Paul Nemir

A study of anastomotic aneurysms following aortofemoral prosthetic bypass.

Between 1960–1979, 19 patients with aortofemoral prosthetic bypass for aneurysmal and/or occlusive disease subsequently developed 36 false aneurysms at the suture line, for an incidence of 4.5% (19/426 patients). The two major aneurysm sites were the femoral anastomosis 4.5% (33/727 patients), and the aortic anastomosis 0.7% (3/430 patients). Additionally, one patient with bilateral false aneurysms of the groin subsequently developed an aortoduodenal fistula. The initial operation was for aortoiliac occlusive disease in 14 and for abdominal aortic aneurysms plus severe occlusive disease in five. The false aneurysm(s) appeared three months to 17 years after the aortofemoral procedure. Eleven of 19 patients (57.9%) had multiple aneurysms (two to five) and developed both right and left groin aneurysms concomitantly or at different times. Suture failure was the major finding at operation. However, a common alternative finding was partial or near complete separation of the prosthesis from the host vessel and an intact suture line, thus indicating a structural weakness in the host vessel and/or severe mechanical stress, as the causative factor. One experience leads us to favor an aggressive surgical approach to these lesions. All false aneurysms were corrected as they were detected with good surgical results.

Significance of ulcerated plaque in transient cerebral ischemia

The results of 210 endarterectomies in 174 patients are reviewed. The average age was 60.3 years for women and 62.1 years for men, with women comprising 53 percent of the population. Pathologic evaluation of tissue removed at time of surgery revealed macroscopic ulcerations in 50 percent of specimens and microscopic ulcerations in 33 percent, with 15 percent of specimens having both macroscopic and microscopic ulcerations. We were unable to identify a set of factors on the basis of symptoms or preoperative studies that would unequivocally indicate ulceration, but we believe that this study reinforces the concept that atheromatous embolization is probably a more frequent remedial cause of transient ischemic attacks than ischemia secondary to large vessel disease.

Effect of local tumor removal and retained oncolysate on lung metastasis

We reported earlier that oncolysate retained in the excision wound of a local tumor inhibits growth of remote tumor in the rat. We further studied this effect on pulmonary metastasis. C57BL/6 mice were given B16 melanoma F10 cells subcutaneously into the gluteal area (Day 0) and then intravenously on Day 10. On Day 14, mice were divided into four groups. Group 1 received a sham operation and no further treatment. Tumors were excised in the remaining mice. Group 2 received tumor excision alone. Groups 3 and 4 received injections of freeze-lysed tumor cells (TC) and lysate modified (PTC) with a hapten, L-phenylalanine mustard (PhM), respectively, into excision wounds. On Day 24, metastases were assessed by determining metastatic burden. Average diameters of excised tumors in repeated experiments ranged from 8.7 to 10.9 mm. In repeat experiments, pulmonary metastatic burden increased by as much as 52 to 181% in the tumor excised group (Group 2) in comparison with those receiving sham surgery (Group 1). However, metastatic burden was always reduced in Group 3. An even greater reduction was seen in Group 4. To study the possible involvement of macrophages, the production of prostaglandin-E2 (PGE2) and cytotoxicity of macrophages in these animals were examined. It was found that tumor excision enhanced PGE2 production by macrophages and suppressed their cytotoxicity, while TC inoculation prevented both of these changes. An even greater prevention was observed with PTC inoculation. These results indicate an association among macrophage cytotoxicity, PGE2 production of macrophages, and metastasis. In order to clarify the mechanism for these reactions, we did experiments using adherent splenic macrophages from the four groups of animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Air embolism as a complication during parenteral alimentation

Abstract A case is reported in which an air embolism occurred during parenteral alimentation via a large bore plastic catheter in the superior vena cava. The increasing use of this modality requires stressing the importance of basic rules of technic to nursing and attending staffs to avoid serious complications.

Reflections on the surgical management of achalasia of the esophagus

Abstract 1. 1. Our experience has indicated that one can expect a good to excellent result from the treatment of achalasia by esophagocardiomyotomy in 85 per cent of the patients. 2. 2. The safety of the procedure, measured in terms of low morbidity and mortality, has caused us to consider this operation as initial therapy and to liberalize the indications for operation recently. 3. 3. Careful attention to technical details, the inclusion of pyloromyotomy or pyloroplasty, and the correction of hiatal hernia whether coexistent or surgically produced may well eliminate poor results from the Heller operation.

Simple intestinal obstruction; prolongation of life for 45 days with parenteral alimentation.

Conclusions The length of survival of dogs having a low simple intestinal obstruction depends upon the ability to maintain fluid, electrolyte, and nutritional requirements. By parenteral alimentation with the methods used adequate nutritional requirements were not obtained, but in 1 animal in which these requirements were approached more closely the length of survival was 45 days.

