Lateral Anastomosis Research Articles

Aneurisma fusiforme de la arteria cerebral media

Introduction. The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. CASE REPORT. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada s test showed the vascular territory with the greatest risk of neurological deficit. Extra intra cranial by pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post operative course was uneventful. Anatomo pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow up the patient remains asymptomatic. Discussion and conclusions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revascularization. Correct pre operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms.

Regeneração de nervo periférico após anastomose término-lateral, com manutenção do epineuro, em ratos

A reinervação dos nervos periféricos pode ser realizada através de anastomoses término - terminais ou término-laterais, e este fenômeno tem sido amplamente estud ado. As anastomoses nervosas término-laterais tem sido utilizadas com pouca freqüência em relação as anastomoses término-terminais e contestada por alguns autores quanto a possibilidade de reinervação, quando a integridade do epineuro é mantida. Devido a estas divergências, estudou-se o efeito do epineuro na reinervação em anastomoses término-laterais, em ratos. Foram utilizados 20 ratos Wistar, adultos, distribuídos em dois grupos (A e B). No grupo A, 10 animais foram submetidos à secção do nervo fibular no membro pélvico direito e fixação desde à musculatura; no membro pélvico esquerdo foi realizada a secção do nervo fibular e anastomasado término-lateral com o nervo tibial. No grupo B, os procedimentos foram idênticos aos realizados no grupo A, sendo somente invertido os membros pélvicos. No nonagésimo dia do ato operatório, foi realizada uma biópsia em cada nervo fibular para análise histológica à microscópia óptica, onde a reinervação foi objeto de estudo. A reinervação ocorreu mostrando que a integridade do epineuro não impediu a regeneração axonal.

Clinical experience with modified Studer's bladder substitute

We modified Studer's bladder substitute technique and constructed continent urinary reservoir for 7 patients with bladder tumors after transprostatic cystoprostatectomy. Studer's bladder substitute technique is characterized by both a tubular isoperistatic proximal limb of 20 cm of the ileum in continuity with the pouch constructed using the detubularized ileum and the ureters reimplanted into the proximal part of the limb using a simple lateral anastomosis of the ureters to the end of the limb. Our modifications, transprostatic resection, was that distal one third or fourth of the prostate was left after cystoprostatectomy followed by either enucleation of the whole residual prostatic tissue including the urethra (type II) or sharp resection of the tissue leaving the urethra (type III). A small hole in the lowest part of the pouch was anastomosed either to the residual prostatic capsule (type II) or to the residual prostatic urethra (type III). Our modified Studer's technique was simple, easy to perform, and had low risk of massive bleeding especially from the central vein overlying the appex of the prostate. Clinical results were as follows; 1) all patients were satisfied with the passing of their urine per urethra without any cutaneous stoma, 2) no patients had clinical signs of pyelonephritis after discharge, 3) urine was not infected.(ABSTRACT TRUNCATED AT 250 WORDS)

Dacron Patch/Tube Graft: A Preliminary Study

A Dacron patch/tube graft was developed specifically to avoid technical complications associated with lateral aortic anastomoses of medium-diameter grafts. This new prosthetic device has now been used in 15 patients without complications. It seems to be particularly useful in patients with thick-walled aortas.

Fenestration of the vertebrobasilar junction

A fenestration of the vertebrobasilar junction was found in an 80-year-old man during autopsy. It was associated with thrombosis of the vertebral arteries which had caused a left Wallenberg syndrome. The left limb of the fenestration presenting the same transverse diameter as that of the remaining part of the basilar artery appeared to be its direct (true) origin. The right limb had a lesser transverse diameter and appeared to bridge the lateral surface of the rostral end of the right vertebral artery and the basilar trunk. According to the authors, this fenestration could have been caused by the persistence of the cranial part of a primitive lateral vertebrobasilar anastomosis, rather then by the usual incomplete fusion of the primitive paired basilar arteries.

