Showing papers in "American Journal of Surgery in 1978"

Metastatic pattern of malignant melanoma: A study of 216 autopsy cases

Abstract: The metastatic pattern and causes of death were analyzed by autopsy of 216 patients with histologically proven advanced malignant melanoma. These cases constituted 3 per cent of all the autopsies done for cancers from 1959 to 1954 at Roswell Park Memorial Institute, Age range was from six to eighty-six years, with a median value of 49.5 years. Male to female ratio was 1.5:1. Multiple organ metastases were present in 95 per cent of the patients. The most common organs involved were lymph nodes (73.6 per cent), lungs (71.3 per cent), liver (58.3 per cent), brain (49.1 per cent), bone (48.6 per cent), heart (47.2 per cent), adrenal glands (46.8 per cent), and gastrointestinal tract (43.5 per cent). Single organ metastasis was extremely uncommon in malignant melanoma of cutaneous origin. The incidence of histologically different, second primary cancer was 7.4 per cent. The most common cause of death was respiratory failure because of massive involvement of lungs in addition to pleura. The second leading cause of death was complications of brain metastases (increased intracranial pressure and hemorrhage). The median survival was twenty-four months. It appears that this is a selected group of patients with a worse prognosis than expected overall.

Meckel's diverticulum: Investigation of 600 patients in Japanese literature

Abstract: A total of 600 cases, comprising 4 of our cases and 596 others in Japan, was analyzed, and the diagnosis of Meckel's diverticulum was made in only 34 of them. The rate of diagnosis was 5.7 per cent, which is very low. The most common complication of this disease was intestinal obstruction, the second most common was intussusception, the third was inflammation, and the fourth was rectal bleeding. Ectopic tissue, present in ninety-three patients, consisted of ectopic gastric mucosa in fifty-eight. 99mTc-P scanning was performed on fifteen patients. In twelve of them ectopic gastric mucosa was observed. However, it was not found in three, all of whom had false-positive scans.

Survival after liver resection for secondary tumors

Abstract: The results achieved by liver resection for metastatic cancer in more than 400 patients have been studied in a collected review. Certain conclusions seem justified: The liver is no longer the surgeon's "no-man's-land," and local excision of metastatic tumor can achieve clinical cure in some patients. The risk-benefit ratio for hepatic resection for secondaries seems to be shifting in favor of benefit for selected patients with primary colorectal tumors. At present liver resection for tumors metastatic from pancreas, breast, lung, stomach, kidney, reproductive organs, and skin (melanoma) cannot be recommended. Liver resection may play an important part in the multi-modal therapy of children with extensive malignant disease.

Mucoepidermoid carcinoma of salivary gland origin: A clinicopathologic study of 367 cases☆

Abstract: A thirty year experience with 367 patients who had mucoepidermoid carcinoma of salivary origin is reviewed. The tumor arose in the parotid gland in 254 patients. The presentation and clinical course depended significantly on whether the tumor was low, intermediate, or high grade in histologic appearance. Metastasis and tumor-related death were occasionally noted in patients with low grade lesions, suggesting that even the most innocuous-appearing mucoepidermoid tumor has malignant potential. Significant correlation was demonstrated between the clinical stage of a tumor and its histologic appearance. Stage I tumors were usually of low histologic grade and were effectively controlled by conservative surgical procedures. Radical operations were often ineffective in patients with stage III tumors, most of which proved to be of high histologic grade. Considering the poor prognosis in the latter patients, adjunctive therapy in the form of postoperative external radiation seems indicated. In our experience, "cure" rates in patients who had intermediate or high grade lesions varied widely, depending upon the stage of the tumor. This strongly suggests that therapeutic decisions should not be based on histologic appearance alone.

