Paul A. Kennedy

Hepatic Artery Ligation

The concept of interrupting hepatic arterial flow in man is undergoing change. There is an ever increasing volume of clinical evidence that hepatic artery ligation can be life saving, and a number of well documented cases are related.

Hepatic artery ligation for metastatic tumor in the liver

Summary A case is reported of extensive metastatic disease of the liver in which hepatic artery ligation resulted in marked clinical improvement. In addition, there were dramatic changes in the liver as demonstrated by liver scan. The results in this patient support the thesis of Breedis and Young that the blood supply of secondary tumors of the liver is predominantly, if not exclusively, arterial in origin.

Coagulopathy associated with peritoneovenous shunting

Le Veen shunts successfully alleviated ascites in 19 of 24 patients (79 percent). Clinical clotting typical of disseminated intravenous coagulation occurred in nine of these patients (37 percent) and was fatal in seven (78 percent). Laboratory findings suggesting disseminated intravenous clotting were present in five other patients (21 percent) but were not associated with troublesome bleeding. Coagulopathy was reversed in 7 of 14 patients (50 percent), if the shunt was ligated and supportive measures were taken early in the postoperative course. Failure to recognize or take immediate action resulted in progressive disseminated intravenous clotting associated with a mortality of 50 percent (7 of 14 patients).

Chronic alcoholic pancreatitis: Treatment by ductal obstruction

Abstract The results of treatment of seven patients with chronic alcoholic pancreatitis by ductal obstruction are presented. In addition, one case is reported in which pancreatic ductal obstruction was carried out that provided an opportunity to study the histologic changes resulting from ductal obstruction after a period of thirty-two months. The procedure we now prefer is described. This operation is the equivalent of subtotal pancreatectomy, but will not cause diabetes or ulcers. We believe the principle of complete ductal obstruction in the treatment of chronic pancreatitis is physiologically sound and has advantages not associated with other surgical approaches. The results to date warrant a continued trial of the procedure.

Surgical Anatomy of the Liver

This article attempts to bring together the facts concerning regional anatomy of the liver as well as intrahepatic arrangements. This will obviate complications associated with liver trauma and will also aid in conserving functioning liver tissue.

Hepatic and vena caval injuries.

The improvement in mortality from liver injuries is largely attributable to advances in resuscitation, early exploration where intraabdominal injury is suspected, a more conservative approach to the definitive care of liver wounds, and improved care of complications.

Management of deep venous thrombosis and pulmonary embolism during pregnancy.

Despite venous stasis and a hypercoagulable state during pregnancy, the reported incidences of deep venous thrombosis and pulmonary embolism are remarkably low, about 1 in 2,000 and 1 in 10,000 cases, respectively. Mortality from antepartum thromboembolism has been reported in about 15 percent of untreated patients and less than 1 percent of treated patients. Adequate anticoagulant therapy significantly reduces maternal mortality and decreases postpartum morbidity. The proper anticoagulant agent for use during pregnancy has been widely debated. Coumarin compounds pass through the placenta and into the fetus. Hemorrhagic complications in the fetus are uncommon if prothrombin times are carefully controlled and if the drug is discontinued before delivery. However, coumarin during the first trimester has the teratogenic hazard of producing chondrodysplasia punctata. Heparin, in contrast, does not cross the placental barrier and is considered more effective treatment for deep venous thrombosis; however, long-term intravenous administration during pregnancy has been considered both impractical and possibly hazardous due to the risk of osteoporosis after 6 months of therapy. In our study, a combined regimen of intravenous and subcutaneous heparin was used successfully in four women with deep venous thrombosis. One patient who had recurrent embolization while on adequate intravenous heparin underwent vena caval clipping and had an uneventful Cesarian section at term with a normal infant. Another patient also underwent Caesarian section with a normal infant, while the other two women had normal vaginal deliveries at term. Miniheparin therapy was continued for 3 months postpartum, followed by long-term aspirin and Ascriptin therapy. Carefully controlled heparin therapy in a pregnant woman with deep venous thrombosis both safe and beneficial for mother and fetus.

Three years' experience with long-term endocardiac pacing. Complications: their care and prevention.

Abstract Forty patients had implantations of endocardiac pacemakers between September 1964 and January 1968. There was no immediate mortality, although there have been eleven late deaths. In only two instances could the pacemaking system be indicted as the cause of death. Complications occurred in thirteen patients. In two instances conversion to epicardial pacemaking had to be done. The remainder were cared for by simple measures. We believe that the incidence of complications can be further reduced.

The Incision and Wound Closure in Blunt Abdominal Trauma

Because blunt trauma frequently leaves considerable doubt as to the extent and location of the organ or organs injured, the incision used must allow for complete exploration of the abdominal cavity and give adequate exposure for carrying out any surgical procedure indicated. The midline incision is readily made and gives excellent exposure for any quadrant of the abdomen, and may be extended into the chest when necessary. The use of a more anatomic incision may restrict the surgeon considerably. Care must be given to the making and repair of the wound, since several factors which mitigate against primary wound healing may be at work in every case of blunt trauma to the abdomen.