Sphincterotomy or sphincteroplasty in the treatment of pathologically mild chronic pancreatitis

We reviewed 67 patients with a mild to moderate degree of chronic pancreatitis, 33 of whom had sphincterotomy and 34 of whom had sphincteroplasty of the sphincter of Oddi and the sphincter of the pancreatic duct. The cause of the pancreatitis was idiopathic in 35 and probably alcoholic in 32. Initial relief of symptoms at 6 months was acceptable in both groups (mean, 64 percent), but thereafter decreased at 2 years and 5 years postoperatively to significant relief in only 48 and 44 percent of patients, respectively. The more complex sphincteroplasty appears to offer no advantage over the simpler sphincterotomy in the management of patients with pain of pancreatitis. In the patients who were alcoholics, avoidance of alcohol seems to be a much more important determinant of the outcome of the operation than the operation itself.     

Parietal cell vagotomy for intractable and obstructing duodenal ulcer

Parietal cell vagotomy can be accomplished with minimal morbidity and mortality. Symptoms and signs of delayed gastric emptying early after operation are common and occur more frequently in patients with preoperative gastric outlet obstruction than in those without, a difference that is statistically significant. These symptoms are generally mild and transient. Dumping and diarrhea were not problems in our series. In patients with preoperative gastric outlet obstruction, parietal cell vagotomy with pyloroduodenal dilatation achieved good or excellent results in 79 percent of patients; however, the possibility of a higher recurrence rate requires further evaluation and suggests caution and selectivity in the use of this procedure. The recurrence rate of 3 percent in patients without gastric outlet obstruction and a very good or excellent clinical result in 91 percent of these patients appear acceptable and encourage us to continue to use parietal cell vagotomy as the procedure of choice in patients with intractable duodenal ulcer. Most patients with recurrent ulcer have been treated medically with success. Close long-term clinical follow-up studies will be required to assess better the success of this procedure.     

Burst therapy: A method of administering fibrinolytic agents

The use of noninvasive studies to establish the diagnosis and to follow the clinical course of patients undergoing fibrinolytic therapy markedly reduces the amount of invasive alternatives and their attendant bleeding complications. Streptokinase administered by the burst therapy protocol is very effective. Streptokinase administered in this fashion is very cost effective and is in keeping with the current economic trends. Administering warfarin the evening before the last burst of streptokinase markedly reduces the time required to adequately anticoagulate the patient with warfarin. Administering acetaminophen before and during therapy decreases the incidence of febrile reactions. Although streptokinase therapy is not without significant complications, the benefits outweigh the attendant risks.     

Anterior resection for adenocarcinoma. Lahey Clinic experience from 1963 through 1969.

The results of anterior resection for adenocarcinoma of the rectum and rectosigmoid are reported with respect to survival rates and complications. Anastomotic recurrence is related to low lying, ulcerated, and less well differentiated tumors that have penetrated the bowel wall. The incidence of recurrent disease at the anastomosis increases with decreases in the margin of resection. Distal margins of at least 6 cm offer significant protection from recurrence. This study shows that anastomotic septic and fistulous complications are related to advanced age, diabetes, anemia, atherosclerotic disease, construction of the anastomosis below the peritoneal reflection, perforated bowel, obstructed bowel, and the use of drains. The determination of those factors that correlate with the development of anastomotic complications can be accomplished with pre- and intraoperative examinations. The role of these factors in operative decision-making and patient management is emphasized.     

