- Email: [email protected]
SUCTION DRAINAGE AFTER STRIPPING OF LONG SAPHENOUS VEINS
586
Fig.
1-Isletcell cluster formation in culture.
Left: group of 50 islets, prepared by collagenase pancreas, at time of initial cluster formation.
digestion of mouse
Right: tight islet cluster after7 days of organ culture in RPMI 1640 supplemented with antibiotics and 10% fetal calf serum. Organ culture was done in hydrophobic plastic culture dishes (Falcon 1008).
of 95% O2 and 5% CO2, or by a shorter period of organ culture if the tissue donor is pretreated with cyclophospharaideto reduce the number of leucocytes carried in the transplanted tissue. Single isolated islets from rats or mice degenerate rapidly when cultured in 95% O2 and 3% CO. However, this toxic effect of oxygen on the islet tissue is eliminated if groups of approximately 50 islets are aggregated into a tight islet cluster during the culture period (fig. 1). Islet clusters can be cultured at 37°C in 95% O2 and 5% COfor up to 20 days. Uncultured mouse islets from BALB/c(H-2d) donors elicit a violent allograft response when transplanted under the kidney capsule of normal allogeneic CBA(H-2k) recipient mice (fig. 2); such allografts are completely rejected within 14 days of transplantation. However, islet clusters obtained from cyclophosphamide-pretreated donors and cultured at 37°C for 7 days in an atmosphere of 95% O2 and 5% CO2 show little or no evidence of rejection when transplanted to normal CBA recipients. Aldehyde-fuchsin staining of the tissue shows the presence of insulin-containing p cells in the transplanted tissue over an observation period of 3 months (fig. 3). In most of our islet studies cyclophosphamide pretreatment of the tissue donor has been combined with organ culture. However, we have now shown that organ culture alone for a period of 7 days is sufficient to eliminate islet allograft immunogenicity. The essential ingredient in this recipe for elimination of islet immunogenicity is organ culture in an oxygen-rich atmosphere. We would suggest this effect results from the selective toxicity of oxygen for lymphocytes and macrophages carried within the tissue, these constituting the major source of tissue
immunogenicity. A detailed report of these studies is
to
be
published
Department of Immunology, John Curtin School of Medical Research, P.O. Box 334, Canberra City, A.C.T. 2601, Australia
in Diabetes.
KERRY M. BOWEN LINDA ANDRUS KEVIN J. LAFFERTY
SUCTION DRAINAGE AFTER STRIPPING OF LONG SAPHENOUS VEINS
Fig. 2-Allograft responses to freshly isolated BALB/c islets 14 days after transplantation to the kidney capsule of CBA recipient mouse. (Hasmatoxylin and eosin; reduced to about4 ofx50.)
Fig. 3-Host (CBA) response to allograft of islet tissue conditioned by cyclophosphamide treatment of islet donors (BALB/c) and 7-day period of organ culture. Tissue was examined 3 months post-transplant (aldehyde-fuchsin; reduced
two4 of312.)
SIR,-Mr Negus (Aug. 18, p. 324) offers one possible solution to the problem of thigh bruising after stripping. I should like to suggest an alternative. The stripping technique that we have adopted since 1970 is as follows: Perforators and main tributaries having been dealt with, the stripper is passed from the trifurcation just below the knee to the groin. The medial thigh tributary which joins the long saphenous vein a few centimetres below the saphenofemoral junction must be ligated. The mid-Hunter tributary is also usually separately ligated. With the stripper still in situ all wounds are now closed and dressed except for the upper incision in which one suture is left untied alongside the stripper. The leg and thigh are bandaged with ’,Elastocrepe’. A shaped tubular support bandage (SSB, Seton Products) is then rolled on over the crepe bandage. This provides graduated compression, especially at the knee area which is otherwise difficult to compress, and prevents the underlying bandage from working lose. The vein is then stripped from knee to groin, and since we do not use sterile bandages, the last suture is tied with sterile forceps and the groin wound dressed. The objection to stripping in an upward direction-i.e., -that it can cause nerve damage--does not appear to apply when only the thigh segment of the saphenous vein is stripped. As well as being applied on a regular basis for inpatients, this technique, in combination with multiple ligations of perforators, has been applied in 434 patients in a day-care unit. It has been very rare indeed for any thigh bruising to be detected postoperatively and any such bruising has been confined to the uppermost few centimeteres of the thigh. By avoiding bruising one also reduces postoperative pain-a special advantage when patients are returning home on the day of operation. Department of Surgery, Royal Infirmary,
Edinburgh EH3
9YW
C. V. RUCKLEY
Fig.
