Showing papers in "Archives of Surgery in 1990"

The Role of Intestinal Barrier Failure and Bacterial Translocation in the Development of Systemic Infection and Multiple Organ Failure

Abstract: Traditionally, evaluation of intestinal function has been limited largely to monitoring gastric pH and intestinal motility. This clinical approach has led clinicians to equate normal intestinal motility with normal intestinal function and to assume that if stress-induced gastric bleeding can be prevented, all will be well. However, it is becoming increasingly clear that the gastrointestinal tract is not a passive organ and that intestinal dysfunction is not limited to ileus and upper gastrointestinal bleeding. Instead, the gastrointestinal tract is recognized as having important endocrine, metabolic, immunologic, and barrier functions, as well as its traditional role in nutrient absorption. Over the last 5 years, there has been a resurgence of interest in the role of intestinal barrier failure in the development of systemic infection and multiple organ failure in the critically ill or injured patient.

Preoperative staging and assessment of resectability of pancreatic cancer

Abstract: • To study the accuracy of preoperative staging techniques for assessing resectability of pancreatic and ampullary adenocarcinoma, we entered 88 consecutive candidates into a prospective study of contrast-enhanced computed tomography, magnetic resonance imaging, angiography, and laparoscopy. Resectability was proved in 16 (29%) of 55 patients for the head of the pancreas, 1 (6%) of 17 for the body and tail of the pancreas, and 14 (88%) of 16 for the ampulla. The combined findings of computed tomography and angiography showed that more than 87% of pancreatic head tumors were unresectable because of vascular encasement, but neither modality sufficed alone. Small liver and peritoneal metastases were found in 15 (27%) of 55 cancers of the head of the pancreas, 11 (65%) of 17 cancers of the body and tail of the pancreas, and 1 (6%) of 16 cancers of the ampulla; computed tomography missed all but 2 of these instances of metastasis, but laparoscopy with biopsy identified 22 (96%) of 23 instances. Magnetic resonance imaging findings did not differ significantly from computed tomography and conferred no added benefit. Ninety percent of unresectable tumors were identified. Seventy-eight percent of pancreatic head cancers were resectable when all test results were negative vs 5% (2/37) when any test result was positive. This study demonstrates that accurate and efficient triage is possible for patients with cancer of the pancreas and ampulla. ( Arch Surg . 1990;125:230-233)

Intra-arterial Floxuridine vs Systemic Fluorouracil for Hepatic Metastases From Colorectal Cancer: A Randomized Trial

Abstract: • Seventy-four patients with liver metastasis from proved colorectal primary adenocarcinoma were entered into a prospective, randomized clinical trial to evaluate treatment with intra-arterial floxuridine compared with standard outpatient therapy with fluorouracil delivered by intravenous bolus injection. Eligible patients were randomized to hepatic arterial chemotherapy with an implanted infusion pump or systemic chemotherapy. No crossover between treatment arms was permitted, and patients were followed up to progression and death. Objective tumor response was observed in 48% of patients receiving intra-arterial floxuridine and in 21% of patients receiving intravenous fluorouracil. Time to hepatic progression was significantly longer in the group given intra-arterial therapy: 15.7 vs 6.0 months. However, time to overall progression (6.0 vs 5.0 months) and survival (12.6 vs 10.5 months) were not statistically different. Based on these data, we cannot recommend treatment with intra-arterial floxuridine as given in this study for metastatic colorectal cancer to the liver. ( Arch Surg . 1990;125:1022-1027)

Early physiologic predictors of injury severity and death in blunt multiple trauma.