Parenteral nutrition-induced gallbladder disease: a reason for early cholecystectomy

Patients who receive long-term parenteral nutrition have an increased incidence of both calculous and acalculous cholecystitis. In an attempt to establish guidelines for the clinical management of patients with TPN-induced gallbladder disease, we have reviewed the records of 35 patients who have undergone cholecystectomy for this problem since 1976 at the UCLA Medical Center. The mean age of the 23 adult and 12 children who had cholecystectomy was 29.1 years. Forty percent of these patients required emergency cholecystectomy. The overall operative morbidity was 54 percent, and the hospital mortality was 11 percent. Significant factors contributing to this high rate of complications included a delay in diagnosis, especially in the young children, and increased operative difficulty due to extensive adhesions and intraoperative hemorrhage. Our analysis suggests that patients receiving long-term TPN should have a program of ultrasound surveillance for gallstone formation, elective cholecystectomy when stones first appear, and consideration of cholecystectomy at the time of laparotomy performed for other reasons. Whether TPN-induced gallstones can be prevented through daily stimulated gallbladder emptying awaits the results of future studies.     

Carotid body tumor. The Lahey Clinic experience

We believe that paragangliomas of the carotid body should be excised in all patients unless formidable medical conditions prohibit the use of general anesthesia. If these tumors are left unresected, they will eventually grow to invade the skull and kill the patient. With definitive diagnostic modalities available, in addition to comparatively low-risk anesthesia, autotransfusion, and replacement of the carotid artery, there are few patients who cannot be surgically treated. The important point is that although such a tumor is rare, its presence must always be considered when dealing with a lateral neck mass. Carotid arteriography should be performed when a carotid body tumor is suspected.     

Segmental pancreatic autotransplantation for chronic pancreatitis

Three patients who underwent 95 percent removal of the pancreas for chronic pancreatitis with autotransplantation of the body and tail of the gland to the femoral area are described. The follow-up periods are 18, 6, and 2 months. Pain lessened in all patients and none required exogenous insulin. Patency of the graft was documented in all patients by angiography, technetium scan, and Doppler studies. Percutaneous selective venous assays of both external iliac veins showed a high insulin concentration in the transplanted side, both early and late in the postoperative period. In one patient the operative insulin levels obtained at the completion of autotransplantation proved to be highest in the external iliac vein on the transplanted side, lowest in the iliac vein on the nontransplanted side, and intermediate in the portal vein. Subsequent biopsies of the autografts showed fibrosis of the gland and atrophy of the acinar tissue with preservation of islet tissue. This technique appears to offer a means of preserving endocrine function in selected patients who require extensive resection for chronic pancreatitis.     

Pyloric and gastric preservation with pancreatoduodenectomy

Pyloric and gastric-preserving pancreatic resection was performed in 35 patients with no mortality. Twenty-seven patients were followed for at least 8 months postoperatively and are reported herein in detail. This variation in the Whipple procedure is associated with a satisfactory weight gain after operation for benign disease, does not produce the usual postgastrectomy digestive symptoms, and so far jejunal or anastomotic ulceration has not been a problem. We believe this variation of the Whipple procedure is the operation of choice for benign disease and for certain types of periampullary malignant growth.     

Esophagectomy without thoracotomy for carcinoma of the esophagus

During the past 2.5 years, 13 patients underwent esophagectomy for carcinoma of the esophagus without the use of a thoracotomy. During the same period, 81 operations on the esophagus or cardia were performed, 73 of which were esophagogastrectomies. Two patients died, for a hospital mortality rate of 2.7 percent. Of the 13 patients, there were 7 women and 6 men with an average age of 59.7 years. The lesion was located in the cervical esophagus in two, the upper thoracic esophagus in eight and the lower esophagus in three. One patient died on the 12th postoperative day, for a hospital mortality rate of 7.7 percent. Satisfactory relief of dysphagia was accomplished in all surviving patients, five of whom have died from the disease, for an average survival of 13.1 months. Seven are currently alive, with the longest period of survival 20.5 months. Esophagectomy without thoracotomy can be carried out with low mortality and morbidity rates. It is most applicable to patients with early lesions, particularly those in the cervical esophagus and the upper thoracic esophagus.     