Robert Abbe 1851-1928

Robert Abbe was born April 13, 1851, in New York City, the fifth and youngest son of a New York merchant. He was of the seventh generation of Abbes in America, tracing his ancestry to the Salem, Massachusetts, settlement of 1635. His mother was a Colgate, daughter of the founder of the soap company. Abbe received his undergraduate training at the City College of New York, graduating in 1870. He demonstrated considerable ability in drawing and was an instructor at the college in this subject and in English and geometry for the next two years. He then entered Physicians and Surgeons, receiving his doctorate in medicine in 1874. Following internship at St. Luke's Hospital, he traveled abroad, touring a number of European medical centers, and returned to become an attending surgeon at St. Luke's Hospital and the New York Hospital. Abbe was an innovative surgeon and a prolific writer. His contributions were reflected in many areas, most notably intestinal surgery, thyroid surgery, and plastic and reconstructive operations. Eponymous procedures include lateral intestinal anastomosis (the subject for thisClassics presentation), division of esophageal stricture, and intracranial resection of the fifth nerve for tic doloureux. He was one of the early advocates of radiotherapy in the treatment of malignant conditions. In fact, he developed aplastic anemia, possibly as the result of ineffective protection in the handling of radioactive material. Abbe died March 7, 1928, at the age of 77.

Renal Arteriovenous Fistula: A Model for Renovascular Hypertension in Rat

Renal arteriovenous fistula (RAVF) was created in the rat. For this purpose the left renal artery and vein were connected by a latero lateral anastomosis. This operation was performed in 40 rats and 12 animals were sham operated. All these animals were subsequently reoperated after 4 weeks to check the fistula and the kidney. Eleven among the 40 operated rats died during or after the surgery. In 16 others animals hypertension developed. Their blood pressure was 161 ± 4.3mm. Hg at 4 weeks vs. 105 ± 1.65mm. Hg before surgery. All these animals had after 4 weeks a permeable fistula and an atrophic but nonnecrotized left kidney (kidney weight was 0.56 ± 0.33gm. vs. 1.32 ± 0.22gm. for the sham operated group). They underwent a left nephrectomy without closure of the fistula and subsequently their blood pressure fell back to normal values (120 ± 2.9mm. Hg 2 weeks after nephrectomy). In the removed kidney, renal renin content per mg. of protein was found to be higher than in the kidney of the sham operated animals (28.5 ± 7.9 vs. 0.66 ± 0.2μg. AI/mg. protein/hour). In 13 other animals the blood pressure remained normal after the initial surgery. These animals had a permeable fistula but a necrotic left kidney. It is concluded that RAVF can induce hypertension in the rat. This hypertension only develops when the ipsilateral kidney remains vascularized and disappears when this kidney is removed without closure of the fistula. Since the renin content in the kidney distal to the shunt was higher than in the kidney of the sham operated rats and since there was a positive correlation between renal renin content and blood pressure in hypertensive animals, it is suggested that an activation of the renin angiotensin system in the ipsilateral ischemic kidney is responsible for hypertension. RAVF therefore appears to be an experimental model for renovascular hypertension in rats.

Evolution of the endoplasmic reticulum during rat spermiogenesis.

AbstractThe endoplasmic reticulum (ER) was stained selectively by a sequence of uranyl acetate, lead and copper citrate, according to the method of Thiéry and Rambourg ('76), and then investigated in 0.5 to 2.0‐μm‐thick sections with the transmission electron microscope. Examination of photographic stereopairs allowed a three‐dimensional visualization of the ER at various steps of spermiogenesis.During the Golgi and cap phases of spermiogenesis (steps 1–7, classification of Leblond and Clermont, '52a), the ER is distributed throughout the cytoplasm as a three‐dimensional network of spherical and tubular cisternae connected by narrow tubules. In addition, a close network of tubular cisternae is located along the convex surface of the Golgi apparatus and lines the plasma membrane. Where the cell membrane joins that of another spermatid to form an intercellular bridge, this network extends across the bridge.During the acrosome phase (steps 8–14), the cytoplasm contains an abundant ER that shows the following modifications: (A) Along the inside and outside of the caudal tube the cisternae form long tubes or plates which run adjacent and parallel to the microtubules. These cisternae are connected by delicate lateral anastomoses; (B) Along the flagellum the ER forms a “fenestrated sleeve” made up of a close network of tubular cisternae; (C) Similar networks are organized as “fenestrated spherules” enclosing large vesicles seen throughout the cytoplasm; (D) At a short distance from the flagellum, the ER cisternae are continuous with a stack of annulate lamellae and an aggregate of radially arranged collapsed cisternae called the “radial body”.During the last or maturation phase (steps 15–19), the ER regresses. Thus, during the final steps in the formation of the flagellum, the ER network fragments and then most of the cisternae disappear from the cytoplasm. The “radial body” is the last element of the ER to be dissolved. Thus the ER undergoes extensive structural modifications during spermiogenesis, suggesting an active contribution of this organelle to the differentiation of the spermatid into a spermatozoon.

