Transcutaneous oxygen tension in selection of amputation level

The utility of transcutaneous oxygen tension measurements in selection of a reliable amputation level was evalulated. Measurements were made at the proposed level of amputation in 37 patients, 22 of whom underwent major limb amputation and in 15 amputation was confined to the forefoot or toes. In patients with successful amputation healing, mean transcutaneous oxygen tension on the anterior skin surface was 50 ± 8 mm Hg (index 0.79 ± 0.1 mm Hg). In contrast, patients with failure of healing had a mean transcutaneous oxygen tension of 22 ± 16 mm Hg (index 0.32 ± 0.19 mm Hg) (p < 0.001). Measurements on the posterior or plantar skin surface and posteroanterior differences provided even greater separation between success and failure groups, with no overlap of transcutaneous oxygen tension values or index.Transcutaneous oxygen tension measurement is easily obtained and noninvasive, and can be applied to all patients irrespective of Doppler signals, non-compressible vessels, or painful lesions. Transcutaneous oxygen tension appears to predict successful healing with accuracy, and should be a useful addition to clinical judgment in selection of optimal amputation level.     

Intraoperative endoscopic evaluation of the bile ducts

On the basis of experience in over thirty common duct explorations, the Storz rigid choledochoscope has proved to be a simple, reliable, and valuable instrument. Its use is associated with few, if any, complications. Applications include examination of proximal and distal ducts to insure complete removal of stones, visualization and biopsy of the sphincter and distal obstructing lesions, and visual introduction of an embolectomy catheter beyond hepatic duct stones for extraction.     

Bile gastritis without prior gastric surgery: contributing role of cholecystectomy.

This study reports on ten patients with typical bile gastritis who had no prior gastric surgery. Clinical symptoms included burning epigastric pain unrelieved by food or antacid, episodic nausea, and vomiting of bile. In all patients the symptoms appeared after cholecystectomy, with (four patients) or without (six patients) transduodenal sphincterotomy; the symptoms were often initially attributed to chronic pancreatitis. Six patients had hypochromic, microcytic anemia. Eight patients had basal achlorhydria; stimulated acid secretion was low or absent in seven patients. Gastroscopic examination revealed gastritis, most prominent in the prepyloric antrum, and abundant bile lakes. Mucosal biopsy disclosed chronic gastritis. Although medical therapy failed, seven of eight patients treated by vagotomy, hemigastrectomy, and long Roux-en-Y gastrojejunostomy had immediate and sustained relief. Cholecystectomy appears to be a critical factor in the pathogenesis of bile gastritis in patients who have not had prior gastric surgery. Without the reservoir function of the gallbladder, the unregulated flow of bile into the duodenum probably promotes the access of bile to the unprotected gastric mucosa.     

Technic for finding and removing stones from intrahepatic bile ducts

Intrahepatic biliary calculi which were missed by routine common duct exploration were discovered by choledochoscopy in the left hepatic ducts of three patients. Removal of stones was accomplished in two of these patients by using instruments for stone extraction under direct vision with the choledochoscope. The use of a Fogarty balloon catheter threaded through the choledochoscope is particularly recommended.     

Limited surgical excision as the basis of a comprehensive therapy for cancer of the breast.

A comprehensive program of therapy has evolved with collaborating roles for surgery, pathology, radiotherapy, and chemotherapy. Our experience includes 131 patients with breast cancer treated at the Massachusetts General Hospital since 1956 by limited excision of the cancer. The tumors of 10 patients were noninvasive or sluggishly so; the patients received no further therapy. Because of the invasive character of their tumor, 121 patients received heavy postoperative irradiation. In 12 of these 121, the irradiation has been followed by immediate and prolonged chemotherapy. It is too soon to judge the effect of the chemotherapy, but survival rates of those treated by limited excision and primary irradiation compare favorably with those of patients treated by radical mastectomy.     

Diverticular disease of the colon. A frequent cause of massive rectal bleeding

Hemorrhage from diverticular disease of the colon is the third most common cause of significant rectal bleeding. The patients are elderly and frequently have major coexisting disease. Hemorrhage will stop with nonsurgical treatment in the majority of cases. However, 17.3 per cent of patients in this study required surgical intervention to control the hemorrhage. The mortality was 11.7 per cent, and 58.8 per cent of the surgically treated patients had complicated postoperative courses.In the past a precise diagnosis has not been possible to make. The rate of diagnostic error in the surgical cases was 26 per cent. It is hoped that the increased use of selective mesenteric artery catheterization in the diagnosis and treatment of patients will afford them better management in the future.     

Randomized trial of emergency mesocaval and portacaval shunts for bleeding esophageal varices.

A randomized trial of emergency portacaval or mesocaval shunting was conducted in twenty-four cirrhotic patients bleeding from esophageal varices. The group of eleven patients having mesocaval shunts was comparable to the group having portacaval shunts in age distribution, sex, and preoperative physical condition. Postoperative fatality rates were 46% after portacaval shunting and 73% after mesocaval shunting. Results favor portacaval shunts for the emergency control of bleeding varices in the spectrum of patients seen in an urban hospital.     

