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This study compared the histology, biochemistry, and tensile strength of laser-welded and sutured canine venotomies, arteriotomies, and arteriovenous fistulas. Twelve animals had bilateral femoral vessels studied, with one repair (control) closed with interrupted 6-0 polypropylene sutures, and the contralateral repair (experimental) welded with the argon laser. Specimens were examined at weekly intervals from 1 to 4 weeks (four animals for each type of repair), and were evaluated histologically by hematoxylin and eosin, elastin, and trichrome stains; biochemically by the formation of [3H]hydroxyproline as an index of collagen synthesis; and mechanically by tensile strength determinations. At removal, all experimental closures were patent without hematomas, aneurysms, or luminal dilatation. Histologic and biochemical examination and tensile strength determinations suggest that laser welding may be an alternative to sutures for repair of large-diameter venotomies, arteriotomies, and arteriovenous fistulas, as healing is comparable to that seen with suture repairs up to 4 weeks postoperatively.

Unlabelled: Transcutaneous oximetry measurements were performed on 25 limbs in 25 patients with clinical and radiographic nonunion, and compared with data obtained from patients with healed tibia fractures and a control group of nonfractured extremities. A technique of "stress testing" vascular inflow patterns by temporary occlusion of arterial inflow was utilized to accentuate differences in perfusion not apparent at rest between normal limbs and those with inflow impairment. Changes in postocclusive hyperemic response were monitored by changes in transcutaneous oxygen detected by sensors placed over the dorsum of the foot, at the fracture site, over the anterior compartment, and at the chest. No statistically significant differences were found between the control group and the group of united tibia fractures. Analysis of results using the unpaired Student's t-test demonstrated statistically significant differences between the control and nonunion groups at each limb site tested (p less than 0.05). The prolonged oxygen recovery time values found in more than half the limbs with nonunion are consistent with the presence of impaired oxygenation following physiologic stress. The impairment of oxygenation appears to be on a perfusion basis and reflects the limited capacity of many limbs with tibial nonunion to respond to experimental ischemia with immediate compensatory hyperemia., Clinical Relevance: This technique is a feasible method for serially assessing the regional oxygenation of a limb, and substantiates ischemia as a possible factor in the genesis of tibial nonunion.

Hepatic amebic abscess presented as an acute abdominal illness in 71 patients seen at the Harbor-UCLA Medical Center during the past 10 years. Most of the patients were young, Mexican and male, and half had coexistent medical diseases. The correct diagnosis was made by ultrasonography in 27 patients, laparotomy in 6, and radionuclide scan in 38. More than half (38 patients) were diagnosed accurately within 24 hours of admission. Sixty-seven abscesses were located in the right or both lobes; only 4 were limited to the left lobe, all of which had caused perforation. Operative findings in 20 patients were ruptured abscess in 12 and unruptured abscess in 2; abscesses were missed during exploration in 6 patients, one of whom had acute cholecystitis and another, a small bowel infarction. Other complications were intrathoracic rupture in four and intrapericardial rupture in one. Metronidazole was successful as initial drug therapy in 64 patients. Ultrasonographically-guided percutaneous drainage was used as a diagnostic and therapeutic adjunct to management in 15 patients. In a metropolitan population, the surgeon must consider amebic abscess in the evaluation of a febrile patient with right upper quadrant illness. With ultrasonography or radionuclide scanning, he can establish a reliable diagnosis in 24 hours. Although medical therapy is effective, surgery is required in 20 percent of patients for drainage of the ruptured abscess or treatment of a coexistent surgical condition. An unruptured abscess should be sought in an apparently negative exploration. A solitary abscess of the left lobe is rare but has a particular propensity to cause perforation.

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.

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.

Idiopathic (Bell's) facial palsy is a self-limiting, non-life threatening, and spontaneously remitting disorder. The natural history of Bell's palsy is favorable: 84% of 1011 patients with Bell's palsy studied by one investigator recovered satisfactorily without treatment, and no valid clinical trials conducted to date have provided definitive evidence that treatment with steroids or surgery improves upon this figure. The authors studied 273 patients with Bell's palsy to evaluate the prognostic significance of evoked electromyography in predicting the possible benefit of transmastoid facial nerve surgical decompression. The results indicated that even when evoked electromyography was used to select those patients who might benefit most from transmastoid surgery, outcome in patients treated surgically was no better than can be expected to occur without treatment. Based upon these observations, transmastoid facial nerve surgery is not recommended to treat Bell's palsy because no benefits have been identified which outweigh the risks of surgery.