Showing papers in "Archives of Surgery in 1974"

The fate of heterotopic pancreatic tissue. A study of 212 cases.

Abstract: A series of 212 cases of pancreatic heterotopia has been analyzed in order to ascertain the frequency of this congenital anomaly and to determine the cause of significant clinical symptoms. In the period from 1952 through 1971, 212 cases of heterotopic pancreas were seen at the Mayo Clinic. A firm causal relationship to symptoms was difficult to establish. Obscure gastrointestinal tract bleeding; often attributed to this lesion, was rarely associated with ulceration or necrosis when the lesion was excised and examined microscopically. When heterotopic pancreas was discovered at operation, however, excision was a safe and warranted procedure. Confusion with lesions such as small myomas and carcinoids was thus eliminated and a further diligent search could be pursued for the cause of persistence of symptoms originally attributed to the heterotopia.

Interspecies healing of porous arterial prostheses: observations, 1960 to 1974.

Abstract: We have implanted 1,084 porous arterial prostheses of four different types in humans and in experimental animals (dog, pig, calf, and baboon) and 81 impervious grafts in experimental animals. Our observations include the following: (1) Though pig and calf do not develop delayed transinterstices hemorrhage through very thin, highly porous smooth-walled prostheses, the dog has a very high incidence, and we have seen two cases in man. (2) Compared to the other three species, man and dog are limited in their ability to develop pannus ingrowth from the anastomoses. (3) Man has the slowest rate of transinterstices ingrowth, and the least ability to accomplish complete inner wall healing, while pig, calf, and baboon heal very rapidly. (4) Healing of porous prostheses is assisted by a filamentous external surface, particularly in man. (5) The dog approximates human healing more closely than do the other three species.

Surgery and sclerotherapy in the treatment of varicose veins. A random trial.

Abstract: Varicose veins are a common problem, and yet there is divergent opinion as to whether surgery or sclerotherapy is the preferred method of treatment. After establishing a reliable injection technique, the method was compared with standard surgical procedures in a random trial. The results showed that after one year 82% of unselected patients were cured by injection, but after six years the cure rate was only 7%. The surgical result was not as good at one year, but much better than injection after six years. When the results were considered for three distinct clinical groups, the analysis showed that the best primary treatment for dilated superficial veins and for incompetent perforating veins in the lower part of the legs was injection-compression. However, surgery was much more successful and long-lasting when there was involvement of the saphenous systems with proximal incompetence.

Role of Proteolytic Enzyme in the Prevention of Postoperative Intraperitoneal Adhesions

Abstract: Peritoneal adhesions were produced in 90 male albino rats by painting the anterior surface of the rats cecum with absolute alcohol to produce an aseptic inflammation. The adhesions were classified into five grades according to their number, extent, and density. A proteolytic enzyme fromCarica papaya(Papase) was given orally to these animals in the immediate postoperative period and was found to reduce markedly the incidence and extent of adhesions as compared with those of a control group of rats. This product was found to be equally effective in reducing the incidence and extent of reformation of adhesions after their lysis.

The Bacterial Etiology of Pneumatosis Cystoides Intestinalis

Abstract: Pneumatosis cystoides intestinalis (PCI) is an uncommon condition of unknown cause characterized by the presence of gas-filled cysts within the walls of some portion of the gastrointestinal tract. In this investigation, gas-filled cysts were produced in the omentum, wound, mesentery, and intestine of the germ-free rat by injecting a pure culture ofClostridium perfringensinto either the wall of the distal part of the small intestine and cecum, or into the peritoneal cavity. The disorder appeared to be self-limited in time, to be related to the amount of contamination, and to occur after minimal trauma to the intestines. These experiments prove that PCI can be caused by bacteria alone. Attempts to produce the lesion by monocontaminating germ-free rats in a similar manner with pure cultures of any one of nine other common intestinal bacteria were unsuccessful.

