Subtotal colectomy with primary anastomosis without diversion in the treatment of obstructing carcinoma of the left colon

A small series of patients with obstruction from an adenocarcinoma of the left colon is presented. The recommended treatment in selected cases is subtotal colectomy with primary anastomosis without diversion. The morbidity and mortality in this small series was minimal compared with those reported in a much larger series of similar cases treated by bowel decompression with or without concomitant resection of the lesion. Further follow-up of this series is needed. However, this procedure should be considered seriously in selected patients with obstructing carcinoma of the left colon.     

Cholecystectomy with and without drainage: A randomized,prospective study of 300 patients

A randomized, prospective study of 300 cholecystectomies was undertaken to evaluate the merits of drainage through a standard Penrose or Chaffin-Pratt sump tube matched against no drainage at all. There was no difference in mortality or length of hospital stay. There was, however, a significantly higher incidence of postoperative pyrexia due to atelectasis and wound infection in the drainage groups. Neither drain fulfilled its objective of providing outflow for a subhepatic collection, thus avoiding bile peritonitis. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and unwise.     

Bacteriologic study of paronychia in children

Pus specimens from 33 children with paronychia of the finger were studied using aerobic and anaerobic techniques. Anaerobic organisms were isolated in pure culture in 9 patients (27 percent) and aerobes only in 9 patients (27 percent); mixed aerobic and anaerobic flora was present in 15 patients (46 percent). A total of 118 isolates were recovered, accounting for 3.6 isolates per specimen. The predominant anaerobic organisms were Bacteroides species, gram-positive anaerobic cocci, Fusobacterium species and Bifidobacterium species. The predominant aerobic organisms were Staphylococcus aureus, gamma hemolytic streptococci, Eikenella corrodens, group A beta hemolytic streptococci, alpha hemolytic streptococci, Klebseilla pneumoniae and Haemophilus parainfluenzae. Candida albicans was recovered in 6 instances. Seventeen beta lactamase-producing organisms were recovered from 15 children (45 percent). The study demonstrates the mixed aerobic and anaerobic bacteriology of paronychia in pediatric patients.     

Colonoscopy as a routine preoperative procedure for carcinoma of the colon

Ninety patients with cancer of the colon who had total colonoscopy in the perioperative period have been reviewed. Almost half of the examinations revealed positive findings, three being unsuspected synchronous carcinomas in an area that would not have been resected with the proposed primary cancer. In addition, 79 polyps in 36 patients, the majority of which were also undetected by barium enema, were found and removed at colonoscopy. Thus, patients with carcinoma of the colon, in view of its tendency to be associated with synchronous polypoid disease, should have colonoscopy in the perioperative period. Whenever possible, this should be carried out preoperatively to confirm the diagnosis, to remove suspected or unsuspected polyps, and to detect unsuspected synchronous carcinoma.     

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.     

Management of obstructing carcinoma of the left colon by extended right hemicolectomy

In obstructing carcinomas of the left colon, primary resection with immediate colocolonic anastomosis is associated with a high risk of anastomotic dehiscence, and therefore, it has become traditional to manage such patients with staged resection. In obstructing carcinomas of the right colon, immediate resection of the lesion with ileocolonic anastomosis is acceptable. The scope of right hemicolectomy can be extended to encompass obstructing carcinomas of the left colon by performing subtotal or total colectomy with ileosigmoid or ileorectal anastomosis. Herein, we have reported the outcome in 16 patients treated in this manner. The operative mortality was 12.5 percent, which compared favorably the mortality of other methods of surgical management. Extended right hemicolectomy achieves in one operation relief of intestinal obstruction, tumor resection, restoration of gut continuity, elimination of the risks of synchronous or metachronous colonic tumors, and a possible increase in the 5 year survival rate. In our experience, the frequent passage of liquid stools is not a problem. This approach justifies further study.     