Abstract: • The importance of admission physiological and biochemical variables was modeled on data from 185 patients with blunt liver trauma with regard to their significance in prediction of mortality. The variables used were admission Glasgow Coma Score, base excess (or deficit), arterial lactate, injury Severity Score, and initial 24-hour volume of blood required for replacement. Each variable was modeled as a predictor of survival alone and in combination, using a linear logistic model. In any two-variable combination, Glasgow Coma Score had a high likelihood ratio for prediction representing the influence of brain injury. But as a single variable reflecting the probability of death, both base excess (LD 50 = -11.8 mmol/L) and initial 24-hour volume of blood (LD 50 =5.4 L) were highly significant. A combined logistic model of admission Glasgow Coma Score and base excess had the greatest likelihood of accurate prediction of outcome: P death = eλ/l + eλ; where λ= -0.21(Glasgow Coma Score)-0.147(base excess) + 0.285. Testing of this predictive model on data from 323 additional patients with multiple trauma who had pelvic fracture as their index injury also showed it to be a highly significant early predictor of outcome. ( Arch Surg . 1990;125:498-508)

Patterns of human tumor-infiltrating lymphocytes in 120 human cancers.

Abstract: • Tumor-infiltrating lymphocytes from 120 samples of human cancers, including melanoma, renal cell carcinoma, breast cancer, sarcoma, and colon cancer, were examined. The percentage of lymphocytes recovered from the cancer varied widely; that of renal cell carcinoma was higher than that of breast or colon cancer (65% vs 45%), which was higher than that of melanomas or sarcomas (30% to 35%). The types of lymphocytes before and after interleukin 2 activation showed specific patterns. CD4 + helper T cells predominated in all tumors except melanomas, which had more CD8 + cytotoxic T cells. CD16 + natural killer cells were recovered in renal cell carcinoma and sarcomas. Three different cytotoxic lymphocytes were identified among interleukin 2–activated tumor-infiltrating lymphocytes: (1) CD3 + CD16 − cytotoxic T lymphocytes with cytotoxicity restricted to autologous tumor cells in melanomas, (2) CD3 − CD16 + natural killer cells with vigorous major histocompatibility complex–nonrestricted cytotoxicity in renal cell carcinoma, and (3) CD3 + CD16 − T cells with modest levels of major histocompatibility complex–nonstricted cytotoxicity in all cancers except melanomas. Thus, there was considerable diversity of tumor-infiltrating lymphocytes among these histologically distinct tumors with respect to magnitude of lymphocyte infiltration, phenotypic expression, and functional capacity. ( Arch Surg . 1990;125:200-205)

Continuous, 10-year wound infection surveillance. Results, advantages, and unanswered questions.

Abstract: • During a 10-year wound infection surveillance program, 1032 wound infections complicated 40 915 operations. Surveillance continued for 30 days postoperatively, and rigid clinical criteria for diagnosis were honored. Operations were distributed unequally among infection risk classes: clean (class I), 63.3%; clean contaminated (class II), 26.4%; and contaminated (class III) 10.3%. Infections occurred with nearly equal frequencies among classes: I, 36.1%; II, 29.5%; and III, 34.4%. Wound infection rates during the 10-year period were 2.5% (all operations), 1.4% (class I), 2.8% (class II), and 8.4% (class III). Index year (1977) infection rates were 4.2% (all operations), 2.3% (class I), 5.4% (class II), and 12.8% (class III). Wound infection rates during the last 9 years of surveillance in every risk class were significantly less than index year rates, representing infection rate decreases of 38% to 56%. Estimated savings in hospital room costs alone reached $3 million during 10 years. (Arch Surg. 1990;125:794-803)

Carcinoma of the gallbladder. Does radical resection improve outcome

Abstract: The records of 111 patients with gallbladder carcinoma operatively treated between 1972 and 1984 were retrospectively reviewed. Fifty-seven percent of patients had distant metastases; another 16% had nodal metastases without distant disease. Median survival was 0.5 years, and 5-year survival was 13%. Clinical jaundice, tumor stage, and tumor grade were all predictive of patient outcome. DNA ploidy, measured in 70 patients, was not a prognostic indicator. In 36% of patients, cholecystectomy (20%) or radical cholecystectomy (16%), which included adjacent liver and regional lymph node resection, was potentially curative. Median survival for patients undergoing radical procedures was 3.6 years, and survival was 0.8 years for patients following cholecystectomy. The 5-year survival rates were comparable (33% vs 32%). While radical cholecystectomy may benefit individual patients and can be accomplished with low morbidity, there was no overall survival advantage compared with cholecystectomy.

