Showing papers in "Annals of Surgery in 1985"

Prognosis in acute organ-system failure.

Abstract: This prospective study describes the current prognosis of patients in acute Organ System Failure (OSF). Objective definitions were developed for five OSFs, and then 5677 ICU admissions from 13 hospitals were monitored. The number and duration of OSF were linked to outcome at hospital discharge for each of the 2719 ICU patients (48%) who developed OSF. For all medical and most surgical admissions, a single OSF lasting more than 1 day resulted in a mortality rate approaching 40%. Among both medical and surgical patients, two OSFs for more than 1 day increased death rates to 60%. Advanced chronologic age increased both the probability of developing OSF and the probability of death once OSF occurred. Mortality for 99 patients with three or more OSFs persisting after 3 days was 98%. The two patients who survived were both young, in prior excellent health, and had severe but limited primary diseases. These results emphasize the high death rates associated with acute OSF and the rapidity with which mortality increases over time. The prognostic estimates provide reference data for physicians treating similar patients.

Vascular access for hemodialysis. patency rates and results of revision

Abstract: Over a 4-year interval, 324 arteriovenous conduits were created in 256 patients with end-stage renal disease as access for chronic hemodialysis. These included 154 Cimino fistulae, 163 polytetrafluoroethylene (PTFE) grafts, and seven miscellaneous grafts. Satisfactory patency rates were demonstrated for as long as 4 years for both Cimino fistulae and PTFE grafts by life-table analysis. Failures of Cimino fistulae usually occurred early in the postoperative period, secondary to attempts to use inadequate veins. Thrombosis caused the majority of PTFE graft failures and was generally the result of venous stenosis. Correction of such venous stenosis is mandatory to restore graft patency and can result in prolonged graft survival.

Role of liver transplantation in cancer therapy.

Abstract: Fifty-four patients underwent total hepatectomy and liver replacement in the presence of a primary liver malignancy. In 13 recipients in whom the hepatic tumors were incidental to some other endstage liver disease, recurrence was not seen and 12 of the 13 patients are alive after 4 months to 15 1/2 years. In contrast, tumors recurred in 3 of every 4 patients who received liver replacement primarily because of hepatic malignancies that could not be resected by conventional techniques of subtotal hepatectomy and who lived for at least 2 months after transplantation. The most encouraging results were in patients with the fibrolamellar hepatocellular carcinomas that grow slowly and metastasize late, but even with this lesion, the recurrence rate was 57%. In future trials, additional effective anticancer therapy will be needed to improve the results of liver transplantation for primary liver malignancy, but what an improved strategy should be has not yet been defined.

Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost

Abstract: Despite recent advances in perioperative support care, surgery for obstructive jaundice is still associated with significant morbidity and mortality. For this reason, preoperative percutaneous transhepatic drainage (PTD) has been recommended for these patients. This method of management, however, has only been supported by retrospective and nonrandomized studies. Therefore, a prospective, randomized study was performed to determine the effect of preoperative PTD on operative mortality, morbidity, hospital stay, and hospital cost. Thirty-day mortality was 8.1% among 37 patients undergoing preoperative PTD, compared to 5.3% for 38 patients who went to surgery without preoperative drainage. Overall morbidity was also slightly, but not significantly, higher in patients who underwent preoperative PTD, (57% versus 53%). However, total hospital stay was significantly longer (p less than 0.005) in the PTD group (31.4 days versus 23.1 days). The cost of this excess hospitalization and the PTD procedure at our university medical center was over +8000 per patient. The authors conclude that preoperative PTD does not reduce operative risk but does increase hospital cost and, therefore, should not be performed routinely.

Volvulus of the colon. Incidence and mortality.

Abstract: Between 1960 and 1980, 137 patients with colonic volvulus (52% cecal, 3% transverse colon, 2% splenic flexure, and 43% sigmoid) were seen at the Mayo Clinic. Among the 59 patients with sigmoid volvulus, four (7%) had colonic infarction. Total mortality with sigmoid volvulus was seven per cent. There were 71 patients with cecal volvulus. Colonoscopic decompression was accomplished in two of these patients; in 15 (21%), gangrenous colon developed and mortality was 33%. Total mortality for cecal volvulus patients was 17%. Mortality for all forms of volvulus in patients with viable colons was 11%. Mortality for all patients with volvulus was 14%.

Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes.