Detection and treatment of recurrent cancer of the colon and rectum

Abstract: A series of 177 patients with recurrent colorectal cancer treated at the Massachusetts General Hospital is examined retrospectively. Two thirds of recurrences were observed by the second postoperative year, and 15 per cent of patients were asymptomatic. Pelvic recurrences were usually attributable to rectal or sigmoid tumors, whereas right-sided carcinomas frequently spread to the liver. The commonest methods of clinical discovery of recurrence included findings of abdominal and pelvic masses, hepatomegaly, and positive chest films. The average survival after discovery of recurrence was only eleven months, but 23 patients having reresections for cure lived an average of thirty-three months. Seven patients (30 per cent) undergoing reresection for cure represented probable cures. Chemotherapy with intravenous 5-FU provided poor palliation, but radiotherapy gave satisfactory relief of symptoms in approximately 50 per cent of patients, particularly those with rectal or low colon lesions. A program of follow-up is offered since there is evidence that even the symptomatic patient may be well palliated of even cured by surgical resection of the recurrence or palliative therapy.

Surgical management of patients with primary operable colorectal cancer and synchronous liver metastases

Abstract: The surgical results were analyzed of 217 patients who had undergone operation for primary colorectal cancer and were found to have synchronous liver metastases. It is recommended that patients with primary operable colorectal cancer who are found to have synchronous liver metastases should at least have an adequate resection of the primary lesion. If the primary lesion is resectable for cure and there are solitary hepatic metastases, then excision of these seems warranted. In most cases this can be accomplished by simple excision or wedge resection, although occasional cases may require lobectomy.

Hydatid disease of the liver

Abstract: Our experience in the surgical management of hydatid disease of the liver in 212 patients over the past eighteen years is reviewed. The most frequent postoperative complications and mortality rates of elective and emergency procedures are presented, and the more frequently utilized operative technics are described. In the great majority of patients conservatism was the rule in excision of solitary or multiple cysts. It is important to establish whether or not hepatic cysts communicate with the biliary tree. In these cases, enteroanastomoses (such as cystjejunostomy or cystgastrostomy) may be utilized depending on the position of the cyst. Any associated biliary disease (such as lithiasis or fibrosis) should be taken care of at the same time. External cystic drainage (marsupialization) is contraindicated because of the high incidence of chronic external biliary fistula, secondary hemorrhage, sepsis, and postlaparotomy hernia. In those patients in whom the cyst has penetrated the diaphragm and communicates with the lung, treatment should be carried out in one stage whenever possible.

Healing of experimental colonic anastomoses

Abstract: Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by the bursting strength technic from four to fourteen days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous suture and interrupted sutures. Bursting strength was tested by determinations of both bursting pressure and bursting wall tension, both of which provided the same information concerning mechanical strength of the colon. The bursting strength test measures the anastomotic strength only during the early stages of healing, since more than 90 per cent of the left colon segments ruptured outside the anastomosis as early as day 7. The two different suture technics resulted in the same bursting strength of the left colon segment with anastomosis. Both types of anastomoses showed a moderate narrowing at the anastomotic line upon inflation. This was due to the fact that the anastomosis constituted a relatively firm fibrotic ring from day 7, and both types of anastomoses had an equal inner diameter at that time. By supporting the colonic wall above and below the anastomosis, it could be calculated that the anastomosis on day 7 withstood at least 50 per cent higher circular wall tension than the surrounding colonic wall. There was no correlation between collagen concentration of the colonic wall and bursting strength of the colon either in unoperated controls or after resection and anastomosis. When interrupted sutures were used for anastomosis of the left colon, bursting strength of the intact transverse colon was significantly higher on day 7 than when continuous suture was used. It actually exceeded that of the transverse colon in unoperated controls by almost 50 per cent on the seventh postoperative day, although the collagen concentration in the transverse colon was within normal range. This finding indicated changes in the proximal colonic wall after left colon resection, which are probably related to changes in the structure or arrangement of collagen.

