The pancreas: a symposium in honor of Charles Frederick Frey, MD.

On October 3, 1997, the University of California, Davis, under the leadership of James E. Goodnight, Jr, MD, chair of the Department of Surgery, gathered together 5 distinguished authorities in surgical pancreatic disease to present a symposium in honor of the retiring professor of 21 years, Charles F. Frey, MD. The atmosphere was one of informality and "give and take," and the result was not only a thorough and up-to-date review of many aspects of pancreatic disease but a wonderful tribute to a colleague who has spent a lifetime in this area of endeavor. Dr Frey has been a leader in this field, both scientifically in refining and extending our treatment of severe acute pancreatitis and administratively in organizing the Pancreas Club and promoting the concept that one could manage the pancreas, not in fear, but with confidence of success.

Pyogenic hepatic abscess in a community hospital.

Pyogenic hepatic abscesses are rare lesions and are most commonly the result of biliary tract disease. During a 3-year period at our institution, 15 patients were diagnosed with pyogenic hepatic abscess. Ten cases were related to biliary disease. Of these, five were associated with previous biliary tract operations. The remaining five were due to metastases, infection at another site, or cryptogenic causes. Most abscesses were multiple. Treatment consisted of antibiotics alone for three patients, percutaneous drainage and intravenous antibiotics for seven patients, open drainage with intravenous antibiotics for three patients, and papillotomy with intravenous antibiotics for one patient. The single untreated patient died. The other death occurred among those patients treated with intravenous antibiotics alone. Four patients initially treated by percutaneous drainage required subsequent open drainage. All of these patients had multiple abscesses. The mean length of stay in the hospital was least among the group treated by operative drainage. Our review suggests that pyogenic hepatic abscesses may be treated by several different modalities, the choice of management should be individualized, and the length of stay may be decreased by operative drainage.

Cardiac injuries: analysis of an unselected series of 251 cases.

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

Gasless laparoscopy and conventional instruments. The next phase of minimally invasive surgery.

OBJECTIVE: To assess the capability of a retractor system that permits laparoscopic surgery without pneumoperitoneum and to determine if the system facilitates the use of conventional surgical instruments during minimally invasive surgery. DESIGN: Prospective evaluation and data collection with review. SETTING: University-affiliated county hospital. PATIENTS: Twenty-nine male and 29 female subjects evaluated prospectively via 27 trauma-related and 31 elective procedures. METHODS: Fifty-eight laparoscopic procedures were performed between July 1992 and February 1993 with a system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm using conventional surgical and laparoscopic instruments. RESULTS: Gasless laparoscopy was used in the evaluation of 27 patients with abdominal trauma (11 gunshot wounds, 11 stab wounds, and five blunt injuries). The need for celiotomy was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphragmatic lacerations, and one gastric perforation were repaired with conventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n = 26), diagnostic laparoscopy (n = 3), and appendectomy (n = 2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) and two superficial wound infections occurred in this group. The ability to use conventional surgical instruments was advantageous in several cases. CONCLUSIONS: Comparable exposure was achieved in this cohort of patients with gasless laparoscopy. The use of conventional surgical instruments provides an advantage with this technique. Further improvements in abdominal wall lift systems and modification of existing surgical instruments may expand the role of gasless laparoscopy.

Pros and cons of parietal cell versus truncal vagotomy.

The reliability of parietal cell vagotomy as a primary procedure for duodenal ulcer is still questioned by many, and several surgeons advocate pyloroplasty in certain subgroups. Since the opening of our hospital in 1972, a randomized, prospective study has been under way. Sixty-seven patients were randomized into three groups: truncal vagotomy and Jaboulay pyloroplasty (Group 1), parietal cell vagotomy and Jaboulay pyloroplasty (Group 2), and parietal cell vagotomy without drainage (Group 3). The overall operative mortality was zero, with an 18 percent morbidity. Postoperative Congo red testing revealed truncal vagotomy to be a more reliable vagotomy, with 25 percent of Group 1 patients noted to have some degree of incomplete vagotomy compared with 36 percent of patients in Group 3 (p less than 0.05). The ulcer recurrence in Group 1 was 4 percent, in Group 2 18 percent, and in Group 3 10 percent. No dumping or diarrhea was noted in Group 3 compared with Group 1 in which 4 percent of patients had dumping and 17 percent had diarrhea and Group 2 in which 14 percent of patients had dumping and 23 percent had diarrhea (p less than 0.05). The higher incidences of recurrence and postoperative side effects obviously related to the pyloroplasty made parietal cell vagotomy with pyloroplasty the least desirable operative procedure. Parietal cell vagotomy is technically a more difficult procedure, but if performed satisfactorily, results in greater patient satisfaction, with 81 percent of the patients symptom-free compared with 63 percent of those who had truncal vagotomy and pyloroplasty.

The congo red test to determine completeness of vagotomy: clinical application.

Over the past 5 years, we have evaluated the Congo red test for vagal competence as to its reliability under varied clinical conditions both intraoperatively and postoperatively. Our technique has been useful and accurate in approximately 200 patients. Insuring completeness of vagotomy during the operation has been of use in 42 patients uncovering an unsuspected incomplete vagotomy in 4. In a series of 31 patients with recurrent ulcer symptoms, the documentation of the cause as well as the presence of the ulcer is possible with one simple maneuver--endoscopy. Furthermore, the test has been utilized postoperatively in over 100 patients to determine the longevity of a negative test as well as the clinical sequelae of apositive study. With a trend to more selective vagal section and a continuing significant incidence of recurrent ulceration, we are convinced that the congo red test is an important adjunct to the surgical care of ulcer patients.