Oral glutamine accelerates healing of the small intestine and improves outcome after whole abdominal radiation.

Abstract: • The healing effects of glutamine given orally for 8 days as a single amino acid nutrient after treatment with whole abdominal radiation (10 Gy) were studied. Rats received isonitrogenous and isovolumic diets containing 3% glutamine or 3% glycine. Control rats were not irradiated but were given identical diets. In irradiated animals, survival was 100% in animals receiving glutamine compared with 45% in animals receiving glycine. Glutamine ingestion diminished bloody diarrhea and the incidence of bowel perforation. Arterial glutamine level was higher in animals receiving glutamine in the diet, as were gut glutamine extraction (35%±8% vs 12%±7%) and intestinal glutaminase activity. These metabolic improvements were associated with a marked increase in villous height, villous number, and the number of mitoses per crypt in rats receiving glutamine. Glutamine was not beneficial in control nonirradiated animals. The data demonstrated that provision of oral glutamine after abdominal radiation supported gut glutamine metabolism, improved mucosal morphometrics, and decreased the morbidity and mortality associated with this abdominal radiation model. ( Arch Surg . 1990;125:1040-1045)

Immunocytochemical analysis of estrogen receptors in human breast carcinomas. Evaluation of 130 cases and review of the literature regarding concordance with biochemical assay and clinical relevance.

Abstract: • An estrogen receptor–immunocytochemical assay (ER-ICA) was performed on frozen sections of 130 samples of human breast carcinoma. A standard dextran-coated charcoal assay (DCCA) was performed on the same samples. Concordance of results between the tests was 91%. The sensitivity and specificity of the ER-ICA, compared with the DCCA, were 92% and 89%, respectively. We describe the ER-ICA technique and review the literature regarding the use of the ER-ICA in evaluating breast cancer with respect to the agreement of results with the DCCA, the nature of discordant results, the ability to predict the clinical response to hormone therapy, and the ability to predict disease-free survival. The combined experience of many studies has shown that the ER-ICA is a highly specific and sensitive method for measuring the level of ERs in breast tumors with a high level of agreement with the DCCA. Early experience has suggested that the ER-ICA can predict the response to hormone therapy and disease-free survival, as well as or better than the DCCA. The evaluation of receptor heterogeneity, made possible by the ER-ICA, may enhance our ability to discriminate ER-positive tumors with a relatively high risk of recurrence. (Arch Surg. 1990;125:107-113)

Is Liver Transplantation Justified for the Treatment of Hepatic Malignancies

Abstract: • Twenty-eight patients received orthotopic liver transplants for malignant disease between February 1, 1984, and December 31, 1989. Preoperative diagnoses included hepatocellular carcinoma (n = 16), cholangiocarcinoma (n = 3), other primary hepatic tumors (n = 6), and metastatic diseases to the liver (n = 3). Overall actuarial survivals at 6 months, 1 year, and 5 years were 67.3%, 51%, and 31%, respectively. Long-term survival longer than 5 years was achieved in 3 patients. The recurrence rate in patients surviving longer than 3 months is 48% (median, 7 months). Hepatocellular carcinoma and cholangiocarcinoma had the poorest survival and highest recurrence rates. Specific prognostic factors correlating with survival or recurrence could not be elucidated. These results indicate that orthotopic liver transplants can provide long-term cure and palliation for malignant disease; however, patient selection is extremely important in predicting outcome. (Arch Surg.1990;125:1261-1268)

Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock.

