Influence of choledochoscopy on the choice of surgical procedure.

1. Direct endoscopy of the biliary tract has been used alone or in conjunction with operative cholangiography as a method of policing choledochal explorations. 2. A series of cases is presented in which endoscopy of the bile ducts has been of significant aid in clarifying the pathologic factors at operation. 3. This experience indicates that operative visualization of the bile ducts deserves a place in the surgical armamentarium.     

Lower intestinal bleeding in the elderly.

Increasing recognition of bleeding vascular ectasias of the right colon prompted the present reevaluation of the importance classically attributed to diverticulosis as a cause of lower intestinal hemorrhage in the elderly.The records of all patients more than age sixty-five years admitted to Montefiore Hospital and Medical Center with lower intestinal bleeding from 1971 to 1976 were reviewed. Of 183 such patients, ninety-nine had major and eighty-four had minor bleeding. Of the ninety-nine patients with major bleeding, forty-three were discharged with a diagnosis of diverticular bleeding, and twenty were discharged with a diagnosis of vascular ectasias of the right colon.In most cases of diverticulosis, there was insufficient evidence to support this conclusion, and in only 18 per cent was the diagnosis based upon the angiographic demonstration of extravasation of contrast material into a diverticulum. In patients in whom a bleeding diverticulum was identified on angiography, segmental colectomy was not followed by recurrent hemorrhage. When no bleeding site was identified, colectomy was associated with a high incidence of rebleeding and subtotal colectomy with a high postoperative mortality. In all twenty patients with vascular ectasias, the lesion was identified on angiography, although extravasation was seen only twice. Eighteen patients were operated on: sixteen underwent right hemicolectomy and two subtotal colectomy; only two have rebled.Segmental colectomy will usually prevent recurrent hemorrhage when a site of diverticular bleeding or a vascular ectasia has been identified angiographically. Subtotal colectomy should be used only as a last resort.This study gives further support to the importance of vascular ectasias as a cause of bleeding in elderly patients and demonstrates the essential role of angiography in the diagnosis and management of this problem. Angiography is used to locate bleeding sites, to identify nonbleeding vascular ectasias, and for infusion of vasopressors into the mesenteric circulation to arrest bleeding.     

The web factor in cholangitis

Choledochoscopy demonstrates that stone-related suppurative cholangitis has the pathologic characteristics of a multiloculated intraductal abscess. The fibrin web compartmentalizes the duct, traps calculi, and limits spontaneous extrusion. The stones act as foreign bodies and stasis maintains the bacterobilia. This is the anatomic basis and rationale for early direct surgical drainage as the definite effective treatment.     

Qualitative and quantitative fluorescein fluorescence in determining intestinal viability

Clinical evaluation and qualitative (visual) and quantitative (fluorometric) fluorescence for predicting intestinal viability were compared in an animal model of temporary arterial occlusion with early revascularization. Quantitative fluorescence was determined with a perfusion fluorometer after an intravenous bolus of fluorescein. Qualitative fluorescence was determined by examination under a Wood's lamp in a darkened room. The effectiveness of each diagnostic technique in determining nonviability was expressed in terms of sensitivity, specificity, and accuracy. All three methods had 100 percent specificity; only bowel deemed nonviable proved to be so. Quantitative fluorescence also had a 100 percent sensitivity, but clinical evaluation and qualitative fluorescence had only a 33 and 11 percent sensitivity, respectively (some segments of bowel that were ultimately nonviable were not correctly predicted to be so). The inaccuracy of qualitative fluorescence was due to the fact that ischemic intestine with a hyperfluorescent pattern often progressed to necrosis. Fluorometric quantitation identified those hyperfluorescent segments that were viable. This study suggests that visual fluorescence is not reliable in assessing intestinal viability after early revascularization after arterial occlusion, but quantitative fluorometric fluorescence is reliable in almost all instances.     

Three year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage

Polytetrafluoroethylene grafts were used for 175 femoropopliteal reconstructions with a cumulative 3 year life table patency rate of 77 percent. Reoperation for early or late failure was required in 27 patients to achieve this patency rate. If these 27 failures were calculated as nonpatent grafts, 3 year patency would be 62 percent. Thirty month life table patency rates were 94 and 91 percent for polytetrafluoroethylene axillofemoral and femorofemoral bypasses, respectively. Twenty-two polytetrafluoroethylene axillopopliteal bypasses were performed because of infection in the groin, previously failed reconstructions or unavailability of femoral vessels due to disease. The 2 year life table patency rate was 69 percent, with nine of the grafts patent for more than 1 year. Forty polytetrafluoroethylene bypasses to arteries at the ankle or in the foot resulted in a 2 year life table patency rate of 48 percent. Thus, polytetrafluoroethylene grafts show early promise as a vascular prosthesis. Although further study will be required to define the exact role of this new arterial substitute, it already can facilitate the performance of otherwise difficult or impossible limb salvage procedures.     

Treatment of carcinoma of the oral tongue by radium needle implantation

Forty-nine patients had a radium implant for carcinoma of the oral tongue. In thirty-four of the forty-nine (70 per cent), local three year control of the cancer was achieved. Three patients in whom the radiation failed were rescued by subsequent surgery. The five year absolute survival in this series was 63.8 per cent. In conclusion, we believe that improved survival rates without functional and cosmetic defect can be obtained by closer cooperation between surgeons and radiotherapists.     

The treatment of operable breast cancer in the elderly female.

