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• Three cases in which seizure disorder was first noticed were examined in the last seven years; low fasting glucose and high serum insulin levels then led to the diagnosis of severe hypoglycemia secondary to nesidioblastosis. Hypoglycemic episodes were uncontrolled by frequent oral feedings and intravenous administration of dextrose, glucagon, and diazoxide. Within three weeks after diagnosis, all three patients underwent subtotal pancreatectomy; all three survived and have been followed-up for two to seven years. Two remain euglycemic and have no evidence of CNS damage. The third has occasional fasting hypoglycemia that is treated with diazoxide; he continues to have a seizure disorder and is mentally retarded. Neonatal hypoglycemia secondary to hyperinsulinism requires prompt recognition and aggressive treatment to avoid irreversible CNS damage. Subtotal pancreatectomy safely and effectively restores the euglycemic state. ( Arch Surg 115:880-882, 1980)

• Between 1962 and 1986, 51 patients 50 years of age or older (mean, 59.7 years; range, 50 to 77 years) underwent operative closure of atrial septal defect. The mean pulmonary vascular resistance was 1.7 ±0.79 wood units and the mean pulmonary blood flow—systemic blood flow ratio was 2.8 ±1.4. Patch closure with pericardium or Dacron was performed in 36 patients (70%), while 15 patients (30%) underwent primary closure. There were no operative deaths, and one patient was not available for follow-up. The remaining 50 patients (98%) have been followed up for 0.5 to 25 years (mean, 9.6 years). Mean preoperative New York Heart Association classification was 2.40±0.70. This improved significantly to 1.21 ±0.42 at follow-up, with all patients improving by at least one category. No patient received long-term anticoagulation treatment, and no pulmonary or systemic emboli were identified. Two (13%) of 15 patients who underwent primary closure developed septal dehiscence. Actuarial survival was 93%, 86%, and 79% at 5,10, and 15 years, respectively. Atrial septal defect closure can be safely performed in older patients with excellent results, provided the ratio of systemic to pulmonary blood flow is greater than or equal to 1.5 to 1.0, the pulmonary vascular resistance is low, and the shunt remains left to right. Primary closure should be discouraged, and postoperative anticoagulation therapy appears unwarranted. (Arch Surg1988;123:965-967)

BLOOD FLOW through femoropopliteal bypass vein grafts has been measured in a group of patients in an attempt to clarify the interrelationships of flow, angiographic findings, and clinical observations. It was hoped that quantitative blood flow data might provide a reliable prognostic indication for long-range patency. However, we have found that the prognosis must be based on an assessment of multiple factors rather than on any single test or observation. Clinical Material Blood flow was measured in 29 femoropopliteal autogenous vein bypass grafts in 26 patients undergoing operation for occlusive disease in the lower extremities ("legs") (Table 1). The indication for operation was claudication in 15 instances, rest pain in three, gangrene in nine, and diffuse aneurysmal change in two. The proximal anastomosis was in the popliteal artery proximal to the joint space in 19 legs and distal to the joint space in ten. Reversed vein grafts were used in

Excerpt Of the 475 patients with isolated ventricular septal defect diagnosed over the past 18 years by catheterization and cineangiography, 285 were observed for their natural history, and 190 had...

IT HAS LONG been known that peripheral pulses which are easily palpable at rest may disappear during claudication induced by exercise.1-3This was formerly attributed to arterial spasm.3-6Later it was realized that arterial pulsations at the ankle normally decrease during moderate exercise2,7,8and that loss of the pulse in occlusive arterial disease is an exaggeration of this normal response. Experimental studies in which blood flow and pressure have been measured indicate that in the presence of an arterial stenosis or occlusion, vasodilation, induced by exercise or pharmacologic agents, is associated with increased blood flow and a fall in mean arterial and pulse pressure distal to the arterial lesion.9,10 Method Fourteen stenotic and one occlusive (case 3) arterial lesions were studied (Table). Ten of the lesions were associated with a resting distal pulse that was lost to palpation with exercise-induced claudication11or papaverine injection. In two