Abstract: • We evaluated the potential side effects of rapidly infusing 250 mL of either 7.5% sodium chloride or 7.5% sodium chloride per 6% dextran 70, using lactated Ringer's as the control, to 106 critically injured patients in two prospective double-blinded emergency department trials. Eight patients had a significant hyperchloremic acidemia in association with infusion of the hypertonic solutions, but all eight were moribund before infusion and many factors other than hyperchloremia could have contributed to their acidemia. Other blood chemistry changes that might have been associated with the hypertonic solutions, such as hyperosmolality or hypernatremia, were made insignificant by other factors, such as high blood alcohol levels or concomitant administration of sodium bicarbonate. There were no cases of central pontine myelinolysis; bleeding was not potentiated. There was no difficulty with crossmatching of blood. No anaphylactoid reactions occurred. In a setting of limited volume resuscitation, the solutions are likely to have a favorable risk-to-benefit ratio. ( Arch Surg. 1990;125:1309-1315)

Occult breast cancer presenting with axillary metastases. Updated management.

Abstract: • An isolated axillary lymph node metastasis in a woman without an obvious clinical primary site most frequently originates from the breast. Mastectomy has been the historical treatment of choice. A retrospective study of 35 patients was undertaken to evaluate the roles of modern mammography, breast preservation, and adjuvant systemic therapy in the management of these patients. Twenty-eight patients underwent a mastectomy, while 7 were managed by a combination of limited resection and/or axillary dissection and radiation therapy. Twenty-two (67%) of the 33 breast specimens contained carcinoma. Comparison of the pathologic results with the preoperative mammograms showed a specificity of 73%, while the sensitivity was only 29%. Actuarial 5-year survival after mastectomy or breast preservation was similar (77% and 65%, respectively). Patients with more than one positive lymph node benefited from adjuvant therapy. Mammography does not locate the majority of occult stage II breast cancers, and both breast preservation and adjuvant therapy may have roles in the management of these patients. ( Arch Surg . 1990;125:210-215)

Level I and II axillary dissection in the treatment of early-stage breast cancer. An analysis of 259 consecutive patients.

Abstract: • Level I and II axillary dissection involves anatomic dissection of levels I and II of the axilla without clearance of the axillary vein or placement of drains. The results of level I and II axillary dissection with breast conservation in a consecutive series of 259 patients treated from 1981 through 1988, with a mean follow-up of 22.5 months (median, 27.1 months) were reviewed. The number of nodes removed ranged from two to 24, with a mean of nine. Axillary seroma was the most frequent complication (11 patients [4.2%]). Lymphedema was observed in seven patients (2.7%). Axillary recurrences occurred in two patients. These results indicate that a level I and II axillary dissection defined anatomically allows prognostic evaluation while limiting morbidity and recurrence. In addition, this procedure can be done safely without drains on an outpatient basis, with further psychological and economic benefits. ( Arch Surg . 1990;125:1144-1147)

Growth Delay in Postburn Pediatric Patients

Abstract: • Dampened height and weight velocities have been observed in our postburn pediatric population. To validate this phenomenon, the medical records of 80 patients who had sustained a greater than 40% total body surface area burn, were older than 2 years of age at the time of the burn, and were at least 1 year post burn were reviewed. All patients were treated with early excision of the burn wound within 72 hours of injury and received standard post burn resuscitational and nutritional support. Admission height and weight plots were within normal distribution parameters. Yearly growth velocities were calculated for up to 3 years after the burn. Despite adequate nutritional support and maximal exercise and/or long-bone stresses, a profound growth arrest was noted during postburn year 1, which slowly resolved to near normal distribution by postburn year 3. This retrospective study demonstrates that severe thermal injury is associated with a growth delay in the pediatric population. The exact cause of this phenomenon remains unknown. ( Arch Surg. 1990;125:392-395)

