Glenn W. Geelhoed

Colon ulceration and perforation in Cyclic Neutropenia

Abstract Cyclic Neutropenia is a rare hematologic disease in which regular episodes of severe neutropenia, usually accompanied by fever, mucous membrane ulceration, and abdominal pain and tenderness, recur at approximately 3-wk intervals. 1,2 A patient with this disease, who developed localized colon necrosis, peritonitis, and clostridial septicemia during a neutropenic period, was treated recently. Exteriorization of the colon prior to perforation allowed for staged elective resection subsequently and provided a unique opportunity to observe the cyclic formation of mucosal ulcerations in the large bowel. Although cyclic neutropenia is rarely accompanied by life-threatening infection, this case serves to emphasize the potential severity of such a complication. Furthermore, abdominal pain, should it occur, merits careful observation since unrecognized colon necrosis has been the cause of death in previously reported cases of this disease. 4,5

Pulmonary effects of autotransfused blood: A comparison of fresh autologous and stored blood with blood retrieved from the pleural cavity in an in situ lung perfusion model

Abstract An in situ pulmonary lobe perfusion model in dogs was used to examine the pulmonary effects of autotransfused blood as compared with fresh and stored blood. Fresh arterial blood was collected in heparin solution from ten dogs and was drained into and collected from the pleural cavity using a commercially available autotransfusion device for continuous filtration. Results of perfusion with autotransfused blood were compared with results of perfusion of blood stored at 4 °C in ACD solution for twenty-four hours in seven dogs and those of perfusion of blood stored for twenty-one days at 4 °C in ACD solution in seven dogs. The fresh and stored blood samples were passed through a standard recipient set filter prior to perfusion. Perfusion with autotransfused blood resulted in a decreased arteriovenous pO 2 gradient as compared with results in control blood, but there was no concomitant elevation in pulmonary vascular resistance (PVR) or endobronchial pressure (P b ) for the autotransfused blood. Stored blood by comparison showed significantly increased PVR and P b but a progressive decline in A-VpO 2 which was in excess of the level reached by perfusion of autotransfused blood. Fresh blood showed essentially no change in pulmonary functional parameters during perfusion. The great majority of animals whose lungs were perfused with stored blood had microscopic evidence of interstitial pulmonary edema, perivascular hemorrhage, intra-alveolar fluid, and alveolar congestion. Significantly fewer animals showed these changes when lungs were perfused with autotransfused or fresh blood. Wet-dry weight ratios of lung tissue after perfusion indicated significantly higher uptake of water by the lung perfused with stored blood than by those perfused with autotransfused or fresh blood.

Effects of autotransfusion on blood elements

Abstract The effects of autotransfusion on cellular and other components of autologous blood were studied in forty adult dogs. An increase in free plasma hemoglobin and a decrease in hematocrit, red blood cells, and white blood cells were seen immediately after autotransfusion with canine blood exposed to the peritoneal cavity (group II) and blood collected in a siliconized beaker (group I). After autotransfusion, a significant decrease in platelets and a significantly higher free plasma hemoglobin level were noted in dogs in group II. In the five day period after autotransfusion the white blood cell and fibrinogen levels remained elevated whereas free plasma hemoglobin, hematocrit, red blood cell, and platelet levels returned to near normal. Prothrombin time, thrombin time, and partial thromboplastin time were within normal limits throughout the experimental period. Red blood cell survival after autotransfusion was found to be normal relative to controls. Screen filtration pressure was markedly elevated in blood suctioned from the abdominal cavity. Filtration with the autotransfusion reservoir filter resulted in a decrease in screen filtration pressure to a measurable but elevated level whereas screen filtration pressure returned to normal after Dacron wool filtration. No alteration in lipoproteins or elevation of plasma lipids was found with prolonged autotransfusion and no fat emboli were observed histologically. All dogs survived and showed no evidence of bleeding, thrombosis, or insult to pulmonary or other organ system function.

Pulmonary injury resulting from perfusion with stored bank blood in the baboon and dog

Abstract An in situ pulmonary lobe perfusion study was undertaken to examine the role of stored blood in the pathogenesis of posttraumatic pulmonary insufficiency. Autologous blood was stored for 21 days in ACD solution, passed through a standard blood-set filter and perfused for 2 hr through the left lower lobe of seven dogs and seven baboons. Seven animals of each species were perfused with autologous filtered blood stored for 24 hr and served as controls. Perfusion with stored blood resulted in significantly increased pulmonary vascular resistance (PVR), end-inspiratory bronchial pressure (P b ), and lung water in both baboons and dogs relative to controls. The arteriovenous pO 2 gradient was significantly decreased in the dog perfusion group while a definite downward trend was noted in the baboon group but lacked statistical significance. Gross and microscopic evidence of pulmonary edema was noted in both groups and the great majority of animals in both species demonstrated perivascular hemorrhage, intraalveolar edema, and hemorrhage and alveolar congestion in response to perfusion with stored blood. The screen filtration pressure (SFP) was immeasurably high in all baboon blood stored 3 weeks in ACD solution. This resembles the response previously noted in stored human blood. In contrast, stored dog blood fails to show a consistent elevation in SFP relative to control blood.