PHYLLODE THEORY IN RELATION TO LEAF ONTOGENY IN SANSEVIERIA TRIFASCIATA

Shoot apices of Sansevieria trifasciata have a three‐layered mantle, a zone of subapical initials, a central meristem, and a peripheral meristem. Leaf initiation begins with periclinal divisions in L‐3 and is followed by periclinal divisions in L‐2 and anticlinal divisions in L‐l. At first, the primordium is a mound of tissue at one point on the flank, but it soon takes the form of a low ridge encircling the apex. An ephemeral adaxial meristem differentiates in L‐2 of the primordium when it is about 50 μ high and is active until the primordium is about 450 μ high. Then it ceases basipetally and is not observable after the primordium is about 600μ high. As the adaxial meristem ceases at the base of the radial tip, its two lateral regions become the submarginal meristems of the expanded portion. Marginal meristems differentiate from the protoderm, and oblique‐anticlinal divisions of the marginal initials result in the formation of an abaxial and adaxial epidermis. These derivatives undergo a few anticlinal divisions, increasing marginal width, and then they divide periclinally, increasing marginal thickness. After the primordium is about 600‐700 μ high it continues to grow in length by a diffuse basal intercalary meristem. When the leaf is 3 dm long, an adaxial rounding meristem differentiates in the region just above the sheath. Leaf vasculature consists of parallel bundles which anastomose acropetally. Vascular bundles are arranged in a semicircle in the expanded portion and in a circle in the radial tip. There is one centrally located bundle at the apex as a result of lateral anastomoses. Present evidence from leaf ontogeny and mature vasculature in S. trifasciata is interpreted as supporting the concept that the liliaceous leaf is homologous with the phyllodes of A corns and Acacia.

Late sequelae of blind intestinal pouches

Five case histories are presented which point out the complications of side to side intestinal anastomosis. In these instances a blind pouch was the sole cause of a variety of clinical problems. The difficulties in establishing an early correct diagnosis are understandable but not necessarily acceptable. Although isolated case reports reach the literature, it is indeed likely that the increasing use of end to end anastomoses will relegate these pouches to the position of actuarial oddities. It must be remembered, however, that the lateral anastomoses employed years ago remain potentially dangerous and may be the causes of many bizarre and longstanding abdominal complaints. An awareness of the possibility of a pouch in a patient with a history of intestinal resection, particularly if operated on a decade or so ago, could lead to early surgical intervention and replacement of the lateral anastomosis with an end to end anastomosis. Five case histories are presented which point out the complications of side to side intestinal anastomosis. In these instances a blind pouch was the sole cause of a variety of clinical problems. The difficulties in establishing an early correct diagnosis are understandable but not necessarily acceptable. Although isolated case reports reach the literature, it is indeed likely that the increasing use of end to end anastomoses will relegate these pouches to the position of actuarial oddities. It must be remembered, however, that the lateral anastomoses employed years ago remain potentially dangerous and may be the causes of many bizarre and longstanding abdominal complaints. An awareness of the possibility of a pouch in a patient with a history of intestinal resection, particularly if operated on a decade or so ago, could lead to early surgical intervention and replacement of the lateral anastomosis with an end to end anastomosis.