Operative mortality in general surgery.

The operative mortality in over 7,000 consecutive cases at a Veterans Administration Medical Center is defined. The mortality in elective procedures is low by most standards and is usually associated with a malignant disease. Older patients appear to have an increased operative mortality. Sepsis is the major factor in death after elective and emergency procedures. Age is a critical factor associated with mortality in this population. Preexisting disease (pulmonary, cardiac, hepatic, and malignant) plays a role in determining outcome. Despite these factors it is possible to achieve excellent operative mortality results in a hospital with a commitment to resident training. An aggressive diagnostic and therapeutic approach is considered reasonable to support these patients with multisystem disease. This often includes the extensive use of expensive resources such as preoperative hospitalization with nutritional support and prolonged stays in the surgical intensive care unit postoperatively.

Recurrent hiatal hernia repair: A potential surgical dilemma.

We studied 96 patients who underwent hiatal hernia repair; 17 of these patients had secondary repair. Nor mortality existed for elective first-time repairs. whereas there was a 17.6% mortality and a 46% morbidity in secondary repairs. No clear differences were noted with the type of repair used. Thirty-five percent of those having a recurrent hiatal hernia repair later had another recurrence. Reoperation for recurrent reflux esophagitis is more of a risk than is often thought. This information should be heavily weighed during preoperative decision making.

Treatment of hemorrhagic gastritis with 15(R)-15 methyl prostaglandin E2: report of a case.

A 19-yr-old male developed severe hemorrhagic gastritis following three abdominal operations. Treatment with intravenous cimetidine and hourly antacids to maintain his gastric pH above 5 failed to affect gastrointestinal bleeding. Also, peripheral venous vasopressin, propantheline bromide, and glucagon were without effect. Total gastrectomy was considered to control his bleeding. However, since a number of prostaglandin analogs prevent gastric lesions produced by many noxious agents (e.g., aspirin, alcohol, strong acid or alkali, etc.) in animals and humans, the patient was treated with 50 micrograms of 15(R)-15 methyl prostaglandin E2 intragastrically every 6 h for 10 days. To epimerize the 15(R) form to the more active 15(S) form, 50-100 ml of 50-mN HCl was placed into the patient's stomach immediately before each dose. Bleeding ceased within 24 h of the onset of 15(R)-15 methyl prostaglandin E2 therapy and did not recur. The prompt response to 15(R)-15 methyl prostaglandin E2 in combination with hourly antacids in this patient with persistent and severe hemorrhagic gastritis suggests a therapeutic effect and the need for a prospective double-blind clinical trial.

Resuscitation with pyridoxalated stroma free hemoglobin: tolerance to sepsis.

The contribution of the reticuloendothelial system (RES) in pyridoxalated stroma-free hemoglobin (SFH-P) clearance may be insignificant. The magnitude of this is not at present clear. Any compromise of RES function would militate against its potential benefit as an oxygen-carrying resuscitation fluid. The relationship between lethal hemorrhagic shock resuscitation with SFH-P and subsequent host depression was examined in a rat model. Host tolerance to a standard intra-abdominal polymicrobial septic challenge was assessed 5 days after hemorrhagic shock. Shock resuscitation with pyridoxalated stroma-free hemoglobin was equal to or better than all other resuscitation groups evaluated. Tolerance to a standard septic challenge 5 days after resuscitation was no different between resuscitation groups. There appears to be no compromise to host defense in general in tolerating intra-abdominal sepsis 5 days following shock resuscitation with pyridoxalated stroma-free hemoglobin.

Management of hyperparathyroidism in patients with renal failure.

Patients with hyperparathyroidism of renal failure fall into two categories: those with hypocalcemia and those with hypercalcemia. If medical management fails and operative indications are present--bone pain or fracture, metastatic calcification, progressive hypercalcemia or uncontrolled pruritus--parathyroid exploration should be done. Total parathyroidectomy and autotransplantation is the procedure of choice when hypocalcemia is present and more than one gland (usually all) is enlarged (which is the case in most patients). Parathyroid adenomectomy is the procedure of choice where autonomy of parathyroid function is established or a single gland is enlarged and all others are small; hypercalcemia is present in these patients. In other instances of hypercalcemia associated with advanced renal disease, total parathyroidectomy and autotransplantation should be performed; that is, in patients in whom more than one gland is enlarged or irregular or in whom all glands are not identified. Continued follow-up is necessary to confirm this rationale of therapy.

Mortality and gastrointestinal surgery in the aged: elective vs emergency procedures.

Elderly patients are often viewed as high-risk surgical candidates. Consequently, elective surgery may not be performed, with the result that a potentially treatable disease process may develop into an acute catastrophic event. We question the validity of this approach. In our experience with 1,411 gastrointestinal (GI) surgical procedures performed between March 1972 and September 1979, 23.6% have been in patients older than 70 years of age. The operations were emergent in this age group 19.5% of the time. Despite the advanced age of these individuals, the overall operative mortality for 269 elective procedures was 6.7%. For the 65 patients aged 70 years or older who underwent emergency procedures, the operative mortality was 20%. While elective GI surgery in the elderly has a significant risk, death is almost always the result of an associated disease (pulmonary, renal, or cardiac). Emergency procedures in the elderly indeed carry greater risk, statistically the same as in the 50- to 69-year-old group. Death is frequently related to an acute process complicating a treatable disease.