Showing papers in "American Surgeon in 1990"

Pathogenesis of complications of percutaneous endoscopic gastrostomy. A lesson in surgical principles.

Abstract: In two comparable series of percutaneous endoscopic gastrostomy differing in only one technical detail, complications were significantly reduced by omitting traction on the gastrostomy tube to approximate the gastric to the abdominal wall Radiologic studies show that traction shortened the tract (49 +/- 11 cm with traction, 116 +/- 23 cm without traction) In two patients with fasciitis, gross pericatheter leak of contrast into a short and patulous tract was observed Tube extrusion and gastrointestinal bleeding from gastric ersion ulcers were eliminated when traction was not used No peritonitis occurred as a result of not attempting to approximate the stomach to the abdominal wall The data suggest that traction on the gastrostomy tube is not only unnecessary, but is the cause of many of the complications reported

Sub-clinical Cushing's syndrome in patients with adrenal gland incidentalomas. Pitfalls in diagnosis and management.

Abstract: Widespread use of contemporary imaging techniques (ultrasound, computerized axial tomography, and magnetic resonance imaging scans) have led to the incidental discovery of asymptomatic adrenal neoplasms with increasing frequency Patients with such adrenal "incidentalomas" typically have no clinical manifestations of adrenal cortical hyperfunction at the time of discovery We have studied 122 patients with asymptomatic adrenal masses ranging in size from 2 to 7 cm in diameter from 1978 to 1988 Selected patients, after adrenal metastases, pheochromocytoma, myelolipomas, and cysts were ruled out, were further evaluated for adrenal cortical hyperfunction by measuring urinary 17-hydroxysteroids, 17-ketosteroids, and free cortisol, serum AM, PM cortisol, and plasma ACTH levels These values were also measured before and after dexamethasone suppression NP-59 adrenal scintiscans were performed on all patients Six patients were identified with sub-clinical Cushing's syndrome Baseline cortisol levels were normal in each of these patients Loss of diurnal rhythm appeared to be the most sensitive indicator of abnormal adrenal cortical function When adrenalectomy is performed in such patients, especially when contralateral adrenal gland suppression is evidenced by NP-59 scanning or other biochemical assessment, perioperative steroids should be administered in a manner similar to that used for patients with symptomatic Cushing's syndrome Unilateral adrenalectomy in a patient with an asymptomatic adrenal adenoma, insufficiently studied, may result in Addisonian crisis

The importance of intraoperative cholangiography during laparoscopic cholecystectomy.

Abstract: Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively. After the gallbladder was removed, three patients underwent open common duct exploration. In another five cases, anatomical anomalies were discovered. Cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication--common duct injury. Cholangiography should be attempted on all patients undergoing LC.

Sinistral (left-sided) portal hypertension

Abstract: Between 1953 and 1988, 21 patients with splenic vein thrombosis (SVT), 12 of whom had sinistral portal hypertension (SPH) were treated at our institution. SVT was identified at autopsy in nine patients. Twelve additional patients presented with SPH: bleeding esophageal varices, SVT and normal hepatic function. SVT was caused by pancreatic neoplasm (5), chronic pancreatitis (5), and pancreatic pseudocyst (2). SVT was diagnosed by splanchnic angiography, splenoportography, computerized tomography, and ultrasonography. Gastric varices were diagnosed by endoscopy (10) and barium swallow (2). Splenectomy was performed as primary therapy in 10 patients. Three of these 10 had en block distal pancreatectomy. Two high-risk patients had splenic artery embolization, one as a prelude to splenectomy performed 48 hours later and the other as definitive therapy. One splenectomized patient continued to bleed. No further bleeding occurred in 10 splenectomized patients in follow-up from 1 week to 14 years. Sinistral portal hypertension is a clinical syndrome of splenic vein thrombosis caused by pancreatic pathology and manifests as bleeding gastric varices in patients with a patent portal vein and normal hepatic function. Splanchnic arteriography is necessary for accurate diagnosis. Splenectomy is the effective treatment of choice.

Blunt diaphragm injuries. A five-year experience.

