Robert L. Hewitt

Tracheo-innominate artery erosion: Successful surgical management of a devastating complication.

Successful management of a patient with tracheo-innominate artery erosion requires the rapid institution of specific resuscitative and operative measures. Ten patients seen at the Charity Hospital of Louisiana in New Orleans and 127 documented cases from the world literature were analyzed regarding predisposing factors, diagnostic features, resuscitative measures and operative treatment. Diagnoses associated with abnormal neck positioning were seen in 48% of patients with tracheo-innominate erosions. In 69% of 96 instances, the site of erosion was located at the cannula end and implicates excessive anterior pressure. Caution is recommended in those patients with abnormal neck positions, low placed tracheostomy stomas and individuals with asthenic habitus. Resuscitative measures were highly successful when the tracheal balloon was inflated or when the method of retrosternal finger pressure was used. All personnel providing care for patients with tracheostomies should be aware of the initial measure of balloon inflation. Operative measures which permanently interrupted the innominate artery in the area of possible future erosion were the most successful. Of the 22 cases in which the innominate artery was sacrificed, only one had evidence of cerebral ischemia. Timely institution of proper measures can result in salvage of an unexpected number of these otherwise dramatic fatalities.

Cardiac contusion: a capricious syndrome.

Cardiac contusions are being recognized with frequency. Among 507 patients with non-penetrating chest injuries, 210 had serial electrocardiograms sufficient to evaluate the heart. Forty-five of these 210 patients (21%) had cardiac contusions. These 45 patients and 3 others who were confirmed to have cardiac contusions at necropsy, comprise the 48 patients in this series. Life-indangering cardiac complications occurred in 14 (29%) of the 48 patients, and 4 patients died. The development of cardiac complications following cardiac contusions appears to have a significant relationship to the presence of shock, hypoxia and to factors related to the severity of multiple injuries. These observations have therapeutic implications in management of patients with cardiac contusions through prevention of hypovolemia and hypoxia and avoidance of fluid overload as well as treatment of specific cardiac complications.

Carcinoid-islet cell tumors of the duodenum: Report of twenty-one cases

Abstract A series of twenty-one carcinoid-islet cell tumors of the duodenum is reported. Eighteen were found at operation, and three were found incidentally at autopsy. Among those patients who came to operation, thirteen had duodenal ulcers, four had polypoid lesions of the duodenum, and one had obstructive jaundice due to an invasive tumor at the ampulla of Vater. Nine patients with duodenal ulcer had evidence of endocrine activity, eight of these had the Zollinger-Ellison syndrome, and one had an elevated level of 5-hydroxyindoleacetic acid in the urine. Six patients had multiple endocrine adenomatosis or evidence of neural ectodermal dysplasia. Seven tumors behaved in a malignant fashion and six of these had endocrine activity. The malignancy of only one tumor could be determined on histologic grounds alone. The remainder were diagnosed by lymph node metastasis or local recurrence. Endocrine activity, mucosal ulceration overlying the tumor, and continued secretion of highly acid gastric contents after excision of the tumor suggested the presence of metastases or multiple tumors. Tumors not associated with a duodenal ulcer were treated by simple excision if they had not metastasized and by pancreaticoduodenectomy if malignant. Tumors associated with an uncomplicated duodenal ulcer were treated by subtotal gastrectomy and excision of the tumor. Although two patients in this series were cured of the Zollinger-Ellison syndrome by partial gastrectomy and excision of the tumor, two patients died after partial gastrectomy. Six of the eight patients with gastrin-producing tumors had either lymph node metastasis or associated pancreatic tumors. For this reason, unless gastrin levels can be shown to fall to normal after resection of a duodenal tumor, we believe total gastrectomy is the procedure of choice in patients with the Zollinger-Ellison syndrome of duodenal origin just as it is with ulcerogenic tumors of the pancreas.

Minute pulmonary chemodectoma

The minute chemodectomas of the lung belong to the paraganglioma group of neoplasms, which include carotid and aortic body tumors. They are frequently multiple, small in size, and are nearly always detected fortuitously on histologic examination of sections of a lung taken from an older patient. They are believed to arise from the normal chemoreceptors of the lung. There is no indication that these small neoplasms are functional. It has been proposed that pulmonary chemodectomas may be induced by pulmonary thromboemboli. This possibility gains some support from an analysis of 10 new cases and a review of 46 cases previously reported.

Iliac vein compression syndrome: Case report and review of the literature

Iliac vein compression syndrome is a clinical condition that occurs as a result of compression of the left iliac vein between the right iliac artery and the fifth lumbar vertebrae. Patients usually have marked edema of the left leg. We report a case of a 16-year-old man who sought medical attention with significant left lower leg edema and four previous episodes of left leg cellulitis. Evaluation demonstrated venous hypertension as a result of left iliac vein compression. The patient underwent surgical correction; his symptoms resolved. Details and management of the case are presented and discussed. A review of the current literature regarding this condition also is included.