Biliary carcinoma. A review of 109 cases

One hundred nine patients operated on for bile duct carcinoma were reviewed. Herein, we reported 83 proximal duct tumors, 12 mid-duct tumors, and 14 distal third tumors. Resectability was 10 percent, 33 percent, and 100 percent, respectively, with an operative mortality of 0 percent, 25 percent, and 23 percent. The median survival time and 5 year survival rate for these resected groups were 21 months and 25 percent for proximal duct tumors, 8 months and 0 percent for mid-duct tumors, and 16 months and 20 percent for distal third tumors. Eighty-three patients were treated with strictly palliative procedures with an operative mortality of 19 percent, an adjusted median survival rate of 10.9 months, and a 5 year survival rate of 0. The 2 and 5 year survival rates of patients with well-differentiated tumors were 73 percent and 15 percent, respectively, whereas for patients with poorly differentiated lesions, it was 6 percent and 0. Although most patients require palliative decompressive procedures, resection should be attempted whenever possible. It is expected that nonoperative techniques will have an increased role in the treatment of poor-risk patients or those who have unresectable disease.     

Colorectal carcinoma at the Lahey Clinic, 1962-1966

A study of carcinoma of the colon and rectum carried out in 513 patients between 1962 and 1966 at the Lahey Clinic revealed an operability rate of 98 per cent. The rate of resection was 94 per cent, and the operative mortality was 4.5 per cent. The uncorrected five year survival rate for those undergoing surgery for cure was 62 per cent. The uncorrected survival rate for Dukes' lesions A, B, and C was 84, 65, and 36 per cent, respectively; the corrected survival rates were 98, 79, and 42 per cent, respectively. Decreased survival is noted with increased nodal involvement and with the presence of blood vessel invasion. A possible change in the metastatic potential of colorectal carcinoma is postulated.     

The stapled abdominal wall closure revisited

Feeding gastrostomy can be troublesome, inconvenient and painful to the patient, especially if the catheter is redundant, thereby causing deformity of the opening and leakage of gastric juice and food around the tube. A skin level permanent feeding gastrostomy was fashioned in four patients with neurologic disease. The mushroom catheter was introduced into the stomach, secured by a purse-string suture and fastened to the abdominal wall by a metal hub. The hub was fitted to a syringe by an adaptor for feeding purposes and was covered between meals. The device is simple to construct, safe, spill-proof and easily adopted by the patients.     

Colonic polypoid disease: need for total colonoscopy.

Colonoscopic examination of the entire colon was performed on 146 patients for radiographically suspected benign polypoid disease. Of thirty-six patients who did not have a neoplastic lesion at the suspected site, seven (19 per cent) had unsuspected small benign polypoid adenomas elsewhere in the colon. Of the remaining 110 patients who had a neoplastic lesion at the radiographically suspected site, 17 lesions (15 per cent) were either adenocarcinomas or neoplastic polyps with invasive carcinoma. One hundred twenty-eight additional unsuspected neoplastic polyps were found in 62 of the 110 patients (56 per cent). Six of the additional neoplastic lesions were either adenocarcinomas or polyps with invasive carcinoma. Four of these malignant lesions were in patients who had a benign polyp at the radiographically suspected site. Suspected colonic polypoid disease should be evaluated colonoscopically despite radiographic evidence of benignity. Colonoscopic evaluation in colonic polypoid disease should include examination of the entire colon with pathologic documentation of all polypoid lesions encountered.     

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunostomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.     

Running synthetic absorbable suture in abdominal wound closure

One hundred thirty-four consecutive, unselected, primary, linear abdominal surgical incisions were closed with running polyglactin suture. The only wound complication was a single infection. No wound dehiscence, incisional hernia, late wound pain or suture sinus occurred.     