Incidental appendectomy at the time of surgery for ectopic pregnancy

Incidental appendectomy at the time of surgery for ectopic pregnancy can be performed safely in the appropriately selected patient. The added procedure does not place the patient at increased operative risk and spares her from the possible subsequent development of acute appendicitis.     

Combined craniofacial resection for locally advanced carcinoma of the head and neck: II. Carcinoma of the paranasal sinuses

Twenty-eight patients with T₃ and T₄ carcinomas of the paranasal sinuses underwent orbital exenteration and combined craniofacial resection of the anterior and middle cranial fossa and the soft tissues of the face. Three patients died from the procedure and nine had nonfatal complications. Seventy-two percent of the patients with carcinoma of the maxillary antrum are free of disease at 3 years and 50 percent are free of disease at 5 years.     

Crohn's disease of the colon: Is there a role for limited resection?

Forty-one patients underwent resection for Crohn's disease of the large bowel. Twelve patients had a total proctocolectomy for diffuse disease of the colon and rectum, and 29 patients with segmental disease of the large bowel underwent limited resection. Thirteen of the 29 patients had a subtotal colectomy, with 7 patients undergoing immediate ileoproctostomy and 6 having an ileostomy. Further surgery was required in 9 f the 13 patients, and long-term enteric continuity was maintained in only 3 patients. Sixteen patients with more localized Crohn's disease of the colon underwent segmental resection. Seven patients required additional surgery, and enteric continuity was restored in 12 of the 16 patients. There was no mortality among these 29 patients. This study suggests that Crohn's disease of the colon may be successfully treated by limited resection when involvement is segmental. In the patient with more extensive disease of the colon with only rectal sparing, morbidity is high and the probability of maintaining enteric continuity is low. Therefore, in these patients total proctocolectomy should be considered.     

Prognosis in patients with obstructing colorectal carcinoma

Over a 30 year interval (1950 to 1979), 1,061 patients with colorectal carcinoma were seen; 148 presented with bowel obstruction and in this retrospective study were compared with those having nonobstructive tumors. The age and sex distribution did not differ between the groups. The curability rate was 53 percent, versus 72 percent for nonobstructed patients; the 5 year survival rate was 16 percent overall and 31 percent in curable cases, versus 37 and 50 percent for elective patients, respectively. Survival within tumor stages did not differ between the groups; the difference in outcome was mainly a result of obstructed patients having fewer stage A and more stage C lesions. Most right-sided growths were primarily resected, while the left-sided growths were mainly treated with staged resection. Operative mortality for curable patients was 8 percent, not different from the 7 percent rate in elective patients. The 5 year survival rate was 19 percent after primary and 35 percent after staged resection. It was concluded that patients with bowel obstruction secondary to colorectal carcinoma have low curability and survival rates, primarily because of advanced disease at the time of diagnosis and treatment.     

Combined craniofacial resection for locally advanced carcinoma of the head and neck: I. Tumors of the skin and soft tissues

A combined intracranial facial approach adopted for head and neck neoplasms extending to or invading the base of the skull is capable of achieving long-term control of disease that has not been effectively treated by conventional resection. This is partially true for advanced lesions originating in the skin and the soft tissues of these sites. With the help of effective maxillofacial prostheses, the functional results of these procedures are quite acceptable.     

Reduced tissue content of vasoactive intestinal peptide in aganglionic colon of Hirschsprung's disease

The colonic tissue content of immunoreactive vasoactive intestinal peptide was measured in four children with histologically proven Hirschsprung's disease. The concentration of vasoactive intestinal peptide was lower in the aganglionic bowel than in nearby normal bowel. Similar results have been described for another gastrointestinal peptide: substance P. Abnormalities of peptidergic control may contribute to the motility disorder of congenital aganglionic colon.     

