Role of subtotal colectomy in the treatment of incapacitating constipation

Nine patients from a community surgical practice have been presented who underwent subtotal colectomy with ileal lower sigmoid anastomosis for the treatment of chronic incapacitating idiopathic constipation. Emphasis was placed on carefully selecting patients for this procedure. The results in this small series have been promising. Long-term follow-up is necessary to determine whether the patients will continue to do well. A review of the literature regarding the surgical treatment of constipation has indicated that subtotal colectomy is the most successful form of treatment in select patients. More studies are needed, specifically in the area of radiopaque markers and anorectal manometry, to determine whether or to what extent these procedures can help select patients who might benefit from this procedure.     

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.     

Contralateral limb and patient survival after leg amputation

Fifty-three patients who required amputation for ischemic disease of the legs were evaluated actuarially. The incidence of subsequent contralateral amputation and the length of patient survival were found to be nearly identical to incidence rates reported during the 1960s. The diffuse end-stage nature of the atherosclerotic process which led to the initial amputation in both time periods accounted for the similarity. Operative mortality decreased from more than 10 percent to 1.5 percent, presumably because of improved cardiovascular support and early rehabilitation.     

Ruptured abdominal aortic aneurysm. The Tacoma experience

The Tacoma, Washington surgical experience with 37 consecutive patients with ruptured abdominal aortic aneurysms seen over a 5 year period has been reported. The overall survival rate was 38 percent. The development of shock before initiation of surgery was a common finding and portended a poor prognosis. The presence of a known aneurysm before presentation with rupture had no influence on the delay required to make the diagnosis and institute surgery or on the proportion of patients in shock but it did negatively influence the survival rate. The need for improved community understanding of aneurysms, their natural history, and the necessity for prompt diagnosis and immediate surgical intervention combined with avoidance of shock when rupture occurs are stressed.     

Management of tracheal tumors

Since 1962, 110 primary tracheal tumors have been seen including 43 squamous cell carcinomas, 38 adenoid cystic, and 29 varied. Sixty-nine patients underwent resection of their primary tumors; an additional 33 patients with secondary tumors involving the trachea also underwent resection. Seventy-three of these 102 patients underwent primary reanastomosis. In 17, laryngotracheal resection was required; staged resections were done for the rest. Survival data indicate that benign tumors are cured by resection with reconstruction and that patients with squamous cell carcinoma, adenoid cystic carcinoma, and other types of malignant lesions obtained either long-term palliation or cure if surgical resection was possible. In patients with selected types of secondary tumors, resection and reconstruction provide prolonged palliation.     

A neuromuscular basis for the development of right inguinal hernia after appendectomy

Abdominal muscular contractions may have a protective influence against the development of indirect inguinal hernia. A portion of the transversus abdominus muscles acts on the internal inguinal rings and produces a closure mechanism during voluntary abdominal muscular activity. It follows, therefore, that injury or inactivation of this mechanism may be an etiologic factor in the development of indirect inguinal hernia. One cause of injury to this mechanism is denervation and regional muscle paralysis occurring during a surgical procedure. Electromyographic findings support the hypothesis that paralysis of inferior fibers of the transversus abdominus muscle occurred after appendectomy, and may have been important in the development of an inguinal hernia.     

Cannulation injuries of the ascending aorta. Repair using the aortic corset

Laceration of the aorta by a side-biting vascular clamp is an unusual but often lethal complication of proximal aortic cannulation. It can be effectively managed with an aortic corset.     

Horse injuries

A series of 622 patients treated at Newmarket General Hospital for injuries resulting from contact with horses was studied. The types of injury and the manner in which they were sustained were analysed.     

Fascia lata paraurethrovesical suspension for the correction of stress urinary incontinence in the woman

Fascia lata paraurethrovesical suspension for the correction of stress urinary incontinence in the female was used 68 times in 66 women. There was an 80 percent overall cure rate (74 percent if allowances are made for potential late failure). This cure rate is not considered good enough to recommend the operation as a primary procedure. The simplicity of the operation and the 75 percent cure rate in failed previous Marshall-Marchetti-Kranz-type procedures commend it as a secondary procedure. Improvement in the cure rate is expected with more experience and refinement of technique.     

Percutaneous transluminal angioplasty. Results and surgical implications

This retrospective study of 91 percutaneous transluminal angioplasties in 80 patients showed an overall patency rate by life-table analysis of 46 percent with a follow-up period of 36 months. Success rates were significantly reduced by predilatation ankle-brachial ratios less than 0.45, by diabetes, by pain at rest or necrosis, and somewhat, by older age. The overall success rate for iliac dilatation was significantly better (58 percent) than that in the femopopliteal segments (18 percent). Although percutaneous angioplasty was performed on many patients thought to be high surgical risks, the complication rate was low, and complications that required surgical intervention were rare (4 percent). Angioplasty was used as an adjunct to vascular surgery in several ways. An attempt to dilate a Dacron graft-femoral artery anastomosis was unsuccessful, and one of two dilatations distal to a femoropopliteal bypass was successful. However, the combination of an iliac angioplasty with outflow femoropopliteal or femorofemoral bypass produced a long-term patency rate of over 85 percent, significantly better than that achieved with iliac dilatation alone. Percutaneous transluminal angioplasty is both an alternative and an adjunct which should be considered by vascular surgeons for their patients.     