Abstract: Between 1983 and 1988, 33 (21 men, 12 women) patients were treated for blunt diaphragmatic injuries following motor-vehicle (90%) or auto-pedestrian (10%) accidents at the Presley Trauma Center. Thirteen patients (39%) were right sided and 19 (56%) were left sided. One patient sustained bilateral ruptures. The mean Injury Severity Score (ISS) in both those that lived and those that died was not significantly different when right- and left-sided injuries were compared. Admission chest films were abnormal in 28 patients and diagnostic in nine patients (27%). The chest x ray was abnormal in 10 (78%) of those with right-sided injury. Twenty-three patients had diagnostic peritoneal lavage (DPL); 19 were initially positive, two were initially negative but became positive on relavage. There were two false-negative lavages. CT scan (4 patients) and barium enema (1 patient) were nondiagnostic. Diagnosis was delayed in four patients, two were diagnosed by repeat chest x ray and two by repeat lavage. All patients had multiple associated injuries, with 82 per cent having concomitant intra-abdominal injuries. All patients were explored via the transabdominal route. Complications occurred in 55 per cent and there were eight deaths (24%), all unrelated to the diaphragmatic injury. There was no relationship to mortality and hemidiaphragm injured. Chest x ray remains the single most beneficial diagnostic test for diaphragmatic injury. DPL is an insensitive test for isolated diaphragm injuries; however, the combination of CXR and DPL will lead to the diagnosis in the majority of cases. Ancillary radiologic tests are not beneficial. An elevated or obscured right hemidiaphragm should raise suspicion for blunt rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Diverticular disease of the jejunum and its complications.

Abstract: Jejunal diverticulosis is an uncommon, acquired condition that has been encountered recently in four patients. These cases (two patients with diverticulitis, one patient with chronic abdominal pain, and one patient incidentally discovered at laparotomy for colonic diverticulitis) are reported. Acute complications of jejunal diverticulosis include diverticulitis, bleeding, and intestinal obstruction. Chronic complications include intractable abdominal pain, malabsorption, and intestinal pseudo-obstruction. Up to 15 per cent of patients with jejunal diverticulosis may require small-bowel resection for treatment of these acute or chronic complications. The clinical significance, proper diagnostic evaluation, and treatment of jejunal diverticular disease are reviewed.

Changing patterns in perforated peptic ulcer disease.

Abstract: We reviewed our experience with 88 consecutive patients (49 men and 39 women) treated for perforated peptic ulcer between January 1983 and May 1988. The mean age was 61 years (range, 15-89); 63 per cent were more than 60 years of age and 44 per cent were more than 70 years of age. One third of patients had a prior history of peptic ulcer disease. Thirty-nine patients (44%) were taking ulcerogenic drugs (28 were using nonsteroidal anti-inflammatory drugs, 6 were using steroids alone, and 5 were using both). Twenty-eight patients (32%) were taking antacid/H2-blockers, including 15 patients with history of ulcer disease and 11 patients taking ulcerogenic drugs. Concurrent systemic diseases were present in 63 per cent of patients; 12 patients were hospitalized for other illnesses at the time of perforation. Abdominal pain was the chief complaint in 83 patients (94%) and 52 patients (59%) had peritonitis. Leukocytosis was present in 49 patients (56%). Pneumoperitoneum was noted in 65 per cent. The duodenal bulb was the site of perforation in 62 per cent, the pyloric region in 20 per cent, and the gastric body in 18 per cent. A definitive ulcer procedure (V + P, V + A) was performed in 32 patients (38%); 51 patients (58%) had plication, and the remaining five patients did not undergo surgery. A delay in diagnosis and therapy of less than 24 hours occurred in 20 (23%) patients. Mortality was 24 per cent, and correlated significantly with age more than 60 years, but not with treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Strictures following gastric stapling for morbid obesity. Results of endoscopic dilatation.

