Nathaniel M. Matolo

Acute suppurative cholangitis

Acute suppurative cholangitis is characterized by obstruction, inflammation, and pyogenic infection of the biliary tract associated with the clinical pentad of fever (and chills), jaundice, pain, shock, and central nervous system depression. The disease occurs most commonly in the elderly who have a history of calculous biliary tract disease. The disease represents a true surgical emergency. Appropriate antibiotic therapy and immediate surgical decompression of the biliary tract are essential and carry a mortality rate of approximately 33 per cent. Nonoperative management is uniformly fatal. If inadequately treated or untreated, the disease follows a fulminant course of progressive systemic sepsis, hepatic abscess formation, and heptic failure leading ultimately to death. Acute suppurative cholangitis, the most serious sequela of calculous biliary tract disease, is preventable by early elective surgical treatment for benign biliary tract disease.

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.

Intestinal necrosis and perforation in patients receiving immunosuppressive drugs

Immunosuppressive agents are frequently used in transplant recipients for prevention of homograft rejection and in patients with leukemia for treatment of their primary disease. From 1973 to 1975, fifty-nine patients undergoing renal transplantation and forty-one patients with leukemia were treated at the University of California (Davis) Medical Center. Intestinal necrosis and perforation developed in four (7 per cent) of those receiving transplants and in four (10 per cent) of the patients with leukemia. One transplant receipient and all four patients with leukemia had extensive necrosis of both the small and large intestines. Two transplant recipients had isolated sigmoid perforations, and one had splenic flexure colonic perforation. All died from septicemia with septic shock. The etiology of these intestinal complication appears related to immunosuppressive agents, particularly high dosages of steroids. Despite the grave prognosis, early surgical intervention is the only method of dealing with these complications. Early diagnosis as well as properly timed and selected operations are necessary for the successful management of these patients.

Selective embolization for control of gastrointestinal hemorrhage

Transcatheter embolization using Gelfoam plugs or autologous clot is an alternative or adjunct to the conventional management of gastrointestinal hemorrhage. During a 12 month period we successfully treated 10 patients who had massive gastrointestinal hemorrhage with selective embolization; 6 patients had upper gastrointestinal hemorrhage and 4 had bleeding from the colon. Most of these patients were critically ill and were poor surgical candidates. Hemorrhage was controlled by selective catheterization of the bleeding vessel, followed by injection of Gelfoam pledgets. Since the procedure was accomplished with ease and prolonged hemostasis obtained, we recommend it for gastrointestinal hemorrhage, especially in patients who are poor surgical risks or are unresponsive to vasopressin infusion, or both. Operative intervention for the primary disease could subsequently be performed electively, if necessary, days or weeks after transcatheter embolization.

Common Iliac Artery Injury from Blunt Trauma: Case Reports

Common iliac artery injury from blunt trauma is uncommon. We describe two cases of common iliac artery injury from blunt abdominal trauma resulting in occlusion in one case and aneurysm in the other. The diagnosis of such injuries is based on clinical suspicion, the presence of bruits, pulse change or discrepancy, or continued unexplained blood loss. Vessel wall damage may not manifest itself initially but may result in thrombosis, subintimal hemorrhage, dissection, or aneurysmal dilatation. These can result in hemorrhage, pain, or ischemia developing remotely from the initial trauma.

The Validity of 99mTc-Pyridoxylideneglutamate (P.G.) Cholescintigraphy as a Diagnostic Test for Cholecystitis

The purpose of this investigation was to determine the diagnostic value (validity) of technetium-99mpyridoxylideneglutamate cholescintigraphy (99mTc- PGC) in patients with and without cholecystitis and to compare its validity to those of oral cholecystography (OC) and ultrasonography (US). 99mTc-PGC was applied to 50 patients with acute, subacute, and/or chronic cholecystitis with cystic duct obstruction proven histologically and operatively, and also to 27 non-diseased volunteers and 43 patients with right upper quadrant abdominal pain who subsequently were proven free of gallbladder disease. In addition, 38 patients had OC, and 31 had US performed. The results shows that the sensitivity and specificity of 99mTc-PGC were 100%. Whereas for OC the sensitivity was 87%, specificity was 100%. For US the sensitivity was 70%, and specificity was 93%. The repeatability of 99mTc-PGC, OC, and US were 100%, 94% and 81% respectively. These data show that 99mTc-pyridoxylideneglutamate cholescintigraphy is a valid diagnostic tool in the evaluation of patients with cholecystitis, and is also safe and simple.

