Advances in surgery for brain tumors.

Significant advances in the management of neurosurgical disorders during the past decade have enhanced the safety of intracranial surgery, resulting in the ability of most patients with brain tumors to undergo successful resection now. Among these advances are stereotactic surgical procedures and intraoperative monitoring devices; future directions in neurosurgery include the application of advances in robotics and virtual reality. The surgical considerations and complications that accompany these advances are factors that the neurosurgeon must evaluate along with the choice of management.

Carotid-cavernous sinus fistula complicating shotgun injuries to the head.

Two cases of carotid artery injury due to shotgun blast are presented, one of which resulted in a carotid-cavernous sinus fistula. The diagnosis, natural history, and treatment of this condition is discussed, with emphasis on patient management.

Endometriosis mimics general surgical disease.

Endometriosis is rarely encountered by the general surgeon but may on occasion mimic general surgical disease. Although usually diagnosed easily because of cyclic symptoms and typical physical findings, six atypical cases are presented. These cases were diagnosed as appendicitis (2), subcutaneous mass (2), pelvic wall malignancy, and lower gastrointestinal hemorrhage. Diagnosis was ultimately made by laparotomy or excisional biopsy in five cases and by fine needle aspiration in one. Resection of the lesion, if feasible, is often curative. If resection is not feasible, therapy depends on the severity of the symptoms, and the patient's desire for fertility. Recognition of the typical appearance of an endometrioma may avoid mistaking it for cancer.

The educational value of community preceptorships in surgery.

Increasing class size provided the impetus to send students on the core surgery course at the Medical University of South Carolina College of Medicine into the community hospitals with members of the clinical faculty. Each student was assigned to a surgeon and accompanied this preceptor on rounds, in the operating room, and in the office. To determine whether the students' learning was affected by being outside the university, the authors looked at the experience from 1977 to 1986 with 683 surgery students who took community preceptorships and 696 surgery students who took only university-based rotations. The two groups were compared in regard to age, sex, basic science grade-point average, class rank at the end of the first two years in medical school, ward evaluations, grades on departmental final examinations, and National Board of Medical Examiners "mini-examination" scores and Part II surgery scores. No differences were found. Choices of specialty for the first postgraduate year and evaluations of program directors were reviewed for 1982, 1985, and 1986, and were similar for all three years. The preceptorship program has been popular with students, who stated that they valued the one-to-one relationship with surgeons who liked to teach. The program has relieved pressure on the university hospital system and provided a good learning experience for students.

Elective cholecystectomy for the patient with sickle cell disease and asymptomatic cholelithiasis.

Experience with elective cholecystectomy in ten patients with sickle cell disease and one patient with sickle-thalassemia from 1977-1984 was reviewed. In contrast to an earlier review from our institution, the current series had a low morbidity. This improvement is attributed to careful perioperative care, especially preoperative transfusion, hydration, and oxygenation. Because of the increasing longevity of sickle cell patients, because of the incidence of eventual significant complications of even asymptomatic cholelithiasis, and in order to simplify medical management by eliminating the diagnostic confusion between acute cholecystitis and sickle cell hepatobiliary crisis, the authors believe that elective cholecystectomy is to be recommended for the sickle cell patient with asymptomatic gall stones.

Comparison of moxalactam with the combination of clindamycin and an aminoglycoside in the treatment of common surgical infections.

The efficacy and safety of moxalactam were compared with those of a combination of clindamycin and an aminoglycoside in a randomized study of therapy for 60 patients with the following surgical infections: intraabdominal or pelvic infections (12 patients), abscesses (13 patients), and severe infections of extremities (35 patients). These infections were equally distributed between the two treatment groups, except that, according to the randomization process, a majority of patients with intraabdominal infections received moxalactam therapy. Surgery was used as adjunctive therapy when necessary. One adverse reaction--fever and leukocytosis with eosinophilia--was due to continued administration of moxalactam. No significant adverse reaction was observed in the patients treated with the clindamycin-aminoglycoside combination. Although the number of isolated organisms resistant to the antibiotics was similar within each treatment regimen, an alarmingly high percentage of gram-positive cocci were intermediately sensitive to moxalactam in vitro. Even in the presence of resistant organisms, moxalactam therapy was as effective as the clindamycin-aminoglycoside therapy when surgical debridement or drainage was properly timed and executed.

