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We compared the effect of an acute protein depletion versus a sustained protein depletion on pulmonary edema formation. Acute hypoproteinemia was produced either by a rapid plasmapheresis or as the result of acute hemorrhagic shock and resuscitation. Sustained hypoproteinemia was produced by a 24-hour plasmapheresis or as the result of a 50% body burn. Unanesthetized sheep with lung lymph fistulas were used as the experimental model. In the acute depletion groups an early twofold to threefold increase in lymph flow was seen, reflecting an increase in fluid flux, across the microcirculation, with the increase in lymph flow after resuscitation from shock being identical to that seen in a nonshocked animal with a comparable protein depletion. With restoration of the plasma-lymph oncotic gradient, the lymph flow returned to baseline. The lymph protein content always exceeded 2 gm/dl. In the sustained depletion groups the lymph flow also increased twofold to threefold but remained elevated for over 48 hours despite a rapid restoration of plasma-lymph oncotic gradient. The increase in fluid flux after burn was identical to that after protein depletion alone. In these groups the lymph protein content was below 2 gm/dl, indicating a significant interstitial protein depletion. We conclude that a marked increase in fluid flux is seen after sustained protein depletion that is unrelated to oncotic pressure. This process appears to be related to the degree of washout of interstitial protein, possibly decreasing the viscosity of the interstitial matrix, leading to a more rapid edema formation.

This report analyzes experience with a modified four-limb W-shaped ileal pouch that has a larger initial capacity than do J- or S-shaped pouch designs. Fifteen patients (median age: 35 years) underwent W pouch reconstruction after proctocolectomy for ulcerative colitis and familial adenomatous polyposis. Follow-up on each patient averaged 14 months (range: 6 to 24 months). All procedures were performed without death and with minimal morbidity. Assessment of functional results showed 24-hour stool frequency (mean +/- SEM) decreasing from 6.0 +/- 0.39 initially to 4.8 +/- 0.43 at 1 year (p less than 0.005). Night evacuation decreased from 1.1 +/- 0.2 at 1 month after surgery to 0.25 +/- 0.12 at 1 year (p less than 0.025), with 10 of 15 patients having no nocturnal pouch evacuation. Continence was excellent in all patients with the exception of three of 15 patients who had occasional minimal nighttime seepage. Pouch volume determined at surgery by saline solution infusion was 200 +/- 21 ml. Pouch volume and compliance (pressure/volume) were measured before ileostomy closure and at 6 months after surgery via a special pressure-monitored balloon catheter. Maximal pouch volume increased from 190 +/- 21 ml (at time of ileostomy takedown) to 470 +/- 85 ml at 6 months. Ileal reservoir construction with a W pouch design resulted in a low 24-hour and nighttime stool frequency and excellent compliance and evacuation characteristics.

We studied the role of hypoproteinemia, induced by a major burn injury, on the edema process in burned and nonburned tissues including the lung in the adult sheep. We used lymph flow (QL) and the lymph-plasma (L/P) protein ratio as indicators of the rate of fluid and protein flux across the microcirculation and into the interstitium. We compared the response after a full-thickness burn to 30% of total body surface plus resuscitation by means of lactated Ringer's solution (n = 8) with a comparable degree of hypoproteinemia produced by plasmapheresis with vascular hydrostatic pressure and cardiac output kept constant. We measured lung QL and soft tissue (prefemoral) QL from both the burned and nonburned areas. A twofold increase in QL and a decrease in the L/P ratio was seen in both lung and nonburned tissue in both burn and plasmapheresis animals, indicating the postburn response to be due to hypoproteinemia with no increase in protein permeability. The QL in burned tissue was increased five to ten times with an increase in the L/P ratio. Four burned sheep were resuscitated with pooled plasma. Restoration of plasma proteins eliminated the increase in QL in lung and nonburned tissue but had no effect on the burn response. In summary, burn-induced hypoproteinemia plays a major role in the edema process in nonburned tissues and is corrected by restoration of plasma proteins. Edema in burned tissue does not appear to be related to this process.

Over the last 10 years, 26 patients have undergone repair of blunt traumatic diaphragmatic injury. Motor vehicle accidents were the cause in 77 per cent of these cases. The diagnosis was made immediately by chest x-ray in eight of 26 cases, and in ten cases, the diagnosis was made at celiotomy because of other suspected intraabdominal injury. The other eight cases fell into two categories; delayed (diagnosis made within same hospitalization) and late (diagnosis made at subsequent presentation). In many cases in which diaphragmatic injuries were missed or delays in diagnosis occurred, radiologic evidence for possible injury was present on the initial chest x-ray, but the diagnosis was not suspected. Seventy-seven per cent of patients (20 of 26) had associated major injuries (spleen, chest, extremities). The left hemidiaphragm was involved in 19 patients and right diaphragmatic injuries in seven patients. Repair was accomplished in 23 cases transabdominally with a thoracoabdominal extension required in three patients because of severe liver trauma. The three cases in which the diagnosis was delayed had diaphragmatic defects repaired by a transthoracic approach.

During the past 8 years, a total of 36 patients were diagnosed as having either ilioinguinal or genitofemoral neuralgia. A multidisciplinary approach (surgeon, neurologist, anesthesiologist) as well as local blocks of the ilioinguinal nerve or paravertebral blocks of L1,2 were essential to determine which nerve was likely to be entraped. Seventeen of the 19 patients having a diagnosis of ilioinguinal neuralgia after previous inguinal herniorraphy were completely free of pain after resection of the entrapped portion of the nerve. Seventeen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorraphy, blunt abdominal trauma, or another operation. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 12 of 17 of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of operations in the inguinal region. When the diagnosis is made by a multidisciplinary approach, neurectomy is frequently successful in relieving severe pain and paresthesias without serious morbidity.

Resuscitation from major trauma or replacement of major operative blood loss frequently results in varying levels of protein depletion and alterations in plasma volume. To assess the importance of these factors on pulmonary and soft tissue transvascular fluid filtration, we compared the effects of hypoproteinemia and plasma volume expansion on the rate of lung and soft tissue transvascular fluid filtration in unanesthetized adult sheep. Ten animals were surgically prepared with chronic lung and soft tissue lymph fistulas. Lung (QL) and soft tissue (Qs) lymph flow rates were used to determine changes in transvascular fluid filtration. Initially, lactated Ringer's solution (LR) was infused to elevate pulmonary arterial wedge pressure of normoproteinemic animals (Norm/LR) 5 mm Hg for 2 1/2 hours. After a plasmapheresis-induced protein depletion of 30% to 35%, similar volume expansions with LR (Hypo/LR) and fresh frozen plasma (Hypo/Plas) were performed. Plasma, lung lymph, and soft tissue lymph oncotic pressures were determined, and transvascular oncotic gradients were calculated. Plasma volume expansion during Hypo/Plas conditions limited (p less than or equal to 0.05, 3 hours after infusion) Qs elevations compared with Hypo/LR expansion. However, there appeared to be no significant advantage with fresh frozen plasma over LR infusion in limiting QL. During fresh frozen plasma infusion, a distinct 10- to 12-hour lag in protein transport into the interstitium was observed in the soft tissue but not the lung microcirculation. The resultant differences in fluid filtration properties were in part the result of significant widening of the oncotic gradient in soft tissue. Plasma protein infusion appeared not to be beneficial over LR in limiting lung transvascular fluid filtration during hypoproteinemic states but significantly decreased soft tissue transvascular fluid flux.