Unusual duplication of appendix and cecum: extension of the Cave-Wallbridge classification.

Duplicated appendix has, to date, been classified into 3 types. The authors present a type of duplicated appendix not previously described. Surgical exploration was done in a 14-year-old girl who had an acute abdomen. Surgical exploration showed a duplicated appendix that arose from the normal appendix and ended in a thick-walled, inflamed, perforated muscular pouch. Duplicated appendix is a treatable condition that rarely occurs with colonic duplication and which should be considered in the differential diagnosis of lower abdominal pain.

Perforated jejunal diverticula.

Jejunal diverticular (JD) perforation is an uncommon cause of acute abdominal pain in the elderly. From 1971 to 1994 we treated 13 such patients, 9 men and 4 women, with a mean age of 68 years. All patients experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis (range of white blood cell counts, 14,000-21,000). On physical examination, three patients had localized peritonitis, were thought to have appendicitis, and underwent immediate laparotomy and segmental jejunal resection for perforated JD. The remaining 10 patients had abdominal tenderness without peritoneal signs. They were hospitalized and managed expectantly. All experienced worsening signs and symptoms and underwent exploratory laparotomy and resection of the involved jejunal segment 13 hours to 8 days after admission. Although 6 of 13 patients had had JD documented previously, in only 2 patients was perforated JD diagnosed preoperatively. In 8 of 13 patients peritoneal contamination was minimal and was contained within the leaves of the mesentery. Soilage was severe with abscess formation in 5 patients. The longer the delay in operative intervention, the greater the peritoneal soilage. The 3 patients undergoing immediate surgery had minimal contamination. Of the 10 patients initially observed, the mean interval before operation was 74 hours in the 5 patients with severe soilage versus 21 hours in those with minimal contamination. The postoperative course was uneventful in 11 patients. Two patients died. Surgical consultation was delayed (8 days, 12 days) in both patients, who had severe peritoneal contamination and died of sepsis. In conclusion, JD perforation is an uncommon and frequently overlooked cause of acute abdominal pain in elderly patients. Timely operative intervention and resection of the involved jejunum are the keys to a successful outcome. Because the presentation and physical findings of perforated JD can be highly variable, a history of preexisting JD should arouse suspicion for JD perforation as the etiology of acute abdominal pain in the elderly.

Surgical scar endometrioma.

Relatively few instances of surgical scar endometrioma have been reported. Herein we review 24 patients treated for this condition at the institutions at which we work between 1972 and 1992. The age of the patients ranged from 17 to 47 years, with an average age of 31.7 years. Surgical scar endometriomas occurred after operations including cesarean section (19 patients), appendectomy (two patients), episiotomy (two patients) and hysterectomy (one patient). The interval between prior surgical treatment and the onset of symptoms ranged from one to 20 years, with an average of 4.8 years. All patients were treated by wide excision. Seventeen of 24 patients were available for follow-up evaluation. The interval between excision and follow-up evaluation ranged from 1.2 to 14.0 years, with an average of 6.4 years. None of the patients had recurrence of surgical scar endometrioma. Patients with the classic presentation of a painful surgical scar mass that increases in size or tenderness during menstruation need no further evaluation of the lesion before excision. Ultrasonographic examination and fine needle aspiration biopsy should be used preoperatively in women who have a constantly painful or asymptomatic mass in a surgical scar. Because medical management yields poor results, wide excision of surgical scar endometriomas is the treatment of choice.

Gastric perforation as a complication of splenectomy: report of five cases and review of the literature.

A rare complication of splenectomy is gastric perforation and fistula. Patients with this complication often complain of pain in the left upper quadrant and left shoulder, and of fever, tachycardia and upper abdominal tenderness. Chest radiographs often show a pleural effusion in the left hemithorax. Patients usually exhibit increased drainage from the tube in the left upper quadrant or a collection of fluid in the left subphrenic space. The diagnosis can be confirmed by radiography after ingestion of meglumine diatrizoate (Gastrografin). Treatment by nasogastric suction and adequate drainage of the left subphrenic space allows some of these fistulas to close. In some cases operative closure is necessary. With appropriate treatment, 75% of these patients can be expected to recover.

Primary neurilemoma of the diaphragm.

A neurilemoma of the diaphragm in an asymptomatic 46-year-old woman is reported, and 12 cases of primary neural tumor of the diaphragm reported previously are reviewed. The common symptoms in these patients are chest pain, cough, and dyspnea. Joint pain or clubbing of the fingers is present in nearly half of the patients. As with diaphragmatic tumors in general, many neural tumors of the diaphragm are malignant. We believe that all such tumors should be resected through a thoracotomy incision, which affords optimal exposure of the diaphragm.

