Laparotomy after using the gastroepiploic artery graft: retrogastric versus antegastric route.

BACKGROUND: Most cardiac surgeons prefer the antegastric route for the right gastroepiploic artery (RGEA) graft. When placed anterior to the stomach, the RGEA pedicle may adhere to the greater omentum, or to the anterior abdominal wall, and may be injured during future abdominal operations. METHODS: To avoid this potentially lethal complication, we prefer to place the RGEA graft behind the stomach and the left lobe of the liver. In our experience with 144 patients in whom the retrogastric route was used, 7 patients required an abdominal operation (2 had cholecystectomy, 2 had a partial colectomy, 1 had repair of paraesophageal hernia, and 2 had repair of abdominal wall complications). There was no need to dissect the RGEA graft in any of these patients. RESULTS: There was no evidence of myocardial ischemia or other complications during or after the operation in any patient. CONCLUSIONS: Based on our experience and the fact that any injury to the RGEA graft may have catastrophic consequences, we strongly advocate the retrogastric route to minimize the risk of injury to the RGEA graft during a subsequent laparotomy.

A comparison of palpable and nonpalpable breast cancers.

Chi-square statistics were used to compare prognostic factors of 60 patients with nonpalpable breast cancer (NPBC) and 112 patients with palpable breast cancer. Noninvasive cancers were more frequent, tumor size was smaller, and nodal metastasis was significantly less frequent in the NPBC group. However, the frequency of nodal metastasis was similar when adjusted for size and grade. There was no significant difference in the incidence of age and menopausal status of the patients, histologic types, hormone receptor status, and histologic/nuclear grade between these two groups. The findings were consistent with the hypothesis that NPBCs are potentially lethal tumors and that mammograms detect them earlier, ie, these tumors are smaller, localized, and, therefore, more curable.

A new technique for hepatic infusional chemotherapy.

Constant-infusion intra-arterial chemotherapy is associated with a significantly greater tumor response rate and perhaps an improved survival rate. Many intra-arterial drug delivery systems have been described, the most popular of which is the implanted Infusaid pump. Unfortunately, this is an expensive device that requires considerable experience in its implantation and maintenance. This paper describes a simplified, inexpensive technique, which can comfortably and reliably provide intra-arterial hepatic chemotherapy to patients treated in most moderate-size community hospitals. Implantation requires angiography and a minor surgical procedure. Maintenance of the system is easy and inexpensive. While use of the Infusaid pump is preferable, this technique is a reasonable alternative for the following: 1) patients with very poor hepatic function, 2) patients who cannot afford the implanted pump, 3) patients who have concomitant extrahepatic tumor, 4) patients with noncolorectal metastasis to the liver, and 5) patients treated at hospitals that do not have implanted pump capabilities.

The use of colonoscopy in the study of synchronous colorectal neoplasms.

Over a 5-year period, 185 patients with primary colorectal carcinoma were studied by colonoscopy for synchronous neoplasms. Twenty-eight patients had incomplete examinations due to obstructing tumors, and 157 had total colonoscopy. Sixty patients (35.9%) had synchronous neoplasms, of which 43 (25.7%) were adenomatous polyps, 5 (3%) were villous polyps, and 12 (7.2%) were carcinomas. The planned surgical procedure was altered on 7 of 12 synchronous cancers (58.3%), 10 of 38 adenomatous polyps, and 17 of 157 (10.8%) patients who underwent total colonoscopy. Preoperative colonoscopy is deemed essential for the optimal management of the patient with colorectal carcinoma.

Postoperative surveillance of colorectal carcinoma.

Two-hundred-forty patients with previously resected colorectal carcinoma were investigated for neoplasia of six months, 12 months and then at yearly intervals during a four-year period. Physical examination, occult blood, rigid sigmoidoscopy, barium enema and colonoscopy were used during the surveillance. Out of 304 colonoscopies, 68 were positive for neoplasia, 11 metachronous, and 17 recurrent cancers with 66 tubular adenomas and nine villous adenomas were found. Barium enema detected 38% of the lesions. Occult blood in stood was positive in 18.5%. The results of the methods of surveillance are analyzed and the relative value of each method is discussed.

Myelolipoma of the adrenal gland.

We report the 14th case of myelolipoma of the adrenal gland. Recommendations for appropriate diagnostic and therapeutic methods are made. Myelolipoma of the adrenal gland is a rare non-functioning tumor composed of lipoid and hematopoietic elements. The most consistent complaint is abdominal pain caused by hemorrhage within the tumor. We identified an association with obesity and hypertension. Ultrasound combined with computed tomography is useful in diagnosis. With expanded use of these studies, myelolipoma will be recognized more frequently. Definitive diagnosis and treatment are accomplished by simple excision; radical surgery is unnecessary.

Indications and accuracy of operative cholangiography.

We have demonstrated that operative cholangiography can be done accurately, rapidly, and without any increase in morbidity. We recommend that operative cholangiography be performed routinely on all patients undergoing cholecystectomy for these reasons: (1) It permits accurate demonstration of the presence or absence of intraductal calculi, thereby decreasing the number of unnecessary duct explorations. (2) It permits demonstration of the number and size of common duct stones, when their presence is highly suspected. (3) It permits recognition of a small but substantial number of patients with unsuspected common duct stones. (4) It permits demonstration of operative ductal anatomy, thereby reducing the chance of inadvertent iatrogenic injury. (5)It permits recognition of unsuspected biliary or periampullary tumors. (6) It is an accurate method and facilitates the performance and accurate interpretation of postoperative T-tube cholangiography.

Fundoplication for major reflux in patients with gallstones.

Patients referred with gallstones were screened for symptoms of reflux. Positive clinical history led to investigation with an upper gastrointestinal series as well as esophageal pH and manometric studies to identify and quantify reflux. Selected patients with symptomatic reflux in whom major or surgical reflux was discovered underwent the combined procedures of cholecystectomy and fundoplication. In all, 250 patients with gallstones were screened. Sixty patients with symptoms of reflux were considered for further study; of that group, 48 patients had major reflux, 38 of whom underwent the combined operative procedures. Fundoplication alone or in combination with cholecystectomy was carried out on 126 occasions upon 121 patients without a death. The combination of fundoplication and cholecystectomy did not prolong the hospital stay significantly, did not materially increase the incidence of postoperative complications and did not compromise the control of reflux symptoms. The postfundoplication syndrome did not occur following the combined procedures and was observed in only one patient in the entire series. Results of our study justify the liberization of indications for fundoplication in selected patients with gallstones who fulfill the criteria of major reflux, as already outlined.