Bacterial contamination of the biliary tree after choledochostomy

Secondary exogenous contamination of bile after choledochostomy could be an important cause of long-term morbidity if infection persists after removal of the T tube. Surprisingly, documentation of the frequency of conversion of sterile to infected bile after choledochostomy has rarely been recorded. Patients undergoing exploration and T-tube drainage of the common bile duct between July 1966 and January 1975, in whom intraoperative and postoperative cultures of bile were available, were studied. Postoperative cultures were obtained from five to forty days after operation. Of ninety-five patients available for study, contamination developed postoperatively in previously sterile bile in 44 per cent. The common duct bile contained bacteria at operation in 42 per cent and remained sterile throughout in 14 per cent. The most common secondary contaminants were klebsiella group and Escherichia coli. The fate of the contaminating organisms in a biliary tree without anatomic abnormalities is unknown. Two cases are presented which suggest that persistent infection may linger in the biliary tree for many years and give rise to pigment calculi. Since bacterial cannot be eradicated so long as a foreign body remains in the common duct and because such bacteria may cause symptoms even in an anatomically normal biliary tree, we suggest that a closed system of biliary drainage be employed and that appropriate antibiotic therapy be instituted for seven to ten days after removal of the T tubes.     

Anastomotic dehiscence after low anterior resection of the rectum

Thirty-two patients who had anastomoses to the extraperitoneal rectum underwent radiographic contrast studies about two weeks after operation in order to determine the incidence of anastomotic dehiscence. No extravasation occurred in the sixteen anastomoses in which the middle hemorrhoidal arteries were intact, but partial disruption occurred in four of seventeen (24%) anastomoses in which the middle hemorrhoidal arteries were sacrificed. Since not all patients with anastomotic dehiscence after low anterior resection are symptomatic, the incidence of anastomotic breakdown will be under-estimated unless x-ray studies are performed. More data are required for a better understanding of the technical features of operation which will reduce the incidence of leakage from anastomoses to the extraperitoneal rectum.     

Outpatient excision and primary closure of pilonidal cysts and sinuses.

A procedure for outpatient excision and closure of pilonidal cysts and sinuses under local anesthesia is described. The operation is designed to reduce hospital expenses and loss of work time. It utilizes the low tissue friction properties of polypropylene sutures to effect full dead space obliteration and a home care regimen to minimize the incisional tension produced by sitting. Of thirty-two procedures performed, follow-up data were available for twenty-eight, with a mean postoperative time of twenty-four months. Full primary healing was obtained in all cases with a single early wound disruption. There have been no late recurrences.     

Gastric mucosal defense mechanisms: effects of salicylate and histamine.

Some of the recent concepts about the gastric mucosal defense mechanisms against damage by luminal acid and the effects of histamine and salicylate on these mechanisms are reviewed. The mucosal barrier to acid appears to consist of at least two physiologic components: a permeability mechanism and a metabolic mechanism related to cellular bicarbonate production as a result of acid secretion. In the absence of salicylate, histamine appears to exert some protection by affecting both mechanisms, but in the presence of salicylate, histamine's protective effect is limited to altering mucosal permeability. The actions of salicylate on the gastric mucosa are complex, related in part to the concentration of salicylate and the pH of the luminal fluid. The damaging effects of salicylate appear to be related more to the concentration of acid in the lumen than to the lipid solubility of the drug. Salicylate increases permeability regardless of pH; the increase is initially selective for cations and subsequently becomes nonselective, involving both cations and anions. Although both low and high concentrations of salicylate increase mucosal permeability to hydrogen ions, only high concentrations of salicylate affect cellular bicarbonate production.     

Recurrent cholangitis after biliary surgery

After a biliary-enteric anastomosis, the development of cholangitis is usually assumed to be due to obstruction of the stoma. Six patients in whom this was not the case are described. Achlorhydria, duodenal diverticula, and foreign bodies are important predisposing factors. When bacterial contamination is severe in an abnormal intrahepatic biliary tree, especially that which follows long-standing intermittent common duct obstruction, symptomatic biliary infection may occur in the absence of extrahepatic biliary obstruction.     