Aortoenteric and Paraprosthetic-Enteric Fistulas: Problems of Diagnosis and Management

Abstract: The clinical characteristics, surgical treatment, and therapeutic results were surveyed in 11 cases of aortoenteric and 8 cases of paraprosthetic-enteric fistulas observed in 2,085 abdominal aortic reconstructive operations. The clinical manifestations of these lesions were exsanguinating hemorrhage or medically uncontrollable retroperitoneal sepsis. The diagnosis of aortoenteric or paraprosthetic-enteric fistulization must be assumed in every case of abdominal aortic reconstruction with late hemorrhagic or septic complications. The treatment is early and aggressive surgical intervention supported with appropriate antibiotic medication. Some operative technical details appear useful in reducing the probability of occurrence of these complications.

Human amniotic membrane as a physiologic wound dressing.

Abstract: In 65 patients, split-thickness donor sites were covered with amniotic membrane. Amniotic membrane was used to dress partialthickness burns in 42 patients. In rats, open wounds were covered with amnion and in others it was placed in a subcutaneous pocket. The amnion acted as a comfortable and effective wound dressing. None of the biopsy specimens, however, showed vascularization of the amnion by the host.

Major venous anomalies complicating abdominal aortic surgery.

Abstract: Four major anomalies of the venous system were encountered during abdominal aortic surgery. These were transposition of the inferior vena cava, duplication of the inferior vena cava, circumaortic venous collar, and retroaortic left renal vein. Although these anomalies are not common, each poses a particular problem related to its recognition, protection from injury, and intraoperative management.

Double Internal Mammary-Coronary Artery Bypass

Abstract: Double internal mammary-coronary artery bypass in 100 patients with angina was associated with 35 single-vein grafts and four double-vein grafts. Hospital mortality was 8%. Postoperative catheterization revealed patency of 80 of 84 (95%) right internal mammary artery (RIMA) grafts, 82 of 84 (97%) left internal mammary artery (LIMA) grafts, and 36 of 41(88%) vein grafts. At one year, 22 of 23 (96%) RIMA grafts and 22 of 22 LIMA grafts remained patent. There were two late deaths, one late infarction, and three of 23 patients with angina at one year. Five of 45 IMA grafts had diffuse narrowing. The right and left IMA are hemodynamically similar, but the right will usually not reach beyond the acute margin and is smaller than the right coronary artery (RCA) one third of the time. The LIMA graft is the graft of choice for left anterior descending (LAD) reconstruction, but use of the RIMA for RCA or LAD bypass must be based on the age of the patient, the size of the coronary artery, and the distribution of atherosclerosis.

Pulmonary response to major injury.

Abstract: The pulmonary function of 49 patients admitted to the trauma services of Parkland Memorial Hospital was studied primarily in terms of volume function and blood-gas exchange. The incidence of fulminant pulmonary failure was low (three out of 49 or 6%). There was no evidence that shock without concomitant direct pulmonary injury increased the incidence of significant pulmonary dysfunction. Factors that predisposed the injured patient to pulmonary dysfunction were ( a ) direct thoracic or pulmonary injury, ( b ) sepsis, ( c ) aspiration of gastric contents, ( d ) head injury, and ( e ) fat embolization. The factor that appeared to jeopardize the patient's normal lung function most was sepsis. Almost all septic patients had defects in compliance and failed to maintain an adequate arterial oxygen pressure. A substantial number of severely injured patients required mechanical respiratory assistance to maintain normal pulmonary function.

The bacteriology of intra-abdominal infections.

Abstract: The bacteriology of intra-abdominal infections was studied prospectively in 64 patients. Special techniques for isolating anaerobic bacteria were employed along with standard microbiologic methods. Infections included generalized peritonitis, intraperitoneal and retroperitoneal abscesses, as well as abscesses of the liver, spleen, and pancreas. Specimens commonly contained multiple organisms (average, 3.8 per infection). Anaerobic bacteria were isolated most frequently (81% of cases) and multiple anaerobes were the only organisms found in 38% of cases. The remaining isolates were Gram-negative bacilli andStreptococcusspecies. Antimicrobial therapy of intra-abdominal infections should be directed atBacteroides fragilisas well as facultative and aerobic organisms that are sensitive to the penicillins, cephalosporins; and aminoglycosides.