Abstract: The results of the analysis carried out on data on 1119 patients with operable breast cancer treated at the National Cancer Institute of Milan from 1965 to 1979 with enlarged mastectomy are reported. Metastases to internal mammary chain were found to be significantly associated with the maximum diameter of primary (16.1% for tumors less than 2 cm and 24.5% for larger tumors, p = 0.007), the age of the patients (27.6% in patients younger than 40 years, 19.7% in patients between 41-50 years, and 15.6% in patients older than 50 years, p = 0.01). The site of origin of the cancer had no impact on internal mammary node metastases. Patients with positive axillary nodes showed metastases to internal mammary nodes in 29.1% of the cases, while 9.1% of patients with axillary negative nodes had positive retrosternal nodes. Survival was significantly affected by the presence of positive internal mammary nodes: the percentage of 10-year survival varied from 80.4% in patients with axillary and internal mammary negative nodes to 30.0% in patients with both nodal basins involved. Intermediate survival rates (54.6% and 53.0%) were found when one or the other of the nodal stations (axillary and internal mammary) was separately affected. Maximum diameter of the primary significantly affected the survival of each group identified by the status of both axillary and internal mammary nodes. In conclusion, the information on the presence or absence of internal mammary node metastases would be of great importance in formulating the prognosis of breast cancer patients. To obtain this information, a biopsy at the first intercostal space may be reasonable in selected patients (age, maximum diameter, and axillary node involvement being the basis for selection) as long as noninvasive methods of diagnosis are available.

Patterns of atherosclerosis and their surgical significance.

Abstract: The records of 13,827 patients admitted on one or more occasions to The Methodist Hospital in Houston on the service of the senior author for the treatment of arterial atherosclerotic occlusive disease from 1948 to 1983 were analyzed. The data derived from this analysis are believed to support the concept that atherosclerotic occlusive disease tends to assume characteristic patterns that may be classified, by predominant site or distribution of the disease, into five major categories: (I) the coronary arterial bed, (II) the major branches of the aortic arch, (III) the visceral arterial branches of the abdominal aorta, (IV) the terminal abdominal aorta and its major branches, and (V) a combination of two or more of these categories occurring simultaneously. Category IV had the highest proportion of patients (about two-fifths), Category I the second highest (almost one-third), and Category III had the lowest percentage (3%). Atherosclerotic occlusive disease in all categories tends to be well localized and usually occurs in the proximal or midproximal portions of the arterial bed. Such lesions are amenable to effective surgical treatment directed toward restoration of normal circulation. Less commonly, however, the occlusive disease in all categories occurs predominantly in the distal portions of the arterial bed, and such lesions are usually not amenable to effective surgical treatment. Patients in Categories I and III were significantly younger than those in the other categories and, although males predominated in all categories, Categories II and III contained significantly more female patients than did the other categories. In general, however, female patients behaved like male patients in virtually all aspects of the study. The rates of progression of the disease may be classified into: rapid (0 to 36 months), moderate (37 to 120 months), and slow (more than 120 months). The rapid and moderate rates of progression occurred most frequently in Categories II and IV, and the moderate and slow rates occurred most frequently in Category I. The possibility for development of recurrence or progression of disease in the same category and in a new category was significantly greater in younger patients. The patient's sex had no significant influence in this regard. Among the various categories, patients in Category IV had the highest incidence of development of disease in a new category, and Category I had the lowest incidence. Patients originally in Category II had a somewhat greater tendency to development of disease in Category IV, and patients originally in Category IV, for development of disease in Category II.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of parenteral nutrition on gastrointestinal immunity. The importance of enteral stimulation.

Abstract: Secretory IgA (S-IgA), an immunoglobulin present in secretions, prevents the adherence of bacteria to mucosal cells and is the principle component of the gut mucosal defense system The purpose of this study was to determine whether the route of nutrient administration affects S-IgA Twenty-five female Fisher rats were randomized into three groups Groups I and II were fed an isonitrogenous, isocaloric standard hyperalimentation solution, Group I intravenously and Group II via a gastrostomy Group III (control) was fed rat chow and water ad lib Since bile is one of the principle sources of S-IgA, animals had biliary T-tubes placed for sampling of bile every 4 days At day 16, Group I animals were fed rat chow and water for an additional 8 days S-IgA was measured by the ELISA immunoassay Results indicated at day 16 that the S-IgA level in mg/ml of Group I was 11 +/- 02, while the S-IgA in Groups II and III was 22 +/- 06 and 22 +/- 026, respectively Furthermore, the S-IgA level in Group I after 8 days of enteral feeding rose to 18 +/- 04 The difference in S-IgA levels between enterally and parenterally fed rats suggests that an important defense barrier is compromised during parenteral hyperalimentation Rats fed the same nutrients by gastrostomy maintained S-IgA levels better than rats fed the same nutrients intravenously The rapid return to normal levels after resumption of enteral feeding suggests that the intraluminal presence of foodstuffs is essential for maintenance of S-IgA

The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients.