Cancer in Crohn's disease after diversionary surgery: A report of seven carcinomas occurring in excluded bowel

Abstract: The incidence of bowel cancer was studied in 132 patients who had undergone bypass surgery for Crohn's disease and who had been admitted to The Mount Sinai Hospital between 1960 and 1976. Seven patients (5.3 per cent) developed cancer (4 of 63 with ileocolitis and 3 of 69 with ileitis). All seven cancers appeared in excluded loops, four in small bowel and three in colon. Six of the cancers occurred at sites of previous active inflammatory disease and one in a relatively normal “skipped” area of cecum. Four were associated with fistulas: two with enterovesical; one with enterocutaneous; and one with both. In only one case was a tumor mass palpable. All seven patients in this series underwent operation and all showed metastatic spread to liver, lymph nodes, or adjacent organs. All patients died within two years of the diagnostic laparotomy. The mean latent period between onset of disease and appearance of cancer was twenty-seven years, and between bypass surgery and appearance of cancer thirteen years. Four of the seven cancers occurred relatively early, within four years of the bypass procedure, but all seven cases had one feature in common—a long duration of Crohn's disease prior to the development of cancer, ranging from seventeen to forty-four years. The diagnosis of cancer in excluded bowel was difficult to make and impossible to confirm prior to laparotomy. Among the large bowel cancers, a preoperative diagnosis was established, by sigmoidoscopy, in only one case. Cancer in a bypassed loop should be suspected in any case of Crohn's disease of long duration when a late recrudescence of symptoms occurs, especially when the symptoms are associated with the new appearance of fistula or mass.

Significance of lymph node metastasis in differentiated thyroid cancer

Abstract: In age-matched patients with differentiated carcinoma of the thyroid, the tumor recurred in 32 per cent of those with lymph node metastases and in 14 per cent of those without lymph node metastases. Twenty-four per cent of patients with nodal involvement at the initial examination died of thyroid cancer, whereas only 8 per cent of those without nodal involvement died of thyroid cancer. In patients less than forty years old, there were no deaths in those without nodal metastases but there were three deaths (11 per cent) in patients with nodal metastases. In patients more than forty years old, nine (41 per cent) with nodal metastases died of tumor, and four (15 per cent) without nodal metastases died of tumor. In the presence of positive nodes the death rate was substantially greater in the older than in the younger patients. Nodal involvement has an adverse effect on prognosis, but appears to be less important than the age of the patient.

The prognostic and therapeutic value of frozen section determinations in the surgical treatment of squamous carcinoma of the head and neck.

Abstract: The records of 216 patients with squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx treated by surgery alone were reviewed. Frozen section control at the time of the surgical procedure was used to evaluate the margins of the excision. Findings at frozen section were correlated with local control and survival. The inability of the surgeon to obtain clear margins by frozen section for whatever reason resulted in a very high incidence of local recurrence and death. The fact that the patient's tumor could be removed with free margins at the time of surgery did not guarantee long-term success, although the frozen section technic did prove to be reliable and an effective tool for evaluating the patient's prognosis and the efficacy of the surgical procedure.

Anaerobic metabolism and wound healing: an hypothesis for the initiation and cessation of collagen synthesis in wounds.

Abstract: The implanted cylinder model was used to measure LDH activity and lactate and pyruvate concentrations in the extracellular fluid of wounds and wound tissue. Total LDH activity corresponded directly to lactic acid concentration and inversely to oxygen availability. LDH isoenzymes in wound fluid were in an anaerobic pattern soon after injury and evolved toward the aerotic pattern as oxygen supply more nearly matched metabolic capacity. Lactate levels in the wound space are elevated soon after wounding and remain elevated far above those in blood. These data again indicate that wound metabolism is characterized by a relatively poor oxygen supply. Current data from several sources indicate that lactate found in the hypoxic area of the wound may stimulate collagen synthesis in fibroblasts lying in the high lactate environment. We postulate that elevated concentration of lactate in wounds is a major signal for collagen synthesis and repair.

Diagnostic peritoneal lavage: fourteen years and 2,586 patients later.

Abstract: During a fourteen year period, diagnostic peritoneal lavage was 98.5 per cent accurate in determining the presence or absence of blunt intraabdominal injuries among 2,586 patients. Of these, 69.4 per cent had a negative lavage and 29.2 per cent a positive lavage. Six patients (0.2 per cent) had a false-positive lavage. Thirty-two patients (1.2 per cent) had a false-negative lavage; however, all but one of these patients underwent exploratory laparotomy on the basis of clinical acumen or other diagnostic tests.

Radical or modified neck dissection: a therapeutic dilemma.