Correlation of pulmonary wedge and left atrial pressures. A study in the patient receiving positive end expiratory pressure ventilation.

Abstract: A prospective study of five patients was performed utilizing both left atrial and wedge catheters. As positive end expiratory pressure (PEEP) was altered, left atrial pressure, cardiac index, net left atrial pressure, pulmonary vascular resistance, and stroke work were determined. At low levels of PEEP, wedge and left atrial pressure correlated significantly ( r =.83). As PEEP increased, cardiac index was frequently compromised. Measurements of net left atrial pressure and stroke work indicated that high levels of PEEP resulted in left ventricular failure. This may have been due to reduced coronary flow secondary to an elevated myocardial interstitial pressure with high levels of PEEP.

Gray's Anatomy, 35th British edition.

Abstract: This monumental work is something of a landmark in anatomic texts. "Anatomy–wheredoes it happen, chemistry–howdoes it happen." With these words, a colleague once summed up the case for dismissing physiology as a needed discipline, yet physiology still is "whathappens." But anatomy, to fulfill its role of really explainingwhereall happens, must present all its modern day facets, ultrastructure, and histochemistry, but relate these matters to gross anatomy as well. In this latest British edition of Gray's, the new editors and main authors, Professors Warwick and Williams, have given us a new text indeed, by integrating those views of the construction of the body obtained by microscopical and other techniques with those appreciated through dissection and the unaided eye. They have thus produced a basic consideration of organs and parts, not only as major structures, but as tissues and cells at the same time–precisely as

The Urologic Clinics of North America

Abstract: Recognizing the growth of urology as a specialty, WB Saunders has launched a new publication, the Urologic Clinics of North America. The first issue is a symposium entitled "Neurogenic Bladder," with Jack Lapides, MD, as guest editor. The goal of the Clinics, as Dr. Lapides states in the forward, is "to present up-to-date material of practical value," and this issue appears to have accomplished this aim. A chapter on neuroanatomy and neurophysiology of the detrusor and urethra is included, which provides the necessary scientific background for the following articles on classification, clinical evaluation, and therapy. Included in the symposium are several articles on intermittent catheterization by noted authorities in the treatment of spinal cord injuries. The surgical treatment of various neurological abnormalities is adequately discussed in several of the articles, and there is a separate article on indications and techniques of urinary diversion. For the most part, the various authors

Hormone-Substrate Interrelationships Following Trauma

Abstract: Serial blood samples were collected from 14 injured persons on admission to the hospital and at regular intervals for 24 hours Seven of the patients had severe and seven had minor trauma Hyperglycemia, elevated free fatty acid (FFA) levels, hypoinsulinemia, hyperglucagonemia, and elevated cortisol levels were observed in many instances These changes were more pronounced when trauma had been more severe Interrelationships between the hormones and the nutritional substrates were revealed as an inappropriately low insulin level for the concomitant glucose concentration and a breakdown of the relationship of glucose to FFA We postulate that, in trauma, the gradual rise in glucagon contributes to the increase in concentration of glucose and FFA, and that the cortisol rise synergizes with the elevated glucagon concentration to favor gluconeogenesis from muscle amino acids Relatively low circulating insulin levels favor these metabolic changes

Recurrent Catamenial Pneumothorax

Abstract: In 1958, Maurer described the syndrome of recurring catamenial pneumothorax associated with pelvic and diaphragmatic endometriosis. Since then, similar cases have been reported, indicating that pelvic endometriosis and pleural or diaphragmatic endometrial implants may be present. On the basis of experience with six patients of our own, and in a review of the literature, we find no support for the explanations so far proposed, eg, that the uterine cavity is the source of air that passes through congenital diaphragmatic defects. Our experience confirms that the syndrome occurs in ovulating women and that symptoms are relieved by hormonal suppression of ovulation; that endometriosis may not be present; and that usually no specific pulmonary process is found. Awareness of this entity will lead to more frequent case findings, thus permitting the determination of its true incidence and the testing of current theories.