Abstract: The natural history of gallstone disease in 691 patients, followed for a mean +/- SD duration of 78 +/- 61.6 months (median 62.9 months), is presented. These patients are all subscribers of a large health maintenance organization and are believed to represent a cross-section of middle income Americans. Symptoms attributed to biliary tract disease were present in 556 (80.5%), and the other 135 (19.5%) patients were asymptomatic. In the symptomatic group, the mean +/- SD duration of observation was 82.9 +/- 63.2 months (median 68.5 months); 242 (44%) eventually underwent biliary tract operations most often because of persistent symptoms. Only 10% of asymptomatic patients followed for 58 +/- 50.2 months (median 46.3 months) developed symptoms of biliary calculi, and seven per cent required operations. There were 50 deaths in this series of 691 patients, 25 in the symptomatic group, and 25 in the asymptomatic. Only two of these deaths were biliary tract related, and both were in the symptomatic group. This study suggests that patients with silent stones do not need to be operated on prior to the development of symptoms. In addition, many patients with symptoms of biliary calculi can tolerate their symptoms for long periods of time and prefer this course of action to cholecystectomy.

Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.

Abstract: Fifty-six blunt multiple trauma patients (HTI-ISS 22-57) were studied for the effects of immediate versus delayed internal fixation of a femur or acetabular fracture on the pulmonary failure septic state. The pulmonary failure septic state may be defined as an alveolar arterial oxygen tension difference greater than 100, plus fever and leukocytosis. These patients were divided into four groups. Group I (N = 20) had immediate internal fixation, postoperative ventilatory support, and was sitting up at 30 hours. Group II (N = 20) had 10 days of femur traction and postoperative ventilatory support. Group III (N = 9) was immediately extubated after surgery and had 30 days of femur traction. Group IV (N = 7) had special circumstances that should increase the duration of the pulmonary failure septic state. These four groups of patients were statistically identical by 20 different criteria on admission except that Group I had more recognized chest injuries than Group II (12 vs. 9). Group I required 3.4 +/- 2.6 days of ventilator support and 7.5 +/- 3.8 intensive care unit (ICU) days; they had 12 +/- 8.8 elevated white counts, 3.8 +/- 4 febrile days, 0.05 positive blood cultures per patient, four fracture complications out of 93 fractures, 59 injections of narcotics, and 23 +/- 8.6 acute care days. Ten days of femur traction doubled the duration of the pulmonary failure septic state relative to Group I at a statistically significant level for nine out of 10 criteria, while increasing the number of positive blood cultures by a factor of 10, the number of fracture complications by a factor of 3.5, and the use of injectable narcotics by a factor of 2. Thirty days of femur traction increased the duration of the pulmonary failure septic state relative to Group I by a factor of 3 to 5 for all criteria at a statistically significant level, while increasing fracture complications by a factor of 17, positive blood cultures by a factor of 74, and the use of narcotics by a factor of 2. Group IV, which had four out of seven immediate internal fixations, behaved similarly to Group II. Femoral shaft traction should be avoided in the blunt multiple trauma patients because it greatly increases the cost of care and the risk of multiple systems organ failure.(ABSTRACT TRUNCATED AT 400 WORDS)

Klippel and Trénaunay's syndrome. 768 operated cases.

Abstract: Since 1945, we have operated on 786 patients with Klippel and Trenaunay's syndrome. Elongation of the impaired limb was invariably found while edema was present in 84%, varicose veins in 36%, and flat angiomata in 32%. Venography and surgical exploration have demonstrated malformation of the deep veins involving the popliteal vein in 51%; superficial femoral vein, 16%; both popliteal and superficial femoral veins; 29%; iliac veins, three per cent; and lower vena cava, one per cent. Good clinical results have been achieved following the surgical release of these deep veins in the lower limb. During childhood, when the difference in limb length is noteworthy, ligature of the popliteal vein of the shorter limb induces a compensating elongation. Klippel and Trenaunay's syndrome may be associated with lymphatic malformations, including lymphedema and malformation of the lymph vessels. Knowledge of the pathophysiology of these malformations of the deep veins enables a better understanding of the clinical manifestations of the condition, as well as the improved treatment of the serious vesical or rectal hemorrhage which occurs in one per cent of these patients.

Epidural electrical stimulation in severe limb ischemia. Pain relief, increased blood flow, and a possible limb-saving effect.

Abstract: Peripheral vascular disease of the extremities causes ischemic pain and, at times, skin ulcerations and gangrene. It has been suggested that epidural spinal electrical stimulation (ESES) could improve peripheral circulation. Since 1978 we have used ESES in 34 patients with severe limb ischemia; all had resting pain and most had ischemic ulcers. Arterial surgery was technically impossible. Twenty-six patients had arteriosclerotic disease, one had Buerger's disease, and seven had severe vasospastic disorders. Ninety-four per cent of the patients experienced pain relief. ESES healed ulcers in 50% of those with preoperative nonhealing skin ulcerations. Seventy per cent of the patients showed improved skin temperature recordings. Only 38% of the stimulated arteriosclerotic patients underwent amputations during a mean followup period of 16 months, as compared to 90% of a comparable group of unstimulated patients. ESES is very promising in severe limb ischemia where reconstructive surgery is impossible or has failed.

Hepatic resection of colorectal metastases. Influence of clinical factors and adjuvant intraperitoneal 5-fluorouracil via Tenckhoff catheter on survival.

