Giant duodenal ulcer: a dangerous variant of a common illness

Giant duodenal ulcers are large posterior penetrations of the duodenum which, when undiagnosed, have a high mortality. Radiographic and endoscopic diagnosis, although not always feasible, enables prompt appropriate management with improved results. Nonoperative treatment is dangerous. Preoperative diagnosis permits planned operative treatment and enables the surgeon to avoid a difficult duodenal dissection. The Bancroft operation, or modification thereof, is the operation of choice. Sixteen consecutive patients with giant duodenal ulcer are described. The success of their treatment is attributed to accurate diagnosis and appropriate operative therapy.     

Technic of chronic thoracic duct “side fistula” for immunologic evaluation of patients with cancer

A technic suitable for long-term study of the human thoracic duct circulation under physiological conditions is described. The results and observations obtained in ten patients studied for three to twenty-one days are presented.     

Pancreatic abscess.

Successful management of pancreatic abscess necessitates early diagnosis and prompt external surgical drainage. The infection is predominantly gram-negative and polymicrobic. Roentgenographic contrast studies are of particular diagnostic value. Prompt recognition and external drainage are associated most frequently with recovery. Multiple system organ failure is the typical pattern of death and should alert one to the possibility of occult sepsis, secondary to pancreatic abscess.     

Efficacy of clinical evaluation and selective splenic arteriography in splenic trauma

The diagnosis of splenic injury after blunt trauma, although clear in most instances, is difficult to make in 16 per cent of our patients.We selected sixty patients who sustained blunt trauma between January 1968 and December 1971 from a large group of patients with multiple system injuries on the basis of isolated splenic injury. Fifty of these patients were evaluated by the usual clinical methods and had splenectomy on the day of admission. Reliable diagnostic criteria are abdominal pain, tenderness localized to the left upper abdomen, fractures of the ninth, tenth, eleventh, and twelfth ribs posteriorly on the left, and evidence of hypovolemia.Ten other patients had initial clinical assessment that cast doubt on the diagnosis of splenic rupture. The splenic artery was selectively catheterized in this group of patients and an arteriogram obtained. Eight arteriograms were positive for splenic trauma. At surgery these arteriographic findings correlated with the splenic disorder in all instances. Two patients had normal arteriograms and were not subjected to surgery.When clinical evaluation precipitates reasonable doubt in the diagnosis of splenic trauma, selective splenic arteriography is an added dimension with marked reliability.     

Fiberoptic endoscopy: Precise definition of upper gastrointestinal disease

When properly employed, endoscopic examination of the upper gastrointestinal tract with the flexible maneuverable-tip fiberoptic instruments is the most accurate method of diagnosing any upper gastrointestinal tract disease. Two hundred consecutive endoscopic procedures in the upper gastrointestinal tract were performed without significant morbidity or mortality; the results were reviewed to ascertain the overall diagnostic value of this modality. Although the overall numbers in each subgroup are still small, the experience indicates that: (1) thorough endoscopic examination of the upper gastrointestinal tract can be carried out expeditiously in most patients without morbidity; (2) upper gastrointestinal tract disease can be precisely defined in the majority of patients; and (3) endoscopic examination frequently alters the initial clinical diagnosis. The precise cause of upper gastrointestinal tract hemorrhage can be diagnosed in at least three of four cases. Some unnecessary operations can be avoided and proper therapy for specific sources of bleeding can be initiated promptly.     

Gunshot wounds of the colon: A review of 100 consecutive patients,with emphasis on complications and their causes

The cases of one hundred civilian patients with gunshot wounds of the colon treated at the Louisville General Hospital have been reviewed. Most injuries were in the transverse colon (44 per cent), followed by the ascending colon (27 per cent), rectosigmoid (19 per cent), and descending colon (10 per cent). Associated injuries occurred in 81 per cent of the patients; the small bowel was the most common structure injured.Primary closure was used in 52 per cent of the patients, with a resultant 19 per cent rate of wound infection and 14 per cent rate of serious complication. When the extent of contamination or tissue destruction required resection, an attempted primary anastomosis was followed by a high rate of wound infection (57 per cent) and serious complications (36 per cent) as compared with end-colostomy and mucous fistula, which resulted in a 24 per cent rate of wound infection and 24 per cent rate of serious complication. The rate of wound infection between these groups is significant (p = 0.05). Results with end-colostomy and mucous fistula were better than with attempted primary anastomosis.Primary closure of missile injuries of the colon is feasible but should not be attempted in the presence of gross fecal peritonitis or massive tissue destruction. If resection is undertaken, end-colostomy (or ileostomy) and distal mucous fistula should be performed in the presence of intra-abdominal contamination to reduce the incidence of postoperative wound infection and serious complications. Delayed primary closure should also reduce the rate of wound infection in these patients.     

Immediate reconstruction of oral cavity and oropharyngeal defects using microvascular free flaps.

Eighteen patients underwent immediate reconstruction of defects involving the oral cavity and oropharynx with free groin and dorsalis pedis flaps. One partial and four complete failures occurred. In the successfully reconstructed patients, the functional results were equal to conventional flaps while the cosmetic improvements were dramatic.     

Value of colonoscopy in patients with rectal blood loss unexplained by rigid proctosigmoidoscopy and barium contrast enema examinations

Total colonoscopy is the procedure of choice for patients with any amount of rectal blood loss unexplained by proctosigmoidoscopy and barium contrast enema examinations. In 168 endoscopic examinations, 46 unsuspected lesions in 39 patients (23 percent) were detected, 50 percent of which were 1 cm or greater in diameter. Considering that 30 percent of all unsuspected lesions, 100 percent of angiodysplastic abnormalities and 40 percent of unsuspected carcinomas were located proximal to the splenic flexure, emphasis is placed on the importance of examining the entire colon to the cecum.     