Abstract: Three hundred ten evaluable patients received a classic, functional, or spinal accessory-nerve-sparing neck dissection during 1970 to 1975. The functional procedure was at least equal to the classic procedure in the patients in whom it was employed. The spinal accessory-nerve-sparing operation is offered as an alternative to the classic procedure in all patients in whom the nerve is not directly invaded by cancer. If these guidelines are followed, the patient will rarely experience the pain and shoulder dysfunction that result from the loss of the trapezius muscle, while the chances of control of cancer in the neck remain optimal.

The aberrant cervical thymus: Embryology, pathology, and clinical implications

Abstract: Cervical thymic anomalies are not as rare as previously suggested. Six cases were encountered over a relatively short period of time, prompting us to report them and emphasize the importance of this entity. Five of the six patients were children, two of them infants less than one year old. The occurrence of thymic remnants in the neck of young children is not surprising, considering the nature and behavior of the thymus at different stages of life. After a brief embryologic survey, the various types of cervical thymus (solitary ectopic, cystic, or partially arrested descent) and their pathogenesis are discussed. The rare occurrence of thyroid and parathyroid tissue within the mass of a large cervical thymic cyst is reported and evaluated. Cervical thymic lesions can either be symptomless or cause severe dyspnea and dysphagia, especially in the young infant. Accurate diagnosis and an intelligent surgical approach in the child with a cervical mass can avoid the obvious parental apprehension and lead to the correct treatment. Symptoms due to pressure on neighoring structures are promptly eliminated after excision, and prognosis is excellent.

Alkaline gastroesophageal reflux

Abstract: Twenty-four hour monitoring provides a continuous record of the pH of the lower esophagus in a near physiologic setting. The upper level of physiologic reflux was determined from the percentage of time and the number of episodes that the pH was less than 4 or more than 7 and the mean duration of each episode in fifteen asymptomatic subjects. One hundred patients with symptoms of gastroesophageal reflux were divided into four groups on the basis of twenty-four hour pH monitoring: those with abnormal acid but normal alkaline reflux, termed acid refluxers (51 patients); those with both abnormal acid and alkaline reflux, termed acid-alkaline refluxers (25); those with normal acid and abnormal alkaline reflux, termed alkaline refluxers (6); and those with both normal acid and alkaline reflux, termed nonrefluxers (18). Nonrefluxers had a similar incidence of heartburn, regurgitation, and dysphagia as acid and acid-alkaline refluxers, proving the inaccuracy of symptoms for detecting reflux. Alkaline refluxers had a lesser incidence of heartburn but a greater incidence of regurgitation, and four alkaline reflux patients presented with severe pulmonary disease secondary to aspiration. Similar incidence and degree of esophagitis was seen in acid, acid-alkaline, and alkaline refluxers. All three groups of symptomatic refluxers had a mean distal esophageal sphincter pressure significantly lower than that of the control asymptomatic subjects. There was no difference in the distal esophageal sphincter pressure between controls and symptomatic nonrefluxers. Nine of the patients with acid-alkaline reflux and one of the patients with alkaline reflux underwent an antireflux procedure and were restudied three months postoperatively. All ten patients had a 24 hour pH acid score within normal limits, but two had an abnormal 24 hour pH alkaline score. In both patients, reflux was demonstrated after placing an acid load in the stomach. It is concluded that symptomatic gastroesophageal reflux in patients with an intact gastrointestinal tract is a mixture of both acid and alkaline secretions, with one or both abnormal due to different degrees of acid production and pyloric regurgitation. Patients with alkaline reflux may develop serious complications of reflux in the absence of typical symptoms of heartburn. Twenty-four hour pH monitoring of the esophagus is useful in the identification of these patients and in evaluating the ability of an antireflux procedure to control both abnormal acid and alkaline reflux.

Platysma myocutaneous flap for intraoral reconstruction

Abstract: Fourteen patients were treated for intraoral epidermoid carcinoma with a single stage reconstructive technic employing a myocutaneous flap based upon the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The flap has proved to be highly reliable and has significant benefits over many other technics commonly employed for head and neck reconstruction.