Abstract: This report analyzes an experience with 33 hepatic resections for metastatic colorectal cancer over a 7-year period and with intraperitoneal 5-FU administered as a postresection adjuvant in 21 of these patients. Particular emphasis is placed on the identification of clinical determinants of postresection survival. There was no operative mortality in this series. Postoperative complications occurred in 27% of patients, and the incidence of complications correlated with intraoperative blood loss (p = 0.002). Two- and 4-year estimated survivals were 72% and 53%, respectively. Patients with three or fewer metastases resected or with unilobar disease had improved survival when compared with patients having more than three metastases or bilobar disease, respectively (p less than 0.05). Disease-free survival was improved in patients with microscopically negative resection margins (p = 0.019). Dukes' stage of the primary lesion, interval between bowel resection and detection of hepatic metastases, method of detection of metastases, preoperative CEA level, and type of operation performed were not predictive of postresection survival. Intraperitoneal 5-FU was well tolerated. There was a trend toward improved survival in patients receiving adjuvant chemotherapy, but this was not statistically significant. It is concluded that the number of metastases resected, the distribution of the metastases, and the technical adequacy of the excision are all predictive of outcome following hepatic resection of colorectal metastases. Encouraging results with the use of intraperitoneal 5-FU as a postresection adjuvant have led to the initiation of a prospective randomized trial investigating this modality at the NCI.

Oxygen free radical induced damage in kidneys subjected to warm ischemia and reperfusion. Protective effect of superoxide dismutase.

Abstract: Superoxide anion free radical (O2-.) has been implicated in the pathogenesis of tissue injury consequent to ischemia/reperfusion in several different organs, including heart and bowel. Superoxide dismutase (SOD), an enzyme free radical scavenger specific for O2-., has been used successfully to protect these organs from structural damage during reoxygenation of ischemic tissue. It has been suggested that the catalytic action of xanthine oxidase in injured tissue is an important source of O2-. during reoxygenation. In order to evaluate the potential of SOD to protect against kidney damage resulting from transient ischemia followed by reperfusion with oxygenated blood, a model of warm renal ischemia was studied. LBNF1 rats underwent right nephrectomy and occlusion of the left renal artery for 45 minutes. Survival in the group of ischemic untreated rats (N = 30) was 56% at 7 days and serum creatinine was greatly elevated (p less than 0.01) in rats remaining alive over the full 7-day period. In strong contrast to these results, all of the animals treated with SOD before reperfusion (N = 18) were alive after 7 days similar to sham operated control rats (N = 8). Serum creatinine in the SOD treated rats was significantly elevated only to postoperative day 3 and thereafter returned to normal. Rats treated with inactive SOD (N = 4) or SOD before ischemia (N = 4) had decreased survival rates compared to ischemic untreated animals and prolonged elevation of serum creatinine. When the ischemia time was extended to 60 minutes, only 19% of the untreated animals (N = 16) survived at 7 days whereas nearly 60% of the SOD-treated animals survived (N = 19). Serum creatinine was greatly elevated during the full 7-day observation period in all surviving rats in the untreated ischemic group, whereas serum creatinine returned to normal (p less than 0.05) after 4 days in the surviving rats treated with SOD. To test whether the action of xanthine oxidase contributed to the kidney damage after reoxygenation, 45 min. ischemic rat kidneys were treated with allopurinol. All of the animals treated with allopurinol (N = 12) were alive at 7 days. Serum creatinine values returned to normal after the episode of ischemia and reperfusion but more slowly than after SOD treatment. Histologic evaluation of kidney tissue taken from animals after ischemia alone showed extensive renal tubular damage, which was essentially absent in kidneys from SOD-treated animals.(ABSTRACT TRUNCATED AT 400 WORDS)

Major hepatic resection for metachronous metastases from colon cancer.

Abstract: Hepatic resection of metastatic colorectal cancer is being performed with increasing frequency. Reports describe wide variations in survival after resection of solitary of multiple metastases. In 23 consecutive patients having major hepatic resection for metachronous metastases from colorectal cancers, 18 patients had one, two, or three metastases and five had four or more individual metastases; the cure rate of one, two, or three metachronous metastases was comparable to reports of resected solitary simultaneous metastases. The median maximum diameter of metastases in patients both surviving and dead was 7 cm. Features separating surviving from dead patients were resection margins of at least 1 cm and fewer than four metastatic nodules. All patients with four or more hepatic metastases died of disease, 80% with further liver metastases. Only three of 18 (17%) patients with one, two, or three metastases developed further hepatic lesions. This study suggests that the biology of the hepatic metastatic disease is paramount; timing of the hepatic resection is of little importance. Delayed resection of suitable biologic situations does not impair survival opportunities, and early resection of inappropriate biologic situations with more than three hepatic metastases does not improve survival. Therefore, programs of early detection with the use of carcinoembryonic antigen (CEA) screening or "second look" operations will not increase cure rates.

Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection.

Abstract: Abdominal wall defects resulting from trauma, invasive infection, or hernia present a difficult problem for the surgeon. In order to study the problems associated with the prosthetic materials used for abdominal wall reconstruction, an animal model was used to simulate abdominal wall defects in the presence of peritonitis and invasive infection. One hundred guinea pigs were repaired with either polytetrafluorethylene (PTFE) or polypropylene mesh (PPM). Our experiments included intra-operative contamination with Staphylococcus aureus. We found significantly fewer organisms (p less than 0.05) adherent to the PTFE than to the PPM when antibiotics were administered after surgery, as well as when no antibiotics were given. In the presence of peritonitis, we found no real difference in numbers of intraperitoneal bacteria present whether PTFE or PPM was used. In all instances, the PTFE patches produced fewer adhesions and were more easily removed. From these experiments, it appears that PTFE may be associated with fewer problems than PPM in the presence of contamination and infection.

Experimental evidence for a vagally mediated and cholecystokinin-independent enteropancreatic reflex.

Abstract: Truncal vagotomy results in diminished pancreatic protein secretion in response to intraduodenal fat. This diminished secretion may be due, at least in part, to interruption of the vagal reflexes between the intestine and the pancreas that work independently of cholecystokinin (CCK). In five dogs with chronic pancreatic fistulas, plasma CCK concentrations and pancreatic protein secretion in response to an intestinal stimulant (intraduodenal oleate) and to two exogenous peptides (bombesin and CCK-33) were compared before and after bilateral truncal vagotomy. Vagotomy decreased integrated protein secretion by about 50% in response to intraduodenal oleate. In contrast, protein output in response to parenteral stimuli increased after vagotomy. Integrated output of CCK in response to intraduodenal oleate or to exogenous bombesin or CCK was not significantly affected by vagotomy, but release of pancreatic polypeptide was decreased significantly in response to all stimuli after truncal vagotomy. These data provide evidence that truncal vagotomy decreases pancreatic protein secretion in response to intestinal stimulants by interrupting enteropancreatic reflexes mediated by the vagus, while maintaining normal (or supranormal) sensitivity of the pancreas to endogenous and exogenous CCK.

The etiology of the Klippel-Trenaunay syndrome.

Abstract: The etiology of the Klippel-Trenaunay syndrome (KTS) remains obscure Although venous hypertension secondary to deep venous obstruction has been suggested as a cause, recent studies have demonstrated that most patients have unimpeded venous drainage Calf blood flows have been measured in 33 patients with KTS using venous occlusion plethysmography Although all flow rates were within normal limits, flow in affected limbs was invariably greater than in normal limbs (p less than 0001), and this is related to the presence of the nevus Biopsies of subcutaneous veins demonstrate the histological features of a response to chronically raised flow The authors suggest that KTS is caused by mesodermal abnormality during fetal development, leading to the maintenance of microscopic arteriovenous communications in the limb bud, as a result of which the triad of nevus, hypertrophy, and superficial varices is produced Deep venous abnormalities occur pari passu with the triad and are not responsible for its development

Neurogenic hypertension: etiology and surgical treatment. I. Observations in 53 patients.

Abstract: Although an extensive literature exists concerning essential arterial hypertension, the primary etiology has been unclear. Arterial compression of the left lateral medulla oblongata by looping arteries of the base of the brain was seen incidently in 51 of 53 hypertensive patients who underwent left retromastoid craniectomy and microvascular decompression for unrelated cranial nerve dysfunctions. Such compression was not noted in normotensive patients. Treatment by vascular decompression of the medulla was performed in 42 of the 53 patients. Relief in the hypertension was seen in 32 of the patients and improvement in four. Arteriosclerosis and arterial ectasia contribute to arterial elongation and looping. If pulsatile compression of the left lateral medulla occurs, hypertension may develop as a consequence of an imbalance in the neural control systems that normally regulate blood pressure. The hypertension may further contribute to arterial elongation, providing a vicious circle of pathophysiologic changes.

The pathogenesis of acute pancreatitis. The source and role of oxygen-derived free radicals in three different experimental models.