Abstract: Gastric-restrictive operations for the treatment of morbid obesity are well established. Postoperative stricture is one complication of this procedure. In a large obesity practice, 40 patients presented with this complication. The authors reviewed retrospectively the management of these strictures, using endoscopic dilatation. All patients were morbidly obese, defined as greater than 100 pounds more than ideal weight. The original gastric-restrictive procedure included vertical-banded gastroplasty (35 patients); revision vertical-banded gastroplasty (2 patients); and revision of gastric bypass to vertical-banded gastroplasty (3 patients). Three methods were used: dilatation with endoscope, balloon dilatation, and Savary-Guilliard dilatation. Twenty-seven patients became asymptomatic after dilatation (68%). Occasionally, multiple dilatations were necessary. In 13 patients (32%), dilatation was unsuccessful and revision surgery was needed. In early postoperative (6 to 12 weeks) stricture, dilatation with the endoscope was often successful. When strictures were associated with an angulated channel, dilatation was almost uniformly unsuccessful. In summary, endoscopic dilatation for postgastroplasty strictures is a useful and effective technique, obviating the need for operative revision in the majority of patients; however, when the stenosis is associated with channel angulation, dilatation is almost uniformly unsuccessful. Such patients should not be subjected to repeated dilatation but rather proceed promptly to revision surgery.

Partial splenic embolization. An effective alternative to splenectomy for hypersplenism.

Abstract: Splenectomy for massive splenomegaly and hypersplenism carries a significant morbidity and mortality. We have used partial splenic embolization (PSE) as an effective alternative to splenectomy. Ten PSE procedures were performed on nine patients without mortality and with minimal morbidity. The age of the patients ranged from 8 months to 32 years (mean 14 years). The causes of splenomegaly and hypersplenism included cystic fibrosis with cirrhosis (2), tyrosinemia and cirrhosis (1); thalassemia (1), hemophilia with Human Immune Deficiency Virus infection (2), chronic hepatitis with portal hypertension (1), malignant histiocytosis (1), and Wiskott-Aldrich Syndrome (1). All procedures were performed under local anesthesia with sedation. A percutaneous femoral artery approach to the splenic artery was used to deliver Ivalon sponge particles (280-800 microns) into the spleen. Splenic infarction was assessed by postembolization angiograms. All of the patients except one demonstrated improvement of hematologic parameters. In one patient, however, cytopenia improved only after a second embolization. In the total series, there was an early mean rise of 8,600/mm3 in the leukocyte count (range 2,900-14,900) and 212,000/mm3 in the platelet count (range 30,000-718,000). Follow-up ranged from 4 months to 7 years. Improvement of the blood picture has been persistent in seven of the eight patients who showed initial improvement. Transient procedural complications included fever (5), pleural effusion (2), pneumonia (1), and splenic abscess (1). One patient had paralytic ileus lasting for 10 days and one patient developed a streptococcal peritonitis 3 weeks after embolization. No patient developed pancreatitis or vascular compromise of other abdominal viscera.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of premature removal of the percutaneous gastrostomy.

Abstract: Percutaneous endoscopic gastrostomy (PEG) has become the preferred method of enteral access for nutritional support. With increased use of this modality, complications are encountered more frequently. Premature withdrawal, inadvertent removal of the gastrostomy tube within the first seven days after insertion, before adherence of the gastric serosa to the parietal peritoneum, has been an indication for laparotomy. This report describes the treatment of premature withdrawal by immediate endoscopic replacement. Over an 18-month period, 271 patients underwent insertion of a PEG. Five patients (1.8%) who inadvertently removed their gastrostomy tube within seven days of insertion were treated with immediate replacement using the retrograde string technique, avoiding laparotomy. All five PEGs were successfully replaced through the same gastrostomy site. Despite the presence of pneumoperitoneum, no patient developed peritonitis or other septic complications. Premature gastrostomy tube withdrawal is safely managed by endoscopic replacement and observation. Laparotomy is unnecessary and potentially meddlesome.

Management of rectal injuries. Dogma versus practice.

Abstract: The current treatment of civilian rectal injuries stems from military practice. Five principles have evolved: 1) complete fecal diversion, 2) debridement and closure, 3) rectal stump irrigation, 4) presacral drainage, and 5) broad spectrum antibiotics. To assess our practice results, the records of 52 consecutive patients with rectal injury seen at Detroit Receiving Hospital from 1980-88 were reviewed. Etiologies were gunshot (40), shotgun (9), anal assault (2), and stab (1). There were no blunt injuries and no deaths. Treatment consisted of celiotomy (52), diverting colostomy (51), presacral drains (35), rectal stump irrigation (26), and primary closure (1). Broad spectrum antibiotics were administered in all patients. Despite lack of universal application of the "standard" principles, only five patients had postoperative complications and none were related to the rectal injury. Our results demonstrate that a single approach may not be justified, as excellent outcome was achieved with low morbidity and no mortality despite selective management. The universal application of colostomy, repair, irrigation, drainage, and antibiotics cannot be supported.