Surgical management of intravascular glomus jugulare tumor

Abstract Extensions of glomus jugulare tumors into the internal jugular vein are unique in that they do not involve the wall of the vein but grow as fingerlike projections in the lumen of the vessel. These intravascular tumor extensions are potentially lethal by direct extension into the heart or as fatal emboli at the time of excision of the primary lesion or during the course of radiotherapy. In a patient with a glomus jugulare tumor, retrograde internal jugular vein phlebography demonstrated a clinically occult extension of the tumor through the venous system into the right atrium. This finding reaffirms the conclusions of others that such tumor extensions are undetectable preoperatively except by venography. Because of the relevance of the extensions to therapy, the case illustrates the importance of internal jugular vein phlebography in all patients with glomus jugulare tumors. The surgical approach and operative safeguards used in the treatment of this patient serve as a guide to the management of these rarely reported tumor extensions.

The blood supply of mediastinal parathyroid adenomas.

Arteriography for parathyroid localization following unsuccessful neck surgery should include selective catheterization of the inferior thyroid and internal mammary arteries bilaterally. When the arterial supply to a mediastinal adenoma arises from the internal mammary artery, recovery from the neck may not be possible and an open mediastinal exploration (or embolization) should be considered.

Carcinoma in situ of the vagina following treatment for carcinoma of the cervix: A distinctive clinical entity

A series of 10 patients who presented with carcinoma in situ of the vagina following treatment for carcinoma of the cervix were seen in a 3 year period and their clinical and histologic features reviewed. Vaginal lesions developed 1 to 22 years after diagnosis of carcinoma of the cervix was made. In three patients the vaginal lesions progressed to invasion. In the remaining patients repeated biopsies have revealed persistent carcinoma in situ. From this series of 10 patients we conclude that the biologic behavior of vaginal carcinoma in situ following carcinoma of the cervix resembles that of carcinoma in situ of the cervix and that carcinoma of the vagina following carcinoma of the cervix should be considered a separate clinical entity distinctive from primary invasive carcinoma of the vagina.

Management of intravenous extensions of endocrine tumors and prognosis after surgical treatment

The capacity of endocrine neoplasms to give rise to intravenous tumor extensions is a feature that is recognized preoperatively by the use of venography employed primarily for tumor localization. A series of adrenocortical tumors, a pheochromocytoma and an extraadrenal chromaffin tumor are reported in which the intravenous tumor component was recognized and the surgical approach was modified to include extirpation of the intravascular tumor. Although intravenous tumor propagation has implied a grave prognosis because of the possibility of blood-borne metastases from the intravascular tumor or physiologic disruption from clot or tumor embolus, resection designed for cure, including distal venous control and tumor thrombectomy, was carried out in each patient. Wider application of preoperative venography enables recognition of these intravenous neoplastic extensions from endocrine tumors; the results of surgical management suggest that this invasive feature should not be a grave prognostic indicator that inhibits attempt at operative eradication of the primary tumor and its intravenous extension.

The Diagnosis and Management of Pneumocystis carinii Pneumonia

Abstract Pneumocystis carinii pneumonia is a disease of increasing clinical significance in patients with impaired cellular immunity. Twenty-seven such individuals who demonstrated the characteristic triad of progressive respiratory failure, minimal auscultatory findings, and roentgenographic hilar infiltrates progressing to consolidation are presented. In this series, open lung biopsy was more effective early in the disease when hilar infiltrates had not consolidated; when consolidation was present, needle biopsy appeared to be effective. Of the patients in whom a diagnosis was established prior to death, 6 of 7 treated with amphotericin died and 9 of 11 treated with pentamidine recovered from their pneumonia though they demonstrated transient drug toxicity. The future role of the membrane lung in supporting patients in severe respiratory failure during the course of drug therapy is suggested by the response of 2 patients.

Autotransfusion in the subhuman primate.

Abstract In the subhuman primate, autotransfusion of up to four times the calculated blood volume has been achieved with a commercially available system without significant development of microaggregates or pulmonary dysfunction when the animal has been adequately heparinized and maintained normotensive. These findings correlate clinical results achieved in elective autotransfusion carried out with systemic heparinization. Persons subjected to trauma and shock may be more susceptible to platelet aggregation, microembolization, and pulmonary insufficiency. Although these sequelae may occur after autotransfusion, they are not necessarily caused by autotransfusion of even massive proportions.