Selective Distal Splenorenal Shunt: Technique and Results of Operation

Abstract: The selective distal splenorenal shunt has been evaluated from the standpoint of its effectiveness in control of gastrointestinal variceal hemorrhage in the cirrhotic and the metabolic changes induced by this procedure. It has been shown to be superior to total portosystemic shunting procedures in the metabolic aspects of the study and has a markedly lower incidence of encephalopathy as compared to previous data from our studies as well as those from numerous other investigators. The operative mortality has been progressively lowered and now has reached levels comparable to those experi

Proceedings: Pancreatic abscess.

Abstract: Compared with the general hospital population of patients with pancreatitis, patients with biliary tract or peptic ulcer disease have de novo pancreatic abscesses develop more commonly than patients with alcoholic pancreatitis. The apparent greater predisposition of the patient with biliary tract or peptic ulcer disease to infection does not seem to be due so much to these patients having potential sources of infection, such as an infected biliary tract or leaking ulcer, as to the fact that many patients with alcoholism and hemorrhagic pancreatitis never survive the fluid loss phase of pancreatitis long enough to have a secondary infection and abscess. The mortality associated with the development of de novo pancreatic abscesses is higher in patients with biliary disease, peptic ulcer or idiopathic pancreatitis in comparison with those patients with alcoholic pancreatitis. Some complications of pancreatic abscesses, such as renal failure, may be avoided through appropriate management of fluid losses during the hemorrhagic phase of pancreatitis preceding absecess formation. Good medical management and aggressive use of newer diagnostic and therapeutic modalities may reduce the mortality and complications of pancreatic abscess. Prompt drainage of an abscess once identified is essential to survival. Proximal colostomy or ileostomy is indicated in the patient with a colonic fistula. Large particulate chunks of necrotic pancreas are not easily evacuated through Penrose, cigarette or sump drains. Marsupialization of the abscess may be considered in patients with this type of abscess.

Extracranial Internal Carotid and Vertebral Artery Fibrodysplasia

Abstract: Arterial fibrodysplastic lesions involving the extracranial internal carotid and vertebral arteries were encountered among 15 women ranging in age from 21 to 79. Concomitant renal artery dysplasia was noted in five patients, including three with associated lesions involving the celiac or superior mesenteric vessels. Multiple intracranial aneurysms were found in seven patients. Rupture of these aneurysms with subarachnoid hemorrhage occurred in four patients and was the cause of death in three. Cerebral ischemic symptoms in certain instances may result from extracranial cerebrovascular fibrodysplasia. Considerable caution was used in selection of patients for surgery. Graduated intraluminal dilation of the internal carotid artery was performed on five occasions in this series. The pathogenesis of this disease is unknown. Hormonal influences and traction-stretch stresses to the vascular wall are implicated in the evolution of fibrodysplastic carotid and vertebral artery lesions.

Mesenteric Cysts: A Review

Abstract: "Cysts of the mesentery are among the surgical rarities," stated Berkeley Moynihan in 1897.1McKeown et al2believed that mesenteric cysts are medical curiosities of historic interest only. Mesenteric cysts are indeed rare, and have been omitted from some surgical textbooks. However, the subject deserves more consideration because of the very fact that the cysts are frequently overlooked. Consequently, inappropriate treatment and late diagnoses are common in the management of mesenteric cysts. The medical history and physical examination findings are seldom characteristic. Roentgenograms are generally suggestive and may lead to the diagnosis, which is made most frequently at surgery.3This review of the literature is presented in order to provide a complete, informative picture of mesentery cysts, thereby alerting the clinician to them as potential diagnostic entities. Historical Background and Incidence The historical background of mesenteric cysts is divided into three periods1(Table 1). The first

