Limited operation for bleeding or perforated gastric ulcer in high risk patients.

Twenty-four high risk patients underwent limited operation for bleeding (15) or perforated (9) gastric ulcers. Limited operation is defined as local ulcer management (oversewing or excision of bleeding ulcer and suture closure of perforated ulcer) with (8) or without (16) complementary vagotomy and pyloroplasty. Sixteen patients had serious coexistent disease and eight were physiologically unstable because of continued bleeding or peritonitis. Nine patients (38%) died; seven of 15 (47%) died after operation for bleeding and two of nine (22%) after operation for perforation. Only one patient rebled prior to death, and only two patients died of causes directly attributable to the operative procedure. The remaining six patients died as a result of coexistent disease. Limited operation for gastric ulcer is an option for treatment of highly selected, high risk patients requiring urgent operation for bleeding or perforated ulcer. The addition of complementary vagotomy and pyloroplasty appears to make little difference as to the immediate result but may influence late results. Limited operation does not reduce the mortality rate after operation on patients with bleeding or perforated ulcers.

Colonic diverticular disease in patients 40 years old or younger.

Diverticular disease in patients 40 years of age or younger has been described as rare but virulent. Previous studies, based on age, on diverticular disease are often confusing because of inexact definitions of the disease status. With these criticisms in mind, the authors studied 322 clinical records on patients admitted with a diagnosis of colonic diverticulosis or diverticulitis to the University of New Mexico Hospital and the Lovelace Medical Center. Of these patients, 285 had documented evidence of colonic diverticula with only 6 per cent of these being 40 years of age or younger. The criteria for acute diverticulitis were met by 86 patients, 17 of whom were 40 years of age or younger. The younger group had disproportionately more men, particularly Hispanics. The authors conclude that acute diverticulitis is more common in the young than suggested by previous reports, but the behavior of the disease is not distinctive.

Morbidity and mortality of ostomy closure.

Ostomy closure following the Hartmann procedure is perceived to be associated with higher morbidity and mortality rates than is ostomy closure following divided colostomy, loop colostomy, and divided ileostomy-colostomy so that ostomy closure after Hartmann procedure may be denied to certain patients. To test that perception, the charts of 59 patients undergoing a Hartmann procedure and 43 patients having ostomy closure after divided colostomy, loop colostomy, or divided ileostomy-colostomy were reviewed. Ostomy closure after Hartmann procedure was accomplished in 46 patients. These 46 patients (Group I) were compared with the 43 patients having ostomy closure following divided colostomy, loop colostomy and divided ileostomy-colostomy (Group II). No deaths occurred in either group. The morbidity rate was 30% for Group I and was 19% for Group II. This difference is not significant. Major complications involved wound, lung, small bowel, and colonic anastomoses. Anastomotic stricture rate was 9% for Group I and 5% for Group II. Small bowel and anastomotic complications in both groups occurred only when ostomy closure was performed after a delay of less than 6 months after ostomy construction. Stricture occurred only after end-to-end colocolostomy and coloproctostomy and did not occur after ileocolostomy or ileoproctostomy. All strictures were successfully treated by reoperation. Anastomotic leak and pelvic abscess did not occur in either group. We conclude that ostomy closure after Hartmann procedure may be more difficult and time consuming than is ostomy closure after loop colostomy, divided colostomy, or divided ileostomy-colostomy, but ostomy closure after Hartmann procedure does not have a higher morbidity rate. We advise a delay of 6 months between ostomy construction and ostomy closure and submit that all patients whose general condition permits reoperation may safely undergo ostomy closure.

Revision and closure of the colostomy.

Reoperative stomal surgery includes the correction of complications and closure of a colostomy. Necrosis, retraction, and stenosis are the most frequently occurring complications and are simply corrected by straightforward techniques. Prolapse of the colostomy and parastomal hernia occur less frequently. Their repair is slightly more complex than that of the previous group of complications. Colostomy closure ranges from simple suture closure of the loop colostomy, through anastomosis of the divided colostomy, to the sometimes difficult gastrointestinal reconstruction after the Hartmann procedure. Death after closure of colostomy is infrequent, but anastomotic complications occur after all types of closure. Leak and sepsis are by far the most frequent anastomotic complications. Stenosis occurs less often. The same degree of care exercised during colectomy and anastomosis is necessary for optimal results after colostomy closure.

Pyogenic liver abscess.

Experience with 34 patients with pyogenic liver abscess is reviewed to evaluate the impact of percutaneous drainage and duration of antibiotic therapy on results of treatment. Patients with shock, adult respiratory distress syndrome, disseminated intravascular coagulation, jaundice, severe hypoalbuminemia, and diabetes had a poor prognosis. Percutaneous drainage was used successfully in 4 of 6 patients, but its use did not affect mortality rate or length of hospital stay. Percutaneous drainage may be the procedure of choice for selected patients. Half of our patients received antibiotics for 2 weeks or less with no abscess recurrences in this group. Long-term antibiotics may not be necessary after adequate surgical or percutaneous abscess drainage.

Intestinal fistula complicating necrotizing pancreatitis.

