Effect of incidental appendectomy on the development of wound infection in patients undergoing staging laparotomy for Hodgkin's disease.

Two hundred ten patients were retrospectively studied to evaluate the risk of appendectomy performed during laparotomy for staging of Hodgkin's disease. Seventy-nine patients did not have their appendix removed, and a wound infection developed in 1. One hundred thirty-one patients had an appendectomy, and 7 wound infections occurred in this group. This difference was not statistically significant. No patient died as a consequence of their wound infection, and no intraabdominal infections occurred. Our data suggest that the risk for development of a wound infection after a staging laparotomy for Hodgkin's disease is increased by performing an incidental appendectomy as part of the procedure. Although the differences noted were not statistically significant, this was probably due to the sample size. Based on our data, we do not routinely remove the appendix at the time of staging laparotomy.

Effect of postoperative radiotherapy on the development of small bowel obstruction in patients undergoing staging laparotomy for Hodgkin's disease.

Two hundred and ten previously untreated patients with hodgkin's disease underwent staging laparotomy at one institution. Medical records of these patients were retrospectively reviewed. The incidence of small bowel obstruction (SBO); whether or not the patient received abdominal radiotherapy and the portals used; whether or not the patient had undergone a previous operation for unrelated disease; and the outcome of operative treatment for the SBO were noted. Mean follow-up for all patients was 62.6 months (1 to 125 months). Ninety-two patients (Group I) were treated without radiotherapy; two developed SBO (2.2%). Patients treated with abdominal radiotherapy numbered 118 (Group II); seven developed SBO (5.9%). The difference between Groups I and II is not significant. Eighty-two received only paraaortic radiotherapy; two (2.4%) developed SBO. Thirty-six patients underwent combined paraaortic and bilateral iliac radiotherapy (Group IV); five developed SBO (13.9%). Data for Groups III and IV approach statistical significance (p = 0.053; Fisher Exact Test [two-Tail]). All obstructions were secondary to adhesions. Four patients in Group IV had significant morbidity associated with operative treatment of SBO. This was an infection in each case. Infections developed in these patients even when the bowel was not entered. Pneumonia and wound infections were most common. Careful evaluation postoperatively for signs of infection and aggressive pulmonary toilet are recommended.

Infection among 210 patients with surgically staged Hodgkin's disease.

To determine the incidence and types of infections in Hodgkin's disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkin's disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkin's disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkin's disease after splenectomy.

Restaging laparotomy for Hodgkin's disease.

The role of restaging laparotomy (RL) in Hodgkin's Disease (HD) was studied in 39 patients. Four patients had two RL and two patients three RL; 47 RL were performed in the 39 patients. Twenty patients had prior radiotherapy, ten patients chemotherapy, and nine patients radiotherapy and chemotherapy. Twenty of the 39 patients had a prior staging laparotomy at the time of initial HD diagnosis. Four of 13 RL for suspected residual HD at the completion of treatment were positive. Two patients had nodal, one splenic, and one nodal plus ovarian cyst HD. Fifteen of 21 RL for suspected recurrent HD after a five-to-111-month (median = 36 months) disease-free interval were positive. Thirteen patients had nodal, seven splenic, four liver and two bone marrow HD. Five of ten RL to disclose intra-abdominal HD at the time of a peripheral node recurrence were positive. Subsequent treatment was altered in all five positive patients. One of three RL to confirm a clinical complete response disclosed residual HD in intraabdominal lymph nodes. All of the 22 negative RL patients remained clinically free of intra-abdominal disease for a median of 63 months after the procedure. RL is useful in assessing response after treatment of advanced HD. A negative RL is associated with prolonged disease-free survival.

Chemotherapy for metastatic basal cell carcinoma.

Metastatic basal cell carcinoma is a rare, malignant neoplasm associated with poor survival. A 63-year-old woman had an extensive primary keratinizing basal cell carcinoma of the scalp, with metastases to the regional lymph nodes of the neck. Disease in the primary site and in the regional lymph nodes was controlled by surgery and irradiation. However, skeletal metastases that responded to therapy with three courses of cisplatin and bleomycin sulfate and then to ten courses of cyclophosphamide, methotrexate, and fluorouracil developed. Subsequent progressive metastases failed to respond to a combined cisplatin and cyclophosphamide regimen as well as to etoposide and doxorubicin hydrochloride used as single agents.

Factors influencing the morbidity of colostomy closure.

In a series of 80 colostomy closures, a total complication rate of 26 per cent was found, with a wound infection rate of 14 per cent and an anastomotic leak rate of four per cent. Patients having preoperative systemic antibiotics had fewer wound infections than those who did not (eight per cent versus 19 per cent). Delayed primary skin closure or closure by secondary intention was associated with less wound morbidity than was primary closure (ten per cent versus 17 per cent). However, the use of preoperative systemic antibiotics decreased the incidence of wound infection in those having primary skin closure (five per cent versus 27 per cent). Patients having diverticular disease had more wound infections (40 per cent) and greater overall morbidity (70 per cent). Older patients had a higher incidence of complications (24 per cent if less than 40 years and 45 per cent if greater than 50 years). Closure of left-sided colostomies was associated with a higher infectious complication rate (26 per cent versus 13 per cent). The time interval to colostomy closure was found to alter subsequent morbidity with a waiting period of one to two months associated with zero complications.

Head and neck cancer. Relationship of the prechemotherapy serum alkaline phosphatase levels to response rate of induction chemotherapy.

Fifty-one patients with stage III or IV squamous cell carcinoma of the head and neck who received induction chemotherapy with cisplatin and bleomycin sulfate with and without high-dose methotrexate were studied. The relationship of the prechemotherapy levels of serum alkaline phosphatase, lactic dehydrogenase, SGOT, SGPT, BUN, creatinine, calcium, total protein, albumin, hemoglobin, uric acid, and bilirubin and the WBC and platelet counts was correlated with the response rate. The overall response rate was 65%. No notable relationship between any of the laboratory values and the response rate was found. In contrast to an earlier report, patients with a low alkaline phosphatase level responded as well as patients with an elevated serum alkaline phosphatase level.

Combination chemotherapy for advanced squamous cell carcinoma of the head and neck.

Fifty-one patients (32 previously untreated, 19 previously treated) with advanced squamous cell carcinoma of the head and neck received a single course of combination chemotherapy consisting of high dose cis-platinum (DDP), bleomycin (Bleo), +/- high dose methotrexate (MTX). Thirty-three (65%) patients responded to therapy; 5 (10%) of these patients had a complete response. Previously untreated patients and those who received the three drugs (DDP, Bleo and MTX) had the highest response rates. The duration of response was 8 to 12 weeks. Seven (15%) patients showed a two-year survival rate. All nonresponders were dead of disease within two years. Three (56%) of the five complete-response patients and 4 (21%) of the partial-response patients survived for two years. The role of preoperative chemotherapy in head and neck cancer is yet to be conclusively defined.

Metastases to lymph nodes of the head and neck from an unknown primary site.

Sixty-four patients with a metastasis to the head and neck from an unknown primary site were reviewed. Survival as a function of cell type, stage of disease, and mode of treatment was analyzed. Survival correlated best with stage of disease prior to treatment.