The treatment of operable breast cancer in eighty-two patients older than seventy years was analyzed. The cancers were treated at an advanced stage and the axilla was involved as frequently as in younger women. The factors influencing survival differ because of competing mortalities from heart disease and stroke. The risks are discussed in relation to life expectancy and treatment method.     

Survival following mastectomy for stage III breast cancer.

Patients with locally advanced breast cancer have been considered unsuitable for curative surgical therapy and are usually approached with other treatment modalities. Review of the results of radical mastectomy in 228 patients with stage III breast cancer demonstrates actuarial survival of 33 per cent at five years and 22 per cent at ten years. Treatment with preoperative or postoperative radiotherapy as employed did not lead to survival superior to that of mastectomy alone. Evidence of local or regional recurrence developed in 27 per cent of patients. In 73 per cent the first recurrence was systemic. This retrospective study suggests that the prognosis for locally advanced breast cancer is not as dismal as has been previously reported. The importance of nodal involvement is again emphasized. A randomized trial of mastectomy with adjuvant chemotherapy for locally advanced breast cancer is warranted. Such a study is in progress at our institution.     

Factors influencing the complications of colostomy closure.

This retrospective review of 206 colostomy closures performed by different methods and at various intervals from the time of creation of the stoma suggests that attention to meticulous surgical technic is the most important factor in limiting the morbidity and mortality of this commonly performed procedure. Considerations of the location and type of colostomy, timing, method of closure, and patient population seem to be less importnat than suggested in previous reports.     

Volvulus of the cecum: choice of operation.

Although it is clear that there is a significant frequency of recurrent volvulus after cecopexy, there is no evidence from either this series or previous reports that resection is associated with a lower recurrence rate than tube cecostomy. In the absence of data suggesting a clear superiority of colon resection, it appears that tube cecostomy should be the treatment of choice for cases of cecal volvulus that are not complicated by vascular compromise.     

Cholecystectomy with drainage: Factors influencing wound infection in 1,000 elective cases

A retrospective review of 1,000 elective cholecystectomies was undertaken to identify factors associated with wound infection. The technic of wound drainage appears to influence the incidence of infectious wound complications to a significant degree.     

Management of post-traumatic vascular malformations of the liver by catheter embolization

Trauma to the liver occasionally produces vascular malformations, usually pseudoaneurysms of the hepatic artery and sometimes arteriovenous fistulas. Hemorrhagic complications, usually in the form of hemobilia, can result, and portal hypertension is a late complication of an arterial-portal vein fistula. The true incidence of these post-traumatic lesions is apparently much higher than previously realized, and they can regress spontaneously. A case is presented in which both complications appeared simultaneously after a stab wound to the liver. Treatment using selective arterial catheterization and embolization with thrombogenic material was successful. The literature on the use of catheter embolization in hepatic trauma is reviewed. We suggest that catheter embolization be added to the standard therapeutic armamentarium for these lesions. Selective catheter embolization is suggested as the initial therapeutic maneuver in treating both of these lesions because of the relatively low morbidity, the great precision available in limiting the area of devascularization and the good expectation of success on the basis of the reported results of this technique in other traumatized organs, as well as the initially promising reports of its use in hepatic lesions. It should be considered at the time of diagnostic arteriography.     

Internal mammary artery-saphenous vein composite conduit: an alternative for the proximal coronary anastomosis

A patient who had previously undergone saphenous vein bypass grafting was seen with recurrent angina requiring reoperation. At the second operation, technical problems with the ascending aorta ultimately excluded its use for the proximal anastomosis for the second of two bypass grafts. Anastomosis of the left internal mammary artery to the proximal end of the saphenous vein graft successfully resolved the problem.     

Carcinoma of the lip.

(1) Carcinoma of the lip occurs predominantly in men in their seventh and eighth decades of life. (2) Epidermoid carcinoma is the most common malignant lip tumor. (3) Metastases to cervical lymph nodes are uncommon. (4) Elective neck dissection is not indicated. (5) Therapeutic radical neck dissection can benefit the patient in the presence of proved suprahyoid lymph node metastases. (6) The five year survival rate for epidermoid carcinoma of the lip is higher than the rate for epidermoid carcinoma of other sites in the oral cavity or pharynx. (7) Local recurrence does not correlate with the size of the primary tumor. (8) Initial treatment failures can frequently be salvaged surgically.     

A Comparison of Flow Gradients across Disposable Arterial Perfusion Cannulas

Five-hundred members of The Society of Thoracic Surgeons were canvassed to discover which cannulas are currently used for open-heart surgical procedures in adults; 120 surgeons responded. The mean arterial line pressure produced by 29 disposable arterial perfusion cannulas (size range, 16F to 30F) at flow rates of 1 to 5 liters per minute was compared. A roller pump with perfusion tubing 95 mm (0.75 inch) in diameter was used with water as the test solution. Line pressures in these cannulas ranged from 22.4 ± 2.30 (standard deviation) to 271.0 ± 6.60 mm Hg at 5 L/min. Four 24F cannulas had gradients of less than 55 mm Hg at a flow rate of 5 L/min, and 6 cannulas—4 of which were 22F and 2, 24F—had gradients higher than 150 mm Hg at 5 L/min. A number of cannulas kinked easily, and these showed marked increases in line pressure.The following results were obtained from this study: (1) a wide range of line pressures was observed in disposable arterial perfusion cannulas currently in clinical use; (2) some cannulas currently used for cardiopulmonary bypass in adults generated excessive line pressure; and (3) both material and design affect function, with some designs being safer than others. Cardiac surgeons should base the choice of an arterial perfusion cannula on the best performance and safest design available to avoid cannula-related problems at operation.