Search

Purpose: The purpose of this study was to use color-flow duplex scanning to identify the anatomic distribution of venous reflux and to quantify venous reflux times in patients with various stages of chronic venous insufficiency (CVI). Methods: Color-flow-assisted duplex scanning was used to identify the anatomic distribution of venous reflux and to quantify reflux times in the deep and superficial venous systems of patients with symptomatic (CVI). Two hundred two patients with class I to III CVI were examined. Results: Only 11% (22 patients) had a documented history of phlebothrombosis. Of the 403 limbs evaluated, 192 had venous ulcers whereas 211 were classified as having class I or II CVI. Nonocclusive venous obstruction was found in only 16 limbs (4%). Venous ulceration was significantly associated with reflux in multiple venous segments as opposed to reflux in isolated venous segments ( p t ) was determined by summing the reflux times of all the venous segments in a limb. The mean R t of patients with venous ulcerations was significantly longer than the mean R t of limbs with class I and II CVI ( p p p

11 cases of cystic degeneration of a limb vein have been described. The etiology and treatment of this degeneration are uncertain. One hypothesis is that there are ectopic cells producing mucopolysaccarides in the venous wall. The main differential diagnosis is angiosarcoma. Accordingly, surgical exploration is mandatory but reccurence occurs in half the cases after surgical treatment. Knowledge of the pathogenesis of cystic degeneration in veins could help suggest an appropriate treatment. A 32-year-old woman was referred to hospital by her family physician in March, 1995. She complained of left-leg swelling for one year, initially diagnosed as phlebothrombosis. Duplex ultrasonography and Doppler showed a solid 3 cm-round mass in the lumen of the femoral vein. Computed tomography scan showed a posterior cystic mass compressing the vein. Surgical exploration showed a posterior mucoid cyst within the vein wall. The inner wall of the cyst was excised. 3 months later, her leg swelling returned. At reoperation the segment of vein was excised and the vein reconstructed with autologus axillary vein. The patient was discharged on the 8th day, with no swelling in her leg. 20 months later she was without symptoms and venography was normal. Histological examination of the surgical specimen showed a cyst deep in the vein wall. The cyst was filled with an alcianblue-positive mucinous material. The inner surface of the cyst had papillae covered by cuboid cells which stained strongly with an antivimentin antibody. Fluid within the cyst was mixed with William’s culture medium containing serum. Mesothelial-like cells attached to the dish within 6 hours, and proliferated after 2 days (figure). These cells contained numerous vacuoles and inclusions and were alcian-blue positive. These data strongly suggest a mesothelial origin of the cyst. We propose that the only curative treatment of cystic degeneration of a limb vein is to excise the cyst together with the vein since there is a high rate or recurrence by excision of the the cyst alone.

Lymphocele and lymphatic fistulae are relatively benign complications in renal transplantation. The incidence in our series of 248 renal transplants was 8%. The origin and pathogenesis of lymph collection and augmented lymph flow are discussed. The main importance of this complication lies in its differential diagnosis with urinary fistula and acute rejection episode or deep phlebothrombosis with all its therapeutic implications. Important lymph accumulations should be drained. We prefer as initial treatment a percutaneous closed aspiration which most successfully solves the problem. In case this method should fail, one can choose between external or internal drainage. As in literature, we actually prefer an internal marsupialisation, but completed by an omentoplasty if the leakage originates from the kidney.

I HAD occasion to see several cases within a short period of time in the fall of 1944 and was fortunate enough to have been able to obtain the help of Doctor F. W. Bancroft in the treatment of these patients. In view of the fact that he is presenting the paper of the evening on this subject, I will avoid any discussion of the anatomic approach to the operation, the advantages or disadvantages of the different types of heparin therapy, such as dicqumarol, intravenous heparin, or that given intramuscularly, and will merely state briefly the salient features in the case reports to illustrate the advantages of surgical treatment.

A clinical survey of 900 consecutive, postoperative gynecological cases, in 450 of which Dicumarol was given routinely as a means of preventing any untoward complications from intravascular clotting has been presented. Plan of dosage was dependent upon the control prothrombin time, which is defined as the value ascertained on the morning of the first postoperative day. The control prothrombin time has proved an excellent index for safe and efficient Dicumarol therapy, as was illustrated in sensitive and resistant patients to the drug, in the preoperative and postoperative variations of the prothrombin time, as well as the variation in the initial prothrombin time in different individuals. The simple bedside test of Ziffren for prothrombin activity is an ideal procedure for Dicumarol therapy. A reliable experience in laboratory tests and individualization of patients are of prime importance for adequate and safe treatment. In 450 Dicumarolized postoperative patients, there were 7 cases of hypoprothrombinemia with consequent bleeding which was readily controlled by vitamin K therapy; however, there was one case of phlebothrombosis in an individual who was refractory to this therapy. In 450 comparable, non-Dicumarolized patients, there were 7 cases of phlebothrombosis, 11 cases of thrombophlebitis, 9 cases of nonfatal pulmonary embolism, and 4 cases of fatal pulmonary embolism.

Causes of death were investigated in 137 ulcerative colitis patients dying between 1930 and 1966. Forty-six patients, averaging 39 years of age, died of causes directly attributable to ulcerativecolitis; these included colonic perforation, operative and postoperative deaths, and fulminating disease. The 46 colitis-related deaths were caused by carcinoma of the colon and rectum, chronic liver disease, suicide, phlebothrombosis, and complications of medical therapy. Deaths in 45 patients were unrelated to ulcerative colitis or any of its known complications. Review of the latest barium enema in 125 of the patients under study disclosed a significant correlation between the presence of severely involved colons and direct colitis and colitis-related deaths. The patterns of mortality over the period under study indicate that both the survival times in ulcerative colitis and the ages at death are increasing. Likewise, the major causes of death are changing. There is a decline in the frequency of deaths directly due to ulcerative colitis and a corresponding increase in both colitis-related and colitis-unrelated deaths. Nonetheless, the high over-all proportion (2 of 3) of those patients dying because of factors directly or indirectly related to their bowel disease emphasizes the continuing therapeutic challenge presented by ulcerative colitis.