Ca rotid Artery Back Pressure and Endarterectomy Under Regional Anesthesia

Abstract: Internal carotid artery (ICA) back pressure correlates collateral cerebral blood flow, providing a critical pressure necessary for carotid endarterectomy without a shunt. The ICA back pressures were measured in 43 patients undergoing 50 endarterectomies under regional anesthesia. A four-minute ICA test occlusion was used to determine need for shunting. Mean ICA back pressure was 69 ± 2 (SE) mm Hg in 22 procedures (group 1), 34 ± 2 mm Hg in 25 procedures (group 2), and 15 ± 3 mm Hg in three procedures (group 3). Differences between groups were significant ( P P >.05) differences in systemic pressure. Group 3 patients did not tolerate temporary carotid occlusion, confirming 25 mm Hg as the lower limit of adequate collateral flow. Five patients developed neurological complications, three in group 1 and two in group 2. Embolization may have occurred in two patients. However, some patients require more than minimum collateral flow and consequently need ICA back pressures higher than 25 to 50 mm Hg.

Excitation Transfer in Bone: Deleterious Effects of Cobalt 60 Radiation-Sterilization of Bank Bone

Abstract: In a bone alloimplant in muscle, the structure of the organic matrix evocates or promotes a morphogenetic response from migratory mesenchymal cells. Radiation sterilization destroys the morphogenetic property at a much lower dose of cobalt 60 in undemineralized than in the demineralized bone. Damage to the organic matrix is heightened by excitation transfer from the radiated bone mineral to the matrix proteins. The mineral having an apatite structure also has a relatively high ionization potential and generates deleterious free radicals, which convert the matrix collagen to gelatin. Radiolysis prevents neither the undesirably delayed hypersensitivity response nor the degradation of the bone morphogenetic property by endogenous protease. These observations account for the failure of freeze-dried and radiation-sterilized bone to promote repair of large bone defects in adult patients.

Symmetrical Peripheral Gangrene

Abstract: Four patients with acute medical illnesses developed peripheral symmetrical gangrene. All were seen in one hospital within a six-month period. There was no evidence of significant proximal arterial occlusion. Hypotension and poor tissue perfusion were present in each case. There was associated sepsis in three. Diffuse intravascular coagulation was documented in one patient and suspected in another. All patients demonstrated some degree of acute renal failure, and myoglobinuria was noted in two. All patients ultimately died. An appreciation of the seriousness of the etiological factors in patients with peripheral symmetrical gangrene will direct therapeutic efforts toward correction of the underlying disorder and avoid unnecessary angiography or surgical intervention.

Intermittent Claudication: Surgical Significance

Abstract: A study was made of 162 persons with intermittent claudication who were observed for an average of 8.3 years. These were all the cases that evolved from a population cohort during 18 years of follow-up. They were essentially untreated until rest pain and tissue loss began. Only four progressed to major amputations and three to toe loss. A profile of the person developing intermittent claudication and gangrene in particular reveals a higher prevalence of diabetes and the cigarette habit, as well as hypertension and hypercholesteremia. The comorbidity and subsequent incidence of coronary disease, stroke, and congestive failure was high. Within eight years, almost half developed a major cardiovascular event and 20% of the men and 30% of the women were dead. This cardiovascular morbidity and mortality, as well as intermittent claudication, is predictable in the general population free of cardiovascular disease. Patients being considered for bypass surgery whose only complaint is claudication should be carefully evaluated for risk of cardiovascular morbidity.

Pathophysiology of the Respiratory Distress Syndrome

Abstract: The sequential pathological changes of the respiratory distress syndrome have been assessed in 200 lung biopsies and autopsy specimens over the past ten years. The initial microscopic changes consisted of thromboemboli in pulmonary arterioles. These were followed by congestion and interstitial edema and hemorrhage over the next 24 hours. Intra-alveolar hemorrhage next became evident and reached a peak at 72 hours. Following this, hyaline membranes became the predominant lesion. Bronchopneumonia may be superimposed on these changes at any point from this time on. If the patient survived for a matter of weeks or months prior to death, pulmonary fibrosis was the terminal lesion. The variable combination of these pathological changes explains the clinical manifestations of the respiratory distress syndrome.