Abstract: Recent experimental work has suggested that oxygen-derived free radicals may play an important role in initiating the early capillary injury in acute pancreatitis. Data from models of ischemic injury in other organs have suggested the enzyme xanthine oxidase is important in generating oxygen-derived free radicals. The present study was performed to determine whether xanthine oxidase is the source of free radical production in experimental pancreatitis. Utilizing the isolated, perfused, ex vivo canine pancreas preparation, three models of pancreatitis were initiated with (1) free fatty acid infusion (FFA), (2) partial duct obstruction and secretin stimulation (POSS), and (3) ischemia (ISCH). In each model, during a 4-hour perfusion, edema developed, weight gain occurred (FFA 120.6 +/- 21.1 gm; POSS 44.5 +/- 6.9 gm; ISCH 63.3 +/- 14.0 gm), and the serum amylase became elevated (FFA 1827 +/- 397 u/dl; POSS 10,171 +/- 1487 u/dl; ISCH 1860 +/- 365 u/dl). When the xanthine oxidase enzyme inhibitor allopurinol was added to the perfusate prior to the 4-hour perfusion, edema formation was absent or minimal, weight gain was significantly less (FFA 15.2 +/- 2.5 gm p less than 0.05; POSS 8.8 +/- 2.7 gm p less than 0.001; ISCH 12.3 +/- 2.8 gm p less than 0.01), and the amylase remained normal or the elevation was significantly decreased (FFA 996 +/- 189 u/dl p less than 0.05; POSS 3021 +/- 1074 u/dl p less than 0.001; ISCH 993 +/- 214 u/dl p less than 0.002). These data confirm that oxygen-derived free radicals play an important role in the pathogenesis of experimental acute pancreatitis, and suggest that the enzyme xanthine oxidase may well be the source of their production.

Septic and technical complications of central venous catheterization. A prospective study of 200 consecutive patients.

Abstract: The results of central venous catheterization for total parenteral nutrition were prospectively evaluated in 200 consecutive patients All catheters were fabricated of polyurethane tubing inserted by the Seldinger technique Two hundred sixty-three lines were inserted in 200 patients for a total of 4103 days Major complications occurred in 23% patients Twenty-four per cent of catheters were associated with suspected sepsis; of these, 52% were removed directly and 48% were changed over a guidewire The total catheter sepsis rate was 57% The incidence of sepsis correlated with the number of attempts to insert the line and with positive skin cultures These data indicate that: use of the Seldinger technique to insert nonthrombogenic flexible catheters results in lower technical morbidity; the incidence of established infection is much lower than the incidence of suspected sepsis; guidewire change may be performed without risk to the patient or interruption of therapy; sepsis rates can be decreased by reducing the number of attempts to catheterize the subclavian vein; and sepsis rates correlate with positive skin cultures at the insertion site

Timing of surgical drainage for pancreatic pseudocyst. Clinical and chemical criteria.

Abstract: Traditional concepts of managing pancreatic pseudocysts have changed with the advent of computerized tomography (CT) and ultrasound scanning, but new misconceptions related to spontaneous resolution have replaced some old ones. This report shows a difference in natural history and treatment requirements when pseudocysts are associated with acute versus chronic pancreatitis. There were 42 consecutive patients with pseudocysts treated over 5 years. Thirty-one were known alcoholics, two had gallstone pancreatitis, and nine had idiopathic pancreatitis. An attack of acute pancreatitis was identifiable within 2 months preceding in 22 patients, but there were only chronic symptoms in 20. Spontaneous resolution of the pseudocyst occurred in three patients (7%), all of whom had recent acute idiopathic pancreatitis, normal serum amylase levels, and pancreatograms showing normal pancreatic ducts freely communicating with the pseudocyst. Factors associated with failure to resolve included known chronic pancreatitis, pancreatic duct changes of chronic pancreatitis, persistence greater than 6 weeks, and thick walls (when seen) on scan. Nearly all (18/19) patients with known chronic pancreatitis had successful internal drainage of the pseudocysts immediately upon admission, whereas 6/20 patients with antecedent acute pancreatitis were found to require external drainage at the time surgery was eventually elected. Isoamylase analysis, performed on serum from 19 patients by means of polyacrylamide gel electrophoresis, detected the abnormal pancreatic isoamylase pattern described as "old amylase" in 15. When old amylase was present in the serum, internal drainage was always possible (14/14). In four of five patients whose serum contained no detectable old amylase, internal drainage was not possible regardless of the length of prior observation. There were four nonfatal complications arising from an acute pseudocyst during the wait for maturity. It is concluded that prolonged waiting is expensive and unnecessary for pseudocysts in chronic pancreatitis when there has been no recent acute attack. However, pseudocysts developing after identifiable acute pancreatitis should be observed in the safety of a hospital for up to 6 weeks to allow for either spontaneous resolution or maturation of the cyst wall. The appearance of old amylase in the serum suggests that the pseudocyst wall has achieved sufficient maturity to allow safe internal anastomosis.

Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity.

Abstract: To evaluate the long-term frequency and severity of anemia and selected vitamin and mineral deficiencies after gastric exclusion surgery for morbid obesity, the authors prospectively examined hematologic and nutritional parameters in 150 consecutive patients. These patients underwent a standardized gastric exclusion procedure during a six-year period (1976-1982) and were closely followed for up to seven years (mean, 33.2 months). Anemia developed in 36.8% of the population at a mean time from operation of 20 months. It was more frequent in women than in men (p less than 0.01), and it required transfusions in 3.5% of the population. A low serum iron concentration developed in 48.6%, iron deficiency in 47.2%, a low serum vitamin B12 concentration in 70.1%, vitamin B12 deficiency in 39.6%, and RBC folate deficiency in 18% of the population. Both iron and folate deficiencies responded to oral replacement. As a result of the high frequency and severity of anemia and nutritional deficiencies noted, all gastric exclusion patients should, as a minimum, be placed on oral multivitamin preparations containing iron, folate and vitamin B12. In addition, it is imperative that these patients be followed closely for the remainder of their lives with appropriate studies and replacement as necessary.

