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Biomedical subjects

H M Cryer

Publications and source records attributed to H M Cryer.

At least 19 recordsLinked to original sources
PubMed1993

Endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.

OBJECTIVE: This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations. SUMMARY BACKGROUND DATA: Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting. METHODS: During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications. RESULTS: Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%. CONCLUSIONS: The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.

Adolescent↗
PubMed1993

Long term outcome of blunt trauma care in the elderly.

Ninety-four consecutive elderly patients with blunt trauma injuries were studied to determine what impact advanced age had on patient outcome. The current study included patients ranging from 65 to 100 years of age who were admitted to our service from July 1986 to December 1988. Follow-up evaluation was conducted on all patients one to three years after the patient was discharged from the hospital. Seventy-six of the patients were injured as a result of automobile related accidents and 18 were injured as a result of a fall. Fifty-six of the 94 patients required admission to the intensive care unit. There was an average of 3.4 operations per patient in this group. Twelve of the 94 patients died; six within the first 48 hours of hospitalization. More than 70 percent of the survivors were able to function independently after discharge from the hospital. Twelve of the 22 patients who required institutional care after discharge from the hospital were eventually able to return home. A prolonged stay in intensive care was not associated with an unfavorable long term outlook. This high hospital survival rate (87 percent) and percentage of patients living independently at home after hospitalization (87 percent) suggests that the expenditure of extensive resources for the care of the elderly trauma patient is worthwhile.

Age Factors↗
PubMed1992

EDRF as a possible mediator of sepsis-induced arteriolar dilation in skeletal muscle.

Vascular endothelial cells influence microvessel diameters in vivo and in vitro and participate in host-defense mechanisms during sepsis. We examined whether small arteriole dilation in skeletal muscle during high cardiac output bacteremia (HOB) and low cardiac output live Escherichia coli sepsis (LOS) is mediated by an endothelium-derived relaxing factor (EDRF). Local chemical blockade of EDRF by hydroquinone (HQ) substantially blunted acetylcholine-induced dilation of small arterioles. HQ also prevented large arteriole (55-135 microns) constriction and small arteriole (6-22 microns) dilation in the cremaster muscle of rats during HOB. In LOS, small arteriole dilation was also prevented by HQ but only during the early period when blood pressure was unchanged from baseline. HQ did not alter large arteriole constriction during LOS. We conclude that small arteriole vasodilation in skeletal muscle is mediated at least in part by EDRF during bacteremia. Because EDRF cannot mediate large arteriole constriction and because HQ blunted large arteriole constriction during HOB, we now suspect that HQ also interferes at least in part with some large arteriole vasoconstrictor mechanism, possibly leukotrienes or an endothelium-derived constricting factor, which mediates large arteriole constriction during HOB. Our data also suggest that large arteriole constriction during LOS is partly mediated by factors that are unaffected by HQ. The endothelium appears to play an important role in the microcirculatory responses of skeletal muscle to live E. coli sepsis through more than one mechanism.

Acetylcholine↗
PubMed1991

Nonthermal surgical complications in burn patients.

Patients with severe burn injuries are generally admitted to specialized units and managed by physicians who specialize in burn care. Complications requiring operative intervention and not directly related to the burn wound occur frequently but are easily overlooked. To determine the nature and frequency of these complications, we conducted a retrospective study of all burn cases in our burn unit over a 5-year period. Twenty-three of the 309 patients (7%) had 45 complications not related directly to the burn wound and required surgical intervention or consultation. The population with surgical complications was generally older (52 vs 42 years), more severely burned (36% vs 25% total body surface area), and had a higher mortality (44% vs 13%). Sixteen of the 23 patients with complications had a single surgical problem, while seven patients sustained multiple complications. In six of the 10 deaths, the surgical complication was believed to be either directly related or significantly contributory to the cause of death. Because the number of burn patients requiring surgical intervention is high, burn patients must be thoroughly examined for possible complications.

Adult↗
PubMed1991

The influence of the cyclosporine vehicle, cremophor EL, on renal microvascular blood flow in the rat.

