Raymond C. Read

Vascular Effects of Hypertonic Solutions

During the course of an investigation into the treatment of metabolic acidosis arising from total body perfusion, it was noticed that the intra-arterial administration of concentrated alkalies resulted in a fall in arteriovenous pressure difference at constant flow. A similar decline in peripheral resistance could be produced by hypertonic sugar and salt solutions. This response was found to be independent of the central nervous system. The role of the vasodilatation in the complex vasomotor reaction to the rapid intravenous injection of hyperosmotic agents was then investigated in the intact and vagotomized dog. It was found that when concentrations of up to 1,500 mOsm./L. were used, the predominant response was a delayed hypotension consistent with peripheral vasodilatation. This reaction was complicated by preliminary pulmonary hypertension when solutions containing more than 2,000 mOsm./L. were administered. Twenty per cent NaCl produced such a severe initial phase that the animals frequently died from acute cor pulmonale. The site of obstruction to blood flow through the lungs was variable. Fifty percent glucose could incite pulmonary hypertension, but urea was anomalous in that it was never observed to produce pulmonary vascular effects. Studies in the isolated perfused lung indicated that, again with the exception of urea, all solutions with an osmolarity equal or greater than 5 per cent NaCl evoked pulmonary hypertension. The increase in pulmonary vascular resistance was transitory in spite of recirculation. No response could be elicited when red cells were absent from the perfusate even though, under these conditions, the lung was still sensitive to serotonin. Microscopic examination of the circulation through the brain, lung, mesentery and thigh of both cat and dog demonstrated that intravascular red-cell agglutination occurred after regional arterial injection of highly concentrated salt and sugar solutions. This alteration in the stability of the red-cell stream is considered to be responsible for the obstructive effects of hyperosmotic agents previously attributed to vasospasm.

Metastatic emphysema a mechanism for acquiring inguinal herniation

Since our previous work had indicated that veterans with inguinal herniation demonstrated qualitative and quantitative changes in connective tissue, we tested the hypothesis that a possible mechanism for the defect was chronic exposure to circulating proteases generated in the lung by cigarette smoke. We investigated 59 men (average age: 60 years) with either primary direct or indirect hernias. Most of the patients smoked. Circulating serum elastolytic activity was significantly greater in patients with direct hernias who smoked when compared with controls (p ≤ 0.001). In addition, the serum alpha-1-antitrypsin inhibitory capacity was significantly lower in this category than controls (p ≤ 0.001). Patients with indirect defects who smoked also had significantly higher elastolytic values but to a lesser degree (p ≤ 0.01). Serum antiprotease and protein concentrations were within the normal range in all categories. Our results indicate that an imbalance between blood proteases and antiproteases, resulting from chronic smoking can damage connective tissue in the groin as well as the lung

Defective collagen synthesis in inguinal herniation

Abstract 1. 1. Fibroblastic cell cultures were derived from the anterior rectus sheath of one control patient, two men with indirect, and three with direct inguinal herniation. The rates of cell proliferation were studied up to thirty-nine days. The results obtained through regression equations indicated that the rate of cell proliferation is decreased among cells derived from patients with herniation as compared to that of a control. The order of decrease corresponded to the type of herniation. The average generation time was about one and a half times longer for cells obtained from herniated tissue as compared to that of normal cells. 2. 2. In vitro studies pertaining to the rates of incorporation of radioactively-labeled proline into the anterior rectus sheath of patients with and without herniation revealed that the incorporation of proline was significantly lower in the rectus sheath from patients with hernias as compared to that of normal tissue. The least incorporation was observed in direct herniation. 3. 3. From these observations it is suggested that the cause of herniation in the adult lies in a reduced collagen synthesis by the fibroblasts, thus rendering the abdominal aponeuroses weaker.

Carotid-subclavian bypass: A twenty-two–year experience

PURPOSE A retrospective review of 124 patients who underwent carotid-subclavian bypass from 1968 to 1990 was done to assess primary patency and symptom resolution. METHODS Preoperative data included age, atherosclerosis risk factors, and indications for surgery. Perioperative data included mortality and morbidity rates and graft conduit. Postoperative follow-up assessed graft patency, resolution of symptoms, and late survival. RESULTS Age ranged from 42 to 78 years (mean 57.9). Indications for surgery were vertebrobasilar insufficiency in 24 (19%), extremity ischemia (EI) in 33 (27%), transient ischemic attacks (TIAs) in 13 (11%), both vertebrobasilar insufficiency and EI in 31 (25%), and both TIAs and EI in 23 (18%) patients. Graft conduits were polytetrafluoroethylene in 44 (35%) and Dacron in 80 (65%) cases. Concomitant ipsilateral carotid endarterectomy was done in 32 (26%) patients. During operation, death occurred in one patient (0.8%), and complications occurred in 10 (8%) patients. Thirty-day primary patency and symptom-free survival rates were 100%. Long-term follow-up ranging from 5 to 164 months was available for the 60 cases done between 1975 and 1990. Three grafts occluded at 30, 36, and 51 months after surgery for a primary patency rate of 95% at 5 and 10 years. Twenty-two patients died, yielding survival rates of 83% at 5 years and 59% at 10 years. Symptom recurrence occurred in six (10%) patients from 9 to 66 months after surgery. The symptom-free survival rate was 98% at 1 year, 90% at 5 years, and 87% at 10 years. Symptoms recurred in three patients with occluded grafts and three with patent grafts. The preoperative symptoms of drop attacks and TIAs did not recur. EI recurred in 5% and was noted only in the presence of graft occlusion. Dizziness recurred in 17% of patients admitted with this symptom and was observed despite graft patency. CONCLUSION Carotid-subclavian bypass was a safe and durable procedure for relief of symptomatic occlusive disease of the subclavian artery. Long-term symptomatic relief appeared particularly likely in patients with drop attacks or upper extremity ischemia.

