Rare presentation of actinomycosis as an abdominal mass: report of a case.

PURPOSE: The purpose of this article was to report an unusual presentation of abdominal actinomycosis masquerading as a tumor. METHODS: The patient was a 54-year-old male who presented with vague abdominal discomfort and a palpable left lower quadrant mass defined on CT scan. Multiple intraoperative core biopsies were nondiagnostic, and he underwent en bloc resection of the mass and adjacent organs for a presumed tumor. RESULTS: Examination of tissue from deep within the excised specimen revealed sulfur granules diagnostic for actinomycosis. CONCLUSION: Abdominal actinomycosis is an extremely rare infection that can mimic multiple disease processes and requires accurate diagnosis for successful therapy. This novel presentation and a review of the literature are reported.

Laparotomy and proximal gastric vagotomy in Zollinger-Ellison syndrome: results of a 16-year prospective study.

OBJECTIVE: Pharmacological control of gastric acid hypersecretion in the Zollinger-Ellison syndrome has steadily improved, but medical treatment does not address the underlying tumor. The objective of this study was to evaluate the long-term effectiveness of a surgical approach to both tumor and acid hypersecretion in 22 patients with the Zollinger-Ellison syndrome. METHODS: Patients underwent laparotomy to resect tumors, combined with vagotomy to reduce acid secretion, followed by postoperative antisecretory therapy, if necessary. RESULTS: No surgical mortality or serious morbidity occurred. Tumor was found at laparotomy in nine patients (41%) and during long-term follow-up in an additional two patients (9%). Ten-year survival is 81%, with a long-term cure rate of at least 14%. Most patients (86%) have had long-term inhibition of acid secretion. Eight patients have discontinued regular use of acid-inhibiting medications. Patients requiring medication need less of it, and they have an improved acid inhibitory response to medication for up to 16 yr after surgery. CONCLUSION: Cure of the Zollinger-Ellison syndrome is possible in a minority of patients. Acid secretion can be safely reduced in almost all patients with laparotomy/vagotomy, usually allowing discontinuation, or reduced dose, of acid-inhibiting drugs. Long-term survival and quality of life are generally excellent.

The anterior operative approach to the cervical vertebral artery.

BACKGROUND: Vertebral arterial trauma continues to be a perplexing diagnostic and therapeutic challenge. Operative management is often required despite improved radiologic interventions for these injuries. Accounts of the operative approaches to anterior cervical vertebral artery injuries have been limited. STUDY DESIGN: We reviewed our experience with anterior cervical vertebral arterial trauma in 53 consecutive patients requiring operative management during a 14-year period. In seven patients, the vertebral arterial injury was identified at urgent surgical intervention either for an expanded cervical hematoma or active bleeding. The remaining injuries were identified by arteriographic investigation of penetrating cervical trauma. The injuries were equally distributed between the three anatomic zones of the anterior cervical vertebral artery. The general features of the operative approaches that were used to manage these injuries were the emphasis of the study. RESULTS: The anterior approaches to patients with vertical arterial trauma were effective in controlling injuries in all cases. Proximal and distal ligation of the artery adjacent to the injury site was accomplished in 95 percent of the patients. Associated major cervical injuries in 43 percent of the patients (carotid artery, eight patients; pharyngoesophageal, six patients; and neurologic, nine patients) contributed to the postoperative morbidity rate and the overall mortality rate of 10 percent. CONCLUSIONS: The surgeon approaching vertebral arterial trauma should have a clear appreciation of the deep anterior cervical anatomy to expedite the operative management and avoid unnecessary complications related to a misdirected surgical dissection. The descriptions of the operative techniques used in this clinical experience can aid the surgeon in managing patients with vertebral vascular trauma.

Use of distal splenorenal shunt in children referred for liver transplant evaluation.

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 +/- 4 years, and the average weight was 39 +/- 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 +/- 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 +/- 20 months after shunt surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

A new balanced operation for complex gastroesophageal reflux disease.

Twenty-seven patients with advanced gastroesophageal reflux disease have been treated with combined transthoracic parietal cell vagotomy and Collis-Nissen fundoplication. Gastric acid analyses (n = 20) obtained preoperatively and 6 months postoperatively demonstrated a significant late reduction in gastric acid output. Twenty-six patients (96%) have experienced relief of gastroesophageal reflux disease at a mean of 13.3 months (range, 6 to 25 months) without postvagotomy symptoms. Transthoracic parietal cell vagotomy may be considered as an adjunct to mechanical surgical control of advanced gastroesophageal reflux disease.

