Subacute subcapsular hematoma of the spleen complicating pancreatitis: successful percutaneous drainage.

Subcapsular hematoma of the spleen is a rare complication of pancreatitis. In one patient successful percutaneous drainage of a large hematoma was performed during the subacute phase, preventing rupture of the splenic capsule and obviating splenectomy.

Difficult mammographic needle localizations: use of alternate orthogonal projections.

Lesions deep within the breast are occasionally visible on only one standard mammographic projection and are therefore difficult to localize preoperatively. Such abnormalities can often be visualized on two orthogonal 45 degrees oblique views. In these cases, needle localizations may be performed in a routine manner without computed tomography or stereotactic methods.

Double pyloroplasty and vagotomy for gastric ulcers.

A group of 31 patients with a variety of gastric ulcers were treated by vagotomy, biopsy, oversewing of bleeding points and a wide double pyloroplasty. On patient, a quadriplegic with multiple stress ulcers, rebled and had to undergo resection. He died a month later of progressive respiratory problems. A second quadriplegic died a month after a bleeding episode from myelitis and encephalitis resulting from a gunshot wound of the neck. He had no rebleeding. A third patient died two years after a gastric operation as a result of bronchial carcinoma. He had no recurrence of the ulcer problem. The remaining 28 patients were observed from six months to five years, an average of two and one-half years. There were no recurrences and only minimal untoward symptoms. It would appear that, for this period of observation, vagotomy with double pyloroplasty offers good treatment for patients with benign gastric ulcers.

Postbulbar peptic ulceration of the duodenum.

One hundred and twenty patients operated upon for peptic ulcer diathesis had intraluminal digital examination of the duodenum seeking post-bulbar ulcers. Twelve such ulcers were found, an incidence of 10 per cent. In six of these patients, the postbulbar ulcer was an unexpected finding, and in two patients, a second ulcer was present. A review of the patients with postbulbar ulcers revealed that these patients had severe ulcer symptoms that responded poorly to medical management. Our patients were treated by truncal vagotomy and an outlet procedure. In ten patients, the anterior duodenotomy was extended to include the stenotic area. A Jaboulay gastroduodenostomy was performed in one patient, and duodenoplasty with pyloroplasty in another patient. These 12 patients were observed from one to six years. There were no deaths. Two patients had temporary gastric atony and one patient had a dumping syndrome. Three patients have had possible recurrence of the ulcer, reoperation being required in one patient. It is possible that unrecognized postbulbar stenosis may be a cause of recurrent peptic ulcer following some surgical procedures. To recognize these ulcers, we believe that the duodenum should be inspected by intraluminal palpation in all patients operated upon for peptic ulcer disease.

Vagotomy and double pyloroplasty for peptic ulcer.

Seventy patients with peptic ulcers (55 duodenal and 15 gastric) were treated by truncal vagotomy and doulbe pyloroplasty during the past four years. Clinical and experimental data as presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This decreases gastric stasis and has led to a lower ulcer recurrence rate (1.5%). In addition the untoward postoperative sequelae are minimal. The 70 patients treated (for the most pare consecutive cases) exhibited the usual complications of peptic ulcer disease. Thirty-three had intractable pain, 23 bleeding (15 massive), 13 obstruction, and one acute perforation. There were no operative or postoperative deaths and the only serious postoperative complication was unrelated to the double pyloroplasty. During the followup period four patients have died of unrelated diseases. Of the remaining 66 patients one developed a probable recurrent peptic ulcer which has responded to medical management. Four patients have intermittent dumping, three have mild diarrhea and one has failed to gain weight, Constipation and weight gain are more common complaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further clinical trials are warranted.