Biomedical subjects
Publications and source records attributed to A Kitahama.
Patients with extensive lower extremity ulcerations initially thought to be vascular disease were subsequently proved to have pyoderma gangrenosum and malignant lymphoma. Both patients died of sepsis; one patient exhibited hypogammaglobulinemia involving immunoglobulins IgA, IgG, and IgE; in the second patient, a polyclonal excess involving IgA and IgE was present.
The value of a routine intraoperative cholangiogram is controversial. We reviewed 352 consecutive instances of cholecystectomy for nonmalignant disease during a period of three years to assess the diagnostic accuracy and additional cost of the roentgenographic technique. Intraoperative cholangiogram was done in all except 11 patients. Forty-nine of 341 patients underwent exploration of the common bile duct. The diagnosis was determined by the cholangiogram and was correct in 46 patients with three false-positive results. The other 292 patients did well without exploration of the common bile duct. The cholangiocatheter and a special cholangioclamp made the procedure easy and minimized additional operation time (five minutes with no mortality and negligible morbidity). Clinical indications for exploration of the common bile duct correlated poorly with abnormal findings in the bile duct. Unsuspected common duct stones were detected by cholangiogram in 17 (5 per cent) patients. Possible iatrogenic trauma to the common duct was prevented when significant abnormal findings were demonstrated by cholangiogram. The results of this study indicate that routine intraoperative cholangiogram is: accurate for diagnosis of common bile duct stones; useful in identification of bile duct anomalies and, thus, aids in preventing injury to the common bile duct; safe with negligible risk, and neither expensive nor time consuming if done correctly as a routine procedure.
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Glucan, a beta-1,3 polyglucose, was evaluated for its ability to enhance resistance of post-operative mice to experimentally induced C. albicans sepsis. Male C57BL/6J mice were injected i.v. with glucan (0.45 mg/mouse) on days 10,7,4 and 1 prior to midline laparotomy and intravenous challenge with 3 X 10(6) C. albicans. The detrimental effect of surgery on survival following C. albicans infection was manifested by a 47% survival in the non-surgery-infected group in contrast to 20% in the surgery-infected group. Protection against C. albicans was observed in the glucan-treated groups. The glucan-treated non-operated mice manifested 100% survival while the surgery group had a 73% survival. Glucan significantly enhanced macrophage phagocytic function in control and operated mice. Laparotomy alone did not significantly depress macrophage phagocytosis. Histopathological studies revealed that glucan markedly inhibited the renal pathology associated with C. albicans challenge both in the presence and absence of laparotomy. These data indicate that glucan increased survival and reduced renal pathology associated with C. albicans challenge in the post-operative period. These observations suggest that Biologic Response Modifiers such as glucan may be effectively employed in patients who are at risk for post-operative infections.
Since modern surgical stapling instruments have found a wide range of usefulness in gastrointestinal surgery, we have attempted to establish the feasibility of staple rather than suture closure of the transected pancreas. Distal pancreatic resection has been performed in eight dogs utilizing the Auto Suture Model TA-55 surgical staple instrument for primary closure of the transected margin of the remaining pancreas. Serial serum amylase determinations for each of the animals remained within normal range. Each animal was sacrificed one week after the initial surgery with examination of the remaining pancreas. None of the animals demonstrated any evidence of pancreatic fistula or abscess. Similar technique for distal pancreatic resection has been utilized in 12 patients. Five of the resections were performed for malignancies, four for trauma, and three for benign pancreatic disease. In each case, the residual pancreas was closed with the TA-55 surgical staple instrument. Although two patients died during the postoperative period of causes unrelated to the pancreas, none developed either fistula or other evidence of difficulty in healing of the pancreas. It is our conclusion that staple closure of the transected margin of the pancreas is a reasonable and safe alternative to standard suture closure technique.
In a specific indigent socioeconomic setting, the nonsurgical management of 65 patients with chronic leg ulcers resulted in 59 cures. There were 42 patients (67%) with postphlebitic syndrome. Twenty-two patients (33%) had varicose veins (eight had postoperative vein stripping), 14 (22%) had deep-vein thrombosis, and 11 (15%) had associated neurological problems. Fifty-six patients (86%) were treated with pressure dressings that were changed once a week in an outpatient clinic, seven patients wore skintight plaster casts for variable periods of time, and two patients had split thickness skin grafts plus lumbar sympathectomies. In more than two thirds of the patients, the ulcers healed. In another 17 patients (26%), a satisfactory response to treatment was observed. In only six patients did therapy fail. Failures were attributed to the multiple medical and surgical problems of the patients or their lack of cooperation. Nonsurgical treatment of venous stasis ulcer is inexpensive and effective.
