Russell A. Williams

Chylous Ascites Following Abdominal Aortic Surgery

Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided.

Computed tomography-assisted management of splenic trauma

BACKGROUNDnIn patients who have suffered an injury to the spleen, preservation of the organ is of the utmost importance. To assist in management, contrast-enhanced computed tomography (CT) has been used. We reviewed our experience with a protocol for nonoperative management of splenic trauma based on CT grading of the injury.nnnMETHODSnDuring the initial period of the study, 50 CT examinations for blunt abdominal trauma in adults were reviewed by staff radiologists for evidence of splenic injury. The radiologists, blinded to clinical management decisions, graded the CT studies as A if there was a subcapsular hematoma or capsular disruption, B if there was a parenchymal injury not extending into the hilum, or C if there was deep laceration of fracture of the hilum. Following confirmation of the accuracy and reproducibility of the grading scale, the splenic trauma management protocol was instituted, in which nonhilar injuries were managed nonoperatively.nnnRESULTSnIn the initial assessment, patients managed nonoperatively had shorter hospital stays and received fewer blood transfusions than those undergoing operation. Among 30 patients subsequently enrolled in the protocol, those treated nonoperatively remained in the hospital for fewer days than those treated surgically. Again, fewer units of blood and platelets were used in the nonoperative group. Institution of the protocol decreased the incidence of celiotomy.nnnCONCLUSIONSnThe severity of splenic trauma evident on CT staging guides safe nonoperative management. Patients not suffering injury to the splenic hilum (A and B scores) can be managed without operation, resulting in shorter hospital stays and fewer blood products used.

Current Status of Vascular Access Techniques

The authors describe in detail vascular access techniques that have proved to be most useful to them in a variety of situations, including total parenteral nutrition, dialysis, cancer chemotherapy and chronic intravenous medication, and plasmapheresis.

Analysis of the morbidity, mortality, and cost of colostomy closure in traumatic compared with nontraumatic colorectal diseases

One hundred sixteen patients with acute colorectal diseases, operated upon emergently and needing an intestinal stoma, were reviewed to determine the cost and morbidity of treatment of patients with colorectal trauma compared to other surgical illnesses. The first group (57 patients) had perforating colonic or rectal trauma, the second (30 patients) perforated colonic disease, the third (24 patients) nonperforated colonic disease, and the fourth (five patients) a colonic injury, unrecognized initially but requiring subsequent treatment with a stoma. For the initial operation, hospital stay, complications, mortality, and costs were less for patients in group 1 (colonic injury) than in groups 2 and 3 (inflammatory or neoplastic diseases). Colostomy closure, whatever the antecedent disease or injury, required an average ten-day hospitalization, had no mortality, a complication rate of 0 to 6 percent, and an average hospital cost of

Thiry-Vella segments applied to ischemic colon studies.

6,500. The hospital stay and costs for the total treatment were slightly higher for nontraumatic illnesses, although the rate of colostomy closure was significantly less (68 and 77 percent versus 86 percent,P=.05).

Radioxenon washout for the diagnosis of low-flow mesenteric ischemia

Abstract A method for producing an isolated ischemic dog colon segment which allows long-term survival of the animal is outlined. The colostomy of this loop permits access to the mucosa of the segment for repeated observation, tissue sampling, and measurement of submucosal blood flow using submucosal injection of radioxenon. These studies indicate there is a return of mucosal blood flow toward normal in the 96 hr following production of ischemia, but the histology of this segment shows persistence of the submucosal hemorrhage, edema, and mucosal ulceration, up to that time. The measurements in any animal or group of animals are reproducible.

Serologic Markers for Ebolavirus Among Healthcare Workers in the Democratic Republic of the Congo.

Abstract Angiogram is accepted as one of the investigations necessary to establish the diagnosis of acute mesenteric ischemia. Unfortunately, the changes seen in the mesenteric arteriogram of patients with low-flow intestinal ischemia are not always clear and easily interpreted. In this study the washout of an intraarterial injection of radioxenon (133Xe), from nonocclusive ischemic bowel, was recorded to determine if it might aid in the diagnosis of low-flow ischemia. For these investigations, a model of low-flow mesenteric ischemia was produced by infusion of noradrenalin into the dogs superior mesenteric artery (SMA). Under experimental conditions of normal and low mesenteric blood flow, the percentage disappearance at 2 min (washout), from the bowel, of a bolus intraarterial (SMA) injection of radioxenon was recorded to determine if this gave a measure of the intestinal blood flow. It was found that Xe washout and the corresponding SMA blood flow, measured with an electromagnetic flow probe, correlated well in the normal and nonocclusive ischemic bowel (r = 0.924). Measurement of the washout of an intraarterial injection of 133Xe to the bowel may be a helpful adjunct to arteriogram for the clinical diagnosis of low-flow mesenteric ischemia.

Cadaveric Renal Transplantation: Surgical Results and Expectations in the cyclosporine Era

Healthcare workers in an area with a previous Ebola outbreak in the Democratic Republic of the Congo exhibited both antibody response and neutralizing capacity to at least 1 Ebola protein, despite never having been diagnosed with Ebola virus disease.

ACUTE DIVERTICULITIS: SAFETY AND VALUE OF CONTRAST STUDIES IN PREDICTING NEED FOR OPERATION

During a 36-month period 100 patients received 104 cadaveric renal transplants with cyclosporine-based immunosuppression. Of the patients 26 required 31 additional operations. Of the 19 secondary operations performed 1 month after transplantation 18 were emergency in nature, whereas beyond this period the majority of the procedures were elective. Both deaths in this series were related to the operation. Only 1 graft loss was directly attributed to a secondary operation. The patient undergoing cadaveric renal transplantation is at significant risk (25 per cent) of requiring at least 1 additional operation. However, despite this high probability of reoperation, graft loss and patient death after such procedures should be rare.