Patterns of Failure in Anorectal Melanoma: A Guide to Surgical Therapy

Abstract: Anorectal melanoma is an aggressive tumor with a reported 5-year survival rate of 6%. Recommendations for local surgical therapy vary from local excision to abdominoperineal resection. Therapy, patterns of failure, and survival were retrospectively examined in 32 patients with anorectal melanoma. Twenty-six patients were treated surgically, 14 with abdominoperineal resection and 12 with local excision. Local recurrence occurred less frequently in patients undergoing abdominoperineal resection (4 [29%] of 14) compared with patients undergoing local excision (7 [58%] of 12) but developed concomitantly with distant or regional metastasis in all but 2 of the 11 patients whose operations failed locally. Inguinal nodal disease developed in 15 patients (47%). Pelvic nodal disease became apparent in only 2 patients (7%). There was no difference in overall survival between the two surgically treated groups (median survival, 19.5 months for patients treated with abdominoperineal resection vs 18.9 months for patients treated with local excision). Therefore, local excision is recommended when technically feasible since these patients eventually succumb to metastasis regardless of surgical therapy.

Microbial Infection and the Septic Response in Critical Surgical Illness: Sepsis, Not Infection, Determines Outcome

Abstract: • The differential roles of infection as a microbial phenomenon and sepsis as a host response were studied in 210 critically ill surgical patients. Infections occurred In 41.4% of all cases and In 82% of nonsurviving patients. Both infection and the expression of a septic response, measured as a sepsis score, were associated with significantly increased Intensive care unit morbidity and mortality. Nonsurviving patients with infection had significantly higher sepsis scores than did survivors. Nonsurvivors with sepsis, on the other hand, did not differ from survivors with respect to any variable reflecting infection but did have higher mean sepsis scores. Maximum sepsis scores and sepsis scores on the day of death were similar in patients dying without infection and those dying with uncontrolled infection. The magnitude of the host septic response, independent of the presence, bacteriologic characteristics, or control of infection, is an important determinant of outcome in critical surgical illness. ( Arch Surg. 1990;125:17-23)

APACHE II score does not predict multiple organ failure or mortality in postoperative surgical patients.

Abstract: • A clinical study was undertaken to evaluate the ability of the APACHE ( acute physiology and chronic health care ) II system to predict the development of multiple organ failure syndrome and subsequent mortality. The study was conducted in a university general surgery intensive care unit using the admission APACHE II score. Over a 1-year period, 92 patients qualified for the study, 24 of whom survived, 69 of whom suffered multiple organ failure syndrome, and 68 of whom died. The APACHE II score did not predict the development of multiple organ failure syndrome or mortality with clinical utility and significantly underestimated the potential for the development of multiple organ failure syndrome. Factors that did predict the development of multiple organ failure syndrome and mortality were the time-dependent changes in the Pao 2 -to-fraction of inspired oxygen ratio and serum lactate, creatinine, and bilirubin levels. Better markers of cell injury are needed for use in decision making and quality assurance analysis in surgical patients. ( Arch Surg . 1990;125:519-522)

Iatrogenic injury to the bile duct. Who, how, where?

Abstract: • We reviewed 81 patients with bile duct injuries that occurred at cholecystectomy and/or common bile duct exploration. Thirty-two of the strictures were recurrent. The median follow-up was 9 years. High injuries were inflicted during the performance of cholecystectomy while low injuries were related to common bile duct exploration. Mitigating circumstances appear to be as follows: (1) inadequate access, exposure, and assistance; (2) absence of operative cholangiogram; (3) patient's obesity; and (4) early dissection of Calot's triangle. Noncontributory factors include the following: (1) level of training of surgeon, and (2) type of institution where the operation was performed. Following repair, 15 patients eventually died and 8 suffered intermittent cholangitis and/or cirrhosis. Mortality and morbidity were related to the following: (1) level of stricture; (2) number of previous attempts at repair; and (3) adequacy of reconstruction. Mucosa-to-mucosa anastomosis without tension is essential for optimal results. (Arch Surg. 1990;125:1028-1031)

The Retained Surgical Sponge Following Intra-abdominal Surgery: A Continuing Problem

Abstract: • The surgical sponge retained following intra-abdominal surgery is a continuing problem. Despite precautions, the incidence of this problem is grossly underestimated. During the past 10 years, we have treated four patients with this problem. The presentation of a retained surgical sponge is highly variable, as is the time before the onset of symptoms. The clinical presentation, predisposing factors, and management are presented as well as guidelines for prevention. ( Arch Surg . 1990;125:405-407)

Albumin supplementation in the critically ill. A prospective, randomized trial.