Intermittent Mandatory Ventilation: An Evaluation

Abstract: Twenty-four patients who had acute respiratory insufficiency necessitating mechanical ventilation were studied. Twelve patients had controlled mechanical ventilation (CMV) with T-tube trials of spontaneous ventilation to accomplish weaning. Twelve received intermittent mandatory ventilation (IMV), a method of mechanical ventilation that allows spontaneous respirations to occur but provides periodic mechanical hyperinflations. Weaning was accomplished by increasing the interval between mechanical breaths until the patient's ventilation was entirely spontaneous. Arterial blood gas tensions, pH, dead space to tidal volume ratio, oxygen consumption, vital capacity, and inspiratory force were monitored for all patients until weaning was complete. The functional residual capacity was reduced in all patients following mechanical ventilation. Controlled mechanical ventilation resulted in alkalosis, an increased ventilation time, and an increase in oxygen consumption compared to IMV.

Intravenous Hyperalimentation: In the Treatment of Inflammatory Diseases of the Bowel

Abstract: Fifteen patients with regional enteritis (14) or ulcerative colitis (one) who were refractory to medical management were treated by bowel rest and intravenous hyperalimentation (IVH). Nine received IVH as primary therapy and all had remissions. Four have done well for four months to three years. Four had recurrences and one died later. Six patients received IVH before planned operations for localized disease. Five had no recurrences for six months to three years and one did not tolerate IVH. The role of IVH for inflammatory bowel disease can be both in preparation for operation and as primary therapy for acute episodes. We reserve IVH as primary therapy for patients with previous resections or extensive disease. It has provided prolonged remissions in some and prevented further operations in most. However, the long-term course of the disease was not altered.

Therapeutic Portacaval Shunt: Preliminary Data on Controlled Trial and Morbid Effects of Acute Hyaline Necrosis

Abstract: In our study of a controlled trial of therapeutic portacaval shunt, preliminary data suggest the superiority of surgical over medical treatment. Utilizing the Life-Table method of analysis, our data thus far indicate a 90% to 95% chance that five-year survival for those patients treated by an end-to-side portacaval shunt is 60%, while survival for those treated medically is 10%. As a result of a prospective study, it is concluded that moderate to severe degrees of acute hyaline necrosis adversely influence survival after portacaval shunt in cirrhotic patients. Thus it is recommended that a liver biopsy precede consideration of either an emergency or an elective shunt.

Cervical thymic cyst. Case report and review of the literature.

Abstract: Thymic derivatives should be included in the differential diagnosis of cystic masses in the neck. A classification of thymic cysts is proposed; namely, true, mixed, or false. Thymic cyst may contain cholesterol crystals in the luminal fluid, cholesterol clefts, granulomas, and lymphocytic follicles as well as Hassall corpuscles in the wall. Treatment consists of simple excision of the cyst and its accompanying tract. The 34th case of cervical thymic cyst in the English literature is reported.

Differentiated Thyroid Carcinomas: Treatment of Distant Metastases

Abstract: During the 26-year period from 1947 to 1973, 333 patients with differentiated thyroid carcinomas were treated with sodium iodide I 131 post-operatively. Thirty-six of these (10.6%) had metastases to lung or bone or both. The mean age at the time of diagnosis was 36.1 years (range, 6 to 69 years). Mortality from thyroid carcinomas was 27.8%. Average follow-up interval from diagnosis was 19.8 years for those with papillary carcinomas and lung metastases and 23.0 years for those with follicular carcinomas and lung metastases. Although seven of ten patients with bone metastases died, the five-year survival was 100% in this group. The average dose of sodium iodide I 131 was 383.2 millicuries for papillary distant metastases and 571.2 millicuries for follicular metastases. Total thyroidectomy prior to treatment of distant metastases with sodium iodide I 131 is important for successful management.