Gastrinoma associated with common bile duct obstruction and the ectopic production of ACTH.

A case of adrenocortical hyperfunction due to ectopic production of ACTH by a gastrin-producing tumor of the pancreas is described. Cushing's syndrome preceded the appearance of the overt Zollinger-Ellison syndrome by 2 years and was treated by bilateral adrenalectomy. The Zollinger-Ellison syndrome was initially treated with cimetidine, which successfully reduced the secretion of gastric acid. Because the pancreatic gastrinoma continued to grow, causing obstruction of the common bile duct, biliary diversion and total gastrectomy were performed. There is evidence that the pancreatic gastrinoma was the source of the ectopic production of ACTH and possibly secretion. The role of Histamine-2 blocking agents as therapy in the Zollinger-Ellison syndrome is discussed.     

Gestational macromastia

Gestational macromastia is a rare entity. Causes are many and include excess hormonal production, hormonal imbalance, and decreased hormonal catabolism. Documentation of elevated serum prolactin levels and tissue hormonal receptor levels brings new light to this pathologic condition. Pharmacologic measures are not recommended because of lack of effectiveness and possible teratogenic side effects. Primary therapy should consist of local measures, such as breast support, bed rest, and analgesics. If this fails and progression is inevitable, we recommend total mastectomy with provision made for reconstruction and nipple banking. Skin flaps must be thin, and all breast tissue must be removed, otherwise the pathologic condition will continue during the ensuing months of the pregnancy and will recur with each successive pregnancy. Abortion is feasible, but this leaves the patient in need of a reduction or total mastectomy at a later date, and thus is not recommended as a primary line of therapy. If the patient progresses to delivery without complication, a reduction mammoplasty can be considered but only if no future pregnancies are planned.     

The Penrose drain: a safe, atraumatic colostomy bridge

Because of the problems associated with the large, bulky bridges presently used for construction of loop ostomies, particularly complications of leaks and skin excoriation, we have studied the use of the Penrose drain as an alternative. This method has been time-tested on 45 patients and has been found to be safe, reliable, and inexpensive and has gained popularity among patients and ostomy nurses. The bulky colostomy bridge should no longer be accepted as a standard of care.     

Management of locally recurrent breast cancer adjacent to prosthetic implants

Local recurrence of breast cancer around prosthetic implants has largely the same significance as local recurrence in a nonreconstructed chest wall. It tends to be a harbinger of systemic metastases, and this fact should influence patient management. It was not necessary to remove any implant either for local control of recurrent breast cancer or for complications of treatment.     

Hypercalcemia in epidermoid carcinoma of the head and neck.

Hypercalcemia occurs rarely at the time of diagnosis in patients found to have epidermoid carcinoma of the head and neck. It is particularly unlike in those patients who present with potentially curable lesions. Only 2 of our 307 patients who presented with potentially curable lesions were hypercalcemic at the time of diagnosis. Two hundred thirty-eight of these patients were followed up for two years or until death. Of the 139 who did not remain free of disease, hypercalcemia of clinical significance developed in ten (7.2 per cent). Pseudohyperparathyroidism was the suspected cause in seven of twelve patients. Debilitating symptoms were present in all patients with serum calcium levels greater thn 12.0 mg/100 ml. Treatment, when given, was effective in alleviating gastrointestinal and central nervous system problems. Although usually temporary, symptomatic improvement was appreciated by most patients and family members.     

Gastrografin-induced hypertonicity. The pathogenesis of a neonatal hazard

Operative mortality in meconium ileus approaches 50 per cent. Recently, operation has been obviated by the administration of high Gastrografin enemas. However, the nonoperative therapy causes hypertonicity, manifested by rising hematocrit and serum osmolality and a decreased cardiac output and pulse rate. The suggested mechanism for hypertonicity is the attraction of plasma water into the gut by the concentrated “nonabsorbable” material. An alternate explanation involves absorption into the vascular system of osmolar active substances from Gastrografin. The purpose of this study is to clarify the pathogenesis of acute hyperosmolality.High Gastrografin enemas were administered to twenty-one neonatal puppies and serial blood studies were performed. A disproportionate rise in measured osmolality as compared to the calculated osmolality suggested significant absorption of the contrast material or its components through the puppy's intact gut wall. The results indicate that the hyperosmolar state is due to a combination of agent absorption and plasma water decrease.     

Immediate oophorectomy and adrenalectomy in the treatment of stage III breast carcinoma: A ten year follow-up study

One hundred twenty-two patients with stage III breast carcinoma had radical mastectomy with or without adjunctive radiation therapy, chemotherapy, or steroids. Thirteen randomly selected persons in the group had immediate bilateral oophoroadrenalectomy. Survival ranged from 10 to 147 months (median, 68.0) with seven of thirteen patients (53.8 per cent) alive five years and three of thirteen (23.0 per cent) alive ten years or longer. No statistical difference in survival or disease-free intervals with respect to menopausal status was observed in the nine patients of this group who died.One hundred and nine patients treated by conventional therapy without endocrine ablation had shorter five year (37.6 per cent) and ten year (15.6 per cent) survival intervals. The difference in survival intervals was statistically significant at p <0.01. This study suggests that immediate endocrine ablation may prolong survival in patients with stage III breast carcinoma.     