Endometriosis of the colon. Its diagnosis and management.

Abstract: Cases of endometriosis of the colon were examined in a retrospective fashion to illustrate the problems in diagnosis and management of this disease entity. Nine patients were identified from 1956 to 1988; their average age was 41 years. Common presenting symptoms were abdominal pain, diarrhea, constipation, tenesmus, small caliber stools, abdominal distention, and blood per rectum. Bowel symptoms were cyclic in four of the nine patients, and seven had a history of gynecologic complaints. Barium enema was performed in six patients and endoscopy in five patients. All cases involved the sigmoid or rectosigmoid colon. In no case was the diagnosis established endoscopically. Surgical procedures included resection with primary anastomosis (6 patients), and resection with sigmoid endcolostomy and Hartmann's pouch (3 patients). In only one case was full-thickness colonic wall involvement noted. One patient had an adenocarcinoma of the colon adjacent to the area of endometriosis. Our data indicate that the diagnosis of endometriosis of the colon should be considered in women with colonic symptoms, especially with an associated history of dysmenorrhea or cyclic changes in bowel habits. Surgical resection offers the best chance for relief of symptoms.

Acute airway management. Role of cricothyroidotomy.

Abstract: Thirty-four cases of emergency cricothyroidotomy performed formed from September 1984 through January 1988 are reviewed. Thirty-one of the cases were required out of 2,200 acute-trauma patients. The indication for cricothyroidotomy was inability to establish an airway by intubation usually in a situation of possible neck injury or severe facial trauma. Fourteen of the patients died as a result of their injuries, 13 of these in the first several hours after injury. The 20 surviving patients are studied in two groups: eleven patients whose cricothyroidotomy remained in place until decannulation (group I) and nine patients who underwent tracheostomy subsequent to cricothyroidotomy (group II). Clinical follow-up included physical examination in all survivors and endoscopic evaluation in twelve patients. Three minor complications were discovered in each of the two groups and two major complications were noted in group II. The major complications included a case of tracheal stomal stenosis requiring tracheal resection and a case of partially obstructing tracheal granulation tissue requiring endoscopic resection. This study supports the use of emergency cricothyroidotomy in situations in which intubation is not successful or thought to be safe. Data is also presented that suggests that tracheostomy subsequent to emergency cricothyroidotomy does not necessarily reduce airway-related morbidity in these patients.

Pseudocysts of the pancreas in children.

Abstract: Sixteen children with pancreatic pseudocysts were treated from 1965-1988. Blunt trauma was the etiology of pseudocyst formation in 69 per cent of children with 50 per cent resulting from the abdomen impacting bicycle handlebars. Chronic pancreatitis is an uncommon cause of pseudocyst formation in children. Medical therapy is directed towards reduction of pancreatic stimulation and nutritional support, which are maintained through pseudocyst resolution or maturation. Pseudocysts spontaneously resolved in 25 per cent of patients. Complications occurred in 25 per cent during nonoperative management. Children may safely undergo internal drainage earlier than adults (3-4 weeks vs 6 weeks). Internal drainage by cystoenterostomy was curative in eight patients. Persistent fistula drainage developed for five weeks in one patient who had surgical external pseudocyst drainage. One patient required distal pancreatectomy for a transected pancreatic duct. Spontaneous resolution of psseudocysts while on medical therapy is more frequent in children than in adults, and major complications (abscess formation, hemorrhage, and fistula formation) are usually not encountered. Pseudocyst rupture is the major complication of conservative management. We had no pseudocyst recurrences and 11 of 12 children treated surgically were discharged home within ten days of operation.