Cyclosporine nephrotoxicity may be due to glomerular hypoperfusion. Previous experimental and clinical studies have demonstrated a decrease in renal blood flow and an increase in renal vascular resistance. Cremophor EL, which is the vehicle in which CsA is dissolved, is thought to be a factor involved in intrarenal arteriolar vasoconstriction. To determine the relative contributions of the vehicle and CsA to intrarenal arteriolar vasoconstriction, we used in vivo videomicroscopy and Doppler velocimetry to measure changes in renal microvascular blood flow in the rat. A 5-min intravenous infusion of 20 mg/kg of CsA resulted in a 17% mean reduction (P less than 0.05) in the diameter of preglomerular interlobular arterioles and an associated 60% reduction (P less than 0.05) in microvascular blood flow by 15 min. Cremophor EL/ethanol equivalent caused less vasoconstriction (up to 10%) but resulted in a 42% mean decrease (P less than 0.05) in microvascular blood flow, probably secondary to a 38% mean decrease (P less than 0.05) in cardiac output and 13% decrease in arterial pressure. We conclude that cremophor EL does contribute to in vivo reduction of preglomerular microvascular blood flow in the rat. This may be particularly important when using this intravenous preparation in the study of CsA nephrotoxicity.

Animals↗
PubMed1990

A prospective, randomized comparison between open and closed peritoneal lavage techniques.

We randomized 327 blunt trauma patients to compare the open peritoneal lavage technique with the percutaneous (Seldinger wire) technique. The open and closed lavage groups were similar with respect to accuracy and safety. There were one complication in the percutaneous group and two in patients treated by the open method. The incidence of positive lavage was similar in each group. There was one false positive in the percutaneous group and none in the open method group. False negative results did not occur by either method. The percutaneous lavage method required less time for performance, had better patient tolerance, and only required one surgeon to perform the procedure. Percutaneous diagnostic peritoneal lavage (DPL), in the hands of trauma surgeons, is a safe and acceptable alternative to the open DPL method and actually had several advantages as mentioned above.

Abdominal Injuries↗
PubMed1990

The management of penetrating pelvic trauma.

Eighty-nine patients with penetrating pelvic trauma were treated during a three-year period. Sixty-three of 72 patients who had mandatory exploration had findings at operation. The negative laparotomy rate was higher for patients with posterior penetrations (40%). Diagnostic peritoneal lavage, sigmoidoscopy, and intravenous pyelography were useful adjunctive tests to confirm the lack of need for exploration in patients with negative physical findings. This protocol of tests was particularly useful for patients with posterior sites of injury. Patients with injury to multiple organ systems had a higher rate of infectious complications (48%) than those with single system injury (11% complication rate). Primary repair of colon, urologic and vascular injuries was safe even in patients with injury to multiple organ systems.

Adolescent↗
PubMed1989

Pelvic fracture hemorrhage. Priorities in management.

Hemorrhage remains the leading cause of mortality in patients with severe pelvic fractures. To evaluate diagnostic and treatment priorities for this problem, we retrospectively reviewed 245 consecutive patients admitted to our institution with pelvic fractures. Supraumbilical diagnostic peritoneal lavage (DPL) was grossly positive in 27 patients, and eight (30%) of these had life-threatening intra-abdominal hemorrhage identified at laparotomy. No patient with a positive DPL by count alone had life-threatening intra-abdominal hemorrhage. Pelvic fracture stabilization with early external pelvic fixation was associated with less requirement for blood transfusion (10 +/- 1 U) than with the pneumatic antishock garment (17 +/- 3 U). Nine patients with pelvic arterial injuries underwent angiographic embolization, and eight patients died (89%). We conclude that pelvic angiography should be performed before laparotomy in hemodynamically unstable patients with pelvic fracture, unless the DPL is grossly positive.

Abdomen↗
PubMed1989

Hypertension alters microvascular responses in skeletal muscle to hyperdynamic bacteremia and hypodynamic Escherichia coli sepsis.

Altered vascular reactivity to numerous vasoactive substances in hypertension formed the basis for studying the in vivo microcirculation of skeletal muscle tissue during high cardiac output bacteremia and low cardiac output sepsis. Large and small arteriole and venule diameters of the cremaster muscle were measured via videomicroscopy in normotensive and 1K-1C-renovascular hypertensive rats before and after the infusion of live Escherichia coli bacteria. During hyperdynamic bacteremia and during hypodynamic sepsis, large arterioles constricted and small arterioles dilated in normotensive animals. During hyperdynamic bacteremia, this differential arteriolar response was blunted in hypertension. In hypodynamic sepsis, large arterioles did constrict in the hypertensive animals, but small arteriolar dilation was still blunted. Sodium-nitroprusside, a postreceptor acting agent applied locally, maximally dilated small arterioles to the same level in all groups to indicate that the ability of vascular smooth muscle to relax is intact in hypertension. We conclude that the failure of the small arterioles to dilate during sepsis in hypertension is not due to a loss of vascular smooth muscle function, but that hypertension may functionally alter arteriolar reactivity at the receptor and/or endothelial level to interfere with E. coli-mediated responses in the skeletal muscle microvasculature.

Animals↗
PubMed1989

Negative findings on laparotomy for trauma.