Eight of 17 patients with necrotizing pancreatitis (47 percent) developed 12 intestinal fistulas. Pancreatitis occurred most often secondary to alcohol abuse, and fistula complicated controlled open drainage of the lesser sac more often than sump or Penrose drainage of the lesser sac. Fistulas appeared more often in patients with two or more drainage operations than in those with a single drainage procedure. Most duodenal fistulas closed with nonoperative therapy, whereas jejunal and colonic fistulas required operative closure. Operative techniques included both simple suture closure and resection with anastomosis. Five patients (29 percent) died. Thus, although frequent debridement and controlled open drainage may reduce the mortality rate of necrotizing pancreatitis, it appears to increase the likelihood of intestinal fistulas, which may require operative treatment.

Analysis of techniques and results in 347 consecutive colon anastomoses.

We have reported our experience with 347 consecutive colon anastomoses in 321 patients seen over an 8 year period. The overall anastomotic failure, mortality, and complication rates were 1.4, 2, and 10 percent, respectively, for the entire series. The complication and death rates were significantly higher in patients whose anastomoses were completed as part of an emergency procedure. Even though various one- and two-layer inverting techniques, suture materials, and staples were used, we could not identify any one method as being clearly superior in preventing anastomotic complications, although the results do suggest that some caution may be appropriate before mechanical stapling devices are universally applied. The results support that adherence to accepted surgical principles of reducing the solid content and fecal flora of the colon prior to operation, insuring an excellent blood supply to both bowel ends, even approximation of the bowel ends with inverting sutures which include the submucosal layer of the bowel, absence of tension, meticulous hemostasis, and avoidance of anastomosis in the presence of peritonitis are the primary means of avoiding dehiscence of colon anastomoses.

Primary breast cancer in patients with previous endometrial or ovarian cancer.

The incidence of primary breast cancer is known to be increased in patients with previous endometrial or ovarian cancer, but the behavior of the breast cancer and the ultimate outlook for such patients is unknown. To provide data concerning these two questions, a group of 123 patients treated for breast cancer alone (Group I) served as a control for comparison with ten patients who had endometrial cancer (Group II) and six patients who had ovarian cancer (Group III) prior to diagnosis of breast cancer. The interval between the diagnosis of endometrial cancer and breast cancer averaged 4.6 yr, and between ovarian cancer and breast cancer, 5.4 yr. Age at diagnosis of breast cancer in Groups I, II, and III was 56, 66 (P = 0.05) and 56 yr, respectively. The incidence of patients with stage I, II, and III breast cancer was similar in Groups I, II, and III as was tumor size and number of metastatic nodes in each stage in each of the three groups. Average duration of follow-up after diagnosis of breast cancer was 3, 3.1, and 2.8 yr in Groups I, II, and III, respectively, with 70%, 60%, and 33% of patients living and free of either breast cancer, endometrial cancer, or ovarian cancer. Two of four deaths in Group II were due to endometrial cancer, and all four deaths in Group III were due to ovarian cancer. The remaining two deaths or recurrences in Group II were due to breast cancer. We conclude that 1) the behavior of breast cancer is similar in patients with or without previous endometrial or ovarian cancer; 2) breast cancer develops at an older age in patients with previous endometrial cancer than in patients with or without previous ovarian cancer and 3) death or recurrent cancer in patients with breast cancer and previous ovarian cancer is due to ovarian cancer, whereas, death or recurrent cancer in patients with breast cancer and previous endometrial cancer is due equally to breast cancer and endometrial cancer.

Perianal suppuration: results of treatment.

Perianal suppuration (PAS) is a common surgical problem that is frequently treated inadequately. A series of 101 patients with PAS was reviewed. Thirty-six patients had a history of PAS. Fifty patients had drainage of a perianal abscess; six patients developed fistulas in ano and in two recurrent abscess developed (total, 16%). Thirty-six patients had fistulotomy for established anal fistula: three patients (8%) had recurrent fistulas. Fifteen patients had single-stage drainage of abscess and fistulotomy, and none had recurrent or residual PAS. All patients ultimately achieved healing. These results illustrate the fact that satisfactory results in the treatment of PAS can be obtained by surgeons if established principles of treatment are observed.

Delayed gastric emptying after palliative gastrojejunostomy for carcinoma of the pancreas.

Fifty-seven patients with carcinoma of the pancreas underwent gastrojejunostomy (GJ) alone or in conjunction with biliary bypass. The mortality rate for GJ alone was 18%; for the combined biliary and duodenal bypass operation it was 5%. Fifteen patients (26%) had delayed gastric emptying (DGE) postoperatively for periods extending from nine to 31 days (average, 16 days); five patients (33%) died. Eight (57%) of 14 patients with preoperative duodenal obstruction and five (42%) of 12 patients with retrocolic GJ experienced DGE postoperatively. Stomal diameter in the patients with DGE averaged 6.5 cm, and 8.4 cm was the average in those without DGE. We conclude that DGE is a frequent and serious problem after GJ for patients with unresectable pancreatic cancer.