Citrate anticoagulation and cell washing for intraoperative autotransfusion in the baboon

Extracorporeal citrate was used for anticoagulation during autotransfusion of baboons. A cell-washing plasmaphoresis procedure was added in one group of animals in order to remove activated clotting materials. Both groups became hypocoagulable, but the cell-washed group had less evidence of disseminated intravascular coagulation as well as lower plasma hemoglobin levels. Citrate anticoagulation plus cell washing is a potential alternative to heparinization for autotransfusion.     

Reoperative parathyroid surgery.

Reoperative parathyroid surgery is associated with a high mortality and morbidity. Morbidity consists of uncorrected hypercalcemia, hypoparathyroidism, and recurrent nerve injury. Initial operative failure is most frequently a result of not identifying four parathyroid glands. On reoperation, parathyroid glands are most often found in the neck and are usually hyperplastic. It is recommended that before attempting rexploration for parathyroid disease, all the patient's records especially the operative note and the previous pathology material should be reviewed. Preoperative localization by selective venous catheterization is of great use in the management of this type of patient.     

Viral-specific humoral immunity to herpes simplex-induced antigens in patients with squamous carcinoma of the head and neck.

Serum antibodies to herpes simplex virus-induced antigens (HSVIA) were quantitated in 122 patients with head and neck squamous carcinoma, 93 patients tumor-free after treatment for these malignant lesions, 27 patients with nonsquamous malignant lesions, 30 heavy smokers, and 36 nonsmokers. Serum IgA anti-HSVIA antibodies were detected in a greater percentage of sera of patients with squamous carcinoma (61 per cent), patients previously treated for these malignant lesions (56 per cent), and heavy smokers (57 per cent) than in patients with nonsquamous malignant lesions (11 per cent) or nonsmokers (8 per cent). Furthermore, titers of these antibodies were higher in patients with squamous carcinoma than in smokers. In patients tumor-free more than three years after treatment, the percentage of positive sera was significantly lower than that in untreated patients and in patients three years or less after treatment. This study demonstrates for the first time a high frequency of antibodies to HSV-induced antigens confined to subjects at high risk of developing head and neck squamous carcinoma and in patients with these malignancies as well as a correlation between the levels of these antibodies and clinical course after treatment.     

Surgical management of ileosigmoid fistulas in Crohn's disease

Seventeen patients with ileosigmoid fistula complicating Crohn's disease are reported on. Eighty-two percent of the fistulas were diagnosed radiologically. Thirteen of the patients (76 percent) were treated by resection of the diseased ileum and cecum with primary anastomosis, division of the fistula, and simple closure of the colon. There were no anastomotic leaks, and long-term follow-up demonstrated excellent results. Segmental sigmoid resection in addition to resection of the diseased ileum and cecum should only be performed when there is radiologic or histologic evidence of Crohn's disease of the colon. Proximal diversion is generally not required, and most procedures can be performed in one stage.     

Acute pancreatitis. Experimental evaluation of steroid, albumin and trasylol therapy

The efficacy of steroids, albumin and Trasylol administration in the treatment of experimental pancreatitis was evaluated. An isolated, ex vivo, perfused canine pancreas preparation was used and pancreatitis was initiated by free fatty acid infusion. Steroid administration worsened pancreatitis, Trasylol had no effect, and albumin was markedly effective in ameliorating pancreatitis. These results were interpreted as evidence against enzyme extravasation and for capillary injury as the initial step in the pathogenesis of pancreatitis.     

Perforating curling's ulcer—a rare but lethal complication

During the last 14 years 8 of 2700 burn patients (0–3 per cent) at the University of Cincinnati Medical Center developed perforated Curling's ulcer. Seven of the 8 patients expired, representing 2 1 per cent of the 328 deaths during that period. All patients were septic. Five of the 8 were operated upon and one of these survived.The incidence of all complications from Curling's ulcer has been markedly decreased by widespread use of prophylactic antacid therapy and hyperalimentation by tube feeding. Only 1 of the 8 patients was receiving antacid therapy at the time of perforation.