Pitfalls in the surgical management of the incomplete duodenal diaphragm

Twenty-one consecutive patients with incomplete duodenal diaphragms were treated without fatality. Observed and reported pitfalls for the surgeon include difficulty in diagnosis before and during laparotomy, coexistence with intestinal malrotation or intrinsic obstructions of the duodenum, stomach or anorectum, intimate anatomic relationship with the bile ducts, the confusing features of the windsock type diaphragm, and a tendency for malfunction of bypassing lateral anastomoses. Successful management has featured increased preoperative diagnostic effort, use of a Foley bag catheter or appropriate instrument to help locate and calibrate intrinsic obstructions, and a preference for excision of the diaphragm with protection of the bile ducts.

Choledochoduodenostomy. In the treatment of stenosis in the distal common duct.

Shortly after the introduction of gallbladder surgery, operative procedures were extended to include the common bile duct. Choledochoduodenostomy was first performed by Riedel, in 1888, 1 who intended to cut across the common duct and implant the severed end into the duodenum, but abandoned this idea and united by lateral anastomosis the dilated common duct to the duodenum. The patient died as a result of leakage of infected bile into the peritoneal cavity. Sprengel, 2 in 1891, reported the first recovery following choledochoduodenostomy; the patient was a woman on whom he had previously performed a cholecystectomy. W. J. Mayo, 3 in 1905, reported successful treatment of stricture of the common duct following cholecystectomy and choledochotomy by suturing the end of the dilated portion of the duct to the duodenum. The fear of ascending cholangitis has caused many surgeons to shun choledochoduodenostomy as a method of correcting distal-common duct obstruction. Experimental

Complications of bypass procedures

R ECENT PROGRESS in medicine and surgery has been remarkable. Medical and lay journals testify to the miraculous achievements and the increasing ability of physicians to cope with conditions formerly considered incurable. Similarly, surgeons are able to treat many diseases with one stage, curative procedures when multistaged operations were the rule in the past. Because of better management of patients, more complete understanding of the pathophysiology of intestinal disease, and improved methods of preoperative diagnosis, one stage definitive surgery has been elected more and more frequently for diseases of the alimentary tract. Multistaged operations on the gastrointestinal tract have been characterized by lengthy hospitalization, prolonged convalescence, and often increased morbidity and mortality. Surgeons may frequently avoid these multistaged procedures by better preoperative evaluation ; however, in advanced disease, emergency surgery, or critically ill patients, nondefinitive lesser surgical procedures are often indicated as a temporizing life-saving measure. Attempts at one stage cure, on the other hand, may lead to unacceptable morbidity and mortality. Bypass or short circuit of diseased intestinal segments provides a rapidly performed technic which can be carried out through noninflamed areas avoiding diseased bowel, infected wounds, fistulous tracts, or adhesions and permitting management of the disease until definitive surgery can be tolerated. The use of these limited operations is restricted to those cases in which locally advanced disease or disturbed physiology prevents curative surgery. When these conditions are present, bypass operations are an invaluable means of management, but under no circumstances should they be considered a substitute for definitive surgery. When a short-circuiting procedure is elected, several factors must be noted: (I) The disease is left in situ and may progress unabated until further definitive surgery is carried out. (2) Bypass should remove as short a segment of normal bowel as possible to avoid iatrogenic malabsorption. (3) Bypass technics are associated with their own unique complications which must be prevented when feasible and recognized when present. There are three types of bypass operations: (1) bypass without exclusion (incontinuity bypass) (Fig. 1A); (2) bypass with partial exclusion (unilateral bypass) (Fig. 1R) : and (13) bypass with total exclusion (bilateral bypass) (Fig. 1C). Lateral anastomosis, used to accomplish incontinuity bypass, is the least effective means joining two loops of bowel. Fecal flow through the intestine is normally linear and continues through the pathologic area unless obstruction is present [I], in which case linear flow is slowed and lateral pressure and flow rise proportionally. Defunctionalization is therefore unpredictable, dependent on distal obstruction, and usually incomplete ; primary or secondary inflammatory disease continues unabated because of constant bacterial and fecal stimulation [Z]. Incontinuity bypass should be used only to obtain a rapid short circuit of an obstructed area when curative surgery must be deferred or avoided [3]. It is not a substitute for an exclusion operation since it does not exclude fecal contents from the diseased intestine. Lateral enteroenterostomy is of inestimable value, however, in the management or palliation of unresectable disease or for malignancy in any segment of the gastrointestinal tract. Incomplete exclusion provides efiective decompression of the proximal bowel and more adequate defunctionalization. It may be per-