Nonsurgical trauma to the extrahepatic biliary tract is being reported with increasing frequency. There has been no recent review of the management of these injuries. Forty patients over the past twelve years at Charity Hospital, New Orleans, were studied. The 10% mortality rate was due to associated injuries. Tangential injuries were best managed by suture closure and T-tube drainage. Biliary-enteric anastomoses were most successful in the treatment of complete transections. Delayed diagnosis is not uncommon, and new methods of diagnosis are discussed. Injuries of this nature are responsible for high morbidity rates due to fistula or stricture formation. Successful management of these injuries is vital, even in those patients with more severe associated injuries.
Expeditious surgical management in serious chest trauma improves survival rates. However, guidelines for emergency thoracotomy that depend on the initial amount of blood loss or continuing blood loss are imprecise and frequently require a period of observation. In an attempt to improve prethoracotomy diagnosis emergency thoracoscopy was used in the operating room in 36 patients who presented with hemothoraces. A diagnostic thoracoscope was inserted through the previously placed incisions for chest tubes. The procedure was well tolerated under local anesthesia and in most patients took less than 15 minutes to complete. No complications resulted from thoracoscopy. When the information obtained did not indicate further operations, the thoracoscope was withdrawn and chest tubes were reinserted through the same incisions. The method provided anatomic definition of the injuries in 35 of 36 patients and allowed the determination of whether blood loss was continuing. Management was altered as a result of thoracoscopy in 16 patients (44.4%). An unnecessary thoracotomy was avoided in 16 patients who had greater than 1,500 ml of blood in the thoracic cavity on admission and allowed a more rapid thoracotomy in one patient. Four patients had wounds located close to the diaphragm and laparotomy was avoided when the diaphragm was found free of injury. Bleeding from lacerated intercostal vessels was stopped with diathermy during thoracoscopy in two of three patients. In addition, 15 patients had 200 ml or more of clotted blood removed. The usefulness of removal of clotted blood remains to be proved but it is hoped that the incidence of empyema will be reduced. Emergency thoracoscopy has proved a valuable diagnostic and therapeutic measure in patients sustaining penetrating chest trauma.
Blunt traumatic injury to the biliary tract is rare, and its management is one of the most difficult and challenging problems confronting surgeons. If disruption occurs in the hepatic ducts, occult ductal injury may even go unnoticed. A high index of suspicion is the single most important factor leading to the identification and successful management of these injuries. A patient with massive upper abdominal injuries secondary to blunt trauma is reported on. Intraoperative cholangiography demonstrated bilateral hepatic duct transection. The injury was successfully managed by Roux-en-Y hepatoportal enterostomy, an approach that has not been previously reported. Primary repair or hepatic cholangiojejunostomy is the treatment of choice for hepatic duct injuries. Hepatoportal enterostomy, however, offers a satisfactory alternative in treatment when the patient is unstable or when primary repair is not possible. The literature is reviewed and the pathogenesis, diagnosis and treatment of nonpenetrating injuries to the biliary tract are discussed.
Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a ten-year period. Ages ranged from 13 to 56 years, and follow-up was up to nine years. Among the 14 patients with bile duct injury, eight were found to have complete transection, and five suffered a tangential laceration or incomplete disruption with a portion of a duct wall remaining intact. Five of the eight patients who had complete transection underwent primary end-to-end repair with T-tube splinting, while three were treated with primary Roux-en-Y choledocojejunostomy. All patients with incomplete disruption underwent primary repair with or without T-tube splinting. Of the five patients with complete disruption who were treated with primary end-to-end anastomosis of the bile duct in conjunction with T-tube splinting, all required secondary biliary tract reconstruction of some type. No patient with complete transection that was treated with primary Roux-en-Y biliary enteric anastomosis required reoperation. Partial transections were successfully treated with primary repair. Portal vein injury was encountered in ten patients. Injury was successfully managed by primary closure, interposition of a vein, or splenicmesenteric vein bypass. Associated injuries to liver, pancreas, kidney and duodenum were common. In four patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.
A soluble fraction of particulate glucan was prepared and evaluated for its anti-tumor and anti-bacterial activity. Thin-layer chromatographic analysis indicated that the soluble preparation was composed of a variety of polyglucoses. Intravenous administration of soluble or particulate glucan resulted in significant reductions in the growth of a syngeneic anaplastic mammary carcinoma and melanoma B16. Survival data demonstrated that intravenous administration of soluble or particulate glucan prolonged survival of A/J and C57BL/6J mice with subcutaneous tumor implants. As regards to bacterial infections, soluble and particulate glucan decreased renal necrosis in S. aureus challenged mice as compared to control mice. Although the exact nature of the active soluble fraction(s) of glucan remains to be delineated, these studies demonstrate that a soluble glucan preparation exhibits significant anti-tumor and anti-staphylococcal activity. The active soluble fraction of particulate glucan may be preferable to particulate glucan in view of the inherent ease of parenteral administration.
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