Spontaneous return of function after surgical excision of the seventh cranial nerve in parotid tumor surgery

Spontaneous return of function after surgical excision of the seventh cranial nerve in surgery of parotid tumors is not impossible. This seems to occur through the several existing neural pathways between the fifth and seventh cranial nerves. It is probable that voluntary motor impulses by reeducation find their way from the cortex through the fifth cranial nerve to the respective muscles.     

Dislodged Nephrostomy Catheter: An Unusual Case of Idiopathic Transposition of Nephrostomy Catheter From Transplanted Kidney to Adjacent Small Bowel Loop: A Case Report

A 72-year-old man with a past medical history notable for deceased renal transplant presented to the interventional radiology department for routine right lower quadrant renal transplant nephroureteral catheter exchange. The nephroureteral catheter was placed in 2016 because of the presence of a hematoma causing partial page kidney and hydronephrosis.An antegrade nephrostogram was notable for opacification of the small bowel instead of the renal collecting system. The patient then subsequently developed urinary retention and intractable abdominal pain. Because of the combination of events, it was deemed necessary for laparotomy and surgical repair of the small bowel. Intraoperative findings were notable for small bowel adhesion to the abdominal wall but otherwise no evidence of acute inflammatory changes. In this case report, we describe the first case of an idiopathically dislodged nephrostomy catheter to the small bowel from a transplanted kidney and its successful management.     

Factors influencing the late results of operation for carcinoma of the pancreas

In 151 patients with carcinoma of the pancreas presenting at the surgical clinic of Tohoku University Hospital, predominant factors affecting postoperative prognosis were studied with relation to the stages of the disease. The presence of lymph node metastasis and of cancer invasion to the pancreatic capsule, particularly the latter, was apparently a significant factor most crucially affecting the survival of the patients who underwent pancreatoduodenectomy. The mean survival periods of resected patients were 16.4 months for those with carcinoma of the head of the pancreas and 11.0 months for those with carcinoma of the body and tail of the pancreas, distinctly longer than after palliative operations. However, in patients with stage III disease, pancreatoduodenectomy tended to lead to a shorter period of survival, suggesting that surgery at that stage is generally unpromising for cure.     

Technic of chronic thoracic duct “side fistula” for immunologic evaluation of patients with cancer

A technic suitable for long-term study of the human thoracic duct circulation under physiological conditions is described. The results and observations obtained in ten patients studied for three to twenty-one days are presented.     

Arteriovenous malformations of the bowel: An obscure cause of bleeding

Of twenty-two patients with intestinal bleeding of obscure origin, four were found by mesenteric angiography to have arteriovenous malformations of the ascending colon after often repeated failure of intubation, endoscopy, barium contrast radiography, and even laparotomy to disclose the cause. The two male and two female patients, fifty-nine to seventy-four years of age, presented clinical pictures of chronic iron deficiency anemia; three had episodic gross hemorrhage. They underwent a total of at least twenty barium contrast radiographs, seven endoscopies, two laparotomies, and sixteen transfusions before the correct diagnosis was established. The arteriovenous malformations were discrete, consisting of a tortuous feeding artery, dilated draining veins, and an intervening tangle of vessels. Extravasation of dye was observed as a consequence of active bleeding in one case. The lesions were not visible on gross inspection of the bowel wall, but their location could at times be inferred by the associated vascular mesenteric dilatation and accurately localized by injection of the feeding vessel. The microscopic appearance was that of dilated vascular channels both with and without elastic tissue intertwined in the bowel wall and, in two of three patients undergoing resection, was associated with fibrofatty tissue suggesting hamartoma. It is concluded that a significant number of cases of otherwise occult intestinal bleeding will be found to be caused by such arteriovenous malformations, readily diagnosed and cured by appropriate arteriography and surgery.     

Gallstone ileus: Review of 112 patients in the Japanese literature

A survey was made of 112 cases of gallstone ileus reported in the Japanese literature, including 3 of our cases. The ratio of males to females was 1 to 1.1, the age range was 13 to 87 years, and biliary-enteric fistulas were demonstrated in 81 percent of the patients. Although cholecystoduodenal fistula was most common, eight cases of choledochoduodenal fistula were reported. Sixteen patients passed obstructing gallstones through a patulous sphincter of Oddi. The ileum was occluded in 54 percent of the cases. Duodenal obstruction was seen in 10 percent. There was no operative mortality in seven patients treated with enterolithotomy, subsequent cholecystectomy and repair of the fistula, whereas a mortality rate of 19 percent followed the one-stage procedure.