Antibiotics in elective colon surgery. A randomized trial of oral, systemic, and oral/systemic antibiotics for prophylaxis

Abstract: A prospective, randomized double-blind study was undertaken to compare the efficacy of three prophylactic regimens (oral neomycin and erythromycin, intravenous cefoxitin, and a combination of both oral and intravenous antibiotics) in patients undergoing elective colorectal surgery. One hundred sixty-nine patients were randomized and 146 patients were evaluable. Septic complications occurred in 11.4 per cent of patients receiving oral antibiotics only, in 11.7 per cent of patients receiving intravenous cefoxitin alone, and in 7.8 per cent of patients receiving both oral and intravenous antibiotics. These differences were not statistically different. The greatest number of septic complications occurred in those patients with anastomotic disruptions. Two patients died (1.3%), both of whom had major anastomotic failures. There was no advantage between any of the groups in the incidence of wound infection (3.9-6.8%). Thus, no advantage could be identified in this study in the combination of oral and intravenous antibiotics in elective colorectal surgery.

Alternatives in the surgical management of in situ breast cancer. A meta-analysis of outcome.

Abstract: The surgical management of lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) remains controversial For in situ breast cancer local excision (LE), local excision and radiation therapy (LERT) and mastectomy (MAST) have all been advocated A search of the English literature found 13 reports concerning the surgical management of LCIS and 12 reports concerning the management of DCIS The data were combined in a meta-analysis of outcome As expected, recurrence rates following LE with both LCIS 84%) and DCIS (17%) are high However,the overall mortality following mastectomy for recurrence, LCIS (28%) and DCIS (23%) does not differ statistically from those treated initially with mastectomy for LCIS (09%) and DCIS (17%) We conclude from these data that local recurrence after breast conserving procedures for in situ breast cancer does not carry an ominous prognosis This knowledge should aid in planning individual therapy

Surgical approach to atrial septal defect in the female. Right thoracotomy versus sternotomy.

Abstract: Repair of atrial septal defect (ASD) remains a high-benefit, low-risk procedure due to technologic improvements. From July 1981 to December 1986, 35 females (age, 7 months to 28 years) had repair of ASD; 20 by right thoracotomy and aortic cannulation (group 1) and fifteen by median sternotomy (group 2). In general, right thoracotomy was applied to patients with secundum ASD two years or older and without associated lesions, while median sternotomy was applied to patients with ostium primum lesions and/or associated lesions. Patients or their families perceived the cosmetic results superior to the right thoracotomy approach over the median sternotomy. We feel that a right thoracotomy and aortic cannulation is effective in females (2 years and older) with secundum ASD for a superior cosmetic result over median sternotomy. However, females with ostium primum and/or associated lesions should undergo median sternotomy for better cardiac access and safety.

Major abdominal operations in acquired immunodeficiency syndrome.

Abstract: Twenty-one major abdominal operations performed on 20 patients with Acquired Immunodeficiency Syndrome (AIDS) were reviewed Fourteen operations were for therapeutic indications, eight were emergent The array of pathology encountered included opportunistic infection with Mycobacterium avium intracellulare, Cytomegalovirus, Cryptosporidium, abdominal tuberculosis, lymphoma, Kaposi's sarcoma, AIDS-related immune thrombocytopenia, perforated appendicitis and colonic pseudo-obstruction Hospital mortality was 20 per cent Major morbidity occurred in 15 per cent of patients and was more common following emergency operations Preoperative demographic, hematologic, or nutritional parameters examined or the presence of single-organ system dysfunction did not predict outcome Fifty-three per cent of hospital survivors are alive with a nine-month median postoperative follow-up It is concluded that major abdominal procedures in patients with AIDS should not be withheld due to fear of excessive morbidity or mortality General surgeons are involved in the evaluation and treatment of increasing numbers of patients with HIV infection Appropriate management requires recognition of a wide range of surgical pathology and attention to details of safe intraoperative conduct

The clinical significance of fluid collections in acute pancreatitis.