1. 1. One hundred thirty-five early ambulatory cases from a private general surgical service are compared with 135 similar but late ambulatory cases. 2. 2. Early ambulation is defined as actual walking by at least the third postoperative day. The average was 2.06 days postoperatively in this series. 3. 3. The average day of ambulation for the control group was 8.8 days postoperatively. 4. 4. The average maximum temperature postoperatively was exactly the same in both series, 100.8∘F. 5. 5. Very little difference was noted between the two groups as to the time of occurrence of the maximum temperature and the day of return to normal temperature. 6. 6. Only seven catheterizations were required in the early ambulatory group whereas thirty-two catheterizations were required in the control series. 7. 7. Eleven and nine-tenths per cent of the early ambulatory patients and 17 per cent of the late ambulatory patients developed complications but there were more than twice as many individual complications in the late ambulatory group. 8. 8. There were no deaths in the early ambulatory group but two deaths in the control group. 9. 9. Pulmonary embolism, thrombophlebitis and phlebothrombosis were more prevalent postoperatively in the early ambulatory group. 10. 10. Wound infections, dehiscences, disruptions and eviscerations were much more prevalent complications in the late ambulatory group. 11. 11. Pulmonary complications such as atelectasis and pneumonia were twice as common (eight to four) in the late ambulatory group. 12. 12. The advantages and contraindications of early ambulation are summarized. 13. The Scultetus binder affords a great amount of comfort, support and feeling of security to the early ambulatory patient. 13. 14. Catgut sutures are not a contraindication to early ambulation. 14. 15. According to this series the main advantages that can be anticipated by employing early ambulation judiciously in selected cases are apparently limited to reduction of the following: number of catheterizations, wound infections, disruptions and eviscerations, and incidence of postoperative complications, including pulmonary complication (but not pulmonary emboli in this series).

P ULMONARY sudden death embolism resuIting in may now be prevented in many patients who in previous years were destined to succumb to this unfortunate condition without any rationa therapy. For a Iong time it was beheved that the hazard of death from puImonary emboIism was one which of necessity had to be borne by the patient who underwent major surgery. Surgeons and internists usually believed that littIe could be done to reduce the possibility of this compIication. In recent years this attitude has been repIaced by a widespread interest in seeking to diagnose thrombotic disease when it first deveIops and by appropriate methods of treatment to prevent the compIication of puImonary emboIism. The current attitude toward the treatment of this condition and the Iives saved as a resuIt of this newer concept have resuIted from a better understanding of the underIying pathoIogic conditions which cause the deveIopment of thrombi in the venous system. In former years puImonary emboIism was usuaIIy considered a complication of surgery. It is now generally recognized that many patients who have never undergone surgery are at times troubIed with venous thromboembohc disease and that these patients may suffer from a fata attack of puImonary embohsm. Internists now correctIy attribute certain chest comphcations as being the result of pulmonary emboli in bedridden patients who have undergone surgery. Attention is aIso being caIIed to the presence of the early signs of venous thrombosis in the extremities. Adequate therapy saves many patients from the unfortunate outcome which in previous years occurred. The majority of venous clots have their beginning in the deep veins of the Iower Ieg and foot. l-* The thrombosis which begins in the pIantar veins or in the deep veins of the Ieg may graduaIIy extend to higher IeveIs by direct propagation. In other instances such a cIot may be disIodged before extensive propagation has taken pIace. In such instances fata puImonary emboIism may occur and at autopsy the origin of the fata emboIus wiI1 not be found unIess the veins of the lower Ieg are examined. Thrombotic venous disease is usuaIIy divided into two types, phlebothrombosis and thrombophIebitis. PhIebothrombosis, a term which Ochsner and DeBakey popularized and which is referred to by Homans as the quiet bIand type of intravascuIar cIotting, is more IikeIy to be foIIowed by puImonary emboIism than is thrombophlebitis.” In my opinion it is rationa to beheve that phlebothrombosis and thrombophIebitis are in reaIity extreme variations of the same genera1 process.6 In thrombophIebitis there is a definite inffammatory reaction present in the waI1 of the vein. This inffammatory reaction increases the probabihty of the cIot becoming adherent to the vein wall; consequently puImonary emboIism is Iess IikeIy to occur in patients with thrombophIebitis than in patients with phIebothrombosis. It is aIso

Subacute cor pulmonale is a distinct clinical syndrome that is often not too easily diagnosed. Its salient features are (1) development of sudden dyspnea of a progressive nature; (2) absence of an underlying cardiopulmonary disorder to account for the dyspnea, or presence of such disorder in an asymptomatic phase; (3) paucity of physical signs in the chest to explain the dyspnea; (4) signs of failure of the right side of the heart developing later in the course of the disease; (5) lack of therapeutic response to the usual measures for congestive heart failure; (6) roentgenographic evidence of lymphangitic carcinomatosis or pulmonary embolization; (7) electrocardiographic abnormalities suggesting hypertrophy and dilatation of the right ventricle; and (8) a clinical course of only a few weeks or months. Inasmuch as an underlying thrombophlebitis or phlebothrombosis may be responsible for the development of pulmonary embolization, one of the causes of subacute cor pulmonale, it appears reasonable to suggest that anticoagulants be administered as soon as the presence of this condition is suspected. Such early prophylactic therapy may prevent a certain number of otherwise inevitable deaths.