of toxemia and disseminated intravascular coagulation with secondary microembolic damage to the liver and other organs has been discussed. Basic surgical principles in the management of hepatic subcapsular hematomas, and the prolonged postoperative course and frequent complications in these patients have been stressed.

Effect of intra-arterial injections of barbiturates*

Summary Two cases are presented and the literature reviewed to illustrate the damaging effects that are produced by the intra-arterial injection of barbiturates. The rationale for discussing these two eases is to emphasize that this condition is no longer confined to the operating room and is seen with increasing numbers of self-injected medications. A plan of treatment using continuous intra-arterial infusion of heparin is advocated.

Acute occlusion of the infrarenal aorta

Summary Acute occlusion of the abdominal aorta is usually the result of either severe atherosclerosis followed by spontaneous thrombosis, blunt abdominal trauma, or aortic embolism. Four cases of acute infrarenal aortic occlusion are presented and the literature is reviewed to illustrate this rare but serious vascular catastrophe. These cases are of interest because they represent examples of the major pathogenic varieties of the abdominal aortic thrombosis. All four patients were correctly diagnosed preoperatively and all were relieved of the aortic obstruction with minimal morbidity and without mortality. Early diagnosis and an aggressive surgical approach are essential if this group of patients are to be managed successfully.

Attributes of Excellence in Various Professions: Their Relevance to the Selection of Gifted/Talented Persons.

Grades will predict grades and the academic-type tests will predict grades but they have been found through research studies to be poor predictors or no predictors at all of who will be the best in professions. The troublesome answer generally is that professional schools do not select the persons who will become the best professionals in their fields, nor who will best keep up-to-date with new knowledge and techniques in their careers. The main exception to this general finding occurs in the field of professional athletics and in the entertainment and artistic fields. The example given comes from the Dallas Cowboys scouting data and outcome of potential football recruits in their professional careers. Their correlations are about .70 with career success, whereas predictors from professional schools range from zeros to about +.20 or slightly higher—such predictors from professional schools still miss over 90% or even over 95% of the target, i.e., what is involved in succeeding in each of the professions. Consequently, neither those chosen into most professions nor their future clients will be well served by such poor predictive procedures.

Femorofemoral bypass with an infrascrotal perineal approach for the patient with an infected groin wound

A technique is presented for revascularization of patients having a groin wound infection, which minimizes the risk of recurrent graft infection. A femorofemoral bypass with a subcutaneous perineal tunnel is constructed farther from the infected groin wound than the standard subcutaneous suprapubic tunnel. The route of the graft appears to result in neither excessive tension on the graft when the leg is abducted nor kinking of the graft when the leg is adducted. Long-term follow-up will be needed to compare the patency of this route with the standard suprapubic tunnel in patients with an infected groin wound who require a femorofemoral bypass graft.

Massive liver trauma involving the suprarenal vena cava

Abstract Experience with major hepatic resections is discussed with particular emphasis on those cases with injury to the suprarenal vena cava. The feasibility of transporting persons with massive liver trauma from small community hospitals to major medical centers using packs to obtain temporary control of hemorrhage is emphasized. The role of major hepatic resections for extensive liver trauma, especially in blunt injuries involving the suprarenal vena cava is discussed. The importance of having blood banking facilities capable of providing massive amounts of blood is stressed. A modification of Schrocks technic for vascular isolation of the liver in injuries to the hepatic veins and suprarenal vena cava is presented.

Peritoneovenous shunting in patients with malignant ascites

The management of incapacitating abdominal ascites secondary to malignant disease is a difficult but not uncommon clinical problem. In-hospital diuretic therapy in conjunction with fluid restriction is effective, but may aggravate hypovolemia with resultant azotemia and hyperaldosteronism. Outpatient medical management often leads to unpredictable results because of poor patient cooperation. Multiple abdominal paracentesis removes significant amounts of protein and can produce profound protein malnutrition. Abdominal paracentesis with instillation of various sclerosing agents has also failed to palliate this disease. Peritoneovenous shunting is the most physiologic answer to the problem because it reduces ascitic volume while maintaining the intravascular space. In addition, the nutrition of these already compromised patients is not further impaired by repeatedly draining protein rich ascitic fluid. The development of reliable one-way pressure-sensitive valves has allowed effective clinical use of this method. Although well-established in the therapy of ascites secondary to chronic liver disease, peritoneojugular shunting in the management of malignant ascites has not been extensively reported on.

Preoperative selection of patients for lumbar sympathectomy by use of the Doppler index

Yao and Bergan [8] have shown that an ankle systolic index of more than 0.25 is associated with a high rate of success from lumbar sympathectomy. This association has been borne out in our small series. We have also suggested that diseases that obviously compromise collateral circulation might be a relative contraindication to sympathectomy. Although incomplete, literature on collateral flow in relation to sympathectomy tends to confirm this idea. Consideration of such diseases as a contraindication to sympathectomy might further increase the success rate after sympathectomy. Regardless, ankle systolic index alone appears to be a reliable objective, non-invasive method of selecting patients with an increased chance of success from lumbar sympathectomy.