Hastings K. Wright

Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion

Massive transfusion may cause abnormalities of electrolytes, clotting factors, pH, and temperature and may occur in a scenario of refractory coagulopathy and irreversible shock. Identification of correctable variables to improve survival is complicated by the interplay of this pathophysiology. Temperature may be an under-appreciated problem in the genesis of coagulopathy. In vitro studies have demonstrated that platelet function and vascular response are critically temperature-dependent. We reviewed the records of 45 trauma patients without head injury or co-morbid medical illness who required massive transfusions. The mean Injury Severity Score was 55±6, a mean of 22.5±5 units of blood was transfused, and mortality was 33%. Nonsurvivors were more likely to have had penetrating injury (88% versus 55%), received more transfusions (26.5±9 versus 18.6±1, p

Controlled, semielective, segmental resection for massive colonic hemorrhage

An aggressive diagnostic work-up to determine the site of bleeding was employed in all 25 patients requiring transfusion of over 1,500 cc of blood for colonic hemorrhage in New Haven in 1977 and 1978. A specific bleeding site that permitted segmental colectomy was found in 23 patients (92 percent). The mortality rate was zero, reflecting the rapid improvement in survival that has occurred in the last decade among patients with massive colonic hemorrhage.

Water absorption in experimental closed segment obstruction of the ileum in man

Abstract The effect of increased intraluminal pressure on secretion and absorption from the human ileum was measured in volunteers with ileostomies. Absorption of a test solution was found to increase at moderate elevations of pressure, but fell below normal at pressures three or four times normal. Conversely, secretion of fluid into the lumen increased as pressure rose. These findings suggest that increased secretion is the primary cause of fluid loss and distention in closed loop intestinal obstruction, while decreased absorption plays a relatively less important role.

Compensatory Hypertrophy of the Ileum After Gastroduodenojejunal Exclusion

One theory of compensatory hypertrophy of the gut suggests that ileal growth after jejunectomy results from exposure of the ileum to villus-enlarging factors emanating from the papilla of Vater. This hypothesis was tested by examination of the ileum after bypass of pancreatobiliary secretions to the colon. Hypertrophy of the ileum occurred after esophagoileostomy and gastroduodenojejunal exclusion, suggesting that adaptive growth of the gut depends on additional factors. There is evidence to support several theories of compensatory hypertrophy. A hypothesis seeking to reconcile the conflicting notions of intraluminal and hormonal stimuli is suggested.

The functional consequences of colectomy.

The colon plays a decisive role in salt and water conservation in the intact human, normally removing from the terminal intestine approximately one liter of isotonic fluid that escapes small bowel absorption. The primary purpose of this colon function is probably to prevent extracellular fluid volume depletion and only incidentally to produce a normal solid stool. The patient with an ileostomy can partly adapt to replace the absorptive capacity lost after colectomy but is still vulnerable if salt and water intake ceases completely. In contrast, patients with ileorectostomies and some patients with continent ileostomies can almost totally adapt to loss of the colon. These findings suggest that the ileal mucosa can adapt under certain conditions to absorb at rates and concentrations previously thought impossible. This property of ileal mucosa might be utilized in the future to significantly improve the condition of patients who require total colectomy.

Impaired intestinal absorption in the Zollinger-Ellison syndrome independent of gastric hypersecretion

Abstract The watery diarrhea observed in the Zollinger-Ellison syndrome has been attributed largely to the effects of acidification of the small bowel contents caused by gastric hypersecretion. However, the present study demonstrates that patients with the Zollinger-Ellison syndrome continue to have significant reductions in jejunal absorption of water, sodium, and glucose when the gastric hypersecretion is controlled without removing the secreting pancreatic tumor. These findings suggest that the gastrin-like hormone released in this syndrome directly inhibits small bowel absorption as well as causing gastric hypersecretion. Both mechanisms may be important in producing diarrhea.

A possible explanation for postoperative diarrhea after colostomy closure

The transient diarrhea that sometimes follows the closure of colostomies has been ascribed to rapid transit in the previously defunctionalized distal colon. However, the present study of the temporarily bypassed colon in the rat indicated that a reduced capacity for the absorption of sodium and water develops within two to three weeks after bypass, without significant decreases in transit time or colon volume. After restoration of continuity, the absorptive capacity for water increased to normal under some of the experimental conditions. It is therefore suggested that postoperative diarrhea after colostomy closure in man may be related to a temporary decrease in absorptive capacity in the previously bypassed distal colon.

Rate of water and sodium absorption from the jejunum after abdominal surgery in man

Abstract Five patients were given intrajejunal infusions at a 10 cc per minute pumping rate before and after major intra-abdominal surgery. Net water and sodium absorption fell from a preoperative value of 2.2 cc per minute to a postoperative value of 1.2 cc per minute in a 30 cm length of jejunum immediately distal to the infusion site in the proximal jejunum. However, net absorption was not abolished and the infusions were well tolerated except for mild cramps after sixty minutes in two patients, suggesting that jejunal motility during clinical postoperative ileus is sufficient to propel large amounts of unabsorbed fluid from the infusion site to more distal intestine to prevent local distention. Intrajejunal infusions at much lower rates (2 cc per minute) were well tolerated for thirty-six continuous hours in three postoperative patients, and maintained hydration without supplemental intravenous fluids.

Specific but limited role of new imaging techniques in decision-making about intraabdominal abscesses

Despite the very high accuracy rate of imaging studies (ultrasound, computed tomography, liver-lung-spleen scans and gallium-67 scans) in detecting intraabdominal abscesses, our experience with 80 recent cases indicate that these techniques have not significantly altered traditional methods of decision-making about when and where to drain such abscesses. In only 12.5 percent of cases were such decisions based on special imaging techniques alone, and most of these cases subphrenic abscesses were diagnosed late after surgery. In the remainder, physical examination and routine radiologic studies sufficed, with special imaging techniques primarily corroborating clinical evidence based on these methods. We conclude that the use of special imaging techniques alone in a search for the cause of fever early after abdominal surgery does not provide evidence upon which clinical decisions can be based unless there are already physical signs of an abscess.

Natural history of occult right colon cancer

Abstract The results of this study indicate that occult right colon cancers have already grown to an advanced local stage when first detected after the discovery of iron deficiency anemia or occult stool blood, or both. However, if promptly treated, two thirds of such patients will survive 5 years. If not detected and treated promptly after discovery of these signs, two thirds of such right colon cancers will metastasize within 1 year, and the survival rate will decrease by one half.