New surgical approach to complicated gastroesophageal reflux disease: transthoracic parietal cell vagotomy.

Surgical treatment of peptic stricture of the esophagus associated with columnar (Barrett) metaplasia can be a difficult problem. Collis-Nissen fundoplication restores an intraabdominal antireflux barrier for most cases of peptic stricture; however, 20% of patients may have persistence of pathological acid reflux. By reducing acidity of postoperative reflux, parietal cell vagotomy may complement nonresectional surgical results for Barrett stricture.

Impaction of the endoscopic basket. An important consideration in the trans-sphincteric management of choledocholithiasis.

Endoscopic papillotomy has become an important management alternative for primary and postcholecystectomy choledocholithiasis. The infrequent but serious complication of endoscopic basket impaction associated with this technique is reported.

Mesenteric venous hypertension: importance after portal systemic shunting?

Hepatic dysfunction after portacaval shunting (PCS) has been attributed to loss of portal perfusion to the liver. Proponents of selective systemic shunting state that reduced encephalopathy and hepatic dysfunction with this procedure result from the maintenance of portal perfusion to the liver through the hypertensive mesenteric venous circulation. We questioned the importance of maintaining the diminished portal flow to the cirrhotic liver because hepatofugal flow is known to develop in many of these patients. We sought to further define mechanisms that may contribute to the maintenance of critical flow to the liver in compensated hepatic cirrhosis. We demonstrated a primary relationship between mesenteric venous hypertension (MVH) and increased hepatic arterial blood flow after diversion of portal blood flow. Fifteen dogs had vena caval stenosis above an end-to-side PCS to establish MVH and deprive the liver of portal blood flow. Another 15 dogs had end-to-side PCS alone. A half hour after shunting, hepatic arterial blood flow had increased significantly in all dogs. Hemodynamic parameters remained stable throughout. Six weeks later, mesenteric pressure increased 98% +/- 3% with intracaval stenosis (from 9.6 +/- 0.1 to 19.0 +/- 0.3 cm H2O). Mesenteric pressure was unchanged with PCS alone (9.0 +/- 0.1 cm H2O). Increased hepatic arterial flow was significantly elevated in all dogs above pre-shunt values by 6 weeks postshunt. With MVH, however, further augmentation in hepatic arterial flow was noted in the chronic state (1.5 +/- 0.1 vs 0.9 +/- 0.1 ml/min/gm, p less than 0.05). There was significant correlation between MVH and increased hepatic arterial flow in the chronic state (r = 0.79, p = 0.05). Hepatic arterial flow 6 weeks after PCS with MVH was associated with lower blood ammonia and improved hepatocellular function compared with animals with PCS alone. These results support the hypothesis that MVH is important in maintaining blood supply--beyond providing driving force for sustained portal flow to the liver. This is an important consideration in the medical and surgical management of portal hypertension, a condition in which profound reduction in portal pressure may negatively affect compensatory hepatic arterial blood flow.

Biliary pancreatitis: clinical presentation and surgical management.

The presentation, surgical management, and clinical outcome in 153 patients with biliary pancreatitis has been reviewed. Only 37 percent of our patients demonstrated any of Ranson's 11 prognostic signs of severe pancreatitis, and only 3 percent had 3 or more signs. Fourteen patients underwent emergency operation within 48 hours of admission, 108 underwent briefly delayed operation during the same hospitalization, and 31 were discharged and scheduled for elective cholecystectomy 6 weeks after admission. The biliary pancreatitis grew worse in 7 of 114 patients during initial medical management and required emergency operation, and 81 percent underwent elective surgery within 10 days of admission. When patients were discharged before cholecystectomy, the recurrence rate of acute biliary pancreatitis that required emergency readmission was unacceptably high (61 percent). There was no statistical difference in total number of hospital days, number of intensive care unit days, or mortality between the three groups. Our study suggests that emergency operation with decompression of the ampulla of Vater is unnecessary in patients with biliary pancreatitis, and that briefly delayed operation during the same hospitalization can be performed safely after resolution of acute pancreatitis.

Treatment of Zollinger-Ellison syndrome with exploratory laparotomy, proximal gastric vagotomy, and H2-receptor antagonists. A prospective study.