15 (R)-15-methyl prostaglandin E2 does not prevent gastrointestinal bleeding in seriously ill patients

A prospective, randomized trial was designed to compare the relative efficacy of 15 (R)-15-methyl prostaglandin E₂ with antacid (usually Mylanta II) in 46 patients admitted to a respiratory-surgical intensive care unit. Bleeding was assessed by a modification of the Hemoccult slide test. Three of 22 patients in the antacid group bled, and 12 of 24 patients in the prostaglandin group bled, for a highly significant difference (p = 0.008). Patients in whom prophylaxis failed tended to have a greater number of risk factors. Other prostaglandin analogues that do not require conversion from an inactive to an active form, may be more useful than the agent we studied. Based on currently available data, the hourly titration of the gastric juice to a pH of greater than 3.5 remains the preferred method of prophylaxis for acute bleeding from the stomach in seriously ill patients.     

Lessons of parathyroid reoperations

The case histories of the 23 patients in this series demonstrate the importance of a systematic approach to parathyroid surgery. Ligation of the superior thyroid vessels and mobilization of the upper pole of the thyroid are often necessary to find the superior parathyroid glands that are located on the posterior surface of the thyroid. Devascularization of the thyroid gland does not occur with this maneuver because of abundant collateral circulation from the inferior thyroid artery and tracheal vessels. Normal appearing parathyroid glands should not be resected because this procedure does not treat hypercalcemia and may leave the patient with insufficient parathyroid tissue if an adenoma is found at a later date. Bilateral cervical exploration [35,36] is performed before resection of any abnormal appearing parathyroid tissue. Patients with hyperplasia may also have supernumerary parathyroid glands [16], especially in the inferior cervical and superior mediastinal areas that are associated with the thymus [37,38].     

Outpatient excision and primary closure of pilonidal cysts and sinuses. Long-term follow-up

Long-term follow-up data are reported on 52 patients who underwent outpatient excision and primary closure of pilonidal cysts, sinuses, and abscesses while under local anesthesia. The procedure consists of conservative excision of all sinus tracts and cavities plus primary closure with a dead-space-obliterating monofilament suture. Sitting was restricted for 1 to 2 weeks after surgery. Primary healing was obtained in all of the patients, and with follow-up on 84 percent of the patients, no late recurrences have appeared.     

Effect of hyperparathyroidism and hypercalcemia on lower esophageal sphincter pressure

Heartburn is a frequent and sometimes initial complaint in hyperparathyroidism, and it is often relieved by successful parathyroid surgery. Four of five patients with primary hyperparathyroidism and heartburn obtained relief of symptoms and had an increase in lower esophageal sphincter pressure after successful operative treatment. Four of five volunteers undergoing calcium infusion exhibited a decrease in lower esophageal sphincter pressure after about 2.5 to 3 hours of infusion. Calcium infusion in a treated patient who had an increase in lower esophageal sphincter pressure postoperatively resulted in a transient return of lower esophageal sphincter pressure to preoperative levels.     

Recurrent hyperparathyroidism due to implantation of parathyroid tissue

Recurrence of hyperparathyroidism after initially successful primary operation is usually caused by inadequate resection of diseased tissue or recurrent carcinoma. Since it is known that normal parathyroid tissue may be autotransplanted into a muscle bed, it is plausible that inadvertent implantation of parathyroid tissue spilled at operation may occur. In four of 23 reoperations for hyperparathyroidism in an 11 year period, we found evidence that iatrogenic parathyroid implantation had occurred. Two of the four patients had multiple parathyroid implants in the previous operative field, and one of these patients had documented spillage of a cystic adenoma during the original operation. Another two of the four patients were found to have recurrent adenomas containing suture material at sites of previous excision of the adenomas. No patient had gross or histologic evidence of parathyroid carcinoma. We conclude that inadvertently spilled parathyroid tissue may implant in the neck or mediastinum and cause persistent or recurrent hypercalcemia. Therefore, all efforts should be made to handle the parathyroid glands only by their pedicles and not to crush, suture, or violate the capsule. Needle aspiration of parathyroid cysts could lead to implantation along the needle tract.     