Effect of retained components of excised tumor upon coexisting tumor

Effects of locally treated and retained tumor tissue on the growth of a tumor at another site were investigated using Lewis rats bearing syngeneic fibrosarcoma. When an established tumor had completely regressed upon repeated intratumoral injections of L-phenylalanine mustard (PhM), the growth of secondarily transplanted tumor cells was inhibited. However, early excision of the PhM-injected tumor prevented the development of this effect. To study this effect directly, we excised one of the two established tumors in each thigh, and reinoculated into the excision wound either freeze-lysed 1 X 10(8) tumor cells (TC) or lysate chemically modified with PhM (PTC). We found that TC inoculation into the excision wound in 7 rats inhibited the growth of the remaining tumor and extended survival time (mean +/- SE, 27 +/- 1 days). With inoculation of PTC into the excision wound, the remaining tumor regressed and survival was significantly prolonged (32 +/- 2 days). In contrast, 7 untreated rats, each bearing two tumors, had a mean survival time of 22 +/- 0.1 days. Excision of one tumor (6 rats) did not affect the growth of the remaining tumor or survival time (23 +/- 1 days). We employed PhM to modify the immunogenicity of TC. However, if PhM dissociates from PTC, its cytotoxic effect may directly inhibit growth of the distant tumor. To examine this possibility, we divided 30 rats who had excision of one tumor, into three groups of 10 10.(ABSTRACT TRUNCATED AT 250 WORDS)

LOCAL AND SYSTEMIC CIRCULATORY EFFECTS OF GASTROINTESTINAL DISTENSION

INTRODUCTION The importance of gastrointestinal distension may be clearly portrayed by a study of the mortality in intestinal obstruction since the turn of the century (FIGURE 1 ) . This graph has been composed from serial statistical surveys of the mortality of intestinal obstruction from the Columbia-Presbyterian Medical Center, the Johns Hopkins Hospital, the Massachusetts General Hospital, the University of Minnesota Hospitals, and the Hospital of the University of Pennsylvania. During the first decade of the twentieth century, mortality ranged from 50 to 60 percent. The first appreciable reduction, to about 40%, occurred in the 1920s, and was undoubtedly due to the demonstration by Hartwell and Hoguet, of the protective effect of parenteral saline solution. The next significant drop in mortality followed the great contributions made by Wangensteen and colleagues2 at the University of Minnesota in the 1930s on the effects of distension and the value of decompression of the gut. During the late 1930s and 1940s, the mortality had dropped to about 20%. Since that time, there has been a gradual, continued decrease to the present overall mortality of approximately ten percent. I t must be stated at the outset that the overriding major sequela of intestinal distension is the occurrence of compromise of the blood supply to the gut. Once this has occurred, the local and systemic effects become much more serious. Analysis of statistical series from many hospitals dramatically demonstrates this fact. As early as 1947, EIiason and Welty3 reported a mortality of only 1 % in cases of intestinal obstruction not complicated by compromise of the blood supply or carcinomatosis. On the other hand, mortality in those instances where gangrenous gut is present is even now in the range of 15-20%, and only recently was reported at 38% by the Milwaukee County General Hospital. Thus, in a discussion of the effects of distension, it is logical to consider distension without ischemia. and distension with ischemia. We shall consider the intestinal tract first.

Role of the basic scientist during the residency program

Abstract The resident in surgery is a graduate student in a correlative science, and should receive some organized course work during the residency. It is generally recognized that most of the major advances in therapy in the present century have been due largely to the judicious application of corresponding advances in the basic medical sciences. With the vast expansion in medical knowledge, it is inevitable that the medical school curriculum will be increasingly oriented toward the development of concept rather than greater content. Thus, much fundamental information necessary for the scientific practice of a specialty and necessary to provide a background for the continued self-education of the specialist should logically be presented during the postdoctoral training period. Not only will the specialized information be more meaningful and more immediately applicable, but such a restructuring will provide for more flexibility in the medical school curriculum. The basic medical scientist has an important role in the educational phase of the postdoctoral program for the development of the specialist. An organized course of instruction devolving from basic biology and oriented toward the particular specialty would appear to be an essential supplement to the clinical program. In addition to providing such an experience for its own house officers, there is a need for the university medical center to supplement programs in selected hospitals in geographic proximity by receiving in rotational assignment certain residents from these institutions for specialized instruction in the fundamental sciences relating to surgery or the surgical specialties. This is a large order but will be necessary for optimal utilization of our intellectual and economic resources. The basic medical scientist has a major responsibility in the development of the surgeon-scientist or teacher-investigator. The growing complexity of the tools and technics in basic science areas which have traditionally contributed to advances in surgery plus the growing necessity for training in depth in basic science areas previously remote from surgery necessitate more than ever before a cooperative interplay between the basic scientist and clinician. The need for expansion in the transmission of fundamental information is clear, and the wall between the two houses of medicine, science and practice, is no longer tolerable.