A retrospective review of 428 exploratory laparotomies for trauma included 199 patients with blunt trauma, 96 with gunshot wounds, and 133 with stab wounds. In the blunt trauma group, 16 laparotomies (8%) showed no injury and 24 (12%) showed that no repair was needed. Physical examination (68 cases) and diagnostic peritoneal lavage (DPL) (121) were used as the primary indication for laparotomy. In the stab wound group, there was a high incidence of negative or nontherapeutic operation when proximity to the abdomen or deep fascial penetration was the indication for operation. Patients sustaining gunshot wounds had a 27% incidence of negative laparotomy, with proximity being the primary indication for operation. Two deaths in the negative laparotomy group occurred due to associated injuries. Complications were minimal. DPL has decreased the number of negative operations but has increased the nontherapeutic operations. The high incidence of negative laparotomy for stab wounds shows the need for selective management rather than routine exploration.

Abdominal Injuries↗
PubMed1989

Hypoperfusion of the intestinal microcirculation without decreased cardiac output during live Escherichia coli sepsis in rats.

In order to determine the intestinal microvascular responses to normotensive, high cardiac output (CO) bacteremia, we measured vascular diameters and blood flow at different levels of the intestinal microcirculation during live E. coli bacteremia in male Sprague-Dawley rats (n = 16). Precollicular brainstem transection was used to allow study free of drug anesthesia. The microcirculation of a loop of small intestine (with intact neurovascular connections) was observed by in vivo video microscopy and optical Doppler velocimetry at a magnification of x1,500. Intraluminal microvessel diameters and red cell velocity were measured in successive branches until the vessel entered a villus. CO was measured by transpulmonary thermodilution. Intravenous infusion of 1 x 10(9) live E. coli caused a 20% increase in CO at 50 min and a 14% decrease in systemic vascular resistance. However, microvascular blood flow to the small intestine decreased by 27% at 1 hr and by 56% at 2 hr. Progressive arteriolar constriction (25-50%, P less than .05) occurred at all levels of the intestinal microcirculation. These data indicate that intestinal hypoperfusion caused by arteriolar constriction occurs during high CO bacteremia. This hypoperfusion could contribute to mucosal injury and intestinal mucosal barrier dysfunction during sepsis.

Animals↗
PubMed1989

Role of the microcirculation to skeletal muscle during shock.

Our laboratory has performed a number of experiments to outline the role of the skeletal muscle microcirculation during hemorrhage and sepsis. We have suggested that the transition from the compensated to decompensated state in hemorrhagic shock could be attributed to the loss of vascular smooth muscle tone in small precapillary arterioles. This loss of tone is not due to a decrease in vascular smooth muscle reactivity to norepinephrine. However, tissue acidosis which is a uniform finding in the shock state contributes to this loss of vascular smooth muscle tone in large arterioles but not in small arterioles. The skeletal muscle responses to hyperdynamic sepsis were a mild constriction of large arterioles with a marked dilation of small vessels. It is this latter dilation which contributes to decreased systemic vascular resistance in sepsis. The microvessels reacted similarly in the hypodynamic septic state and do not appear to be responsible for the transition from the hyper- to the hypodynamic state in sepsis. The marked constrictor influence of large vessels seen in hemorrhage were not present in sepsis, indicating a possible vasodilator influence or loss of vasoconstrictor reactivity during sepsis but not hemorrhage. Similar findings were noted in both hyper- and hypodynamic endotoxemia suggesting that the energy metabolism effect of high dose endotoxin does not play a major role in skeletal muscle microvascular responses. Overall skeletal muscle vascular tone is due to a balance of vasoconstrictor influences that predominate in large arterioles which appear to be mediated by adrenergic nerve activity and vasodilator influences in small arterioles which are due to an escape from adrenergic nerve activity along with activation of local control factors by mediators of the inflammatory process, such as complement. The initial vasodilator response appears to be mediated by release of EDRF from the endothelial cell. Prostaglandins but not histamine or serotonin appear to be important in the initiation of vasodilation in small arterioles and in the modulation of existing vasoconstricting influences.

Acidosis↗
PubMed1989

Differential response of the microvasculature in the liver during bacteremia.