Blind pouch syndrome a complication of side to side intestinal anastomosis

The “blind pouch” syndrome is defined as the series of symptoms associated with formation of a blind pouch secondary to side to side intestinal anastomosis. It should be distinguished from the “blind loop” syndrome. Symptoms associated with formation of the blind pouch are anemia, intermittent abdominal pain, diarrhea, and failure to gain weight. Three instances of “blind pouch” syndrome with severe anemia due to intestinal bleeding are reported. The treatment is excision of the lateral anastomosis followed by end to end anastomosis of the normal intestine.

The role and management of enterostomy in intestinal obstruction in infants

The history of use of the Mikulicz exteriorization resection in jejunoileac obstruction in infancy is reviewed. The double-barreled enterostomy is rarely employed now in adults but its revival over fifteen years ago as part of a two stage Mikulicz procedure was associated with a gratifying sustained improvement in survival rates in this demanding group of patients. Much of the condemnation of enterostomy in infants probably arose from the misconception that its role was that of a definitive therapeutic step rather than a temporary expedient designed to insure immediate effective decompression and safer anastomosis. Dissatisfaction with the continued poor results achieved by lateral anastomosis and reluctance to adopt the older, complicated exteriorization operation have led several surgeons to advocate primary end to end anastomosis during the past few years. Their demonstration of increasingly favorable recovery rates that rival those of the inherently less appealing staged procedure suggested that this review of the indications and rationale for choice of operative technic in specific situations might reveal opportunity for further improvement using a combined or flexible approach. The advantages and disadvantages of the Mikulicz procedure have been considered in the light of the specific and exacting demands of the surgical problems posed by neonatal intestinal obstruction. We believe that this admittedly less attractive staged procedure will continue to deserve use in certain small infants because: 1. 1. It can obviate the malfunction inevitable in the anastomosis of intestinal segments of tiny and disparate caliber. 2. 2. It provides immediate, effective, sustained decompression for the critically ill “fragile” infant. 3. 3. It provides the safest and most effective opportunity for evaluation and clearing of abnormal distal intestinal segments. 4. 4. It has been proved capable of a sustained high recovery rate in the hands of both widely experienced and resident surgeons. The essential steps and some of the important details in construction, care, and extraperitoneal closure of the double-barreled enterostomy have been outlined and illustrated. Some of our metabolic studies on infants with enterostomies are reviewed to show the common patterns of enterostomy loss of fluid and electrolyte and their use in a plan for satisfactory control and replacement. It is concluded that the Mikulicz procedure should still be part of the training of every general surgeon and, properly used, can salvage certain obstructed infants with relatively little chance of survival by primary anastomotic technics.

Surgery of endometrioma of the ileum and colon

1. 1. The subject of endometrioma of the small and large intestine associated with intestinal obstruction is reviewed. 2. 2. The clinical manifestations, the treatment and the associated pathology are presented pertinent to ten patients with involvement of the intestine by isolated endometrioma. Range in age of these ten patients was thirty-three to forty-eight years. 3. 3. A solitary endometrioma of long-standing may involve the ileum and sigmoid or rectosigmoid colon to such an extent that gastrointestinal symptoms and signs of partial or complete intestinal obstruction may appear. 4. 4. The occurrence of obstructive symptoms, accentuated preceding or during the menstrual period, should suggest endometrioma of the small or large intestine in the differential diagnosis of intestinal obstruction. 5. 5. An endometrioma of the small or large intestine may be diagnosed on an awareness of the possibility of the disease, a complete history, and a combined rectovaginal examination coupled with the findings of the proctoscopic and barium enema examinations. 6. 6. The symptomatology and the gross appearance of an endometrioma and carcinoma of the colon are so similar that it is often difficult to distinguish these lesions even at operation. Anterior resection of the colon is recommended if any doubt exists. 7. 7. The management of patients with a solitary endometrioma or multiple endometrial implants affecting the small or large intestine should be individualized. The choice of treatment depends upon the age of the patient, the evaluation of the severity of symptoms, and the extent of the involvement of the intestine and pelvic organs. 8. 8. The recommended treatment of an acute obstruction of the ileum and sigmoid or rectosigmoid colon by an endometrioma is resection with end to end anastomosis, whenever possible. A Mikulicz procedure or lateral anastomosis may be indicated in patients who are poor risks. 9. 9. When chronic or recurring symptoms of low-grade intestinal obstruction are present, segmental resection of the colon may be contemplated. Local excisions of small isolated endometriomas may be adequate treatment in certain instances. 10. 10. In the surgical management of these patients, the preservation of ovarian function is advocated whenever possible.

