Pectoralis "paddle" myocutaneous flaps. The workhorse of head and neck reconstruction.

The pectoralis paddle myocutaneous flap is extremely dependable and provides an added advantage of covering the vital structures of the neck with adequate length without excessive bulk. The donor defect is more acceptable than any we have previously encountered. The use of this skin muscle paddle in irradiated necks has distinct advantages. In addition, the ability to carry bony segments for use in mandibular reconstruction proved a distinct advantage in the two cases in which it was used.

The trapezius myocutaneous flap used for closure of pharyngeal fistulas.

A procedure for the closure of pharyngeal fistulas utilizing an upper trapezius myocutaneous flap is described. The anatomical basis of the flap is reviewed. The operative technique is described and applied in 2 cases. The excellent vascularity of the flap is stressed.

Primary intrahepatic gallstones.

Caroli's disease is characterized by congenital segmental dilation of the intrahepatic bile ducts producing a variety of symptoms and, usually, primary intrahepatic gallstones. We are reporting five new cases of Caroli's disease in addition to the 91 reported in the literature. The diagnosis is made by intrahepatic cholangiography; techniques are emphasized. The diagnoses were confirmed by the surgical specimen of the left lobe of the liver in cases 1 and 2, by autopsy in case 3, and by intrahepatic cholangiogram in cases 4 and 5. The treatment resulted in leftsided lobectomy of liver in cases 1 and 2. Cholecystectomy, removal of common duct stones, choledochoduodenostomy or, preferably Roux-en-Y choledochojejunostomy, were done in cases 3, 4, and 5. Two patients died more than five years after their original surgery, and three are alive at six months, six, and 13 years, respectively. This is a more encouraging outcome than is usually reported.

Hepatic trauma: pitfalls in management.

We reviewed 233 traumatic injuries to the liver. The mortality was 11%. Deaths were due to either uncontrolled intraoperative hemorrhage or the postoperative complications of multiple organ injuries. The majority of liver injuries can be safely managed with manual compression, porta hepatic control, simple sutures, or drainage. Liver injuries involving the hepatic veins or retrohepatic vena cava continue to be highly lethal despite the use of vascular isolation and hepatic resection.

The management of carcinoma of the larynx in a prominent patient, or did Morell Mackenzie really cause World War I?.

The influence of fate on history is a fascinating subject. This paper reviews the death of the Crown Prince of Prussia from carcinoma of the larynx. This was a critical turning point in history. The roles of the European physicians involved in his care are reviewed. It was not until after the death of Queen Victoria that the true character of these physicians was revealed.

Duodenal varices.

Upper gastrointestinal bleeding from isolated duodenal varices is a rare occurrence. We report the case of a patient with idiopathic duodenal varices in whom the diagnosis was established preoperatively by endoscopy. The patient did not have esophageal varices or portal hypertension, and he was treated by exicising the varix with a full thickness of duodenal wall. Bleeding has not recurred. Duodenal varices as well as duodenal ulcer and gastritis must be considered in evaluating a patient with cirrhosis and upper gastrointestinal bleeding.

Traumatic injuries of the duodenum: a comparison of 1 degrees closure and the jejunal patch.

Twenty-two traumatic injuries of the duodenum were reviewed. In this series either primary closure, or primary closure plus the jejunal serosal patch prove satisfactory methods of repair. The addition of the jejunal serosal patch may be more secure but its superiority could not be documented in this small series. The mortality was related to the associated organ injuries. When blunt or penetrating injuries to the duodenum alone occur, there should be minimal mortality.

Penetrating injuries to the neck. Pitfalls in management.

One hundred patients with penetrating injuries to the neck were evaluated. The safest, most expeditious method of managing a penetrating injury to the neck is still prompt surgical exploration. Patients with positive physical examination have definite indications for surgerymin our series, 93 per cent of these patients had significant injuries. Patients with negative physical examinations are still optimally treated with neck explorations. The mortality of this series was 2 per cent. In specific situations, nonoperative management of penetrating injuries to the neck may be useful. This modality, however; should not be construed as "conservative" management. Specific pitfalls noted include inadequate neck exploration, failure to completely examine the patient, and being unprepared for exploration outside the neck.

Occult gastrointestinal bleeding. An evaluation of available diagnostic methods.

Occult gastrointestinal bleeding was defined as continued bleeding in spite of a normal series of roentgenorgrams of the upper part of the gastrointestinal tract, barium enema, and sigmoidoscopy. Twenty-six such patients were treated. A thorough systematic evaluation, including gastroscopy, colonoscopy, visceral angiography, and isotopic scanning, was done preoperatively. Using colonoscopy and arteriography, nearly 60% of the bleeding sites were identified. Seventy-six percent of the lesions identified were in the terminal part of the ileum or the ascending colon. Exploratory laparotomy should be performed for life-threatening hemorrhage or as a diagnostic test only after a thorough preoperative evaluation. If results of a complete preoperative evaluation including arteriography were normal, then the likelihood of finding a discrete cause of bleeding at laparotomy was high (80%). A systematic evaluation and diligence of both physcian and patient in localizing the site of bleeding are essential.