Peritoneal approach to prosthetic mesh repair of paraostomy hernias.

Abstract: A new method for repair of large hernias at stoma sites is presented. The old abdominal incision is reopened and prosthetic mesh is sutured in place aseptically. The bowel courses above the mesh to be secured to the lateral abdominal wall creating a flap valve. Seven paraostomy hernia repairs in six patients were performed with no recurrences in a 4- to 7-year follow-up. The peritoneal approach to insertion of prosthetic mesh into the hernia defect is recommended especially for recurrent paraostomy hernias. This technique is appropriate for a hernia that possesses a large fascial defect.

The surgical treatment of fibrous dysplasia. With emphasis on recent contributions from cranio-maxillo-facial surgery.

Abstract: Fibrous dysplasia is a congenital, metabolic, nonfamilial disturbance that occurs in one or more bones, at times in association with skin pigmentations or endocrine abnormalities. The authors report on a large personal series of 23 patients with fibrous dysplasia involving the craniofacial skeleton. The etiology, clinical findings, pathology, and differential diagnosis of this condition are reviewed and a working hypothesis is offered for the pathophysiology of this disorder. Approximately one-third of patients with fibrous dysplasia have involvement of the cranial or facial bones. The authors describe how new techniques in craniofacial surgery have opened up additional options for this group of patients. Deformity, diplopia, proptosis, sinus infection, deafness, and loss of vision, are some of the clinical features that may require early surgical management. Evidence is given to support more complete resection of bony lesions with immediate reconstruction by several techniques. The removal, remodeling, and replacement of the dysplastic bone is advanced as a promising new method for the management of these complex problems. Successful use of this technique in four patients is reported. In a separate group of patients, continuing good experience is reported with cranio-orbital reconstruction by means of large methyl-methacrylate implants. Both of these surgical approaches eliminate donor site morbidity that results from the grafting of large amounts of autogenous bone. Both techniques also avoid the problems associated with postoperative absorption of bone grafting. Several patients are reported in whom serious disturbances in visual function appear to have been prevented or reversed by early treatment. Factors leading to malignant change in patients with fibrous dysplasia are reviewed.

Improved survival in 45 patients with pancreatic abscess.

Abstract: The reported mortality due to pancreatic abscesses after acute pancreatitis has been 30 to 50%, a statistic that has remained unchanged for decades. This is a report of 45 patients treated over 10 years, showing a dramatic improvement in survival during that period. They represent 2.5% of admissions at the Massachusetts General Hospital for acute pancreatitis. The identifiable antecedents included alcohol (38%), gallstones (11%), and surgical trauma (16%), or were unknown in 24%. Computerized tomography (CT) was clearly the best means of specific diagnosis (unequivocal evidence in 74%, suggestive in 21%). Treatment in 44 patients was surgical debridement and catheter drainage, and in one it was resection of the pancreatic head. Multiple abscesses were present at the first operation in 21 patients. Seven had second drainage procedures for additional abscesses. In the first 5 years (1974-1978), 10 of 26 patients died (38%). In the second 5 years (1979-1983), one of 19 died (5%) (p less than 0.01). Postoperative complications (84%) included wound hemorrhage (9 of 26 vs. 1 of 19), systemic sepsis (7 of 26 vs. 1 of 19), pancreatic fistula (14/45, 13 of which closed spontaneously), colonic perforation (4), duodenal perforation (2), and gastric perforation (1). The causes of death were renal and respiratory failure with sepsis (7), hemorrhage (3), and pulmonary emboli (1). Analysis of the findings shows in the second 5-year period more frequent use of CT to certify the diagnosis of pancreatic abscess earlier, a more aggressive attitude producing earlier surgical intervention, and more extensive drainage and debridement of associated necrotic tissue. Transcatheter arterial embolization was used successfully to control postoperative hemorrhage from the abscess cavity. CT-guided percutaneous catheter drainage was used occasionally for drainage of recurrent abscesses. Neither open packing of major pancreatic abscesses nor lavage of the abscess cavity, as recently advocated, was necessary.

Accidental lesions of the common bile duct at cholecystectomy. II. Results of treatment.