THE ADVISABILITY of operation in many patients is based on an assessment of the cardiac status. 1-3 If operation is directed at the heart itself, preoperative study of the patient often includes a detailed hemodynamic evaluation by cardiac catheterization. On the other hand, evaluation of general surgical patients rarely includes cardiac catheterization; considerable reliance is placed on an estimate of exercise tolerance and the presence or absence of overt cardiac failure. Since pulmonary disease or disturbance in many other organ systems may impair exercise capacity when the heart appears to be functioning normally, we need criteria more specific than simple exercise tolerance to estimate reserve capacity of the heart. How can we quantitate the pumping capability of the heart and relate this to the probability of survival in the face of anticipated operative stress? Techniques for such assessment, previously confined to the experimental laboratory, are now applicable to patients in

In the course of cardiac transplantation, all tissue connections between the body and heart are completely divided; this necessarily eliminates extrinsic neural regulation of the coronary circulation for an extended period. 1 Changes in other cardiac regulatory mechanisms, including altered hormonal responses, 2 might also exert an effect on coronary blood flow. Because of the role of vasculitis and impaired tissue perfusion in the homograft rejection process, it seemed important to measure coronary flow in the autotransplanted heart as a basis for assessing changes superimposed by immunologic or immunosuppressive mechanisms. Methods We have studied coronary blood flow in ten dogs after excision and reimplantation of the heart by a technique reported previously. 3 The studies on coronary flow were made at least two months following the procedure. This period provides adequate time for recovery from the acute effects of the procedure, but is less than the interval after which reinnervation

Occlusive disease of the femoropopliteal artery is now commonly treated with an autogenous, saphenous vein bypass graft. Excision and reversal of the vein has been the most frequently employed technique. An alternative method first described by Rob, 1 utilizing the in situ, nonreversed saphenous vein, has yielded satisfactory results. To evaluate possible advantages, 2 we used the in situ saphenous vein for femoropopliteal arterial reconstruction in 25 instances. This is a report of the results of these 25 arterial reconstructions which are compared with 25 similar reconstructions using reversed saphenous vein. Methods Fifty consecutive femoropopliteal arterial reconstructions were performed from August 1965 to January 1968. In situ grafts were used from November 1965 to May 1967. There was patient selection in that initially there was higher enthusiasm for use of the in situ saphenous vein. Average age in the "in situ group" was 67 (range of 51 to 81 years)

Intermittent claudication occurred in 16 patients (22 legs) despite the presence of a pedal pulse at rest. Exercise, by walking or toe-stands, sufficient to induce claudication resulted in disappearance of the pedal pulse until the claudication subsided (one to three minutes) when the pulse was again palpable. Blood pressure at the ankle normally declines with exercise due to dilatation of the muscular vascular bed. Proximal occlusive disease results in a profound fall in distal blood pressure with concomitant loss of the pedal pulse. There was atherosclerotic occlusive disease at the aorto-iliac level in nine legs and at the femoro-popliteal level in nine legs. Traumatic or congenital arterial disease occurred in four legs. There were persistent pedal pulses after arterial reconstruction in 19 legs, and three have not been treated. Claudication in the presence of resting pedal pulses is usually associated with major artery disease that is amenable to reconstruction.

Five dogs had aorto-coronary bypass with autogenous jugular vein and six had coronary bypass with internal mammary artery (IMA). Cineangiography 8 to 10 months later in dogs with vein grafts demonstrated irregularity and narrowing of the grafts while 12 to 22 months later the IMAs were smooth and patent. All dogs were studied on right heart bypass and one minute of graft occlusion produced similar changes in reactive hyperemia, cardiac hemodynamics, and myocardial metabolism in both groups. Gross and microscopic study of the grafts revealed generalized intimal fibrous proliferation in all vein grafts which was focally severe and produced anastomotic stenosis in two. Intimal proliferation did not occur in IMA grafts. These observations support the use of the IMA for coronary reconstruction in man.

