Acute Surgical Illness in Patients With Sickle Cell Anemia

tional Stlpport foT or absorb sufficient nutrients to pn:<\1 ent death_ from st;_:trvation. The dran1atic demonstration that intravenous the sole means of nutritional support, pron1ote in a child and restore loss m an 'idult has received appropriate acclaim. Widespread 11µ,µ1J,cau•c11J of total parenteral nutrition The enthusiastic patients of starvation has led to claims that nutritional support should be a primary means of therapy in organ failure, including renal, cardiac and gastrointestinal failure, or a support method during therapy in a multitude of diseases. Indeed, the emotion about such aspects as they affect the patient with cancer was sufficient to receive attention from a congressional committee. Subsequent review conferences were designed to evaluate total parenteral nutrition in several areas, including cancer. The latter application provoked sufficient ire to be the subject of comment in a major medical journal. Alternative causes of malnutrition in cancer involve either increased nutrient demand the neoplasm or by the stressed host) or some remote effect of the tumor, The latter possibility can be explained readily when the tumor produces an identifiable hormone with known actions but it is less easily explained when no specific hormone is identified, There is evidence of mild to moderate increases in energy demand and failure to adapt energy expenditure to available intake but these minimal changes are not considered the primary cause of cachexia. Substrate consurnption the tumor, whether based on an with ;;urnsuH,n,uu,u in the human brain, in vivo studies in transplanted tumors or on in vivo use of the substrate sarcoma-bearing human limbs, can be substantial and can account for small increases in energy expenditure at rest. However, only a large tumor (> 1.4 kg.) would consume 50 per cent of the intake of the at rest, Therapies designed to direct nutritional to the particular requirements of the cancer-bearing host have not been successful in human beings and the data in animals are conflicting. The theoretical attractiveness of taking advantage of the obligate need and glycolytic activity of the tumor while providing the host's tissue with alternative substrates, such as ketones or glycerol, is only now being examined in animal experiments. Total parenteral nutrition allows total control of all exogenous nutrients and it should be used to alternative therapies in oncologic medicine. In the meantime, total crn,m,>a>'Q nutrition is a tool in the managexnent of cancer, not a weapon for anticancer wanare, G.P.lVI. 4 tables, 139 references

nionary r£1icrocirc-ulatioE, ha:ve been der:aonst:rated in postrnortern tissue sections obtained from patients with cancer, hepatic insufficiency, infection, sepsis, hemorrhages, specific hern.atologic uo,,rrc,Q,o and coagulopathies. However, megakaryocytes have been seen rarely within the glomerular capillaries. The authors reviewed 118 autopsies in which cases significant pulmonary megakaryocytosis had been reported. Of the 118 cases reviewed 27 showed significant increases in the number of megakaryocytes within the glomerular capillaries. These increases corresponded to increases in the pulmonary microcirculation and in the bone. In cases with coagulopathy megakaryocytic hyperplasia was not evident in the bone marrow. In patients with normal renal blood flow a corresponding increase in renal glomerular megakaryocytes also can be noted with increased megakaryocytes in the pulmonary microcirculation. F. T. A. 2 figures, 1 table, 21 references

A Renal Inhibitor to Hepatic Erythropoietin (Ep) Production

B. A.

NAUGHTON,

J.M.

RYAN,

Megakaryocyte§ in Renal Glomeruli

w.

L. BROGHAMER, JR. AND B. WEAKLEY-JONES, Laboratory Service, Veterans Administration Medical Center and Department of Pathology, University of Louisville, Louisville, Kentucky

Amer. J. Clin. Path., 76: 178-182 (Aug.) 1981 Increased numbers of megakaryocytes, particularly in pul-

NAUGHTON, P.

LIU, L.A. DEPAOLA,

PILIERO AND

A. S.

GORDON,

A.

S. Gordon Laboratory of Experimental Hematology, De-

partment of Biology, Graduate School of Arts and Sciences, and Department of Histology, College of Dentistry, New York University, New York, New York J, Med., 12: 159-182, 1981

The anemia associated with chronic renal insufficiency in man is owing primarily to a diminution of erythropoietin, which is responsible for the differentiation of hematopoietic stem cells into the erythroid line and is produced in response to hypoxia. Erythropoietin is elaborated almost exclusively by the kidneys but extrarenal sources also exist, the most important being the liver. In this experimentation evidence is presented for the existence of a factor in renal venous blood, evoked by subtotal hepatectomy, which inhibits the production of erythropoietin in nephrectomized rats exposed to hypoxia. This finding has fundamental and practical implications in the comprehension of the mechanism that triggers hepatic erythropoiesis. Should this inhibitory factor possess antigenic properties an antibody developed against it might find use in the further simulation of erythropoietin production in renal insufficient patients as well as anephric µ«s,c.ac~ on D. J. A, 5 figures, 2 tables, 44 references

Acute

Amer. J.

DISEASES OF' BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY

G. K

J. LoBuE, S. J.

Illness fo Patients With Sickle Cell Ane-

142: 113-117 (July) 1981

Acute pain in the right upper quadrant of the abdomen occurs frequently in patients with sickle cell crisis. The pain usually is associated with nausea and vomiting, and this symptom complex mimics acute surgical conditions, such as acute cholecystitis, appendicitis, duodenal ulcer disease and peritonitis. It is important for the clinician to distinguish between those conditions that may require laparotomy from sickle cell crisis that is managed conservatively. To determine the criteria for differentiating sickle cell crisis from acute surgical conditions the authors reviewed the records of 7 patients with sickle cell disease who underwent laparotomy during a period of 17 years. All 7 patients had confirmation of the diagnosis of sickle cell

