Death from hepatic failure after jejunoileal anastomosis.

Severe liver dysfunction and even death from hepatic failure after jejunocolic anastomosis has led to the virtual abandonment of that procedure for the surgical treatment of massive obesity. This complication after the currently employed jejunoileal anastomosis has rarely been described before. We present two cases of hepatic necrosis and death after end to side jejunoileal anastomosis and compare the clinical data and liver function test results in these two patients with findings in 124 other patients who underwent a similar procedure for treatment of morbid obesity. No significant differences could be found that would allow early identification of those patients in whom massive hepatic necrosis was developing. Careful follow-up study and perhaps repeated liver biopsy may be necessary to monitor the hepatic status after jejunoileal anastomosis so that reanastomosis can be undertaken at a time when the damage may be reversible.     

Congenital mesocolic (paraduodenal) hernia: Embryologic basis of repair

Paraduodenal hernia is a misnomer and the term “congenital mesocolic hernia” preferred. The etiologic features of mesocolic hernias are explained by an abnormal rotation of the gut during embryonic development. Three types of congenital mesocolic hernias are described. A safe method for surgical reduction of a left mesocolic hernia is described and discussed.     

Perforated diverticulitis of the terminal ileum

The clinical course of a patient with perforated diverticulitis of the terminal ileum is described and six other reports in the literature are reviewed. The acute symptoms and signs simulate those of acute appendicitis, although two patients were seen with a less acute stage of disease; one had an enterovesical fistula and one (our patient) a walled-off abscess. Primary resection with ileotransverse colostomy is probably the preferred treatment, but mortality and morbidity have been significant.     

Surgical management of patients with primary operable colorectal cancer and synchronous liver metastases

The surgical results were analyzed of 217 patients who had undergone operation for primary colorectal cancer and were found to have synchronous liver metastases. It is recommended that patients with primary operable colorectal cancer who are found to have synchronous liver metastases should at least have an adequate resection of the primary lesion. If the primary lesion is resectable for cure and there are solitary hepatic metastases, then excision of these seems warranted. In most cases this can be accomplished by simple excision or wedge resection, although occasional cases may require lobectomy.     

Cerebral hemodynamic crisis: Physiology,pathophysiology, and approach to therapy

The physiology and pathophysiology of the cerebral circulation have been discussed in relation to treatment of the cerebral hemodynamic crisis. Data are presented to show how cerebral vascular resistance, the intracranial compartments, and brain metabolic demand may be manipulated to effect internal decompression and raise local perfusion pressures. It is quite apparent that irreversibility occurs rapidly in cases of complete ischemia and therapeutic success is often limited by this fact. Application of sound therapeutic principles will limit the extent of cellular destruction. Of particular importance to the general surgeon treating the multiply injured patient, is the effect of anesthesia on intracranial pressure in patients with compromised intracranial volume reserve.     

Combined abdominotranssacral reconstruction of the radiation-injured rectum.

Reconstruction of the rectum by a technic of combined abdominotranssacral proctocolectomy and proctocolostomy is presented as an alternative to the surgical conservatism that has been the time-honored approach to the management of radiation-injured rectum. The procedure has permitted safe accomplishment of rectal anastomosis with as little as a 1 cm distal rectal stump. Satisfactory, true anal sphincteric continence is enjoyed by six patients who have been completely reconstituted, and satisfactory reconstitution in the remaining two is anticipated. These results suggest that reinspection of the traditional approach to the radiation-injured rectum is warranted now that safe and physiologically effective reconstitution can be accomplished by a combined abdominotranssacral technic.     

Hypercalcemia of seven years' duration after kidney transplantation

A case is reported of hypercalcemia persisting for seven years after kidney transplantation, with hormocalcemia being achieved after subtotal parathyroidectomy. The finding of post-transplantation hyperparathyroidism of this extreme duration, in association with several other reports of hyperparathyroidism persisting for years after kidney transplantation, raises serious questions about the completeness of parathyroid involution after kidney transplantation. Extensive review of the literature reveals that little is really known about the natural history of parathyroid function and involution after kidney transplantation.     

Carotid artery aneurysm of granulomatous origin.

A native of the Western Caroline Islands presented with a granulomatous aneurysm of the right common carotid artery measuring 7 to 8 cm, which was resected and replaced with a reversed segment of saphenous vein. Adequacy of the collateral circulation to the brain was established by occlusion of the common carotid artery with local anesthesia. This was followed by definitive operation with general endotracheal anesthesia and induced hypertension. Although tuberculosis was the most likely etiologic agent, sarcoid could not be ruled out. Granulomatous aneurysms of the common carotid are extremely rare, and if this case was sarcoid in origin, it is the first such case reported. Only one other similar aneurysm could be found in the literature. Of the various methods of reconstruction of the common carotid artery reported, autogenous reversed saphenous vein is recommended strongly.     