Pulmonary resection for metastatic neoplasms in the lung. Experience at the Massachusetts General Hospital

Cumulative survival in a series of 142 patients undergoing 163 pulmonary resections for metastatic malignant disease is 30% at five years, a statistic that is slightly higher than survival for 820 cases of resection for primary lung carcinoma at the same institution (26%). Removal of pulmonary metastases continues to be a relatively safe approach with hospital mortality of 1.2% and low operative morbidity. Unfavorable predictors, if primary disease is under control, are limited. The primary ones include extent of disease requiring pneumonectomy, melanomatous disease, and appearance of the metastasis antedating knowledge of the primary. An aggressive approach to removal of pulmonary metastases merits continued consideration.     

Plasma amino acids in patients with hepatic encephalopathy. Effects of amino acid infusions

Amino acid patterns in a group of patients with severe liver disease and hepatic encephalopathy were studied when patients were taking proteinrestricted diets per os and being infused with two solutions used for total parenteral nutrition. A somewhat constant amino acid pattern was found, with elevated levels of phenylalanine and methionine and decreased levels of the branched chain amino acids isoleucine, leucine, and valine.Patients with severe liver disease are apparently unable to utilize some essential amino acids, creating an amino acid imbalance. The significance of these findings and their possible relation to hepatic encephalopathy are discussed.     

Recent experience in the management of cancer of the colon and rectum

A review is presented of 1,566 cases of cancer of the colon and rectum at the Massachusetts General Hospital in the ten year period 1961 to 1970. Comparisons are made with similar numbers of patients treated at this institution during the two previous decades. Although there were striking improvements in mortality and five year survival rates from those of the years 1937 to 1948 to those of the years 1949 to 1960, no further progress was evident in the last ten years covered by this study.Comparisons are made between the groups of patients treated during the last two periods. Little difference was found in the length of delay from onset of symptoms to treatment, sex of the patient, type of symptoms, location of the tumor in the bowel, or details of operative technic. Although the patients in the more recent series are somewhat older, the resectability rate remained the same and the operative mortality was actually lower after both curative and palliative resection.It is emphasized that until other modalities of detection and treatment of cancer become available, the details of past surgical management must be assiduously practiced.     

Sensitivity and specificity of serum ribonuclease in the diagnosis of pancreatic cancer

The serum levels of a poly-[C]-specific acid ribonuclease (RNase) found in the pancreas was measured in 40 normal persons and 137 patients with pancreatic cancer, other cancers, obstructive jaundice, acute pancreatitis or chronic pancreatitis. Serum RNase increased by as much as 800 percent above normal in 69 percent of patients with pancreatic cancer. Analysis of the serum isoenzymes of RNase by isoelectric focusing did not reveal any unique RNases produced by the tumors. In contrast, serum RNase rose in only 8 percent of patients with other cancers, 11 percent of other patients with obstructive jaundice and in no patients with chronic pancreatitis. These data suggest that the finding of increased serum RNase is of adjunctive value in the diagnosis of pancreatic carcinoma and may be particularly helpful in distinguishing it from other causes of biliary obstruction and from chronic pancreatitis.     

Management of severe obstruction of the large bowel due to malignant disease

One hundred twenty-four patients with complete bowel obstruction from colorectal cancer requiring emergency surgery were treated between 1961 and 1970. Two thirds of the tumors were distal to the transverse colon. Curative resection was possible in 72 per cent and the over-all mortality was 15 per cent. Forty per cent survived five years after resection for cure. Primary resection was preferred for obstructions of the right side of the colon and the transverse colon, and staged procedures rather than primary resection were more satisfactory for lesions of the left side of the colon and rectum. The mortality rate was lower after transverse colostomy than after cecostomy. Combined perforation and obstruction (twenty-four patients) had a particularly high mortality (42 per cent) and a poor prognosis (14 per cent five year survival).     

Side-to-side portacaval shunt versus nonsurgical treatment of Budd-Chiari syndrome

Although a side-to-side portacaval shunt will relieve some patients with Budd-Chiari syndrome, distinction between relief as a result of operation and spontaneous recovery may be inexact. A nonshunting operation relieved one of two patients as much as a side-to-side portacaval shunt did. In these two patients and one additional patient, streptokinase therapy may have been beneficial.     

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.     

Angiography in the diagnosis and management of bleeding stress ulcers and gastritis

Eighteen patients with upper gastrointestinal hemorrhage from erosive gastritis or stress ulcers were studied by selective visceral arteriography.Thirteen patients had positive results on arteriography. Vasopressin (Pituitrin) was administered intra-arterially to six patients. Bleeding was controlled completely in four patients and partially in one patient. There was no control in one patient in whom the left gastric artery was not selectively infused.     

Villous adenomas of the colorectum.

During a ten-year period 258 patients with villous adenomas were seen at the Massachusetts General Hospital: seventy-four of these patients (29%) had invasive cancer that developed in adenomas. The operative mortality ascribed to removal of benign adenomas was zero, but for cancer arising in villous adenomas it was 3 per cent. Therapy often is difficult because of the size and location of the tumors. Methods of removal have been considered in detail.