THERE are now a large number of patients with heart block treated by implantable pacemakers. Such individuals are subject to noncardiac conditions which demand treatment by operation. The presence of heart block as well as the generally advanced age of these patients may be viewed by some as a contraindication to operation. We have reviewed our experience in order to determine the advisability of secondary operations in patients with heart block, controlled by electrical pacing. Material This study is based upon 66 patients with second and third degree heart block who have undergone operation. Their ages varied from 5 to 89 years with a median of 70 years. Seventyone percent were 65 years of age or older. There were more than twice as many male patients (47:19). Heart block was thought to be caused by arteriosclerotic heart disease in 30, by fibrous replacement of the conducting system 1 in 30, by

Common femoral artery to tibial artery bypass with reversed autogenous vein in a subcutaneous tunnel was performed in 23 patients for claudication (one), rest pain (five), or gangrene (17). Concurrent minor amputation was done in 16. Four grafts thrombosed, one was ligated for wound hemorrhage, and one failed to heal distal gangrene and resulted in amputation, for a hospital patency rate of 74% (17). One graft failed at 3 and one at 11 months for a long-term patency rate of 65% (15) with a follow-up of 3 to 29 months. These patients have relief of symptoms and have healed their amputations. A grading system was devised for the outflow tract (stages I to IV) which correlated well with graft flow. Graft flow was not predictive of early or late failure.

The serious morbidity and mortality of staphylococcal pneumonia in infants and children is associated with a high incidence of complications requiring surgical management. These complications include tension pneumatocele, residual pneumatocele, pneumothorax, and acute and chronic empyema. 2,11,12,14,24 Although the management of such complications has been repeatedly discussed in the past,* further emphasis is justified by the current, relatively greater, incidence of staphylococcal pneumonia 3,11-13 and the desirability of prompt definitive management of these patients by a broad segment of the profession. 18 A review of 12 recent instances of complicated staphylococcal pneumonia provides material to illustrate the importance of early drainage for such complications. We shall not attempt a detailed presentation of the clinical picture in each of the 12 patients. They varied in age from one month to 4 years, all but one being less than a year old, with an average age of 9 months. All showed empyema

The autotransplanted heart, while free of rejection problems peculiar to homotransplantation, presents functional abnormalities 1,2 which may extend to cardiac failure during the postoperative period. 3 Nevertheless, many animals tolerate complete excision and reimplantation of the heart indefinitely. 4 The intrinsic adaptations required of the heart during the postoperative period are incompletely understood. We have, therefore, surveyed the effect of the operation on the activities of certain myocardial enzyme systems. This report details our experience with the myocardial adenosine triphosphatase (ATPase) and glucose-6-phosphate dehydrogenase activity. Methods Cardiac excision and reimplantation (orthotopic autotransplantation) was done in five dogs. This operation, described previously, 5 involves transection of the aorta, pulmonary artery, venae cavae, and left atrium, after which the heart is sutured into its original position. With the animal under general anesthesia the heart is rapidly excised and frozen in dry ice after separation into atrial, ventricular, and septal components. This was

THE DEMONSTRATED effectiveness of pulmonary embolectomy with the aid of extracorporeal circulation 1-4,9,10 increases the need for a diagnostic method of differentiating pulmonary embolism from other causes of shock, particularly acute myocardial infarction. It is suggested that measurement of the pulmonary arterial pressure and left atrial pressure provides such a differentiation. This suggestion has been tested in the experimental laboratory; in addition, the diagnostic value of pressure measurements in the left atrium and pulmonary artery by suprasternal puncture has been shown in a small group of patients suspected of pulmonary embolism. Methods Animal Experiments. —In 15 mongrel dogs under light pentobarbital sodium anesthesia, pressures were measured in the aorta, left atrium, and pulmonary artery using a cannulation-strain gauge technique. Pulmonary flow was also measured by a gated sine wave electromagnetic flow meter with a noncannulating, extravascular probe. In five animals, branches of the left anterior descending coronary artery were serially