1-Isletcell cluster formation in culture.
Left: group of 50 islets, prepared by collagenase pancreas, at time of initial cluster formation.
digestion of mouse
Right: tight islet cluster after7 days of organ culture in RPMI 1640 supplemented with antibiotics and 10% fetal calf serum. Organ culture was done in hydrophobic plastic culture dishes (Falcon 1008).
of 95% O2 and 5% CO2, or by a shorter period of organ culture if the tissue donor is pretreated with cyclophospharaideto reduce the number of leucocytes carried in the transplanted tissue. Single isolated islets from rats or mice degenerate rapidly when cultured in 95% O2 and 3% CO. However, this toxic effect of oxygen on the islet tissue is eliminated if groups of approximately 50 islets are aggregated into a tight islet cluster during the culture period (fig. 1). Islet clusters can be cultured at 37°C in 95% O2 and 5% COfor up to 20 days. Uncultured mouse islets from BALB/c(H-2d) donors elicit a violent allograft response when transplanted under the kidney capsule of normal allogeneic CBA(H-2k) recipient mice (fig. 2); such allografts are completely rejected within 14 days of transplantation. However, islet clusters obtained from cyclophosphamide-pretreated donors and cultured at 37°C for 7 days in an atmosphere of 95% O2 and 5% CO2 show little or no evidence of rejection when transplanted to normal CBA recipients. Aldehyde-fuchsin staining of the tissue shows the presence of insulin-containing p cells in the transplanted tissue over an observation period of 3 months (fig. 3). In most of our islet studies cyclophosphamide pretreatment of the tissue donor has been combined with organ culture. However, we have now shown that organ culture alone for a period of 7 days is sufficient to eliminate islet allograft immunogenicity. The essential ingredient in this recipe for elimination of islet immunogenicity is organ culture in an oxygen-rich atmosphere. We would suggest this effect results from the selective toxicity of oxygen for lymphocytes and macrophages carried within the tissue, these constituting the major source of tissue
immunogenicity. A detailed report of these studies is
to
be
published
Department of Immunology, John Curtin School of Medical Research, P.O. Box 334, Canberra City, A.C.T. 2601, Australia
in Diabetes.
KERRY M. BOWEN LINDA ANDRUS KEVIN J. LAFFERTY
SUCTION DRAINAGE AFTER STRIPPING OF LONG SAPHENOUS VEINS
Fig. 2-Allograft responses to freshly isolated BALB/c islets 14 days after transplantation to the kidney capsule of CBA recipient mouse. (Hasmatoxylin and eosin; reduced to about4 ofx50.)
Fig. 3-Host (CBA) response to allograft of islet tissue conditioned by cyclophosphamide treatment of islet donors (BALB/c) and 7-day period of organ culture. Tissue was examined 3 months post-transplant (aldehyde-fuchsin; reduced
two4 of312.)
SIR,-Mr Negus (Aug. 18, p. 324) offers one possible solution to the problem of thigh bruising after stripping. I should like to suggest an alternative. The stripping technique that we have adopted since 1970 is as follows: Perforators and main tributaries having been dealt with, the stripper is passed from the trifurcation just below the knee to the groin. The medial thigh tributary which joins the long saphenous vein a few centimetres below the saphenofemoral junction must be ligated. The mid-Hunter tributary is also usually separately ligated. With the stripper still in situ all wounds are now closed and dressed except for the upper incision in which one suture is left untied alongside the stripper. The leg and thigh are bandaged with ’,Elastocrepe’. A shaped tubular support bandage (SSB, Seton Products) is then rolled on over the crepe bandage. This provides graduated compression, especially at the knee area which is otherwise difficult to compress, and prevents the underlying bandage from working lose. The vein is then stripped from knee to groin, and since we do not use sterile bandages, the last suture is tied with sterile forceps and the groin wound dressed. The objection to stripping in an upward direction-i.e., -that it can cause nerve damage--does not appear to apply when only the thigh segment of the saphenous vein is stripped. As well as being applied on a regular basis for inpatients, this technique, in combination with multiple ligations of perforators, has been applied in 434 patients in a day-care unit. It has been very rare indeed for any thigh bruising to be detected postoperatively and any such bruising has been confined to the uppermost few centimeteres of the thigh. By avoiding bruising one also reduces postoperative pain-a special advantage when patients are returning home on the day of operation. Department of Surgery, Royal Infirmary,
Edinburgh EH3
9YW
C. V. RUCKLEY