Three cases of uretero-cystostomy for megaloureter.

SUMMARY This small series of three cases of lateral ureterovesical anastomosis is presented, not as suggesting that this operation offers an ideal solution of the problem of megalo-ureter, but as being an easy, simple procedure of low mortality (there was none in this series), and capable of prolonging life (when this is threatened, as by a tightening ureteric stricture of a solitary kidney), and, in any case, of giving the patient great relief from painful and pyrexial episodes.

Blind-pouch formation following lateral anastomosis.

Side-to-side anastomosis is an expedient method for reestablishing intestinal continuity after resection. However, this procedure may be followed by a unique complication, which does not occur after the end-to-end or end-to-side technique. Infrequently, saccular dilatation develops in the portion of the proximal segment of intestine that projects beyond the anastomotic stoma. This is not necessarily due to leaving in an excessively long blind end. A closed section no longer than an inch beyond the stoma may develop into a large dilatation. This complication is illustrated in the first case reported. Report of Cases Case 1. —A 63-year-old white man was admitted to the hospital on July 18, 1956. Apparently in good health, he suddenly fainted after eating his dinner. When he became conscious, he vomited bile-stained food, and brownish-red blood was found oozing from the rectum. His skin was moist and cold. Oral temperature 98 F; pulse 64 per minute;

MANAGEMENT OF GANGRENOUS INTUSSUSCEPTION IN INFANTS

DISCUSSION continues at the present time as to the best means of dealing with the young child who has an irreducible or gangrenous segment of ileum or cecum resulting from intussusception. Three methods are employed and are still debated: (1) primary resection and anastomosis; (2) two-stage resection and anastomosis (Mikulicz), and (3) lateral anastomosis leaving the intussusception in situ. Primary resection and anastomosis is obviously the ideal method of treatment if it can be performed safely, but before accepting it as the routine treatment it is advisable to consider the problem in two ways: 1. The local hazard: the technical difficulties and risks involved in anastomosing the bowel immediately after excision of the infarcted or gangrenous segment. 2. The general hazard: the state of illness of the child. The first danger is not insuperable. The literature contains several accounts of single cases in which primary resection and anastomosis has succeeded

Symptomatic blind pouch following lateral anastomosis of intestine.

VARIOUS observations relative to the occurrence of macrocytic anemia, intestinal obstruction, borborygmus, diarrhea, bowel ulceration and malnutrition were recorded coincident with the early growth of gastrointestinal surgery, but the pathogenesis of these ills were speculative at best. As early as 1897, Faber 1 associated a macrocytic with stricture, and in 1906, Cannon and Murphy 2 reported roentgenologic evidence that in cats the proximal segment of a lateral anastomosis failed to empty well if the blind ends extended beyond the anastomotic opening. In 1924 Seyderhelm, 3 in Germany, described pernicious anemia in dogs consequent to the production of strictures of the small intestine just above the cecum using strips of aponeurosis. Tonnis and Brusis 4 also produced a macrocytic, hyperchromic in dogs but by another method, namely, the production of a 50 cm. cul-de-sac in the small intestine. Surgical excision of the culde-sac resulted in restoration of the hemogram