Twenty-two patients with Zollinger-Ellison syndrome were managed by a combined medical and surgical approach. Patients were treated initially with cimetidine or ranitidine. A laparotomy was performed to remove easily resectable tumors and to carry out a proximal gastric vagotomy. Tumors were found in 9 patients (41%) and all visible tumors were removed from 6 of the 9 patients. Fasting serum gastrin concentrations and serum gastrin responses to intravenous secretin were normal 6 wk after surgery in each of the patients from whom all visible tumors were resected and are normal in 4 patients, 6 wk to 5 yr after surgery. Acid secretion was reduced after vagotomy in each patient, even when tumors were not found or completely resected. Thus, vagotomy decreased the acid secretory response to endogenous hypergastrinemia. In addition, vagotomy augmented the inhibitory effect of H2-receptor antagonists on acid secretion. Follow-up has ranged from 6 wk to 6 yr (median, 2 yr). Dosages of cimetidine or ranitidine have been reduced, compared with preoperative amounts, in all but 1 patient. Two patients are taking no antisecretory drugs. Only 3 patients have had occasional symptoms of ulcer disease. Complications such as bleeding, perforation, or obstruction have not occurred in any patient. Endoscopy was performed in all patients to estimate the point prevalence of active ulcers and an ulcer was found in 1 patient. Based on these results, it is our opinion that this combined medical and surgical approach is an effective treatment for patients with Zollinger-Ellison syndrome.

Blunt traumatic rupture of the right hemidiaphragm: experience in 12 patients.

In a 9-year period (1972 to 1981), 35 patients with blunt traumatic rupture of the diaphragm were seen in our institution; 12 had involvement of the right hemidiaphragm, an incidence of approximately 34%. In 9 of these 12 patients, the right-sided diaphragmatic injuries were seen soon after the accident (acute), and in 3, late after the accident (chronic). A large diaphragmatic rent, usually 10 cm or more, without any predilection to a specific area of the right hemidiaphragm, was a frequent operative finding. Expectedly, the most common viscus that was injured or herniated through the defect was the liver. Total or nearly total herniation of the liver was noted in 5 patients and partial herniation, in 1. Injury to the juxtahepatic vena cava or hepatic vein, or both, was also encountered in 5 patients. This highly lethal injury accounted for the 3 deaths in the series, all of which were directly related to an uncontrollable exsanguinating hemorrhage from the injured vena cava or hepatic vein. The surgical approach for repair of a ruptured right hemidiaphragm is best individualized. The right thoracotomy approach through a right posterolateral incision is preferred for chronic diaphragmatic injury. It is also our choice in patients in whom acute right-sided injuries are definitively diagnosed and who are hemodynamically stable. This approach not only provided the best exposure of the defect, but also made the repair of associated retrohepatic caval injury surprisingly easy in at least 2 of our patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Parietal cell vagotomy in a surgical training program.

Parietal cell vagotomy was performed in 48 patients at the Parkland Memorial Hospital and the Dallas Veterans Administration Hospital between April 1977 and January 1981. The maximum follow-up time was 50 months and the average was 28 months. Seventy-five percent of the patients were followed for more than 1 year. There were no operative deaths. Four patients (8.3 percent) had persistent postoperative side effects including two documented ulcer recurrences (4.2 percent). Acid secretion studies were reviewed to characterize the longterm effect of parietal cell vagotomy. These studies demonstrated marked postoperative reductions in gastric acid secretion. The results of this study suggest that with the simplified technique described in this paper, parietal cell vagotomy can be performed with minimal mortality and morbidity by surgical residents under direct staff supervision.

Reduction in the morbidity and mortality of major hepatic resection. Experience with 52 patients.

The general surgeon can be expected to encounter patients who require major hepatic resection with increasing frequency. Successful resection of large neoplasms requires meticulous attention to surgical technique. Use of the Lin hepatic compression clamp significantly reduces morbidity and mortality, operative time, and blood loss, and should be employed whenever possible during hepatectomy. In addition, an extended subcostal incision with use of the table-attached Hepco Upper Hand retractor offers superb exposure and avoids the morbidity associated with thoracoabdominal incisions.

Effect of parietal cell vagotomy on gastric emptying in duodenal ulcer disease.

Gastric emptying was delayed preoperatively in 9 of 19 patients with duodenal ulcer disease, but all 9 patients with evidence of retention by scan were asymptomatic; gastric emptying was normal in the remaining 10 patients. A significant delay in gastric emptying was documented by scan in 17 of 19 patients immediately after parietal cell vagotomy (despite the absence of symptoms of gastric retention). Delayed emptying was demonstrated in three patients who were restudied more than 1 year after parietal cell vagotomy; again these patients had no symptoms of gastric retention at any time. A sustained reduction in basal and stimulated acid secretion in both the early and late postoperative period was documented in all 19 patients, and serum gastrin levels also remained low. This absence of acid or gastrin stimulation is corroborated by the fact that there was no recurrence of ulcers in these patients during a follow-up period of up to 37 months.

