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Perfluorocarbons are now being used as oxygen carriers in clinical settings. Because these chemicals may have a role as a blood substitute, in organ preservation, and in the management of respiratory failure, we have reviewed some of the research leading to these applications.

Two hypotheses were investigated: (1) helical computed tomography (CT) of the chest on victims of decelerating trauma can yield a diagnosis of, or "rule out," a traumatic rupture of the aorta (TRA) without the need for an aortogram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol. Screening helical CT examinations were done on 6169 victims of blunt thoracic trauma; 47 were found to have TRA; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated with a proved TRA. It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries. Drugs (beta-blockers +/- vasodilators) to decrease the stress in the aortic wall were used in 93 patients when the diagnosis was suspected and were continued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done between 2 days and 25 months in 15 patients who were deemed to be excessive risks for emergency aortic repair; there were 2 deaths (13. 3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether repaired emergently, electively, or not at all, developed free rupture of the periaortic hematoma and death from TRA.

Blunt injury of the brachiocephalic artery can pose diagnostic and management problems for the trauma and thoracic surgeon. To arrive at recommendations for dealing with this injury, we reviewed a seven-year experience at our trauma center. Between 1988 and 1995, five patients presented with blunt injuries of the brachiocephalic artery. All patients were stabilized and underwent repair through a median sternotomy with extension of the incision anterior to the sternocleidomastoid muscle. All patients had restoration of flow to the subclavian and carotid arteries utilizing bypass grafts (4) or primary repair (1). All patients survived to leave the hospital with no complications related to the procedure. Postoperative neurologic findings were present before the operative repair. Patients with blunt injuries of the brachiocephalic artery should be stabilized, and circulation of the subclavian and carotid arteries should be restored with graft placement or primary repair. Cardiopulmonary bypass and heparin or temporary shunts were not needed in this series of patients. Complications were related to associated injuries.

Thirty-two consecutive patients with subclavian artery injuries were evaluated to assess the mechanism of injury, types of repair, and results. In this series, most wounds were from firearms. Although the mortality was high (19%), most patients had the vessel repaired successfully. Associated injuries, especially to neural structures, led to significant morbidity. Principles used in dealing with these injuries should be 1) proximal and distal control prior to exposing the injury site, 2) reestablishing distal circulation through primary repair or graft placement, and 3) identifying and treating associated injuries.

An association between carotid and coronary artery disease is well recognized. Routine preoperative duplex carotid screening of all coronary surgery patients is common, but may delay surgery and increase cost. To evaluate such a policy: A retrospective review of the records of 308 consecutive patients undergoing coronary surgery at one hospital was performed. Duplex studies were done on 210. A history of TIA/RIND, CVA, AS-PVD, AAA, neck bruit, or prior carotid surgery was considered suggestive for carotid disease. The history and/or physical exam (HPE) suggested carotid disease in 114; 37 of these (32%) had a positive scan. Of 96 patients without +HPE, three (3%) had a significant stenosis. A prospective study of cardiac surgery patients was done, categorized into "carotid" (n = 33) or "no-carotid" (n = 50) disease by two independent observers, based on +HPE. Positive scans were found in 27 per cent of the "carotid disease" group; No positive scans were found in the "no-carotid disease" group. We conclude that coronary surgery patients with peripheral or cerebral vascular disease or a neck bruit should have preoperative carotid studies. Duplex carotid screening of all cardiac patients is neither medically efficient nor cost-effective.

Approximately 10% of all cases of Ewing's sarcoma arise from a rib. Conventional management has included chest wall resection (3 or more ribs) and radiation therapy. These forms of therapy have led to complications such as scoliosis and local deformity. The addition of radiation therapy can result in damage to the lung and adjacent viscera and also potentiate pulmonary restrictive disease. Between 1971 and 1978, 9 patients were treated with surgery, radiation therapy, and combination chemotherapy (three- or four-drug regimen). Only 2 patients (22%) survive. Since 1979, 14 patients were entered into a new protocol consisting of sequential induction chemotherapy, followed by delayed surgical resection whenever feasible. Three patients had complete resection of their primary lesion at onset. Initially, 7 patients had either biopsy (N = 4) or incomplete chest wall resection N = 3). All 4 patients with biopsy only at diagnosis had excellent responses to induction chemotherapy, allowing delayed resection of the involved rib without chest wall resection. Overall, 12 of 14 patients (86%) treated since 1979 survive, with only 2 receiving radiation therapy for residual disease in the primary rib site.