Polytetrafluoroethylene grafts in the peripheral venous circulation of rabbits

We demonstrated by venography that the patency of 3 mm PTFE grafts in the jugular veins of rabbits could be maintained by pretreating the animals with either an anticoagulant (warfarin sodium) or an antiplatelet agent (aspirin, dipyridamole, or both). Examination of the lining of the grafts up to 4 months after grafting by scanning electron microscopy or light microscopy showed that endothelial cells extended across the anastomosis for a short distance and that a neointima lined the remainder of the graft. This lining could hypertrophy to the point of almost occluding the graft unless the drugs were continued.     

Prognosis of undifferentiated carcinoma and lymphoma of the thyroid

The experience with 126 patients with poorly differentiated thyroid carcinoma or lymphoma treated at the Lahey Clinic between 1931 and 1970 was reviewed. Undifferentiated thyroid tumors predominate in women and present late in life. While no giant cell tumors were found in patients less than forty years of age, small cell carcinoma and especially lymphoma can be seen earlier in life. Giant cell tumors were the most frequently found undifferentiated tumors in men while small cell types were commonest in women. These tumors involve extraglandular structures early; complete surgical removal is possible in only one third of the patients. Clinical course, survival, and biological behavior are closely related to the histologic type of the tumor. While patients who died of giant cell carcinoma had a median survival of three months and a five year survival of 8 per cent, patients with small cell carcinoma and lymphoma have a far better prognosis with a five year survival of 33 and 29 per cent, respectively. Differentiation of small cell carcinoma from lymphoma is often difficult but may be of no clinical significance at present.In view of our results we recommend: (1) total excision of tumor whenever possible, including limited neck dissection when this is required; (2) “debulking” procedures when feasible to aid in tracheostomy placement and use of radiotherapy and chemotherapy; (3) tracheostomy placement in the presence of any airway obstruction; (4) high dose external radiotherapy after operation or used as palliation in patients with nonresectable disease; (5) aggressive combination chemotherapy utilizing either adriamycin or actinomycin when palliation cannot be achieved by surgery and radiotherapy; and (6) thyroid hormone to avoid hypothyroidism, as the thyroid gland is usually functionally destroyed by the effects of invasive tumor and radiotherapy.     

Large intrahepatic cysts and pseudocysts. Pitfalls in diagnosis and treatment

The records of forty-seven patients with large intrahepatic cysts or pseudocysts were analyzed. Thirty-one of the cysts were developmental and sixteen were acquired. Patients with developmental cysts and those with neoplastic cysts had similar features, including an absence of constitutional illness, but patients with infective pseudocysts generally had features of systemic disease and often had hematologic abnormalities.Sonography indicated the cystic nature of the lesions, but operation was usually necessary to establish a precise diagnosis. Four of the solitary giant cysts were successfully treated by subtotal excision—a less extensive procedure than hepatic resection or total excision of the cyst. Recurrences were common after lesser procedures. The nature of two malignant cysts was not recognized at operation, and cysts with macroscopic features of neoplasia should be treated by hepatic resection even when frozen section biopsy fails to support such a diagnosis. Pyogenic pseudocysts were treated adequately by drainage, but echinococcal cysts required injection with hypertonic saline or Formalin and partial or complete excision for cure. Traumatic pseudocysts healed only when bleeding or bile leakage into the cyst cavity was controlled.     

External counterpressure to control postoperative intra-abdominal hemorrhage

The effectiveness of the G-suit in controlling massive postoperative intra-abdominal hemorrhage was studied in twenty-eight patients whose diffuse bleeding could not be controlled during operation. Most patients had developed deficiencies of platelets and clotting factors due to dilution, and in addition three had documented disseminated intravascular coagulation. After application of the G-suit, hemorrhage stopped in nineteen patients, allowing the replacement of platelets and clotting factors in patients with deficiencies and the administration of heparin to three patients with disseminated intravascular coagulation. After an average of twenty-one hours the G-suit was removed without rebleeding in seventeen patients. The major cause of G-suit failure was an arterial source of intra-abdominal bleeding. Application of the G-suit had no adverse effect on renal function in at least half the patients; urinary output declined in one third. Most patients experienced respiratory impairment and some had ischemic skin lesions. The G-suit is frequently effective in halting postoperative intra-abdominal hemorrhage, allowing correction of acquired coagulopathies with acceptably few complications. Its use does not replace the need for proper surgical hemostasis.     