Use of a tubed pectoralis major myocutaneous flap for salvage of a failed colonic bypass of the esophagus.

The use of tube PMCF as salvage for a failed colon bypass of the esophagus has not been described previously. The present report describes the technique and successful use of a tubed PMCF as a solution to the problem of a failed cervical anastomosis after colon bypass of a long distal esophageal stricture.

Appendectomy during pregnancy.

Twenty-nine patients suspected of having appendicitis while pregnant had appendectomies, and 20 patients had appendicitis. Right lower quadrant pain and tenderness of less than 24 hours duration with nausea and vomiting, a fever of 38 C or less, and a leukocyte count of more than 15,000 were the more common findings in patients with appendicitis. Right lower quadrant pain and tenderness of more than 24 hours' duration, fever of more than 38 C, and a leukocyte count of less than 15,000 were more common findings in patients with idiopathic right lower quadrant pain or such pain associated with urinary tract infection. Neither fetal nor maternal death or complication occurred. The use of antibiotics and progestational agents appeared to be a matter of choice and did not appear to influence fetal or maternal outcome. These data support the concept that peritonitis rather than appendectomy is the cause of fetal and maternal death and complication in pregnant women suspected of having appendicitis and further argue for early appendectomy in such patients.

Defects in natural killer cell activity and interferon response in human lung carcinoma and malignant melanoma.

The natural killer (NK) activity of peripheral blood mononuclear cells from 25 patients with squamous cell carcinoma of the lung, malignant melanoma, or epitheloid cancers of the gastrointestinal tract was measured by the lysis of 51Cr-labeled K562 target cells. NK activities of many patients with lung cancer or malignant melanoma were decreased relative to normal controls. This abnormality was significantly correlated with advancing stage of disease and the percentage of monocytes in the cell suspensions. Addition of indomethacin or removal of monocytes did not restore depressed NK function to normal levels. Abnormalities of NK function did not appear to be secondary to the presence of mononuclear suppressor cells. The response to interferon was also impaired in patients with advanced disease. The number of effector:target conjugates was normal even in patients with depressed NK function; however, the number of active lytic effectors was decreased. These results imply that the cells which bind tumor targets are present in patients with advanced cancers, but these cells are either immature or functionally inactive.

The diagnostic yield of lymph node biopsy.

A series of 169 patients having biopsies of palpable lymph nodes was critically reviewed to increase the diagnostic yield. The overall yield was 70.4%. The yield in patients suspected of having neoplasms was 80.6%, in patients in whom differential diagnosis involved neoplasm and infection, 60%, and in patients suspected of having infection or disease with lymphadenopathy as a prominent part of the picture, 27.2%. High yields were found in patients with palpable cervical nodes (76.4%), female patients (74%), and patients older than 40 years (85.5%). Supraclavicular nodes produced the highest yield in any group (90%). Axillary and inguinal nodes produced yields of 62.5% and 38.5%, respectively. The size of lymph nodes was not related to yield, and only eight of 79 (10.9%) nodes produced growth on culture.

Morbidity and mortality after operation in nonbleeding cirrhotic patients.

The purpose of this study has been to provide information on the mortality and morbidity rates for operation on nonbleeding cirrhotic patients and to identify factors that portend a grave prognosis. A review of 102 cirrhotic patients who underwent a variety of major therapeutic operations revealed a mortality rate of 19.6 percent. Mortality rates were significantly increased (p less than 0.05) by emergency operation (45.8 percent), gastrointestinal related operation (27.6 percent), ascites (37.5 percent), a bilirubin concentration greater than 3.5 mg (44.4 percent), a prothrombin time increase greater than 2 seconds (36.1 percent), a partial thromboplastin time increase greater than 2 seconds (50 percent), an alkaline phosphatase concentration greater than 70 units (40.9 percent), an operative blood loss greater than 1,000 ml (33.3 percent), and the presence of one or more postoperative complications (39.6 percent). Mortality rates were not increased after extremity, genitourinary, or gynecologic operations, an albumin concentration less than 3 g, a serum glutamic oxalacetic transaminase concentration greater than 40 units, hepatomegaly, and a history of previous gastrointestinal bleeding. When significant risk factors were added, mortality rates were significantly associated (p less than 0.001): zero to one factors 5.1 percent, two to three factors 19.4 percent, four to five factors 33.3 percent, and more than six factors 66.7 percent. The complication rate was 47.1 percent and included liver failure (42.2 percent), sepsis (18.6 percent), and bleeding (8.8 percent). Thus, in cirrhotic patients a clear need for operation must exist, liver function must be optimized preoperatively, and the most simple and expeditious procedure must be performed to avoid excessive blood loss and postoperative complications.

The diaphragm. A caveat in the selective management of penetrating abdominal trauma.

Summaries of two patients who were not operated upon because they seemed to have only minor upper abdominal stab wounds are presented. Both patients later developed symptomatic diaphragmatic hernias for which operation was required. These patients illustrate a shortcoming of the selective method of management of upper abdominal stab wounds and suggest that diagnostic paracentesis and peritoneal lavage should be employed regularly in patients who do not have a clear indication for laparotomy.