In certain infants with ventricular septal defect and severe pulmonary hypertension, intensive nonoperative management fails to control the progression of cardiac failure.2,4-6,8,14Definitive operation for closure of the defect in these seriously ill infants has been so lethal in the experience of most surgeons that a palliative constriction of the pulmonary artery has been preferred.1-3,9,12,13We have employed this "pulmonary banding," introduced by Muller and Dammann10in 23 patients, most of whom were infants under the age of 12 months with tentative diagnosis of ventricular septal defect or other lesion giving pulmonary hypertension. Because the procedure is admittedly a temporizing measure in preparation for a subsequent definitive operation, final assessment of its worth must await the results of complete repair by this staged approach.7,12Meanwhile, it seems desirable to report on the status of those infants who have undergone pulmonary arterial constriction as the first phase

Many factors influence the adequacy and distribution of systemic blood flow during extracorporeal circulation. 1 The liberation of endogenous vasoactive substances may alter the character of the perfusion or modify the function of various organs. Even during perfusions with conditions maintained within "physiologic" limits, there may be alterations in blood catecholamine levels. 2 Another vasoactive amine which may be liberated from intracellular sites by a variety of interventions is histamine. This substance has many pharmacologic properties which might alter the status of an animal during cardiopulmonary bypass. 3 It may increase vascular permeability, modify ganglionic transmission in the sympathetic nervous system, alter regional flow by relaxation of vascular smooth muscle, or affect the heart directly. In addition it may cause bronchiolar constriction; this could have a bearing on the pulmonary complications that may follow cardiopulmonary bypass. Because of these relevant possibilities, it seemed desirable to study plasma histamine levels during

Seventy patients with iliofemoral venous thrombosis underwent 73 thrombectomies. There were 12 deaths in the first postoperative month, one of which was due to pulmonary embolism. Eleven late deaths were unrelated to thromboembolic disease. Seven patients had phlebography one to three weeks after operation and ten were studied 16 to 102 months after thrombectomy. Despite a "good" or "fair" clinical result the early phlebograms frequently demonstrated extensive deep vein thrombosis or recanalized deep veins. Later phlebograms revealed thrombosed deep veins, recanalized deep veins, and collateral veins in patients with good and fair clinical results. Despite a favorable clinical course after thrombectomy, deep vein patency and valve function are infrequently restored. The proper indications for thrombectomy are as yet difficult to define.

Physicians have long debated the advisability of giving digitalis as a prophylaxis against cardiac failure which may occur in connection with the stress of general surgical operations. While there is agreement as to its benefits for the failing heart, in the nonfailing heart it has often been considered not only useless but even harmful. The problem has recently been brought into sharper focus by the widespread use of cardiotomy for correction of intracardiac defects, especially when such physical trauma to the myocardium is accompanied by the metabolic insult of induced cardiac arrest. We have recently demonstrated the beneficial effects of digitalis in experimental animals subjected to periods of induced cardiac arrest. 6 With 30 minutes of potassium cardioplegia in dogs, there is profound depression of ventricular function. 15 The digitalized canine heart arrested with potassium citrate is subsequently able to perform more than 19.5 grammeters stroke work in response to

TRANSPLANTATION RANSPLANTATION of the heart results in complete cardiac denervation which has been shown to cause significant chemical, 1 histological, 2,3 metabolic, 4 and functional 5 changes in the dog. In anticipation of cardiac homotransplantation in man, we have studied the effects of cardiac denervation in another primate. This presentation details the studies in nine normal baboons as controls and in six baboons with autotransplanted hearts and three with hearts completely separated from extrinsic neural connections. Methods Autotransplantation by the technique described in the dog 6 was performed in ten baboons. Six animals surviving longer than one month were available for study along with three animals more than one month after total mediastinal neural ablation. 7 Nine animals were taken at random as normal controls from a large baboon colony. In all 18 animals, cardiac output (CO) was determined by dye dilution technique with indocyanine green (Cardiogreen) injection into a