Surgical management of subclavian artery injury

During a 10 year period, we have had operative experience with 13 injuries to the subclavian artery. The factors that led to the successful management in 10 consecutive patients were analyzed. Nonspecific signs, such as pain and swelling, were present in all of the patients. Some aspect of vascular injury was present in each patient and included change in the quality of the distal pulse, hematoma, active hemorrhage, and bruit. Roentgenologic signs such as lung opacification, fractured clavicle, fracture of the first or second rib, and pulmonary opacification were present in each patient. Arteriograms were obtained from all stable patients in whom this injury was suspected. There were no false-positive or false-negative findings. The operative approach for the right subclavian vessels was midline sternotomy, whereas for exposure of proximal left subclavian injuries, anterolateral thoracotomy was utilized. Claviculectomy permitted excellent exposure for distal subclavian artery injuries. This exposure was associated with minimal blood loss and permitted direct repair of complex injuries of the arteries and veins. All patients who reached the emergency room with measurable vital signs survived, and all those who underwent subclavian vascular repair had circulation restored. Principal morbidity was due to associated brachial plexus and lung injuries. A high index of suspicion, rapid transportation, aggressive resuscitation, and proper surgical exposure and repair are essential for the successful management of these rare vascular injuries.

Neurovascular complications of brachial arteriovenous fistula

Abstract Fifty-one patients with renal failure underwent construction of arteriovenous fistulas at the University of Utah Medical Center and the Salt Lake Veterans Administration Hospital during the last three years and have been maintained on hemodialysis using these fistulas. Forty-three of the patients had arteriovenous fistulas at the wrist level (radial artery) with several failures, primarily from clotting. Eight patients had fistulas at the elbow level (brachial artery) and in two of these patients neurovascular complications developed which were confined to the forearm and hand in the extremity with the fistula. The neurovascular problems were characterized by pallor, paresthesias, pain, weakness, and muscle atrophy in the forearm and hand. These complications were reversed rapidly by surgical correction of the fistula which restored normal circulation to the extremity.

Comparison of ultrasonography, computerized tomography, and radionuclide imaging in the diagnosis of acute and chronic cholecystitis

Seventy-five patients with abdominal pain in the right upper quadrant who were subsequently confirmed operatively and histologically to have acute or chronic cholecystitis underwent radionuclide imaging of the biliary tree, ultrasonography, and/or computerized tomography before operation. fifty-eight of the patients had acute cholecystitis and 17 had chronic cholecystitis and cholelithiasis. Analysis of our data indicates that ultrasonography is an accurate and better screening test than cholescintigraphy in the diagnosis of chronic cholecystitis and cholelithiasis, but it is less accurate in the detection of acute cholecystitis. On the other hand, radionuclide imaging is highly sensitive and specific in the early diagnosis of acute cholecystitis, but it is poor in the diagnosis of chronic cholecystitis and cholelithiasis unless the cystic duct is obstructed. CT scanning is more expensive than ultrasonography but may be extremely helpful in problematic cases such as the diagnosis of the cause in biliary obstruction or in imaging of the pancreas.

Technetium-99m pyridoxylideneglutamate (P.G.) cholescintigraphy.

Technetium-99m P.G. cholescintigraphy was performed in 27 human volunteers and 81 patients referred for hepatobiliary tract disease. The gallbladder, biliary system, and gastrointestinal tract were well visualized in the normal patients and volunteers. The gallbladder was not visualized in 22 patients with histologically proved cholecystitis with cystic duct obstruction. Nine patients with complet extrahepatic obstruction of the common bile duct were correctly diagnosed. Hepatocellular disease and incomplete obstruction, with and without jaundice, were diagnosed with this technique. Oral cholecystography is superior to this method for the detection of cholelithiasis in nonjaundiced patients.