This survey of 1,097 Fellows resulted in usable data from 336 surgeons, of whom 129 had claims (n = 212) against them from January 1, 1984, through December 31, 1989. Risk by specialty varied greatly, but population of practice area seemed unimportant. Plaintiff expert witnesses could be identified by 28 surgeons; four of these were from medical school faculties. Defense expert witnesses were identified by 37 surgeons, 18 of whom were from university faculties. We were unable to identify any repeat "itinerant" plaintiffs' expert witnesses from this five-year period in Tennessee. It seems obvious that surgeons, even those who have been sued, pay little attention to even the identification of opposing expert witnesses.

1. Freeze-dried cortical grafts in dogs are definitely superior to similar frozen grafts in the rate of healing. This is especially true in the earlier stages of healing, but it is also rather marked in the later stages. 2. This advancement of freeze-dried bone-graft healing occurred in spite of a considerably longer average storage period for freeze-dried grafts than for frozen grafts. 3. The superiority of freeze-dried bone grafts over frozen grafts demonstrated in this series is much more striking than that in the original experimental comparison. This is probably the result of improvements in the technique of freeze-drying and storage of freeze-dried grafts in vacuum.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.

The sick asplenic patient bears risk to infectious complications and mortality. That risk is not widely accepted since no specific syndrome is applicable to all asplenic patients who are ill. In order to determine outcome following splenectomy, 624 patients having simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, or splenectomy associated with transplantation were studied. Nonfatal complications specifically related to splenectomy occurred in 23 per cent of patients with multiorgan injury and 18 per cent with incidental-accidental splenic removal; splenectomy associated with transplantation had the highest mortality. The classic postsplenectomy sepsis syndrome was encountered late only twice. In the already sick patient rendered asplenic, conditions heralding susceptibility to progressive and sometimes fatal infection must be considered at all times. Sound indications for splenectomy must prevail before splenic removal since morbidity and mortality follow splenectomy, especially in the sick asplenic patient.

Cefoperazone, a third-generation cephalosporin derivative, has been reported to have excellent antibacterial activity against a wide range of gram-positive and gram-negative pathogens, including Pseudomonas aeruginosa. We treated 54 patients with a variety of clinical infections with cefoperazone and determined the susceptibilities of their 90 bacterial isolates. An additional 25 aerobic isolates obtained from patients treated with cefamandole in a comparison study were also tested for susceptibility to cefoperazone. Thus a total of 115 isolates were studied in vitro. One hundred nine (95%) of 115 bacterial isolates, including gram-positive and gram-negative aerobes and anaerobes, were susceptible to less than or equal to 32 microgram/ml. Only four isolates (three Escherichia coli and one Serratia marcescens) were highly resistant (minimal inhibitory concentration greater than or equal to 128 microgram/ml). We were able to assess clinical outcome of cefoperazone therapy in 53 patients; favorable responses (cure of improvement) were found in 48 (91%). P. aeruginosa was a major pathogen in three patients treated with cefoperazone; all three showed a favorable response. Side effects of cefoperazone therapy were noted in seven (13%) patients, and laboratory abnormalities were observed in 11 (20%) patients; all of these were mild and readily reversible. Cefoperazone thus appears to be safe, well tolerated, and suitable for use in a variety of human infections.

Digital venous angiography (DVA), a new radiographic technique, was prospectively compared to conventional intra-arterial angiography (CA) in a group of 153 patients with trauma and suspected peripheral arterial injury ( PAI ). Criteria for entry included: large hematoma, proximity to a major vessel, shotgun wounds, blunt injury of the extremities, and fractures or dislocations of areas with high risk of arterial injury. Patients with unequivocal clinical evidence of PAI were excluded. Study patients had both DVA and CA. Sixteen injuries were diagnosed: lacerations (9), transection (1), AV fistulae (2), thromboses (2) and minute intimal flaps (2). All patients with abnormal studies were surgically explored; there were no false-positives. There were no known false-negatives with CA. The intimal flaps were not recognized initially on DVA and their clinical significance is questioned. DVA, compared to CA in PAI , had decreased patient discomfort, cost, and morbidity. It has the potential for study of multiple areas of the body from a single I.V. catheter. DVA can probably replace CA for civilian penetrating wounds. CA may remain the standard for blunt and high velocity injuries.

