Surgical anatomy of the human spleen.

Post-splenectomy sequelae are now well recognized, and conservative splenic surgery is widely advocated. However, controversies exist regarding splenic surgical anatomy. We studied 127 human spleens using anatomical dissection and a sequential injection method involving both radiology and corrosion casting, with the primary aim of examining segmental splenic anatomy and blood supply. The existence of well-defined splenic segments was confirmed and these ranged in number from 3 to 7 with a mean of 4.3. Each segment had its own arterial supply and venous drainage. The segments were separated from each other by avascular planes. Subsegments with independent blood supply were also identified. The splenic artery was found to divide into two branches; in all cases these further divided into segmental arteries supplying the central segments of the spleen. The polar segments were supplied by segmental vessels of highly variable origin and size. This study aims to highlight the importance of identifying these segmental vessels at operation when splenic conservation is considered.

The role of CT in the management of carcinoma of the oesophagus and cardia.

The role of computed tomography in assessing tumour spread and tumour resectability was evaluated in 50 patients with oesophageal carcinoma (17 middle third, 33 lower third). CT accurately identified all patients with tumour confined to the oesophagus (Stage I or II) but was limited in its ability to assess direct organ invasion (Stage III) with an overall accuracy for evaluating middle third lesions of 82% (aorta 70%, tracheobronchial tree 94%, other mediastinal structures 82%) compared to an overall accuracy for lower third lesions of 97% (aorta 97%, pancreas 100%, diaphragm 97%). Tumours deemed resectable on CT were always resectable at operation but two of seven middle third tumours and one of twelve lower third lesions deemed unresectable underwent curative resection. Preoperative CT evaluation of oesophageal tumours is useful in that it may reliably identify tumour lesions confined to the oesophagus and reliably identify distant metastases. Because of its limitations however in the assessment of organ invasion, particularly by middle third lesions, this study suggests that patients with oesophageal tumours with no evidence of distant metastases, who are otherwise fit to undergo tumour resection, should not be denied surgery on the sole basis of positive organ invasion on CT particularly if that organ is the aorta.

To tunnel or not to tunnel catheters for parenteral nutrition.

The effect of subcutaneous catheter tunnelling on the incidence of catheter sepsis and on catheter life span in the absence of a nutrition team was determined in a prospective controlled clinical trial. Eighty one patients who received 92 courses of parenteral nutrition had 110 catheters inserted. Alternate catheters were tunnelled. Four patients who received parentheral nutrition for less than 48 hours were excluded from the study. Catheter related sepsis occurred in one tunnelled (1.8%) and 4 non-tunnelled catheters (7.6%) (P greater than 0.05 NS). Mean life span of tunnelled catheters was 21 days (range 5-37 days) compared to 12.6 days for non-tunnelled (range 3-19 days) (P less than 0.05). Six non-tunnelled catheters became displaced, a complication which did not occur with tunnelled catheters (P less than 0.01). In conclusion subcutaneous tunnelling of silicone catheters prolongs catheter life span but does not significantly influence catheter sepsis.

Malignant duodenocolic fistula. Report of a case and review of the literature.

Malignant duodenocolic fistulas are rare; the most common cause is carcinoma of the ascending or hepatic flexure of the right colon. Thirteen cases reported to date have been treated by right hemicolectomy combined with a Whipple procedure, with a 46 percent 2.5-year survival. A case is reported in which stapling devices facilitated an extended Whipple procedure.

The association of impaired neutrophil chemotaxis with postoperative surgical sepsis.

Postoperative sepsis remains a major problem in current surgical practice. This study assesses the predictive role of neutrophil chemotaxis in the development of sepsis in surgical patients. Neutrophil chemotaxis was measured in 30 cancer patients undergoing gastrointestinal surgery and in 26 healthy age and sex-matched controls. Neutrophil chemotaxis was significantly reduced (P less than 0.02) in the patients (mean 79.2 micron +/- 2.7 s.e.m.) compared with the controls (mean 86.8 micron +/- 1.9 s.e.m.). In the entire patient group neutrophil chemotaxis did not change to any appreciable extent following surgery. However, in the seven patients who developed postoperative septic complications, chemotaxis, which was similar to control levels in the pre-operative stage, declined significantly following surgery. Pre-operative values for the septic group of patients are 92.4 micron +/- 4.02 s.e.m.. These declined to 73.4 micron +/- 3.15 s.e.m. (P less than 0.05) and to 68.2 micron +/- 2.89 s.e.m. (P less than 0.05), 5-8 days (early) and 10-14 days (late) postoperatively respectively. Neutrophil chemotaxis in the non-septic group of patients did not alter over this same period. The data suggest that the onset of postoperative sepsis in patients is accompanied by impairment of chemotactic properties in their neutrophils. However, it is also evident that measurement of this variable in patients before operation does not help to define an 'at risk' group for the development of postoperative sepsis.

Successful treatment of a post-operative external biliary fistula by endoscopic papillotomy.

A patient presenting with a bile collection in his abdominal wound following an oesophagogastrectomy was found to have an external biliary fistula. The obstruction in the common bile duct was due to gallstones. The patient underwent endoscopic papillotomy and his fistula closed without further surgery.

Management of perforating diverticulitis of the colon.

A retrospective study was carried out of all patients admitted to the hospital with either local or free perforating diverticulitis. Fifty-one patients had perforating diverticulitis of the sigmoid colon with local abscess formation, while 26 patients had free perforation with generalized peritonitis. Of the 67 patients who had a defunctioning colostomy, 18 died, while of ten patients who had either resection or exteriorization of the perforated segment, one died. Thus, exteriorization or resection as the primary surgical procedure for perforating diverticulitis is the procedure of choice, since it leads to a low operative mortality because of removal of the septic focus, preventing continuing intraperitoneal soilage.

Host resistance in sepsis and trauma.

Host resistance to infection was measured by the in vivo response to 5 delayed hypersensitivity antigens and to sensitivity and challenge by dinitrochlorobenzene (DNCB) in 55 seriously ill or injured patients and in 50 preoperative patients. A close correlation between infections, septicemia, death related to infection and anergy was found in the postoperative and post injury patients and was predictive of these complications in the patients studied preoperatively. Decreased body cell mass was noted in both the anergic and non-anergic patients which was consistent with protein-calorie malnutrition but the two groups were not significantly different. A serum factor which inhibited cellular immunity in vitro was found in 4 patients. This factor disappeared in the two patients who recovered. The study suggests the therapeutic value of the in vivo measurement of delayed hypersensitivity in seriously ill and especially preoperative patients in whom specific or non-specific stimulation of cell mediated immunity might alter the risk of infection.