Prevention of complications from prolonged tracheal intubation

Abstract: Eight commercially available soft cuff endotracheal tubes were studied to determine the relationship between inflation pressure distention of the cuff. Although the balloon cuff may be easily distensible in open air, when confined within the trachea small increments in the inflation volume may produce high pressures. This means that continuous external control of cuff pressure is required to prevent ischemia of the tracheal wall. Major tracheal complications in a busy ICU were examined before and after the introduction of a controlled pressure tube. Control of intratracheal cuff pressures decreased major tracheal complications tenfold and eliminated complications specifically related to the cuff.

Endocrine-induced regression of cancers.

Abstract: Cancer is not necessarily autonomous and intrinsically self-perpetuating. Its growth can be sustained and propagated by hormonal function in the host which is not unusual in kind or exaggerated in rate but which is operating at normal or even subnormal levels. Hormones, or synthetic substances inducing physiologic effects similar thereto, are of crucial significance for survival of several kinds of hormone-responsive cancers in man and animals. Opposite sorts of change of the hormonal status can induce regression and, in some instances, cure such cancers. These modifications are deprivation of essential hormones and hormone interference by giving large amounts of critical compounds. The control of cancer by endocrine methods can be described in three propositions: (i) Some types of cancer cells differ in a cardinal way from the cells from which they arose in their response to change in their hormonal environment. (ii) Certain cancers are hormone-dependent and these cells die when supporting hormones are eliminated. (iii) Certain cancers succumb when large amounts of hormones are administered.

Surgical morbidity after mastectomy operations

Abstract: The records of 146 consecutive patients with mastectomy operations over a three year period were reviewed. Of these, ninety-three (63.6 per cent) had one or more complications secondary to surgery. There were 175 complications, of which complications, of which 107 (73.2 per cent) were wound-related. Seroma formation occurred most frequently but was of minor consequence. The incidence of flap necrosis was 19.1 per cent, with cellulitis or suppurative infection appearing in thirteen patients. Immediate postoperative edema of the arm was fairly rare (2.7 per cent) and appeared related to delayed wound healing. Postoperative complications after total, modified radical, and radical mastectomy present problems unique from those seen after other major surgery, in that local complications predominate. The very nature of the procedure, with the creation of large thin skin flaps, extensive axillary dissection, and an open wound for a prolonged period of time, predisposes to wound morbidity.

Slope analysis of the postoperative CEA time course and its possible application as an aid in diagnosis of disease progression in gastrointestinal cancer

Abstract: The postoperative carcinoembryonic antigen (CEA) time courses of patients with histologically proven adenocarcinoma of the gastrointestinal tract were analyzed to establish a possible correlation with distinct types of disease progression. The diagnosis of tumor progression was obtained by second-look surgery, and in some cases by other clinical diagnostic procedures. In thirty-one of thirty-four patients studied, tumor progression correlated with increasing CEA levels. The calculation of the slopes of the CEA increase in the computerized CEA surveillance diagrams represented a parameter that discriminated between local tumor recurrence and widespread tumor dissemination. All localized tumor recurrences exhibited a flat slope in the range of 0.08 to 0.30 ng CEA increase/ml serum within ten days, with a mean value of 0.17 ng/ml in ten days. The CEA slopes in cases of liver metastases were relatively steep and ranged from 0.9 to 3.8 ng/ml in ten days, yielding a mean slope of 2.2 ng CEA increase/ml serum in ten days.

Pseudoobstruction of the colon.

Abstract: Pseudoobstruction of the colon is a specific variety of adynamic ileus. Its characteristic clinical presentation is severe cramping lower abdominal pain, a massively distended abdomen, and a characteristic x-ray picture. Thirty-five patients with this disease complex have been reviewed, and their surgical and medical therapy is discussed. Guidelines for continued medical versus surgical intervention are suggested. Two patients underwent decompression with the colonoscope. Its use and a possible hazard of the procedure are discussed. For those patients who develop pseudoobstruction after trauma or surgery, a pathophysiologic explanation is offered. The possible role of prostaglandin abnormality in the genesis of pseudoobstruction is also discussed.

Debridement: an essential component of traumatic wound care.