Abstract: Computed tomography (CT) displays fluid collections in patients with acute pancreatitis as well defined intra- or extrapancreatic homogeneous areas with low attenuation numbers. We followed, prospectively, the clinical courses of 128 patients who had CT during an episode of acute pancreatitis, to determine the natural history and clinical significance of any fluid collections that developed. Fluid collections were found in 48 (37%) of the 128 patients with pancreatitis. Thirty-eight developed in the 86 (44%) patients with alcoholic pancreatitis, five in the 33 (15%) with biliary pancreatitis and five in the nine (55%) with other causes of pancreatitis (excluding chronic pancreatitis, trauma, or malignancy). On clinical follow-up of the 48 patients with fluid collections, 21 patients required operation; two died before an operation was done and 25 did not require operation. Operations were done to treat pseudocysts (14), abscess (5), and necrosis (3). One patient had an operation for a pseudocyst and an abscess. All 14 patients requiring operation for pseudocyst had collections greater than 7 cm and 13 of these patients had alcoholic pancreatitis. Of the 25 patients not requiring operation, five were lost to follow-up, and 19 of the 20 who had spontaneous resolution of their fluid collection(s) had collections less than 6 cm in diameter. The eight patients who required operative pancreatic debridement for abscess or necrosis had multiple small fluid collections. In summary, fluid collections were found in one-third of patients with acute pancreatitis and were often associated with the development of local complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Local resection of tumors of the ampulla of Vater.

Abstract: Local resection of an ampullary tumor with reimplantation of the pancreatic and bile ducts was first described by William S. Halsted in 1899. Technical hazard and unsuitability in malignant ampullary tumors have unfortunately led to a disregard for this operation that is unwarranted. Radical pancreaticoduodenectomy is now the most common method of resecting benign and malignant ampullary tumors. Experience was gained with two high-risk patients with benign adenomatous polyps obstructing the ampulla of Vater. Their medical unsuitability for radical pancreaticoduodenectomy led us to revive the procedure of wide local excision of these tumors with reimplantation of the pancreatic and bile ducts. Operative time and blood loss were substantially less than radical resection and postoperative recoveries were relatively uncomplicated. Radical resection of benign ampullary tumors may be appropriate for good-risk patients in whom the risk of local recurrence outweighs the operative risk. We suggest that local resection of benign ampullary tumors is the procedure of choice in high-risk patients and that it be considered in palliation of limited local malignancies of the ampulla in high-risk patients.

Ruptured hepatic adenoma. A spectrum of presentation and treatment.

Abstract: Six cases of ruptured hepatic adenoma treated in our medical center were reviewed with attention directed toward presenting symptomatology and methods of treatment These patients, five women who were long-term users of oral contraceptives and one man who had never taken steroid medication, presented with right upper quadrant abdominal pain of variable degree and duration The cardiovascular status of these patients was also variable, ranging from a normal blood pressure, which allowed an orderly workup, and planned resection of the tumor to hypovolemic shock requiring emergency laparotomy for control of hemorrhage The extent of surgery depended on the location and the number of adenomas, with the goal being to resect the adenoma and control hemorrhage while preserving as much normal liver parenchyma as possible The treatment of choice in this disease is resection of the tumor with a margin of normal liver parenchyma In those cases in which that is not practical, resectional debridement has proven to be an effective alternative

Needle aspiration of nonfunctioning parathyroid cysts.

Abstract: Until recently, nonfunctioning parathyroid cysts were usually identified at operation for a presumed thyroid mass. Thyroid needle biopsy now allows their preoperative diagnosis and potential definitive treatment. This study reviews four patients with nonfunctioning parathyroid cysts treated during a two-year period. Three women and one man range in age from 28 to 70 years. Each presented with an asymptomatic thyroid mass ranging from 3 to 5 cm in length. None had symptoms of primary hyperparathyroidism. Serum calciums were from 9.2 to 10.7 mg/dl and serum phosphoruses were 3.2 to 4.4 mg/dl. Needle aspiration revealed 5 to 85 cc of water-clear fluid. C-terminal parathyroid hormone in three patients was 12,600, 6,500 and 61,200 pg/ml and N-terminal PTH was 1,700 pg/ml in one. All four had normal serum calcium and phosphorus on follow-up ranging from six months to two years. Two patients had resolution of their cysts with a single aspiration. One patient had recurrence but has no evidence of recurrence six months after injection with tetracycline. Another patient had a recurrence but remains well one year following reaspiration. Nonfunctioning parathyroid cysts present as a thyroid mass. Needle aspiration of water-clear fluid high in parathormone is diagnostic and, in most patients, is the therapeutic modality of choice.