Abstract: • Albumin replacement to correct hypoalbuminemia in critically ill patients has been controversial. This study was a prospective, randomized trial of 25% albumin administration in 40 hypoalbuminemic (serum albumin, 25 g/L [2.5 g/dL]), critically ill patients. The treatment group (18 patients) received 25% albumin supplementation to achieve and maintain serum albumin levels of 25 g/L (2.5 g/dL) or greater, while the nontreatment group (22 patients) received no concentrated albumin. There was no clinical benefit from albumin therapy when assessing mortality (39% vs 27%, treatment vs control) or major complication rate (89% vs 77% of patients). There were also no significant differences in length of hospital stay, intensive care unit stay, ventilator dependence, or tolerance of enteral feeding, despite significant elevations of albumin in the treatment group. The costly use of exogenous albumin as treatment for hypoalbuminemia in this patient population does not appear to be justified. ( Arch Surg . 1990;125:739-742)

Liver Transplantation for Polycystic Liver Disease

Abstract: • Four female patients with severe complications of polycystic liver disease were treated with liver replacement; two patients were also given kidneys from their liver donors. All four of the patients were suffering from extreme fatigue. Three of the recipients have survived for 8, 11, and 60 months with normal liver function and present good health. The fourth patient recovered from a liver-kidney transplantation, but 5 months later, fulminant hepatic failure developed in this patient due to hepatitis B virus, and she died despite emergency hepatic retransplantation. ( Arch Surg . 1990;125:575-577)

Diagnosis and treatment of pancreatic injuries. An analysis of management principles.

Abstract: Ninety-one pancreatic injuries, 47 from blunt trauma, were reviewed with respect to management principles stressed in qi previous reviews. The pancreatic complication rate was 25%. Blunt injury was suspected preoperatively in only 30%. Even short-term observation led to morbidity. Operations done more than 6 hours after admission had a higher complication rate (45%) than those done less than 6 hours after admission (18%). Penrose drainage without a sump was not associated with increased complications. Distal pancreatectomy was done 32 times; splenectomy was done in only 18 patients. Individual duct ligation was rarely done and did not result in a high fistula rate. Pancreatic stump oversew with nonabsorbable suture was associated with a higher rate of pancreatic complications than absorbable suture (58% vs 30%). Only 56% of patients receiving distal pancreatectomy required hyperalimentation. Postoperative serum amylase values were not useful, and amylase values from drainage fluid predicted complications only when they were above 100,000 U/L. Details of pancreatic trauma management are less important than early operation in minimizing morbidity.

Comparison of magnetic resonance imaging and computed tomography in the preoperative staging of rectal cancer.

Abstract: • Nineteen patients with middle and lower rectal carcinomas were operated on, with abdominoperineal resection in 10 patients, lower anterior resection with coloanal anastomosis in 6 patients, and colorectal anastomosis in 3 patients. The distance of the lower margin of the tumor to insertion of the levator ani on the rectal wall was correctly evaluated by computed tomography in 12(63%) of 19 patients and by magnetic resonance imaging in 13 (68%) of 19 patients, while digital examination correctly assessed the distance in 15(79%) of 19 patients. Computed tomography and magnetic resonance imaging were unable to assess extension through the rectal wall. No significant difference was observed between computed tomography and magnetic resonance imaging in assessing extension to the perivesical fat, adjacent organs, pelvic side wall, or lymph nodes. According to the TNM classification, magnetic resonance imaging correctly staged 74% (14/19) of carcinomas, while computed tomography correctly staged 68% (13/19). ( Arch Surg. 1990;125:385-388)

Axillary lymphadenectomy. A prospective, randomized trial of 13 factors influencing drainage, including early or delayed arm mobilization.