Blunt injuries to the carotid and vertebral arteries

A small series of patients with blunt injury to either a carotid or vertebral artery is presented. In three patients the injury was recognized relatively promptly. Two underwent surgery and one was observed with reasonably good results. In two patients the injury was unrecognized, resulting in death in one patient and in a severe, fixed, long-term neurologic deficit in the other. It appears likely that reconstruction may be the treatment of choice in any patient with angiographically proven injury unless coma or severe dense hemiplegia is present.     

Preoperative radiation and chemotherapy for anal and rectal cancer

It became apparent on review of the recent literature that the combination of radiation therapy and chemotherapy may offer increased response in patients with locally advanced carcinomas of the anus and rectum. The protocol for this group is 1 week of chemotherapy with 3 weeks of radiation, followed 3 to 6 weeks later by surgical intervention. In this limited group of 10 patients, considerable benefit was noted. All of the lesions decreased dramatically in size, with 8 of the 10 patients showing more than a 50 percent decrease. Only 1 of the 10 patients showed evidence of nodal involvement at the time of surgery. Three of the patients showed no evidence of tumor and three others showed microscopic tumor only.While the number of patients is small and follow-up is still short, the study seems to have shown the same improved results which have been reported by others using similar protocols. If our long-term follow-up remains equally satisfactory, then the concept of low dose drug therapy combined with radiation could have broader implications, and perhaps be extended to other neoplastic diseases with the same excellent tolerance. This form of therapy can be provided in the setting of a community cancer center, where radiation therapy and medical oncology services are available as an adjunct to surgery.     

Tibial artery injuries

Twenty-eight consecutive patients with tibial or peroneal artery injury are reported. Of these, eight underwent direct arterial repair, eight received vein graft reconstruction, and the involved artery was ligated in the remainder, with amputation required for various reasons in four. Tibial or peroneal artery injury is a relatively common problem. Successful management requires an aggressive approach to early diagnosis, which in turn requires a high index of suspicion and arteriography. Early appropriate management will prevent the serious complications of ischemia, false aneurysm, arteriovenous fistula, and fascial compartment compression. The reconstruction of injured arteries of the lower leg is usually possible and should be accorded more attention than it has received in the past.     

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 percent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.     

Lower limb injuries in motorcycle accidents

A four month study was conducted at Southampton General Hospital of the injuries sustained by motorcycle riders, 104 of whom (60%) returned a postal questionnaire about the accident, rider and motorcycle. The study confirmed that injuries to the lower limbs are a major cause of morbidity and the long time spent in hospital. Further investigation identified specially vulnerable areas. In particular, for 'severe' lower limb injuries, the 'shin' region was identified as the most vulnerable area, and the force producing the injury was generally applied to the other side of the other side of the limb by another vehicle. 'Crash bars' were found to be ineffective in reducing either the incidence or severity of lower limb injury.     

The treatment of Sudeck's atrophy in the upper limb by sympathetic blockade

The incidence of Sudeck's atrophy as a sequel to injury in the upper limb has been estimated in relation to casualty attendances in a 3-year period. Seventeen patients were treated at varying intervals after the onset of the condition either by stellate ganglion block or by regional intravenous guanethidine. The results are compared and the advantages of each method are discussed.     

Abnormal mammographic findings. A critical appraisal

We performed a 1 year review of mammographic interpretations and breast biopsy experiences at Madigan Army Medical Center, correlating biopsy results with mammographic interpretations when possible. Fibrocystic mammary dysplasia was reported in two thirds of our patients, with interpretations heavily weighted toward findings of moderate or severe dysplasia. Sixteen percent of our patients had indeterminate or suspicious mammograms, and only 11 percent of the mammograms were read as normal. Of 19 patients who underwent needle-directed biopsy for nonpalpable lesions and suspicious or indeterminate mammograms, two had invasive cancer and one lobular carcinoma in situ. Our data suggest that many patients who have indeterminate mammograms are followed in preference to early biopsy if there is no palpable lesion and no high yield radiologic criteria of malignancy.     

Penetrating stab injuries of the chest and abdomen

A retrospective review was carried out of 100 consecutive patients with penetrating stab injuries of the chest and/or abdomen, requiring admission to hospital.Laparotomies were performed in 44 patients, while a further 7 were subjected to thoracotomy. Only 1 patient died, and this was a case of combined thoraco-abdominal injury.There was an annual increase in the numbers of such injuries. which were particularly prevalent in young, unemployed persons, often under the influence of alcohol.