Abstract: The harmful influences of devitalized tissue on wound defenses are documented and the importance of wound debridement in the care of the traumatic wound is stressed. All devitalized soft tissues damaged the host's defenses and encouraged the development of infection. The capacity of divitalized muscle, fat, and skin to enhance infection was comparable. The infection-potentiating effect of skin was enhanced by exposing it to a dry thermal injury. The mechanisms by which devitalized soft tissue enhanced infection are several. The devitalized soft tissue acts as a culture medium promoting bacterial growth. In addition, the devitalized tissue inhibits leukocyte phagocytosis of bacteria and subsequent kill. Finally, the anaerobic environment within the devitalized tissue may also limit leukocyte function.

Plastic mesh repair of incisional hernias

Abstract: During eight years polypropylene mesh was used in fifty-three patients for the repair of difficult incisional hernias. There was no operative mortality, and the mesh has been uniformly well tolerated. To date, recurrences have been observed in six patients (11.3 per cent), a distinct improvement over the era before mesh was used. Greater attention to the details of mesh fixation may further lower the recurrence rate.

Laryngeal carcinoma: transoral treatment utilizing the CO2 laser.

Abstract: The CO2 laser has been found to be a useful adjunct in our efforts to treat laryngeal carcinoma. Utilized endoscopically, it has been of help in establishing the proper staging, in diagnosing recurrence after radiation therapy, in reestablishing airways blocked with tumor, in debulking tumor mass prior to radiation and/or chemotherapy, and as a primary mode of excisional therapy, all accomplished with minimal morbidity. Most patients may return home the first postoperative day, eating, with serviceable voice, and requiring no tracheotomy or analgesics, all of which provide a significant cost benefit.

Carcinoma of the papilla of vater: A review of fifty-seven cases

Abstract: Fifty-seven cases of carcinoma of the papilla of Vater are reviewed. Clinical and pathologic features as well as results of various surgical treatments are summarized. The Whipple operation may be the operation of choice for cancer of the papilla of Vater, offering a chance for cure and obviating further surgery.

Acalculous cholecystitis in critically III patients

Abstract: Acute acalculous cholecystitis is a treacherous and potentially fatal complication of severe trauma and prolonged intensive care. The present study reviews seventeen patients seen between June 1974 and August 1977. Although specific causes have been suggested—transfusions, fractures with immobilization, central hyperalimentation, respirators, and “refeeding”—there was no common denominator among our patients. Refeeding was a feature in 30 per cent of our cases, 50 per cent received more than 10 units of blood, 65 per cent had prolonged gastric suction, and 60 per cent had mechanical ventilation. Thus, although all suggested causes were seen, no single factor was dominant. Clinical presentation in this civilian group resembles that of other reports, but differs in remarkable areas. Only 65 per cent of our group presented with one or more of the classic symptoms of cholecystitis—pain, tenderness, or mass. Sixty-five per cent of patients had elevated bilirubin levels. However, the same incidence of hyperbilirubinemia was seen in another group of traumatized patients who did not develop acalculous cholecystitis. The smoldering and nonclassic presentation frequently delayed diagnosis for several days. It was correctly made in 65 per cent, discovered at autopsy in one patient, and found at laparotomy for “sepsis” in the rest. The present report is unique because 88 per cent of the patients had cholecystostomy as initial therapy. Although five patients who underwent operation ultimately succumbed, cholecystitis could be implicated in only one. This patient died of sepsis at 24 hours but also had multiple unrelated intraabdominal abscesses at surgery. Clinical presentation is more complex than previously reported and simple cholecystostomy is an effective mode of therapy in these critically ill patients.

Cervical presentation of thymic cysts.

Abstract: Sixteen cases of cervical thymic cyst are added to the previously reported fifty-six cases. Seventy-five per cent of the patients were less than twenty years old. Eighty per cent complained of a painless mass preoperatively. The histologic diagnosis of cervical thymic cyst was made if thymic epithelial elements could be found adjacent to the cyst cavity; Hassall's corpuscles were usually present. Cholesterol granulomata could usually be identified. The theories of origin of cervical thymic cyst are discussed.