Fiberoptic endoscopy: Precise definition of upper gastrointestinal disease

When properly employed, endoscopic examination of the upper gastrointestinal tract with the flexible maneuverable-tip fiberoptic instruments is the most accurate method of diagnosing any upper gastrointestinal tract disease. Two hundred consecutive endoscopic procedures in the upper gastrointestinal tract were performed without significant morbidity or mortality; the results were reviewed to ascertain the overall diagnostic value of this modality. Although the overall numbers in each subgroup are still small, the experience indicates that: (1) thorough endoscopic examination of the upper gastrointestinal tract can be carried out expeditiously in most patients without morbidity; (2) upper gastrointestinal tract disease can be precisely defined in the majority of patients; and (3) endoscopic examination frequently alters the initial clinical diagnosis. The precise cause of upper gastrointestinal tract hemorrhage can be diagnosed in at least three of four cases. Some unnecessary operations can be avoided and proper therapy for specific sources of bleeding can be initiated promptly.     

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.     

Efficacy of clinical evaluation and selective splenic arteriography in splenic trauma

The diagnosis of splenic injury after blunt trauma, although clear in most instances, is difficult to make in 16 per cent of our patients.We selected sixty patients who sustained blunt trauma between January 1968 and December 1971 from a large group of patients with multiple system injuries on the basis of isolated splenic injury. Fifty of these patients were evaluated by the usual clinical methods and had splenectomy on the day of admission. Reliable diagnostic criteria are abdominal pain, tenderness localized to the left upper abdomen, fractures of the ninth, tenth, eleventh, and twelfth ribs posteriorly on the left, and evidence of hypovolemia.Ten other patients had initial clinical assessment that cast doubt on the diagnosis of splenic rupture. The splenic artery was selectively catheterized in this group of patients and an arteriogram obtained. Eight arteriograms were positive for splenic trauma. At surgery these arteriographic findings correlated with the splenic disorder in all instances. Two patients had normal arteriograms and were not subjected to surgery.When clinical evaluation precipitates reasonable doubt in the diagnosis of splenic trauma, selective splenic arteriography is an added dimension with marked reliability.     

Pancreatic abscess.

Successful management of pancreatic abscess necessitates early diagnosis and prompt external surgical drainage. The infection is predominantly gram-negative and polymicrobic. Roentgenographic contrast studies are of particular diagnostic value. Prompt recognition and external drainage are associated most frequently with recovery. Multiple system organ failure is the typical pattern of death and should alert one to the possibility of occult sepsis, secondary to pancreatic abscess.     

Effect of a topical adrenergic agent on gastric blood flow

Irrigation of the stomach with saline containing levarterenol has only a small additive effect on the reduction of gastric blood flow, regardless of the temperature of the saline.     

Transferrin level derived from total iron-binding capacity: Is it a reliable relationship?

Serum transferrin is an important protein used to assess visceral protein status in patients requiring nutritional support. Since serum transferrin assays are not readily available in all institutions and there is a correlation between the serum transferrin level and TIBC, Blackburn's formula to compute the serum transferrin level is widely used. To evaluate the relationship between TIBC and serum transferrin, as described by Blackburn et al, we observed the TIBC and serum transferrin levels of 91 patients at our institution. Rajamaki et al [14] and Miller et al [13] have suggested that when Blackburn's formula was used, there was a significant difference in actual and derived serum transferrin values. Our formula, derived from such a comparison, approximates Blackburn's more closely than those of Rajamaki et al [14] and Miller et al [13]; however, they are still statistically significantly different. We agree with Miller et al, that each institution using serum transferrin as a nutritional index should either derive its own formula by regression analysis or should determine the actual serum transferrin level with radial immunodiffusion kits.     

Giant duodenal ulcer: a dangerous variant of a common illness

Giant duodenal ulcers are large posterior penetrations of the duodenum which, when undiagnosed, have a high mortality. Radiographic and endoscopic diagnosis, although not always feasible, enables prompt appropriate management with improved results. Nonoperative treatment is dangerous. Preoperative diagnosis permits planned operative treatment and enables the surgeon to avoid a difficult duodenal dissection. The Bancroft operation, or modification thereof, is the operation of choice. Sixteen consecutive patients with giant duodenal ulcer are described. The success of their treatment is attributed to accurate diagnosis and appropriate operative therapy.     

Value of colonoscopy in patients with rectal blood loss unexplained by rigid proctosigmoidoscopy and barium contrast enema examinations

Total colonoscopy is the procedure of choice for patients with any amount of rectal blood loss unexplained by proctosigmoidoscopy and barium contrast enema examinations. In 168 endoscopic examinations, 46 unsuspected lesions in 39 patients (23 percent) were detected, 50 percent of which were 1 cm or greater in diameter. Considering that 30 percent of all unsuspected lesions, 100 percent of angiodysplastic abnormalities and 40 percent of unsuspected carcinomas were located proximal to the splenic flexure, emphasis is placed on the importance of examining the entire colon to the cecum.     

Effects of concurrent sepsis with clinically significant pulmonary embolic disease.

Forty-one patients with significant pulmonary emboli were reviewed. The presence of heart disease and obesity was found with relatively constant frequency throughout the groups presented. Postoperative infections (wounds or abscess) were frequently associated with fatal or significant pulmonary embolism, particularly after abdominal and pelvic operations. The infection rate (65 per cent) in patients in whom significant pulmonary embolism developed after abdominal and pelvic operations is particularly striking when compared to the overall infection rate of 7 per cent for major operations in our hospital. Recent studies of prophylactic minidose heparinization reveal an increased number of complications due to the heparin [24], and thus the proper selection of cases for prophylactic minidose heparin is mandatory. The data suggest that patients at high risk for the development of postoperative complications of infection are also at high risk for the development of significant pulmonary emboli and should be considered candidates for prophylactic minidose heparinization.     