Metastatic melanoma involving the colon. Report of a case.

A patient with isolated cecal metastasis of malignant melanoma whose symptoms of fatigue, exertional dyspnea, and an abdominal mass were relieved by operation is reported. Palliative resection appears to offer significant benefit in patients with symptomatic melanoma involving the colon, particularly if the lesion is solitary.

Umbilical fistulas in Crohn's disease.

Four patients with enteroumbilical fistulas complicating Crohn's disease are described herein. We recommend that, in such patients, the affected small intestine be excised and the umbilical sinus debrided.

A mechanical device for sutureless aorta-saphenous vein anastomosis.

The aorta-saphenous vein anastomosis is a very common anastomosis with constant anatomy. A device for sutureless aortovenous anastomosis is presented which adapts the principle of venous eversion to the end-to-side anastomosis. The use of this device in 20 dogs demonstrated that reasonable early patency (85%) and subsequent long-term patency (100%) can be achieved. The device possesses the potential for rapid multiple anastomoses to the proximal aorta, but the eversion principle requires that the anastomosis be smaller than the vein utilized. Clinical application of this technique will require both modification to enlarge the anastomosis and demonstration of long-term patency competitive with suture techniques. The device is not yet ready for clinical use.

Significance of subendocardial S-T segment elevation caused by coronary stenosis in the dog. Epicardial S-T segment depression, local ischemia and subsequent necrosis.

A model of partial thickness ischemia has been developed using subendocardial S-T elevation without epicardial S-T elevation to detect partial thickness ischemia which is sufficient to cause subsequent necrosis. Subendocardial blood flow in this model (measured with radioactive microsphere techniques) may be reduced to 25 percent of normal (P less than 0.001) by coronary stenosis and tachycardia while subepicardial flow remains normal. Epicardial S-T depression seems to indicate reciprocally subendocardial S-T elevation as long as a layer of nonischemic epicardial muscle is present, but when ischemia becomes transmural, epicardial S-T elevation occurs. Regional pressure-flow relations were determined as distal coronary pressure was reduced at a constant aortic pressure, heart rate and cardiac output. These relations revealed remarkably effective autoregulation of epicardial blood flow concomitant with progressive subendocardial ischemia.

Evolution of regional ischemia distal to a proximal coronary stenosis: self-propagation of ischemia.

The temporal evolution of myocardial ischemia was studied in open chest dogs at constant preload, afterload and heart rate. In one group of animals, a variable circumflex arterial stenosis was used to maintain constant distal circumflex arterial hypotension (40 to 50 mm Hg). During a 3 hour period of stenosis, flow in the subendocardial fourth of the ischemic ventricular wall decreased from 0.22 to 0.09 ml/g per min (P less than 0.02), whereas subepicardial flow was not significantly changed. Local vascular resistance, therefore, doubled in the most ischemic area of myocardium. In a second group of animals in which proximal coronary stenosis was held constant and pressure varied, an ischemia-mediated increase in local vascular resistance was also demonstrated. In addition, a reciprocal relation was observed between changes in flow in the left anterior descending coronary region and changes in collateral flow to the region of the circumflex artery. A coronary steal mechanism and an ischemia-mediated resistance increase may be two means by which ischemia is self-propagating.

The effects of isoproterenol and dopamine on regional myocardial blood flow after stenosis of circumflex coronary artery.

The effects of isoproterenol and dopamine on regional myocardial blood flow were studied in 10 open-chest dogs after acute stenosis of the proximal circumflex coronary artery. Blood flow was determined by the radioactive microsphere technique. Isoproterenol led to a homogenous increase in blood flow in the normal myocardium. In the myocardium with compromised coronary blood flow, isoproterenol led to a relative subendocardial ischemia. This occurred despite increased aortic flow and peak left ventricular dp/dt. Dopamine also increased aortic flow and peak left ventricular dp/dt, but it did not cause regional myocardial ischemia. The findings suggest that dopamine is the preferable inotropic agent in managing low cardiac output in patients with significant coronary artery disease.

Tricuspid regurgitation. A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement.

The best means of managing tricuspid regurgitation associated with mitral or mitral and aortic valve disease is still to be determined. During the period 1972 to 1974, we treated 76 patients who had tricuspid regurgitation along with associated valvular dysfunction. Patients with mold regurgitation were treated conservatively, those with moderate regurgation underwent annuloplasty, and those with severe regurgitation had tricuspid valve replacement. We found the results to be less satisfactory in the group treated by annuloplasty than in the other two groups. We still manage conservatively those patients with mild regurgitation, but we believe it appropriate to replace the valve in an increasing number of subjects who have tricuspid regurgitation of moderate severity.