To determine the initial hepatic microvascular responses to bacteremia, male Sprague-Dawley rats (n = 19) were decerebrated and the left liver lobe from each animal exteriorized and suffused with environmentally controlled Krebs solution. Direct in vivo videomicroscopy was used to measure diameter changes in at least four portal venules (PV) and four proximal periportal sinusoids (PS) at the inlet of hepatic lobules in each of seven livers or four terminal centrilobular sinusoids (CS) and four collecting central venules (CV) at the outlet in each of 12 livers during a baseline period and for 2 hr after intravenous (i.v.) infusion of 1 X 10(9) live Escherichia coli or saline (control). Cardiac output, systemic arterial blood pressure, and body temperature were monitored continuously during the experiments. These data indicate that E. coli bacteremia causes a redistribution of hepatic microvascular blood flow within the liver lobule at both the inlet and outlet regions with increased perfusion of certain microvascular segments and decreased perfusion of others. In the areas observed, a 2:1 dilated/constricted microvessel ratio suggests an initial increased overall liver blood flow within the first 2 hr of experimentally induced bacteremia.

Animals↗
PubMed1989

Role of CT in diagnosis of major arterial injury after blunt thoracic trauma.

The role of computed tomography (CT) in the diagnosis of blunt thoracic vascular injury is controversial. Several recent reports have advocated the use of CT to exclude aortic and major branch injuries in hemodynamically stable patients with blunt trauma. This approach potentially avoids invasive angiography and unnecessary treatment delays in multiply injured patients but risks missed aortic transections if the CT or its interpretation is not accurate. We prospectively evaluated 153 consecutive trauma patients in whom we suspected blunt aortic injury between September 1985 and August 1988. All hemodynamically stable patients underwent contrast-enhanced chest CT followed by immediate aortic arch angiography. Forty-nine unstable patients underwent immediate angiography without chest CT, and 11 (22%) had major thoracic arterial injuries. Data from the remaining 104 stable patients indicate that the sensitivity of chest CT for diagnosis of major thoracic injury is 55%; specificity, 65%. If the chest CT had been used as a screening modality to perform aortic angiography, two transected aortas and three major aortic branch injuries would have been missed. We conclude that chest CT has no screening role in the evaluation of blunt trauma patients with possible major vascular injury.

Adolescent↗
PubMed1988

Role of muscle microvasculature during hyperdynamic and hypodynamic phases of endotoxin shock in decerebrate rats.

Microcirculatory derangements in skeletal muscle could act to change cardiac output during endotoxemia. To explore this idea, we measured arteriole and venule responses to low-dose and high-dose endotoxemia in the rat cremaster muscle by direct in vivo videomicroscopy. Our data indicate that cardiac output increased in the low-dose group and decreased in the high-dose group. In both animal groups, a differential arteriolar response occurred to give small arteriole dilation and large arteriole constriction while venous diameters did not change. We conclude that: 1) changes in cardiac output during endotoxemia are not related to microvascular responses in skeletal muscle, and 2) the microvascular responses in skeletal muscle could be responsible for the decreased systemic vascular resistance during high cardiac output endotoxemia, but not for the elevated systemic vascular resistance during low cardiac output endotoxemia.

Animals↗
PubMed1988

Prostaglandins maintain renal microvascular blood flow during hyperdynamic bacteremia.

Any beneficial effects of prostaglandin synthesis inhibitors on systemic hemodynamic derangements during sepsis may be offset by the effect of these inhibitors to reduce renal blood flow. To determine the specific role of prostaglandins in maintaining renal perfusion during hyperdynamic live Escherichia coli bacteremia in rats, we used in vivo video-microscopy and optical doppler velocimetry to quantitate changes in renal microvascular blood flow, and to determine if endogenous prostaglandins participate in these responses. E. coli infusions constricted preglomerular arterioles and decreased renal microvascular blood flow in decerebrate animals without drug anesthesia but dilated pre- and postglomerular arterioles in urethane-anesthetized rats. Local inhibition of renal prostaglandin production with mefenamate after E. coli infusion caused renal arteriolar constriction in both groups and decreased renal blood flow to indicate that renal prostaglandin production is an important mechanism for maintenance of renal microvascular blood flow during high cardiac output sepsis.

Animals↗
PubMed1988

Pelvic fracture classification: correlation with hemorrhage.

Hemorrhage remains the leading cause of death in patients with pelvic fractures. To identify patients at greatest risk for massive hemorrhage, we retrospectively reviewed charts and initial emergency room anterior-posterior (AP) radiographs of 245 consecutive patients. Pelvic fractures were classified according to our modification of the Pennel and Sutherland classification scheme. A simple pelvic fracture classification scheme was developed. Using this classification, we can be 90% confident that 50 to 69% of patients with "unstable" pelvic fractures will require 4 or more units of blood, 30 to 49% will require greater than 10 units of blood, 36 to 55% will have an intra-abdominal injury, and 6 to 18% will have a pelvic arterial injury. Therefore we conclude that this pelvic fracture classification based on the initial emergency-room AP X-ray can predict a patient population at high risk for massive hemorrhage for which an aggressive treatment protocol is justified.

Adolescent↗