The mechanism of hypocalcemia in acute pancreatitis remains unknown despite continued investigative work over the past several decades. Because acute pancreatitis is accompanied by multiple systemic manifestations and alterations of plasma membranes, the possibility that an abnormal translocation of calcium from extracellular to intracellular compartments could play a role in hypocalcemia of acute pancreatitis was investigated in dogs. Acute pancreatitis was induced by injecting bile into the pancreatic duct. Plasma calcium, magnesium, and amylase concentrations were determined. Calcium and magnesium contents were also measured in biopsy specimens of pancreas, liver, skeletal muscle, and kidney before and after induction of acute pancreatitis. As expected, hypocalcemia and hyperamylasemia occurred 6 hours after induction of pancreatitis, and persisted throughout the experiment, 13 to 25 hours. Plasma magnesium concentration fell at 6 and 18 hours, and returned to an almost normal level by the end of the study. A significant elevation in calcium content of pancreas (71%), liver (24%), and muscle (112%), and 25% reduction of calcium in kidney were observed in dogs with histologic signs of pancreatitis. However, tissue magnesium concentration fell in pancreas (18%) but remained unchanged in the other tissues investigated. No significant changes in any variables were detected in sham-operated animals. In another group of dogs in which the accessory pancreatic duct was not occluded when bile was injected, the histologic lesions were extremely mild, although the plasma calcium concentration and the pancreatic calcium and magnesium contents were altered just as much as in the severely affected dogs. Data suggest that the hypocalcemia of acute pancreatitis may be the result, at least in part, of accumulation of calcium in soft tissues. The decreased calcium content in kidney could be related to hypocalcemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypocalcemia frequently occurs in acute pancreatitis (AP), but its pathogenesis remains unknown. Since AP is often accompanied by acute alteration in the structure and function of cellular membranes, we investigated whether hypocalcemia associated with AP can be explained by acute translocation of Ca from extracellular to intracellular compartments. AP was induced in dogs by injection of autologous bile into the pancreatic duct, and in rats by controlled infusion of artificial bile containing Na-taurochlorate, Keflin, and trypsin into the cannulated bile duct. Plasma Ca, Mg, amylase, and PTH concentrations were determined in the serial samples. Tissue [Ca] and [Mg] were determined in pancreas, liver, kidney, and abdominal wall muscle biopsies obtained immediately before and 24 h after induction of AP in dogs or 2 h following induction of AP in rats to evaluate the temporal correlation between hypocalcemia and excessive intracellular Ca accumulation in soft tissues. Hypocalcemia (p less than 0.001) and hyperamylasemia (p less than 0.01) occurred within 6 h of AP in dogs, and persisted throughout. Plasma [Mg] was lowered and PTH activity was elevated at 6 and 18 h, and returned to a near normal level by 24 h. Concomitant with persisting hypocalcemia and lower ultrafilterable plasma [Ca2+], tissue [Ca] was significantly elevated in pancreas (71%), liver (24%), and abdominal muscle (112%), but was depleted in kidney by 25%. Pancreas biopsy following AP revealed histological signs of fulminant pancreatitis. [Mg] was depleted only in the pancreas (18%) and remained unaltered in other tissues. No significant changes were noted in the sham-operated animals. The observed temporal correlation between profound hypocalcemia and acute excessive intracellular Ca accumulation in soft tissues strongly suggests that hypocalcemia in AP may be precipitated by leaky-plasma-membrane-mediated excessive intracellular Ca accumulation. Similar data together with significantly reduced cellular energy charge (p less than 0.01) obtained from AP rats provided additional support to our hypothesis.

Carcinoma of the esophagus, the fourth most common malignant tumor of the gastrointestinal tract, still has a dismal outlook. Since July 1960, we have collected data on 642 patients with this lesion. Adenocarcinomas (which might arise from gastric mucosa) have been excluded. Almost one-fifth of the patients were far-advanced and inoperable when first diagnosed. Time between onset of symptoms and diagnosis was deemed excessive in over half of the patients; physicians frequently accounted for much of this delay. Preoperative diagnosis proved accurate in 99 per cent of the cases. Evaluations of direct extensions and distant metastases and attention to nutritional status correction were of prime importance. Operative technique and indications for surgery have become "standardized," and while surgical mortality has remained about 20 per cent throughout the period, morbidity has decreased steadily. Comparisons of irradiation and surgery in relation to palliation indicate that palliation is probably better in the surgically treated patient. However, it is emphasized that this comparison, as well as comparison of other results, is not scientifically valid since the groups of patients are not comparable due to clinical selection.