Abstract: Sixty-five cases of accidental lesion of the choledochus at cholecystectomy reported from 51 Swedish hospitals to the Patients' Insurance Syndicate in Stockholm 1975-1981 were studied. The results were evaluated as to the time of detection and the primary surgical repair done. Fifty-five of the 65 lesions were detected and repaired at the cholecystectomy and ten were detected and repaired the first 10 days after the primary operation. In 38 of 55 lesions detected before surgery, an end-to-end choledochostomy was performed. Good results without further surgical intervention were achieved in 22%. The 17 other preoperatively detected lesions were treated with choledocho/hepaticoenterostomy, and good results were achieved without further surgical intervention in 54%. Of the ten patients in whom the lesions were detected after surgery, three were reconstructed with an end-to-end choledochostomy; all of these developed obstruction that led into further reoperations. In the remaining seven patients the lesions were repaired within 10 days with a choledocho/hepaticoenterostomy; three of them did not require further surgical intervention and four had to be reoperated. There was no mortality at the first repair, but two cases of hospital mortality at reoperations. However, the morbidity have been substantial for patients with as well as without obvious further surgical complications. The results indicate that in this selected group choledocho/hepaticoenterostomy should be the procedure of choice. However, the accumulated rate of biliary strictures increased with time, which requires a considerably longer follow-up to know the end results of this of avoidable complication to "a straightforward cholecystectomy."

The Emory prospective randomized trial: selective versus nonselective shunt to control variceal bleeding. Ten year follow-up.

Abstract: From 1971 to 1975, 55 patients with variceal bleeding secondary to cirrhosis were entered into a prospective randomized trial comparing distal splenorenal (selective) and H-graft interposition (nonselective) shunt. This 10-year follow-up documents that selective shunt is better (p less than 0.05) in four of the five variables monitored. Control of bleeding: selective shunt prevented variceal bleeding better than interposition shunt due to the higher (0.05 less than p less than 0.1) occlusion rate (30%) of interposition shunt. Selective shunt maintained postoperative portal perfusion better (p less than 0.01) than patent interposition shunt. Seventy-five per cent of selective shunt survivors have portal perfusion at 10 years: no patient with a patent nonselective shunt perfuses the liver. Quantitative liver function was better preserved (p less than 0.01) 10 years after selective shunt than nonselective shunt. Postoperative encephalopathy occurred in fewer (p less than 0.01) selective (27%) than nonselective (75%) shunt patients over the 10 years. Survival: in the randomized population, the improved survival in the selective shunt subgroup did not reach statistical significance. However, improved survival was confirmed in nonalcoholics. Five of eight nonalcoholics operated with selective shunt are alive at 10 years with patent shunts. No nonalcoholic, of seven total, operated with nonselective shunt survived 10 years with a patent shunt. These data show that selective shunt was superior to nonselective shunt. There was less rebleeding and encephalopathy after distal splenorenal shunt; postoperative portal perfusion and hepatic function were maintained.

Tube gastrostomy. Techniques and complications.

Abstract: For prolonged gastrointestinal decompression or enteral nutrition, gastrostomies are preferable to nasogastric tubes. To assess the safety of tube gastrostomy, the authors reviewed 424 gastrostomies systematically selected from a total of 3,359 done from 1975 through 1980. Feeding gastrostomies composed 22% of the total; the remaining 78% were done for decompression. Complications were rare (6.6% major, 6.6% minor) and were not influenced by patients' age. Perioperative steroid therapy promoted laparotomy wound infections. External and internal leakage of stomach contents, as well as bleeding from the gastrostomy site, were independent of the method of gastrostomy and the type of catheter used. Feeding gastrostomies were more likely to leak internally than were decompression gastrostomies. Unless the gastrostomy site was sutured to the anterior abdominal wall, there was a 7% incidence of extravasation of stomach contents into the peritoneal cavity after removal of the tube. The low complication rate justifies use of gastrostomies as an alternative to prolonged nasogastric intubation. Problems are minimized by employing the Stamm technique with a straight catheter and anterior gastropexy.

Accidental lesions of the common bile duct at cholecystectomy. Pre- and perioperative factors of importance.

Abstract: The 65 reports of accidental lesions of the choledochus at cholecystectomy from the records of the Patients' Insurance Syndicate in Stockholm, Sweden, 1975-1982, were studied in order to characterize avoidable factors and/or situations at cholecystectomy. Compared with control materials, there were significantly less men (28 vs. 34%) and the patients were younger (46 vs. 54 years). The patients were without significant other diseases and former operations, and were slim or of a normal weight. The patients had a short history of known biliary tract disease and there was seldom a suspicion of common duct stone. Most of the surgeons were under training and 80% of them had done 25 to 100 cholecystectomies before, seldom assisted by a more experienced surgeon. The inflammation was never severe, the bleeding insignificant, and an anomaly was found after the lesion was done in only 16 of 55 cases. The lesion was done before cholangiography in 27 cases and after the cholangiography, but before the films were available in 32 cases. The gallbladder was excised about as often from the fundus as from the pouch. We have found it probable that most of these accidental injuries of the choledochus could have been prevented with a policy that considers cholecystectomy as a major operation that requires well-trained surgeons with a humble and concentrated approach to their task.