Abstract: • Greater amount and duration of postoperative wound drainage after lymphadenectomy impede healing. We evaluated the influence of early vs delayed initiation of shoulder mobilization on postoperative drainage. Fifty-seven women with clinical stage I or II breast cancer were randomized to either early (postoperative day 2) or delayed (postoperative day 5) shoulder motion. Early vs delayed time of exercise initiation had no effect on total amount or duration of drainage, either as an inpatient or outpatient. The two groups were determined to be homogeneous as to age, breast size, weight, height, obesity, previous biopsy, excision of pectoralis minor, excision of thoracodorsal complex, level of axillary dissection, total number of lymph nodes, number of positive lymph nodes, lymphatic vessel invasion (with negative lymph nodes), and whether the dominant hand was on the side operated on. The two factors predicting greater drainage were large numbers of positive lymph nodes and no previous surgical biopsy (as in one-step procedure). ( Arch Surg. 1990;125:378-382)

Surgical Therapy for Recurrent Liver Metastases From Colorectal Cancer

Abstract: • Forty percent of patients whose disease recurs after hepatic resection for liver metastases from colorectal cancer initially will have liver-only metastases. We have retrospectively reviewed our experience with repeated surgical treatment for liver-only recurrence after previous hepatic resection for colorectal metastases. Repeated hepatic procedures were performed with no mortality in 10 patients. Intraoperative ultrasound allowed identification of three unsuspected metastases and determination of unresectability of two metastases during 11 procedures. Three patients were free of disease at 31, 41, and 48 months from the first hepatic procedure and at 15, 31, and 43 months from the second procedure. Five patients have remained free of hepatic disease. Patients whose initial metastases were less than 6 cm in diameter and had single liver recurrences after hepatic resection appeared to be the best candidates for further surgical therapy. These data and a review of the literature suggest that surgical treatment of recurrent liver metastases from colorectal cancer can be performed safely, and it is associated with long-term disease-free survival in up to 38% of highly selected patients. ( ArchSurg . 1990;125:718-722)

Blunt intestinal injury. Keys to diagnosis and management

Abstract: • Fifty-six patients with blunt intestinal injury seen during 39 months were reviewed for keys to diagnosis and treatment. Motor vehicle accidents were involved in 80% of the cases and seat/lap belts were in use 69% of the time. Blunt intestinal injury was the only abdominal injury in 70% of the cases. There were 42 perforations and 20 devascularizations; multiple injuries were common (27%). Abdominal tenderness was present on admission in 43 of 44 patients in whom a reliable examination was possible. Peritoneal lavage was positive in 13 (93%) of 14 patients. Computed tomography was falsely negative in three of four instances in which it was used. Perforations were most common in the upper and lower ends of the small bowel and in the sigmoid colon; devascularizations were most common in the distal ileum and sigmoid colon. Resection/anastomosis was performed in 38% of small-bowel perforations and in all small-bowel devascularizations. Resection/diversion was required in most colonic perforations (five of six patients) and devascularizations (four of six patients). There were five deaths (9%), none due to intestinal injury. There were seven complications related to intestinal injury. Diagnostic delay occurred in two patients; both had resultant morbidity. Blunt intestinal injury is associated with physical findings in conscious patients. Peritoneal lavage should be used when tenderness cannot be evaluated. Timely operative intervention minimizes morbidity and hospital stay. ( Arch Surg. 1990;125:1319-1323)

Adjuvant Therapy for Resectable Colorectal Carcinoma With Fluorouracil Administered by Portal Vein Infusion: A Study of the Mayo Clinic and the North Central Cancer Treatment Group