Immediate reconstruction of oral cavity and oropharyngeal defects using microvascular free flaps.

Eighteen patients underwent immediate reconstruction of defects involving the oral cavity and oropharynx with free groin and dorsalis pedis flaps. One partial and four complete failures occurred. In the successfully reconstructed patients, the functional results were equal to conventional flaps while the cosmetic improvements were dramatic.     

Selective management of gunshot wounds to the neck. Report of a series and review of the literature.

Thirty-two patients with gunshot wounds to the neck, 13 with multiple pellet injuries and 19 with single missile injuries, were managed selectively. Although 3 of the 32 patients died in the hospital, no death was attributable to the neck injury. This experience and a review of the literature support the concept of selective management of penetrating neck injuries with intervention based on specific indications.     

Palliative intubation in the management of esophageal carcinoma

Intubation for unresectable esophageal carcinoma has been analyzed from a collective review of 2,459 patients covering the period of 1960 to 1971.The overall hospital mortality (including a technical mortality of 4.5%) was 13.9%. For the two most commonly used pull-through tubes (Celestin and Mousseau-Barbin) the hospital mortality was 23.5% and the technical mortality 6.6%. For the push-through tube, mortality was, in general, less and was least for the Souttar tube; hospital mortality ranged from 3.6 to 11%, and technical mortality was less than 2%.The overall complication rate was 25.4%. The most common complications were tube dislodgment and tube obstruction. Dislodgment occurred most frequently with the Souttar tube. The average survival period was 4.2 months after intubation. Though not perfect, this mode of treatment provides satisfactory palliation for patients whose survival is limited. The best results were recorded for the Celestin and Souttar tubes.     

Changing concepts in head and neck surgical oncology

Preoperative infusion of volume to increase the wedge pressure will maintain stable flow and arterial pressure at the time of aortic declamping. Usually 1,500 ml of balanced salt solution given with 75 g of albumin is sufficient to accomplish this purpose. Pressor or inotropic agents are not required. In our experience 14 percent of patients will have a down-slope in the preoperative myocardial performance curves. In these persons, volume infusions should be adjusted to keep the pulmonary arterial wedge pressure on the ascending portion of the curve. The use of vasodilator agents in normotensive patients has a deleterious effect on cardiac performance.     

Hereditary polypoid diseases of the gastrointestinal tract: A working classification

Almost all published cases of hereditary intestinal polypoid diseases can be meaningfully classified into a relatively few distinct syndromes including familial polyposis of the colon, Peutz-Jeghers syndrome, and juvenile polyposis.Familial polyposis is characterized by the development of numerous adenomatous polyps of the colon and subsequent development of colorectal carcinoma in nearly all patients. Extracolonic manifestations are common but do not influence the premalignant nature of this syndrome.Peutz-Jeghers syndrome is identifiable by a combination of circumoral melanin pigmentation and hamartomatous polyps. These polypoid lesions have an unusually wide distribution and may occur in the respiratory, gastrointestinal, or genitourinary tract. There is a small but definite increased incidence of gastrointestinal cancer in these patients.Juvenile polyposis presents a more variable spectrum. In one form there is extensive intestinal involvement leading to diarrhea, inanition, and increased susceptibility to infection. Another form is limited to the colon and easily confused with familial polyposis. With the third form, there is involvement of the stomach, intestines, and colon, which makes it easily mistaken for the Peutz-Jeghers syndrome.     

Continuous epidural anesthesia in abdominal vascular surgery: A review of 100 consecutive cases

The use of continuous epidural anesthesia in 100 consecutive abdominal aortic operations since 1975 was reviewed. There were no anesthetic complications. Low-dose systemic heparinization was used. General anesthetic and narcotic requirements were reduced, and postoperative pain was greatly alleviated.     

Systemic anaphylaxis secondary to the use of 5 per cent plasma protein fractions

A severe anaphylactic reaction developed in a twenty-six year old female after the administration of only 40 ml of 5 per cent plasma protein fractions (Plasmanate). The reaction was characterized by generalized tingling, chest pain, sudden severe hypotension, and urticaria. The patient responded to intravenous fluid, epinephrine, diphenylhydramine, and steroid administration.     

Results of esophageal transection for esophageal varices: Experience in 100 cases

The results of transthoracic esophageal transection in 100 patients with esophageal varices are described. There were 11 operative deaths in this series, and the majority of patients died from hepatic failure. Esophageal varices disappeared completely in 81 percent of the patients and faded in 18 percent. Post-transection rebleeding was observed in six cases. There were 16 late deaths, caused mainly by hepatic failure and hepatoma. The 3 year and 5 year survival rates including operative deaths were 70 and 58 percent, respectively. Based on the low operative mortality rate, the efficacy in eliminating varices and the sufficient survival rate, it is presumed that esophageal transection is the most suitable operation for esophageal varices, even in poor risk patients.     

Evaluation and management of penetrating wounds of the neck: the role of emergency angiography.

With the use of emergency angiography, careful observation, and monitoring, 40 consecutive patients with penetrating wounds were selectively managed. Eleven patients were operated on with one negative exploration and one death. Twenty-nine patients were observed after negative angiography without operation on the neck and were subsequently discharged without' overlooking a significant vascular or visceral injury or amy complication. We believe this policy to be safe and effective. It should reduce the number, the morbidity, and the cost of needless mandatory surgical explorations and should guard against clinically undetected serious injuries. Operations should be reserved for those patients with clinically obvious servere vascular or visceral injury and for those with radiographically demonstrated significant lesions.