Anterior transpericardial closure of a main bronchus fistula after pneumonectomy

A young woman sustained a penetrating wound to the right anterior chest during a vehicular accident. Septic complications led to emergency pneumonectomy followed by infection of the pleural space and disruption of the right bronchus closure. Her condition improved after creation of a pleural window for dependent drainage and gauze packing of the pleural space. Subsequently, the open bronchial stump was closed utilizing a transpericardial approach through a median sternotomy incision which permitted eventual closure of the pneumonectomy space without thoracoplasty. When the length of the bronchial stump permits its application, the transpericardial approach to postpneumonectomy bronchial fistula closure offers important advantages over conventional transpleural techniques.     

Nonfamilial medullary thyroid carcinoma

On the basis of this report and the current literature, we conclude that the familial type of medullary thyroid carcinoma can be diagnosed early using basal and poststimulation levels of calcitonin. However, most of the patients with sporadic disease present with a neck mass later in life. The tumor has a tendency to invade locally and metastasize to lymph nodes early in its course. Prognosis is negatively influenced by the extent of disease, lymph node involvement and elderly age. The surgical procedures of choice should be total thyroidectomy with clearance of central nodes of the neck as well as neck dissection when indicated. All parathyroid glands should be inspected. For patients treated for cure, the determinant 10 year survival is 48 percent, and 20 year survival is 33 percent. Recurrence of local disease should be treated aggressively, as important palliation and prolongation of life can be achieved. Radiotherapy may be helpful in the management of residual tumor or recurrent disease. Basal calcitonin assays and poststimulation studies are useful in diagnosing residual or recurrent disease. In the familial cases, the existence of other endocrinopathies has to be considered in the management of the patients.     

Safe management of patients with simultaneously occurring prostatism and abdominal aortic aneurysm

In patients who present with both an abdominal aortic aneurysm and signs or symptoms of urinary obstruction from prostatic hypertrophy, prostatectomy should be performed first if the patient's condition permits. Since bleeding from the site of prostatic resection is rare, the interval between prostatic and subsequent aneurysm operations need not be long. One to 2 weeks after hematuria disappears should be sufficient. If clinical conditions prompt emergency operation for a abdominal aortic aneurysm in a patient with prostatism, blood spectrum antibiotics should be used which include coverage for enterococci. Subsequent prostatectomy should be delayed as long as possible unless the patient cannot void or develops a urinary tract infection that cannot be cleared with appropriate antibiotics. Broad spectrum antibodies during and after prostate surgery, in this instance, are mandatory.     

Reoperation after esophagomyotomy for achalasia of the esophagus

Eleven patients who required reoperation for persistent or recurrent symptoms after esophagomyotomy are reported on. Failure of the original operation was attributed to inadequate myotomy in three, healed myotomy in four, and reflux esophagitis in four.The myotomy was extended or a new myotomy created in the first two categories of patients. Three of the four patients with reflux esophagitis were treated by antrectomy and Roux-en-Y esophagojejunostomy; one of these also required concomitant excision of the esophagogastric junction because of stricture. The fourth patient with esophagitis ultimately required colonic interposition for relief of symptoms.Ten of the eleven patients were improved after reoperation, but results were less good than those achieved by a properly performed primary esophagomyotomy. This re-emphasizes the need for attention to the technical details of esophagomyotomy if good results are to be achieved.     

Effects of prophylactic antibiotics on wound infection after elective colon and rectal surgery: 1960 to 1980

Wound infection continues to be a common complication of elective colon and rectal surgery. During the period from 1960 to 1980, 42 prospective, controlled prophylactic antibiotic trials were undertaken which addressed this problem. In this report we have analyzed these trials and compared them to all noncontrolled, prospective wound infection surveys and a representative sample of the retrospective surveys of the same period. From this analysis several conclusions have become apparent: (1) wound infection remains a common complication for which prophylactic antibiotics are generally effective, (2) the most effective agents are those with activity against anaerobic bacteria, (3) orally administered nonabsorbable antibiotics have little effect on reducing wound infection following these procedures, and (4) the optimal antibiotic regimen is yet to be found. The data do suggest, however, the more preferred regimens currently available as well as those worthy of further investigation.