Abstract: • We randomized 224 patients with resected Dukes' stage B2 or C colorectal cancer to either an untreated control group or to a group receiving 7 days of fluorouracil therapy (500 mg/m2 per day) by portal vein infusion. Randomization was accomplished during surgery after staging by frozen section. Only 5 (2.2%) of our 224 patients were ineligible, but an additional 10 patients assigned to portal vein infusion could not be treated because of technical problems with catheter placement. Toxic reactions were mild. There was only 1 postoperative death on each study arm. At present, the median follow-up for all patients is 5.5 years (range, 1.5 to 9.5 years). Interval to progression and survival curves essentially overlap. The same lack of treatment effect is seen in both the stage B and C subsets. ( Arch Surg . 1990;125:897-901)

Duplex imaging and incidence of carotid radiation injury after high-dose radiotherapy for tumors of the head and neck.

Abstract: Radiation-induced carotid artery disease following high-dose (greater than 50-Gy) radiotherapy for head and neck cancer may become more common as improved treatment results in longer survival. Duplex ultrasound scans were obtained in 91 consecutive patients to determine whether increased incidence and severity of extracranial carotid disease correlate with prior radiotherapy. Fifty-three patients who underwent radiotherapy an average of 28 months previously and 38 patients who received no radiotherapy were studied. Thirty percent of the irradiated group had lesions of the carotid arteries that were either moderate or severe vs only 6% of the control patients. Five patients were symptomatic; all had undergone radiotherapy. Long-term follow-up with sequential duplex ultrasound examinations is indicated in patients receiving high-dose radiotherapy for head and neck tumors, to detect radiation-induced carotid artery disease and prevent late sequelae.

The impact of microinvasion on axillary node metastases and survival in patients with intraductal breast cancer.

Abstract: • A rational approach to the local treatment of intraductal breast cancer continues to generate considerable debate. However, the finding of an invasive component in intraductal breast cancer is widely regarded as an appropriate indication for axillary node dissection as part of the local treatment and staging of this disease. Despite this view, the natural history of patients with intraductal breast cancer with foci of microinvasion is poorly defined. Between 1965 and 1988,41 patients with this pathologic finding of intraductal carcinoma with foci of microinvasion were seen at the UCLA Medical Center. Twenty-three patients presented with mammographic abnormalities, while 17 patients presented with a palpable mass. One patient presented with Paget's disease of the nipple. Thirty-three patients underwent axillary node dissection as part of their local treatment. No lymph node metastases were identified. The median follow-up in 37 patients was 47 months. There have been no local recurrences and no deaths from recurrent breast cancer. Intraductal breast cancer associated with microinvasion appears to be an extremely favorable lesion with minimal risk of nodal metastases. ( Arch Surg. 1990;125:1298-1302)

Postoperative chylous ascites: diagnosis and treatment. A series report and literature review.

Abstract: The accumulation of chylous fluid in the abdominal cavity is an infrequent yet alarming complication in abdominal surgery. Excessive lymphatic leakage is occasionally encountered in the course of operations at the base of the mesentery or retroperitoneum. A source can usually be identified and the leak controlled at the time of laparotomy by suture or clip. In the region of presumed leakage the importance of these efforts is reinforced by the are patient in whom such leakage persists, creating problems in recognition and management postoperatively. The development of this complication in a patient undergoing total abdominal colectomy and left-sided hepatic lobectomy prompted a review of our experience and a literature review. We report four cases of postoperative chylous ascites seen over 5 years. The fluid accumulation followed operations on the abdominal aorta (two patients) and on the colon and liver (one patient) and after a mesocaval shunt procedure (one patient). Two patients responded to low-fat, medium-chain triglyceride diets; one patient required peritoneovenous shunting; and one patient died of progressive nutritional deterioration. We review the recognition and management of chylous ascites based on our experience and that reported elsewhere.