A five-year U.S. Army experience with 36,250 abdominal hernia repairs.

Abstract: Thirty-six thousand two hundred fifty abdominal hernia repairs were performed in U.S. Army medical treatment facilities during a five-year period. This study presents data about the type of hernia, incidence of complications by obstruction or strangulation, age, sex, and mortality. Hernias occurring with intestinal obstruction or gangrene (strangulation) are referred to as complicated hernias. Inguinal hernias in children less than two years of age, femoral hernias, and unusual (such as internal or obturator) hernias were found to have an increased incidence of complications. Surgical repair of ventral, umbilical, and femoral hernias was done with a low surgical risk and the presence of complications did not significantly increase this risk. An increased risk of mortality is associated with the repair of complicated unusual hernias and complicated inguinal hernias in patients more than 60 years of age.

Temporal artery biopsy.

Abstract: Though surgeons have little input in the selection of patients for temporal-artery biopsy, a knowledge of temporal-artery anatomy and the pathophysiology of temporal arteritis is important. All temporal-artery biopsies done at Carraway Methodist Medical Center between January 1980 and January 1985 were reviewed. Seventy-three biopsies were performed on 70 patients and eight (11.4%) were found to have temporal arteritis histologically. One patient was judged to have temporal arteritis clinically, despite a negative biopsy of short length. Six of eight patients with positive biopsies were female, with an average age of 71.7 years. The most common signs and symptoms of those patients with positive biopsies were temporal headache (8/8), elevated erythrocyte sedimentation rate (7/8), temporal tenderness (5/8), jaw claudication (3/8), and visual changes (3/8). All biopsies were done under local anesthesia and there were no complications. With increasing awareness of the segmental nature of the disease, the length of biopsy specimens (formalin treated) increased from an average of 0.4 cm in 1980 to 2.4 cm in 1984. During this time, the positive rate increased from 0 per cent (0/9) to 17 per cent (4/24). A generous biopsy of approximately 5 cm in length of fresh vessel is recommended to confirm the suspected diagnosis of temporal arteritis.

Penetrating pancreatic injuries. Analysis of 103 consecutive cases.

Abstract: The present study analyzes 103 consecutive patients with these wounds treated in a 14-year period. Twenty-seven patients died within 48 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 46.7). The majority of the remaining 76 patients were treated by debridement and drainage. Nineteen patients with grade III injuries had distal pancreatectomy. Six patients whit extensive combined pancreatoduodenal injuries had pancreatoduodenectomy

The use of serum amylase and lipase in evaluating and managing blunt abdominal trauma

Abstract: In order to determine the usefulness of serum amylase and lipase in the initial evaluation and subsequent management of blunt abdominal trauma (BAT) patients, we collected serum amylase and lipase on 85 consecutive BAT patients at admission, hospital day 1, hospital day 3, and hospital day 7. Only one patient had a pancreatic injury. A total of 45 patients (53%) had at least one enzyme abnormality during the study. There was no correlation between amylase or lipase values and age, sex, type of injury, diagnostic tests, operation, and outcome. In a control group of nonabdominal-trauma patients with admit studies only, all enzyme values were normal. We conclude that serum amylase and lipase are randomly elevated in patients with nonpancreatic-BAT both initially and during subsequent hospitalization and are not useful clinical tools in these patients.

Surgical significance of acquired ileal diverticulosis.