Postoperative necrotizing fasciitis of the abdominal wall

Abstract Postoperative necrotizing fasciitis of the abdominal wall is usually caused by peritonitis in patients who have undergone multiple procedures for complications of emergency laparotomy. Better patient survival may be achieved by the following method: thorough peritoneal exploration to drain abscesses, excision of necrotic fascia, temporary Marlex placement, and delayed closure of the wound with skin flaps.

Collagen Deficiency in Rectus Sheath of Patients with Inguinal Herniation

Summary Chemical composition of rectus sheath from normal, and indirect and direct inguinal hernia patients has indicated that in inguinal hernia the rectus sheath contains decreased amount of collagen as compared to controls. Total hexose, uronic acid, and hexosamine were not significantly altered.

Systemic effects of smoking

Abstract Millions of people continue to smoke. Recent studies confirm the pioneering epidemiologic data that indicated that, despite the well-established effects on the lung, most of the hundreds of thousands of premature deaths annually result from extrapulmonary toxicity, particularly accelerated cardiac and vascular disease. As with lung cancer, abstention significantly reduces the risk, even after myocardial infarction or surgery for complications of vascular disease. Erythrocytosis, thrombocytosis, and leukocytosis, by increasing blood viscosity, aggravate ischemia. The neutrophils of smokers release excessive amounts of oxidants which damage tissue and antiproteases. Increased alveolar permeability enhances allergy. Lymphocytic suppressor cells increase, which leads to immunocompetence, increased infection, and cancer. Smokers lose weight and die at an earlier age, even after cancer chemotherapy and peptic ulcer surgery. Smoking prevents inhibition of gastric night acid secretion by histamine-blocking agents. Menopause occurs earlier and children are damaged in utero and after birth by passive smoking. Recent evidence indicates that nicotine releases endorphins, which account for the addiction. Surgeons need to do more to combat this menace. Many victims need professional assistance to stop the habit.

Arterial embolectomy in the leg. Results in a referral hospital.

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.

Surgical injury of the common bile duct

Review of our experience with twenty-two bile duct injuries and the literature leads us to the following conclusions: (1) Most biliary strictures follow surgery and can be avoided by adequate exposure, accurate dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. (2) Injuries diagnosed at the time of surgery should be repaired by end-to-end anastomosis over a T tube if length is adequate or by Roux-en-Y choledochojejunostomy if length is inadequate. (3) The diagnosis of biliary injury should be suspected when jaundice, biliary fistula, or cholangitis occur in the postoperative period. (4) IVC, PTC, ERCP, or fistulography should be used when possible to delineate the site of injury or stricture and assist in planning the operative repair. (5) Surgery should be performed as soon as the diagnosis is made and the patient is in satisfactory condition for operation. (6) Early reoperation may be necessary to establish drainage and prepare for a later definitive procedure. In some cases, definitive repair can be performed this time. (7) Most late strictures should be repaired with a choledochojejunostomy to a defunctionalized limb of jejunum when resection and primary end-to-end repair cannot be accomplished.

Bilaterality and the prosthetic repair of large recurrent inguinal hernias.

From 1966 to 1977, 396 men aged 25 to 89 years (mean 58) underwent 505 repairs for recurrent inguinal herniation (including bilateral defects and recurrences). Since by 1972 it was realized that the approach precluded an effective relaxing incision, when this was indicated (66 per cent) a Marlex prosthesis was used. Seventy-four patients underwent 83 repairs with this material; 26 (35 per cent) had had previous repairs for recurrence, 29 (40 per cent) underwent contralateral herniorrhpahy, whereas another 12 (16 percent) underwent bilateral repair. Fifty-five (2 of 3) protrusions were direct. None of the patients died. Although overall 110 (22 per cent) of the operations failed, only 6 of 83 hernias (7 per cent) in which Marlex was used recurred, with a mean follow-up study of 4 years. It is important to use a large enough piece of plastic and remove attenuated fascia from around the defect. No infection or extrusion occurred. Preperitoneal placement of Marlex is recommended for difficult, repeatedly recurrent inguinal hernias.