Liver abscess: a changing entity.

Over the past 12 years, 25 patients with liver abscess have been treated at the Medical University of South Carolina. Their clinical course was compared with a previous series of 22 patients from this institution reported in 1968. Our findings were discussed in the light of clinical aspects of liver abscess reported in the surgical literature over the past four decades. These comparisons show a diminishing role of amebic infection and appendicitis as etiologic factors in the development of liver abscess. Immunologic deficiencies are emerging as an important etiologic category. Over the past decade, anaerobic organisms have demonstrated a more obvious role in this infection. The clinical presentation of these patients in recent years has been characterized by an increasingly chronic pattern rather than the frequent septic presentation of the preantibiotic era. Over the past two decades, the mortality of liver abscess has diminished markedly in spite of few changes in operative approach. This is partly due to earlier, accurate diagnosis with the use of liver scanning. Hopefully, this trend will continue with the more frequent use of new diagnostic techniques, such as computerized axial tomography, and with improvement of pre- and postoperative care.

Necrotizing fasciitis.

Necrotizing fasciitis is a lethal and insidious disease with a high mortality. It often begins in areas exposed to fecal or urinary contamination, and about 70% of cases occur in diabetics. A high index of suspicion should be maintained in diabetic patients with an infection in the perineum, genitalia, thigh, or buttocks. Factors leading to a poor prognosis are increased age and extent of disease at the time of diagnosis, especially myonecrosis. Therapy is primarily radical surgical debridement with adjunctive antibiotic therapy.

Treatment of cholelithiasis in patients with sickle cell anemia.

The incidence of cholelithiasis and surgical risk of cholecystectomy in patients with sickle cell anemia is reviewed. Records of all patients with sickle cell disease currently attending the Medical University of South Carolina Hematology Clinic were reviewed. An oral cholecystogram has been part of the initial evaluation for the past year. The records of 16 patients having cholecystectomy from 1968 to 1977 were reviewed with regard to diagnostic studies, preoperative preparation, morbidity, and mortality. When the status of the gallbladder is known, the incidence of cholelithiasis is 67%. The morbidity of elective cholecystectomy was high (37%); there was one death. Cholecystectomy is not recommended for the discovery of asymptomatic gallstones because of the relatively poor surgical risk and short life expectancy of these patients.

Cefoxitin therapy for surgical patients.

Cefoxitin was administered to 25 patients on a general surgical service. In 16 of these patients, a bacteriologic diagnosis was made: four patients had peritonitis, one had ascending cholangitis, seven had cellulitis, and four had abscess. The dosage of cefoxitin varied from 4 to 8 g per day and was generally well tolerated, although there were three cases of phlebitis and one superinfection. There was no evidence of renal, liver, or bone marrow toxicity. All isolates of Bacteroides (eight), Escherichia coli (six), and Staphylococcus aureus (five) were sensitive to cefoxitin. Two of three strains of Pseudomonas aeruginosa were resistant. All patients recovered with cefoxitin and corrective surgery. The results indicate that cefoxitin has the potential of replacing combination therapy in some surgical patients.

Serum prognostic indicators in experimental Bacteroides peritonitis.

Serum lysozyme and hemolytic complement (CH100) levels were measured in dogs with experimental Bacteroides peritonitis. The CH100 levels showed little change in surviving animals. Nonsurvivors showed a moderate decrease in complement levels shortly after contamination. Both surviving and nonsurviving animals showed a slight initial decrease in lysozyme levels shortly after contamination. In surviving dogs this was followed by an increase to normal levels. In nonsurvivors, levels continued to increase, reaching a threefold magnification just prior to death. As a result of antibiotic therapy, CH100 levels exhibited no major changes; however, dogs deprived of antibiotic showed noticeable and persistent increases in lysozyme levels while treated animals showed only a mild elevation in lysozyme levels. The changes in the level of serum lysozyme may be a good indicator of antibiotic efficacy and approaching death from Bacteroides peritonitis.