Pelvic fractures: an anatomic guide to severity of injury: Review of 100 cases

A series of 100 cases of pelvic fracture secondary to violent trauma were reviewed and divided into two anatomic groups, those with pure anterior arch fractures (57 patients) and those with posterior fractures (43 patients). By this classification, mortality and associated injury are shown to be markedly increased in those patients with posterior fractures. A detailed study of the major complications has shown that a conservative approach to these injuries is probably the safest for the patient. Major blood loss is the rule rather than the exception and restoration of an adequate circulating volume by transfusion should precede operative attempts to control continuing retroperitoneal hemorrhage.     

A new treatment for ischemic bowel disease: Steroid delivery via retrograde venous route

The present therapeutic approach to occlusive mesenteric disease is unable to alter its high mortality and morbidity. We attempted to stabilize the intestinal lysosomal population with steroid prior to revascularization and thus reduce the lysosomal effluent.Steroid delivery during the occlusive period was accomplished via retrograde venous flow in the portal system. During revascularization steroid was further infused via the superior mesenteric artery. Our experimental model compared systemic venous delivery with retrograde portal venous delivery of steroid. Analysis of tissue acid phosphatase levels suggested steroid delivery via retrograde portal venous flow is the most efficient method of lysosomal stabilization.     

Duodenal hematoma: Critical analysis of recent treatment technics

Analysis of the fifty-six cases of duodenal hematoma reported since 1966 shows a significant rise in incidence, with uncertainty regarding the most appropriate approaches to therapy. The diagnosis can generally be made by recognizing the “coil spring” sign on upper gastrointestinal series. Thirty-four per cent of the patients reviewed were treated successfully with conservative management. Sixty-two per cent were treated surgically. Fifty-one per cent of the surgical patients were treated by simple evacuation of the hematoma, and 12 per cent of these required reoperation for recurrent obstruction. Forty per cent of the surgical patients were treated by evacuation and gastrojejunostomy, and 21 per cent of these required reoperation for marginal ulceration. A previously unreported case is presented and a new surgical approach utilizing gastroduodenostomy is described, which is believed to offer potentially less risk of subsequent marginal ulceration or recurrent duodenal obstruction.     

Contiguous cervical and deltopectoral flaps for skin lining and replacement with en bloc resection of cancer of the head and neck

Contiguous cervical and deltopectoral flaps have several advantages in reconstruction of the head and neck after extirpation of cancer. The cervical skin provides an excellent color match for facial skin, and nonhair-bearing skin is available if lining of the oral cavity is required. The deltopectoral flap provides superior coverage for the carotid artery.     

Hyperparathyroidism with coexisting hyperthyroidism

Diagnosis of parathyroid disease in patients with hyperthyroidism may be difficult on clinical findings alone. Radiologic examination of the bones suggested the possibility of parathyroid disease in this patient. Confirmation of the diagnosis was made when serum calcium levels remained elevated in spite of adequate antithyroid medication. Measurement of serum parathyroid hormone levels may prove to be of greatest value. Of additional interest is the fact that the patient, before her symptoms became apparent, delivered an infant with congenital hypoparathyroidism.     

Gastric aneurysms: unusual lesions with lethal potential.

Extravisceral gastric aneurysms are rare lesions infrequently producing symptoms prior to life-threatening intraperitoneal rupture. Elective resection is indicated in those unusual cases diagnosed preoperatively. Ruptured visceral aneurysms should be included in the differential diagnosis of obscure intraperitoneal hemorrhage. In contrast, intramural gastric aneurysms produce massive hematemesis managed successfully in two cases by subtotal gastrectomy. Acknowledgment: I wish to thank Doctors Stephen A. Ockner and John Cacciamani for the kind referral of their patient and Doctor Edito Cabal, St. Louis Veterans Administration Hospital, who performed the arteriography.     

The relative effects of lesser curvature vagotomy and esophageal vagotomy on the acid secretory effect of proximal gastric vagotomy

Proximal gastric vagotomy is an operation consisting of division of all vagal fibers to the acid-secreting portion of the stomach. These fibers are usually divided along the lesser curvature of the stomach; however, because of a high rate of duodenal ulcer recurrence in some series, it has become apparent that it is important to divide the vagal fibers to the stomach leaving the main vagal trunks along the distal 5 cm of esophagus in order to achieve both adequate control of acid secretion and also a lower duodenal ulcer recurrence rate. The data presented in this study of ten mongrel dogs suggest that, in the dog, division of the vagal fibers along the lesser curvature is more important in reducing acid secretion than is esophageal vagotomy; but the data also emphasize the contribution of the vagal fibers along the distal esophagus since a marked reduction in 2 DG-stimulated acid secretion can only be achieved by dividing the vagal fibers around the distal esophagus as well as those along the lesser curvature.     

A review of spigelian hernias

Although spigelian hernias are rare, they do not appear to be as uncommon as previously thought. Thirty-one cases, one a bilateral hernia, have been documented over the last ten years at a 350 bed community hospital. Spigelian hernias continue to be misdiagnosed preoperatively, often forgotten in the differential diagnosis, as physical examination is usually of little benefit. In this review younger individuals were more commonly affected than previously expected. Treatment continues to be surgical repair.