Warren C. Widrich

Control of bleeding varices by vasopressin: a prospective randomized study.

From July 1975 to November 1976 25 patients with bleeding esophagogastric varices documented by endoscopy who failed to respond to conservative medical treatment were transferred to the Surgical Service. These patients, who were mainly Childs Class “C” alcoholic cirrhotic patients, were treated with vasopressin infused continuously using a standardized dose into cither a peripheral vein or the superior mesenteric artery (SMA) according to a predetermined randomization. No significant difference in efficacy for control of bleeding (average rate = 56%) related to route of administration was found. Because catheter-related complications in the SMA group were significantly greater, we concluded that the method of choice in vasopressin treatment of esophagogastric variceal bleeding is a continuous infusion by way of a peripheral vein.

Necrotizing Angiitis in a Methamphetamine User with Hepatitis B — Angiographic Diagnosis, Five-Month Follow-up Results and Localization of Bleeding Site

THE vascular changes of necrotizing angiitis have been demonstrated angiographically in a number of drug users, and the disorder has been putatively linked to methamphetamine sensitivity.1 , 2 Acut...

Endoscopic Pancreatography: An Analysis of the Radiologic Findings in Pancreatitis

The endoscopic pancreaticographic findings in 46 proved cases of pancreatitis are analyzed. Pathologic ductograms were demonstrated in approximately 60%. Significant information was obtained in many cases, allowing both proper diagnosis of the primary disease process and complications thereof. Because of the latter, the procedure has proved to be quite helpful in isolating those patients who could benefit from surgery.

Portal hypertension changes following selective splenorenal shunt surgery. Evaluation by percutaneous transhepatic portal catheterization, venography, and cinefluorography.

Considerable diagnostic data can be gathered by selectively catheterizing the portal vein and the major tributaries of the splanchnic venous system to evaluate pressure and blood flow. Combined with cinefluorography, this is a superior method for demonstrating the anatomy and hemodynamics of portal hypertension as well as the effects of splenorenal shunt surgery. Thirty-one attempts with a 19 gauge trocar in 17 patients resulted in 28 successful portal entries and 24 successful selective catheterizations. Portal vein pressure, flow, and diameter were less after shunting.

The use of intra-arterial lidocaine to control pain due to aortofemoral arteriography.

Intra-arterial lidocaine has been utilized to decrease pain by administration prior to contrast material injections during aortofemoral arteriography in over 600 patients. Because this observation was uncontrolled, a double-blind study was performed in 15 patients comparing the effectiveness of intra-arterial lidocaine and saline in the control of pain from contrast material injections (methylglucamine iothalamate) in pelvic and peripheral arteriography. Two per cent lidocaine was compared with 1% lidocaine in the same manner in an additional 10 patients. Peripheral vein blood samples were obtained in 4 patients to measure the plasma concentration of lidocaine. Intra-arterial lidocaine is safe and effective in reducing pain from intra-arterial contrast agent injections.

Gelfoam and autologous clot embolization: effect on coagulation.

An episode of disseminated intravascular coagulation following therapeutic gelfoam embolization to control bleeding from esophageal varices in a patient with liver disease is presented. We have since followed 13 patients prospectively (six control and seven gelfoam/autologous clot) to determine the effect of this procedure on clotting. We were unable to show significant differences between the two groups as measured by the prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen and platelet count. However, fibrin (ogen) degradation products were significantly elevated (p less than .01) in the gelfoam/autologous clot group. We suspect this occurred secondary to clot lysis at the site of embolization. No subsequent bleeding diathesis attributable to this abnormality occurred in any of the patients.

Cause of wound complications in elderly patients with above-knee amputation

Seventy-six above-knee amputations performed on elderly debilitated patients were reviewed. Fifty-one wounds healed without complications; 25 amputation wounds developed postoperative complications. The quality of the femoral pulse has a significant effect on wound healing after an above-knee amputation. Other significant conditions that appear to influence the frequency of wound complications are hypertension, a failed bypass procedure to the groin, and angiographic evidence of stenosis or occlusion of the common femoral or the profunda femoral artery. Multiple variable analysis suggests a beneficial effect of antibiotics in patients with a diminished or absent femoral pulse. Age, presence of cardiac disease, diabetes, associated diseases and the use of drains have no significant effect on the outcome. Before an above-knee amputation, patients with a diminished femoral pulse should undergo arteriography and perhaps reconstructive surgery. Primary hip disarticulation may be the initial procedure of choice in the presence of multiple risk factors.

Technetium 99m isotope venography

Abstract Technetium 99m isotope venography was performed in 116 extremities. By x-ray contrast venographic confirmation in forty-eight extremities, it was accurate in 92 per cent of the patients with a “definitive” diagnosis of thrombosis and in 78 per cent with normal results of the study. Radioactive transit time from foot to groin was not a statistically reliable parameter for detecting thrombosis. The excellent visualization of the venous system, the ease of performance, and the acceptance by the patient of this relatively simple technic make isotope venography an attractive method for the diagnosis of major venous thrombosis. The indications for isotope venography are: (1) as a diagnostic alternative to x-ray venography; (2) as an improved means of detecting pulmonary embolism when combined with a lung scan; (3) as a simple means of following thrombolytic phenomena in the veins of the lower extremities.

Computed tomographic angiography

Computed tomographic angiography performed by the intravenous administration of contrast medium was evaluated in 86 vascular patients. This experience demonstrates a new approach to the evaluation of patients with symptomatic aortic aneurysms, in whom computed tomographic angiography will aid in evaluating the need for emergency surgery. Nonoperative patients are serially evaluated by computed tomographic angiography to detect significant changes in the geometric configuration of their aneurysms. Computed tomographic angiography was beneficial in the evaluation of the patency of vascular reconstructive procedures such as femoropopliteal bypass, aortoiliac bypass and application of a vena caval device. More clinical experience and possibly a rapid sequence technique are needed to evaluate patients with portasystemic shunts.

Bleeding esophageal varices: treatment with vasopressin, transhepatic embolization and selective splenorenal shunting.

The fate of 359 consecutive alcoholic cirrhotic male patients with bleeding esophageal varices was determined through chart review and personal interview. Three historical periods (1966-70; 1971-75; 1976-80) were defined based on availability of different therapeutic modalities. Management of acutely bleeding varices by conservative, nonsurgical means, including embolization, was preferable to emergency surgery when considering 30-day mortality rates. Percutaneous transhepatic embolization of esophagogastric varices significantly improved the rate of control of hemorrhage and 30-day survival over previously employed nonsurgical methods. The combination of nonsurgical management of acute variceal hemorrhage followed by selective distal splenorenal shunting resulted in maximum salvage of the alcoholic cirrhotic patient.