No abstract

In patients not undergoing beta-blocker therapy, large AAA expand at a significantly greater rate than smaller AAA. Large aneurysms that rupture show more rapid expansion than those AAA that do not rupture. We have demonstrated a significantly reduced rate of expansion of large AAA in patients receiving beta-blockade.

Objective: To assess the short-and long-term outcomes of vena cava filter (VCF) placement for prophylaxis against pulmonary embolism in patients at high risk due to trauma.Design and Setting: Case series at a level I trauma center.Patients: Patients were considered for prophylactic VCF placement if they met 1 of the injury criteria-spinal cord injuries with neurologic deficit, severe fractures of the pelvis or long bone (or both), and severe head injuryand had a contraindication to anticoagulation.Intervention: Vena cava filters were placed percutaneously by the interventional radiologists when the acute trauma condition was stabilized following admission. Main Outcome Measures:Filter tilt of 14°or more, strut malposition, insertion-related deep vein thrombosis, pulmonary embolism, or inferior vena cava patency.Results: There were 132 prophylactic VCFs placed. A 3.1% rate of insertion-related deep vein thrombosis occurred, all of which were asymptomatic. Filter tilt occurred in 5.5% of patients and strut malposition in 38%. Three cases of pulmonary embolism (1 fatal) occurred in a prophylactic VCF, and all patients had either filter tilt or strut malposition. The risk of pulmonary embolism developing was higher in those patients with filter tilt or strut malposition than in those who did not have these complications (6.3% vs 0%; P=.05; Fisher exact test). The 1-, 2-, and 3-year inferior vena cava patency rates (±SD) were 97%±3%.Conclusions: Prophylactic VCF can be placed safely with an acceptable rate of insertion-related deep vein thrombosis and long-term inferior vena cava patency. Patients with prophylactic VCF remain at risk for pulmonary embolism if the filter is tilted 14°or more or has strut malposition. In such patients, consideration should be given to placing a second filter.

THE FIRST to successfully remove all of the liver located to the right of the falciform ligament, or about 80 to 85 per cent of the organ, were Wangensteen (19), Lortat-Jacob and Robert (11) and Quattlebaum (17). The potential enthusiasm for the procedure which became known as extended right hepatic lobectomy was apparently dampened by a heavy mortality rate in the early trials of its use by Brunschwig (1) and by others. Although Pack and Molander (16) and Miller (14) acquired experience with more than 40 patients in the ensuing two decades, large collections were not reported by others. More recent series of hepatic resections have contained few extended right lobectomies. For example, Longmire and his associates (10) had only two in their experience with 75 hepatic resections. There were no such operations among the 107 hepatic resections recently reported by Lin (8).The literature concerning extended right hepatic lobectomy has added little about the surgical technique since the original descriptions. It is our purpose to focus upon a neglected aspect of the operation which concerns the anatomy encountered in dissecting the left branches of the portal triad toward the falciform ligament and umbilical fissure. At the same time, other principles of extended right lobectomy will be reviewed; their relevance to less extensive partial hepatectomies will be mentioned. SURGICAL UNITSThe basis for orderly subtotal resection of the liver is found in anatomic studies which were published a quarter of a century apart. The first of these influential reports was by McIndoe and Counseller (13) in 1927. They proved that the division between the true right and left lobes of the liver was not at the falciform ligament as had been previously believed but rather at a line going through the bed of the gallbladder and projecting posteriorly toward the vena cava. From 1950 to 1954, Hortsjö (7), Healey (5) and Healey and Schroy (6) demonstrated that each true lobe was further divided into two segments. The portal venous, hepatic arterial and hepatic duct branches conformed to the four segment organization. These observations were confirmed and extended by Couinaud (2) and Goldsmith and Woodburne (4). The larger hepatic veins were distributed differently since a number of their ramifications are between rather than within segments and lobes.For practical purposes, there are only four surgical units that lend themselves to controlled excision (Fig. 1) including the right and left true lobes which consist of two segments each. The third possibility is removal of the complete right lobe plus the medial segment of the left lobe. The operation is most correctly called trisegmentectomy, although the term of Pack and his associates (15) of extended right hepatic lobectomy has been frequently used. Fourth, the

Treatment with anti-CD18 monoclonal antibody slows the expansion of AAA in this experimental model. The associated inflammatory process at day 14, as indicated by monocyte infiltration, is reduced, but this effect may be opposed by the presence of hypertension. Further evaluation of the role of leukocytes and adhesion molecules in the expansion of AAA is warranted.