The effect of transcutaneous electrical nerve stimulation on pain after thoracotomy

The effect of postoperative transcutaneous electrical nerve stimulation (TENS) was evaluated in 24 patients in two randomly selected groups who underwent thoracotomy. The patients in one group received TENS through periincisional electrodes, and the remaining patients were treated with sham stimulator setups. The stimulators remained in place for 48 hours after operation. Subjective pain scores, duration of stay in the recovery room, tolerance to chest physical therapy, complaints of nausea, time to end of mechanical ventilation, and narcotic requirements were evaluated. Patients in the TENS group had significantly lower pain scores during the first 24 hours postoperatively (p = 0.014), shorter recovery room stays (p = 0.013), and better tolerance of chest physical therapy on both day 1 (p = 0.018) and day 2 (p = 0.006). No respiratory complications occurred in either group.     

Regional infusion chemotherapy of hepatic metastases from carcinoma of the colon

The effects of hepatic intra-arterial infusion of 5-fluoro-2′-deoxyuridine (5-FUDR) in fifty-one consecutive patients with hepatic metastases from carcinoma of the colon were studied. An objective response was recognized in 57 per cent by decreased hepatic size, 61 per cent by improved hepatic scan, 59 per cent by improved biochemical hepatic function tests, and 39 per cent by improved angiograms. These categories of objective response were not always interrelated. Thus, on the basis of at least one objective response and symptomatic improvement, a clinical response rate of 71 per cent was achieved.Patients with a clinical response had a median survival of sixteen months; nonresponders had a median survival of five months. Factors related to response rate and prolonged survival were young age, absence of ascites, presence of jaundice, and less extensive involvement of the liver. The presence of extrahepatic intra-abdominal metastases did not affect the response rate or survival time, indicating the controlling effect of the hepatic metastases. These response rates are substantially higher than those reported with systemic chemotherapy and indicate that regional chemotherapy of hepatic metastases from carcinoma of the large bowel should be more widely studied and adopted.     

Hyperalimentation in inflammatory bowel disease

The effect of total parenteral nutrition on a group of thirty-four patients with inflammatory bowel disease over the past three and a half years was reviewed. Only patients in whom medical management had failed were included. Patients in whom the decision for surgery had been made and who were treated with total parenteral nutrition in an effort to prepare them for surgery were excluded. Of the group with Crohn's disease, those patients with small bowel involvement appeared to fare best; surgery was avoided in approximately 70 per cent of these admissions. Crohn's disease with colonic involvement had a less favorable prognosis, and 43 per cent of these patients underwent operation. Parenteral nutrition does not appear to affect the course of ulcerative colitis, as almost all patients in the group were treated by colectomy.     

Refractory primary common bile duct stone disease

Thirty-seven cases are reported of primary common bile duct stones considered typical of primary stone disease with an asymptomatic period of at least 2 years after cholecystectomy and stones of a soft brown, easily crushable characteristic. Two other groups with a total of 57 cases closely related to those in the first group are reported, for a total of 94 cases. These three groups have similar patient ages, large common bile ducts averaging 19 mm in diameter, ampullas easily open to a no. 6 Bakes dilator and a high incidence of recurrent or overlooked stones despite the use of operative cholangiography in at least half of the procedures. The use of a duct anastomosis in ducts over 11 mm in diameter is mandatory for a satisfactory result. In smaller sized ducts a generous sphincterotomy or sphincteroplasty must be carried out in addition to choledocholithotomy. The exact indication for endoscopic papillotomy in the treatment of this condition has not been settled. Other conditions associated with primary duct stones include traumatic and nontraumatic strictures, sclerosing cholangitis, oriental cholangiolitis, congenital cystic disease, Caroli's disease and congenital hepatic fibrosis. More information is needed to explain the soft stone syndrome, such as data on the bacteriologic and chemical characteristics of the bile and on the physiologic features of common bile duct emptying.