These studies are in agreement with others that aortocoronary vein grafts done for severe angina pectoris are associated with a low operative and late mortality rate. Most patients were significantly improved in regard to pain and exercise tolerance. "Optimal" graft site is associated with a graft patency rate of about 90 per cent. There is clear evidence that left ventricular function, particularly with exercise, is improved in some patients. When a graft is placed in an obstructed coronary artery supplying a segment of abnormally contracting myocardium, there frequently is significant improvement of contraction when the graft remains patent.

The ability of ethyl cyanocrylate monomer adhesive in preventing leaks following pancreatic surgery dogs was evaluated. Seventeen of 18 dogs in the control group had evidence of pancreatic leak following biopsy. There was no evidence of leak in 17 of 18 dogs on which the adhesive was used to seal the cut surface of the pancreas. Similar successful use of ethyl cyanoacrylate in patients would provide a safe method of taking a specimen from a mass for biopsy in the pancreas.

Postinfarction ventricular septal defects are best repaired surgically several weeks after occurrence; however, deterioration of the patient's condition may require emergyncy operation. Ventricular aneurysms are resected when associated with low cardiac output, emboli occur or when present in a patient who is otherwise a candidate for aortocoronary grafting. Mitral valve replacement may be required when coronary disease produces severe malfunction of a papillary muscle or rupture of a chorade tendineae. Acute infarctectomy alone is not recommended at this time. The balloon assist device may result in some patients who are candidates for infarctectomy with aortocoronary bypass graft. Preinfarction angina which is not controlled by medical therapy should be treated by immediate aortocornary bypass. Tachyarrhythmias are not an absolute contraindication to surgery. Stable angina that is unacceptable to the patient under optimal medical therapy and is associated with operable anatomical lesions is the prime indication for coronary artery surgery. Relief of pain and increased exercise tolerance are usual after surgery. Sometimes life may be prolonged.

While routine formal exploration for all neck wounds penetrating the platysma remains a safe policy, our experience indicates that it is not necessarily the best policy in large, well-staffed teaching hospitals with extensive trauma services. Careful and repeated physical examinations and observations supplemented by simple radiograph examinations allowed selection of a large group of patients who were satisfactorily treated by simple wound closure and clinical observations. Aggressive emergency room management and adequate exposure and repair of vascular injuries prevented cerebral damage so common in previous reports.

Postsplenectomy complications were reviewed among 420 patients with simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, and those having splenectomy prior to renal transplantation. Complications not specifically related to splenectomy occurred postoperatively in 52 per cent and 41 per cent, respectively, in the complex trauma and incidental-accidental splenectomy groups. Nonfatal complications specifically related to splenectomy occurred in 15 per cent of patients with multi-organ injury and in 18 per cent of patients with incidental-accidental splenic removal. Morbidity was infrequent when simple splenic trauma prompted splenectomy or in elective splenectomy. Mortality related to splenectomy occurred most often following renal transplantation, but also appeared high when the spleen was removed for multiple trauma or incidental to other surgery. The latter category is at risk for morbidity and mortality when splenectomy is incidental to a planned procedure (e.g., radical gastrectomy) or accidental as when injured by the surgeon. These splenectomies and those planned prior to transplantation may be unnecessary in many instances. The postsplenectomy sepsis syndrome was encountered late only once in this entire series; nonetheless, sound indications for splenectomy must prevail before splenic removal since significant early morbidity and mortality follows splenectomy.

The anhepatic period of canine orthotopic hepatic transplantation is usually accompanied by cardiovascular instability due to occlusion of both the portal and inferior systemic venous systems. The present study was undertaken in order to determine some of the hemodynamic and renal alterations that occur during a 2 hour anhepatic period in the dog and to investigate the use of a passive endoportal, endocaval venovenous shunt that places both the portal and infrahepatic vena caval limbs of the shunt directly into the divided ends of these vessels. Three groups of experimental animals were studied. One group had hepatectomy without a shunt and was compared with two other groups which had hepatectomy with some form of venovenous shunting. Systemic arterial blood pressure, portal and inferior vena caval pressure, urinary output, and renal histology were all better maintained when a shunt was used.