194

DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY

disease .by hemoglobin electrophoresis. The patients ranged from 11 to 27 years old. Five of the 7 patients had multiple previous hospitalizations for sickle cell crisis with abdominal pain. The remaining 2 patients had not been hospitalized previously. The diagnosis at the time of admission to the hospital was incorrect in all 7 patients. Six patients were hospitalized with the diagnosis of sickle cell crisis but were later found to have conditions requiring operation. One patient was hospitalized with the diagnosis of appendicitis but exploratory laparotomy was negative. Review of the clinical features of recurrent sickle cell crises revealed a consistent pattern as it related to the precipitating events and the character of pain from crisis to crisis in individual patients. Deviation from such pattern should raise suspicion of conditions other than sickle cell crisis. Patients with intraabdominal disease had fever and significant leukocytosis, whereas those with sickle cell crisis did not. Elevation of serum bilirubin levels usually follows a pattern from crisis to crisis. An unusual increase in serum bilirubin may indicate cholelithiasis. The authors conclude that in patients with sickle cell disease deviation from previous patterns of presentation suggests a condition other than sickle cell crisis. N. S. D. 3 figures, 1 table, 12 references

Editorial comment. This review of abdominal problems in patients with sickle cell anemia is informative. The problems are pertinent to the urologist who often sees the patient because of possible obstructive necrotizing papillitis. Careful evaluation and the presence of significant clinical and laboratory data to support the proper diagnosis are essential for the cause of abdominal pain-be it gastrointestinal or urological in origin. The authors concisely indicate the danger of surgical intervention in sickle cell anemia crisis. A. T. E. Complications After Percutaneous Transluminal Angioplasty J. E. CONNOLLY, J. H. M. KWAAN AND P. M. MCCART, Department of Surgery, University of California at Irvine, Irvine, California Amer. J. Surg., 142: 60-66 (July) 1981 Percutaneous transluminal angioplasty is used widely for the treatment of abdominal and peripheral arterial stenotic lesions. Since the advent of a new balloon catheter in 1974 this procedure has become popular because of its simplicity and rather noninvasive nature as compared to direct arterial reconstructive surgery. However, the procedure is not devoid of complications, some of which are serious. Little information is available in the literature regarding such complications. The purpose of the present report is to emphasize the seriousness of those complications and to define the indications for performing the procedure. The serious complications encountered by the authors included antegrade dissection of the femoral and iliac arteries with acute thrombosis, perforation of an iliac artery with retroperitoneal hemorrhage, widespread embolization of the mesenteric and peripheral circulation leading to renal failure, gangrene of the buttocks, the perineum and the legs with eventual death, thrombosis and embolization of the renal artery with secondary infarction of the kidney, thrombosis of the popliteal trifurcation, acute peripheral ischemia secondary to propagation of the thrombotic occlusion and occlusion of collateral arteries above and below the site of dilatation. The authors believe that the transluminal angioplasty should be considered only in those patients who are poor risks for

conventional vascular reconstructive surgery. In their opinion the procedure should never be used for carotid lesions and in patients with a history of atheromatous embolization. An ideal patient for transluminal angioplasty appears to be the one with flat and isolated lesions caused by fibromuscular disease. They suggest that the procedure should be performed in conjunction with a vascular surgeon and that it should be done in the operating room, so that if the transluminal angioplasty fails or results in complications an immediate vascular reconstruction could be done.

Abstracter's comment. In my opinion the term angioplasty is inappropriate and misleading. Since no plastic reconstruction is performed by the use of the balloon catheter and only a dilatation of the stenotic segment of the artery is done the procedure should be called angio-dilatation rather than angioplasty. Urethral dilatation for a urethral stricture is not called urethroplasty. I wonder why angiographers like to use the term angioplasty. N. S. D. 8 figures, 12 references Editorial comment. All that glitters is not gold. A. T. E. Percutaneous Angiographic Embolization: A Procedure of Increasing Usefulness. Review of a Decade of Experience F.

s. KELLER, J. ROSCH, G. M. BAUR, L. M. TAYLOR, C. T. DOTTER AND J.M. PORTER, Department of Diagnostic Radiology, Division of Vascular Surgery, University of Oregon Health Sciences Center, School of Medicine, Portland, Oregon

Amer. J. Surg., 142: 5-13 (July) 1981 During the last decade percutaneous therapeutic vascular occlusion was done on 152 occasions in 124 patients. The primary indication was acute or recurrent bleeding. Upper gastrointestinal arterial bleeding was controlled in 92 per cent of such patients and acute variceal bleeding was controlled in 83 per cent. Infarction was done for 31 primary renal carcinomas and 1 squamous cell metastasis to the kidney associated with hematuria and severe pain. Seven of these were in patients with resectable malignancies to decrease surgical blood loss and to facilitate operations. Three patients with chronic renal failure and severe hypertension or proteinuria were referred for "catheter nephrectomy" to improve the management. Massive hematuria in 2 patients (1 after trauma and 1 after biopsy) was controlled by selective vaso-occlusion of the responsible intrarenal branch. Eight patients with congenital arteriovenous malformations underwent 21 vaso-occlusive procedures. These 8 patients included 2 with small intrarenal arteriovenous malformations, which were easily selectively embolized with preservation of a maximum amount of renal tissue. The remaining 6 were large complex lesions in other areas, which were difficult to eradicate by angiographic vaso-occlusion. A typical syndrome offever, leukocytosis, pain and, occasionally, ileus developed after infarction of kidneys with large neoplasms. Mild to moderate flank pain occurred only in patients with chronic renal failure who had catheter renal ablation and in those who had selective occlusion of more peripheral renal vessels. There were no deaths or significant procedurerelated complications in this group of patients.

Abstracter's comment. This study represents one of the largest reported series of patients treated by percutaneous angiographic embolization. It attests to the safety and effectiveness of the procedure when done in selected patients by