Below-knee amputations for vascular insufficiency.

In the case of below-knee amputations for vascular insufficiency, divisions of the tibia and fibula in the proximal one-third followed by coverage by a long posterior soft tissue flap gives the best results. Emphasis must be placed on sharp division of structures, perfect hemostasis, and accurate skin approximation. The use of suction drainage and gentle compression dressing is demonstrated.

Effect of vagotomy in Zollinger-Ellison syndrome.

We evaluated the effect of vagotomy on gastric acid secretion and the clinical course in 3 patients with Zollinger-Ellison syndrome. Basal acid hypersecretion was reduced by 49, 86, and 96%, and peak acid output in response to pentagastrin was reduced by 36, 39, and 71% in the 3 patients. In one patient, 300 mg cimetidine reduced basal acid secretion from 65 to 20 meq/hr before vagotomy; whereas after vagotomy basal acid secretion was reduced from 36 to 0.6 meq/hr by the same dose of cimetidine. One patient has required no antisecretory therapy for 14 yr, whereas 2 patients have also been treated with cimetidine with excellent results. We conclude that vagotomy facilitates control of acid secretion in Zollinger-Ellison syndrome, and we recommend vagotomy and cimetidine rather than total gastrectomy or cimetidine alone for the management of these patients. This combined surgical and medical approach should also allow discovery and removal of isolated tumors in about 10% of patients.

Effect of selective proximal vagotomy on food-stimulated gastric acid secretion and gastrin release in patients with duodenal ulcer.

We studied effects of selective proximal vagotomy on food-stimulated acid secretion and gastrin release in 7 duodenal ulcer patients. Food-stimulated acid secretion was evaluated by sham feeding patients and by infusing food directly into their stomachs. Vagotomy reduced sham feeding-stimulated acid secretion from 28.2 +/- 4.6 to 1.2 +/- 0.7 meq/hr (95% reduction) whereas infused food-stimulated secretion was decreased from 36.1 +/- 4.6 to 17.9 +/- 5.5 meq/hr (50% reduction). In contrast to the reductions in acid secretion, the gastrin response to infused food doubled after surgery. Although selective proximal vagotomy reduced the rate of acid secretion in response to infused food and also reduced by 64% the peak secretory capacity (peak acid output to pentagastrin), fractional secretion (i.e., the secretion rate in response to infused food expressed as a percentage of the peak secretory capacity) increased significantly after vagotomy from 63 +/- 7% to 91 +/- 11%. This increased fractional secretion in response to infused food was probably a result of exaggerated gastrin release after vagotomy.

Relief of acute, persistent postvagotomy atony by metoclopramide.

Seventeen patients with acute, persistent postvagotomy atony after vagotomy with antrectomy or pyrloroplasty for peptic ulcer underwent a doubleblind study of the relief of postvagotomy atony by metoclopramide. All patients had complete, functional gastric obstruction for at least three weeks postoperatively, precluding oral alimentation. Contrast studies and gastroscopy ruled out mechanical obstruction in each patient. Gastric outlet obstruction was confirmed by radioisotope assessment of gastric emptying of a special solid meal labeled with Technetium 99m DTPA. A gamma camera over the epigastrium precisely quantitated the emptying rate of the labeled meals. After baseline scanning an intravenous placebo was given to each patient and all 17 showed gastric retention of the meal after 90 minutes. Gastric emptying rates were restudied 24 hours later after intravenous metoclopramide and all 17 patients then immediately emptied the labeled meals. These patients then received standard postgastrectomy diets. Eight patients received metoclopramide tablets (10 mg 30 minutes a.c., q.i.d.) and nine received placebo tablets. Each of the eight patients receiving metoclopramide ate normally immediately after treatment with no further evidence of gastric atony. The nine patients receiving the placebo were unable to retain any oral feedings and were then given oral metoclopramide which promptly relieved gastric atony. All 17 patients received metoclopramide for one month without side effects after which the drug was discontinued with no recurrence of gastric symptoms during follow-up periods ranging from three to 27 months. Metoclopramide safely and effectively relieves acute, nonmechanical gastric atony when this occurs after surgical treatment of peptic ulcer.