Timing of Consent for the Research Use of Surgically Removed Tissue Is Postoperative Consenting Acceptable

Consent by patients to perform surgery (‘surgical consent’) and consent for the research use of residual tissue (‘research consent’) is desirable to respect individual autonomy and human dignity. The need to obtain this research consent lies at the heart of ethical research involving human tissues, but it should be noted that in some jurisdictions and under certain circumstances, it is possible for researchers to obtain a ‘‘waiver of research consent.’’ This may occur if an Institutional Ethics Review Board (IRB) determines that the research use is of minimal risk and it is impractical to obtain the research consent. In the past, documentation of these consents has been conveniently obtained before surgery by the same person using the same form. More recently, however, ethical concerns have forced a separation between the 2 consents so that they are now often obtained by different people using different forms. This raises the possibility of obtaining the research consent postoperatively. Unfortunately, there have been uncertainties regarding this relatively new practice, and this has slowed down its widespread implementation. The current study seeks to clarify the issues and explain why a postoperative informed consent process has distinct advantages in certain circumstances. The points presented herein are based on a listserv discussion among members of the International Society for Biological and Environmental Repositories (ISBER).

Concurrence of anaphylaxis and acute heparin-induced thrombocytopenia in a patient with heparin-induced antibodies

We report the occurrence of acute heparin-induced thrombocytopenia in a patient with anaphylaxis that began immediately after an intravenous bolus dose of unfractionated heparin. This case report is the first to document the concurrence of these 2 reactions to heparin. An abrupt fall in platelet count was documented immediately after the anaphylactic response. Study results for antibodies characteristic of heparin-induced thrombocytopenia were positive in 2 assays: serotonin release assay and heparin platelet factor 4 enzyme-linked immunosorbent assay. The patients antibody was exclusively immunoglobulin G. Any explanation for the relationship between the antibody response observed and the histamine release remains speculative.

Blunt injury to intrahepatic vena cava and hepatic veins with survival.

Abstract Injuries to the intrahepatic vena cava and hepatic veins are extremely lethal, particularly when caused by blunt trauma. Repair of the vena cava and hepatic veins often will require liver resection before adequate exposure can be obtained. To prevent lethal hemorrhage during resection and vascular repair, total vascular isolation of the liver may be necessary. Anoxic injury under these circumstances may be minimized by local hypothermia. The two patients reported here were successfully treated by direct suture of the vascular injuries without hepatic resection; however, vascular isolation was utilized in one patient.

Reactive edema and necrosis after restoration of blood flow in the limb

Abstract A model for study of the extremity having temporary circulatory interruption by a tourniquet and followed by restoration of blood flow has been used to evaluate the possible protective effects of local hypothermia and dexamethasone phosphate to prolonged circulatory arrest in the limb. Adult guinea pigs were consistently observed to develop edema after restoration of arterial flow after 3–4 of hindlimb ischemia. Cooling the limbs to 5–15°C during injury, administration of dexamethasone phosphate prior to or after injury, and a combination of hypothermia and dexamethasone phosphate prior to injury failed to prevent the edema. All animals not protected by hypothermia and observed for more than 24 hours developed necrosis and gangrene of the injured leg. Animals treated with local cooling during injury all survived with viable limbs. Results of this study fail to confirm a protective effect of either local hypothermia or dexamethasone phosphate in preventing the edema after the injury described. However, local hypothermia does consistently prevent necrosis after such injury. The possible clinical application of local hypothermia for limbs subjected to prolonged ischemia deserves further inquiry.

Atherosclerotic Gangrene: Improved Results of Treatment

Advanced atherosclerosis of the lower limb often necessitates major amputation unless arterial flow can be restored. To improve results of treatment on the Tulane Surgical Unit at Charity Hospital, we decided in 1964 to extend indications for restoration of arterial flow to all patients who faced possible loss of a lower limb and who had a patent distal segment of artery to which anastomosis could be made. The general condition of the patient was not held to be a deterrent if operation could be done with use of a local anesthetic.From July 1, 1957 to July 1, 1964, an average of 21 operations was performed each year for restoration of arterial flow to the lower limb: two-thirds for femoropopliteal occlusive disease and one-third for aortoiliac occlusive disease. In contrast, 108 operations were performed from July 1, 1964 to July 1, 1965: three-fourths for femoropopliteal occlusive disease and one-fourth for aortoiliac occlusive disease. The fatality rate for operative restoration of arterial flow to the lower limb was 4.1% for the first seven years and 5.5% for the eighth year.An average of 79 major amputations of the lower limb was done for atherosclerosis each year from 1957 to 1964, whereas only 53 amputations were done during the 1964–1965 period. The annual number of major amputations was thus reduced by 33%. The increased number of digital and transmetatarsal amputations from an average of 22 each year during the period 1957–1964 to 42 during 1964–1965 reflects our increased effort to avoid major amputation. Our recent experience suggests that the criteria for restorative operations in patients faced with loss of limbs may safely be extended and that a positive attitude toward operation for advanced atherosclerosis will result in preservation of more limbs.