Abstract: Acquired (non-Meckel's) ileal diverticular disease is uncommon, and most surgeons have limited, if any, experience with this condition. To gain insight into the frequency of surgical complications of ileal diverticula, we reviewed our experience during the past ten years with 21 patients, 12 women, and nine men. The mean patient age was 62 years; 16 patients (76%) were more than 50 years of age. Thirteen patients had associated diverticula in another segment of the small intestine. In 15 patients ileal diverticulosis was diagnosed during gastrointestinal (GI) radiologic evaluation of abdominal symptomatology. Ileal diverticula were identified intraoperatively in the remaining six patients. In three patients ileal diverticulosis was an incidental finding. Documented surgical complications of acquired ileal diverticula occurred in four patients (19%). Three patients had acute diverticular perforation, and one patient had diverticulitis without perforation. These patients underwent successful operative intervention. Three other patients, all managed nonoperatively, had abdominal symptoms that may have been related to ileal diverticula and were of potential surgical significance. Two patients experienced recurrent rectal bleeding, and the third patient had severe chronic abdominal pain. Although the majority of patients with acquired ileal diverticula do not require surgical treatment, complications such as perforation, bleeding, or incapacitating abdominal pain may necessitate ileal resection.

The role of endoscopic retrograde pancreatography (ERP) in blunt abdominal trauma.

Abstract: The diagnosis of pancreatic injury is often difficult because it lies retroperitoneally in a protected area. Delayed diagnosis and treatment of blunt pancreatic trauma can result in significant morbidity and mortality. Endoscopic Retrograde Pancreatography (ERP) is infrequently used in the diagnosis of pancreatic injury. We reviewed our experience with the use of ERP in patients with blunt pancreatic injury. Two stable patients with traumatic pancreatitis underwent ERP shortly after injury. CT scans revealed a transverse fracture of the distal pancrease in one and fluid accumulation in the other around the pancreas extending to the right kidney and left hepatic lobe. The absence of ductal disruption on ERP allowed nonoperative management of the pancreatitis. Resolution was documented by the absence of symptoms on regular oral intake, normal serum amylase levels, and normal follow-up CT scans. A third patient with persistent fistulae three months postinjury underwent preoperative ERP revealing ductal obstruction. This facilitated the planning of a distal pancreatectomy and subsequently the fistulae healed. A fourth patient underwent an exploratory laparotomy on the basis of clinical and CT scan findings that could have been circumvented with preoperative ERP. ERP in selected patients allows nonoperative treatment in the absence of ductal injury or earlier operative treatment of ductal injury. It also aids the treatment of late complications by delineating ductal anatomy.

Effect of preoperative chemotherapy on mastectomy for locally advanced breast cancer.

Abstract: Mastectomy is frequently performed after intensive chemotherapy for locally advanced breast cancer. The effects of preoperative chemotherapy on the postoperative course and the timing of subsequent adjuvant therapy, however, have not been defined. We therefore reviewed the perioperative course of 54 patients undergoing mastectomy after combination (CAMFPT) chemotherapy for stage IIIA,B (IIIA - 25 pts; IIIB noninflammatory - 5 pts; IIIB inflammatory-24 patients) breast cancer. A median of 7 cycles (6 months) of chemotherapy was administered preoperatively. Mastectomy was performed a median of 20 days after last chemotherapy; white blood cell count (WBC) and platelet counts returned to normal limits preoperatively. Total mastectomy with or without axillary node dissection was performed in 53 patients, and a Halsted radical mastectomy in 1 patient. Negative margins on breast and/or axillary tissue were achieved in 47 patients (87.0%). Postoperative complications included skin flap necrosis in 8 patients (14.8%), seroma formation in 5 patients (9.3%), and wound infection in 1 patient (1.9%). Median operative blood loss (550 cc), hospital stay (8 days), and duration of wound catheter drainage (6 days) were comparable to published reports for modified radical mastectomy without preoperative chemotherapy. Systemic chemotherapy was resumed a median of 16 days after mastectomy, and radiotherapy started a median of 33 days after mastectomy. These findings indicate that intensive preoperative chemotherapy does not increase the hospital course or the postoperative complications of mastectomy for locally advanced breast cancer. In view of the current interest in treatment of stage I and II breast cancer with preoperative chemotherapy, this information may be useful in their management as well.

Carcinoid tumor of the bile duct. A case report and literature review.

Abstract: A 35-year-old woman presented with painless jaundice that on evaluation was attributed to a tumor at the confluence of the hepatic ducts. There was no evidence of tumor spread on preoperative workup. The tumor was resected and histologically was typical for carcinoid. There have been only ten previously described cases of bile duct carcinoid tumors excluding gallbladder and ampullary lesions. This study presents a discussion of the management of these tumors and a review of the literature.