Analysis of safety factors in percutanous deep venous cannulation

Percutaneous deep venous cannulation has become a widely accepted procedure. However, little attention has been directed at equipment design that may minimize the complications of percutaneous deep venous cannulation. The adoption of a semi-sealed system for percutaneous cannulation offers several important advantages. It reduces the possibility of air embolism, decreases the risk of sepsis, and permits more accurate intravenous placement. The combination of a standard technic and the semi-closed catheter assembly described herein should simplify deep venous cannulation and reduce its hazards.     

Retroperitoneal iliac fossa abscess: a complication of suppurative iliac lymphadenitis

The clinicopathologic manifestations in four patients with staphylococcal abscess localized to the retroperitoneal iliac fossa are presented. This type of abscess may represent a distinct entity and is most likely a complication of suppurative iliac lymphadenitis.Retroperitoneal abscesses localized to the iliac fossa rarely have any osseous component. Extraperitoneal drainage is curative.     

Gastritis and gastric blood flow in hyperdynamic septic pigs.

The present study was designed to determine the gastric hemodynamics in a septic model that causes both a hyperdynamic state and acute erosive gastritis. Sepsis was established in twelve pigs by the intramuscular shank injection of Pastuerella multocida (42 X 10(8) colonies) in triptose phosphate broth; four pigs received sterile broth injections (shams) and eight received sterile saline injections (controls). After 18 hours, cardiac output was measured by both the cardiogreen dilution technic and the radioactive microsphere dilution technic; cardiac output was then compared to total and regional gastric blood flow measured by the raioactive microsphere entrapment technic. Acute erosive gastritis developed in septic pigs in the fundus and body of the stomach; the antrum was spared. Cardiac output was significantly increased in septic pigs compared with sham and control pigs. Total gastric blood flow and regional blood flow to the fundus, body, and antrum were also increased in direct proportion to the increase in cardiac output. These data suggest that acute erosive gastritis is primarily due to an end-organ cellular insult from sepsis and is not primarily due to a decrease or redistribution in gastric blood flow.     

A new device for recording pO 2 , pCO 2 and blood flow in focal areas of the myocardium

A new technic using a membrane-tipped cannula connected to a mass spectrometer permits the monitoring of perfusion rates and metabolic gas tensions simultaneously in selected regions of the myocardium.Using this technic in the normal canine heart, perfusion of the left ventricular wall was found to be homogeneous and the oxygen reserve was lower in the endocardium than in the epicardium. This suggests a higher energy consumption in the deeper layers of the myocardium.As a result of changes after coronary artery occlusion, it can be concluded that the endocardial perfusion is inadequate to protect the endocardium from ischemic damage     

Hemigastrectomy and truncal vagotomy in the treatment of duodenal ulcer. With a summary of related secretory data emphasizing preoperative basal acidity and postoperative basal-insulin achlorhydria

We have found carefully performed basal acidity studies before and basal-insulin testing after operation to be very helpful.The preoperative basal acidity data provide a simple physiologic basis for classifying patients and, because of the wide range of fasting gastric acidity from patient to patient (0 to 56.6 mEq/hr), alert one to the magnitude of the secretory problem that one is attempting to correct by means of an operation. (Tables II and IV.)The postoperative basal-insulin data identify the patients who are achlorhydric and consequently protected against recurrence and those who are not and in whom a recurrence may therefore develop. (Table VIII.)The preoperative basal acidity data used in conjunction with the incidence of postoperative basalinsulin achlorhydria serve as an excellent basis for judging the results of different operations and for selecting the most effective procedure for a given patient. (Table VI.)For patients who are not achlorhydric, the postoperative basal-insulin data reveal the quantity of acid still present. This, in turn, indicates whether the patient is in the category that contains the great majority of recurrent ulcers. It also identifies the cases which have the largest amount of residual vagal activity and serves as an additional basis for judging the results of different operations. (Table IX.)These secretory data enabled us to identify hemigastrectomy with vagotomy as a procedure that would in all probability be very effective in preventing recurrent ulceration twenty years before [1,2] the clinical results [4] justified that conclusion and indicated that it would be more effective than other operations in this regard. (Tables VI and IX.)We recommend truncal vagotomy with hemigastrectomy or antrectomy (40 per cent resection) as the procedure of choice for the management of duodenal ulcer when no contraindications to its use are present.We recommend truncal vagotomy with a drainage procedure for poor risk patients undergoing emergency or elective surgery. Many patients over sixty should be managed in this manner.In good risk patients and elective situations in which resection is contraindicated because of disease in the duodenal area, we would call attention to the fact that truncal vagotomy combined with gastroenterostomy has been more effective than when combined with pyloroplasty in controlling acidity especially in the higher preoperative basal acidity zones. (Table VI.) This group of patients might benefit from some selective or modified truncal technic for vagotomy if it can be used with uniform success by qualified surgeons and if the postoperative basal-insulin secretory data indicate that the late results may be expected to be significantly improved over those of truncal vagotomy with drainage.When vagotomy cannot be performed, subtotal gastrectomy (two thirds) of the Billroth II type is indicated. When neither vagotomy nor resection can or should be performed, gastroenterostomy should be used.     

Effect of cimetidine on canine gastric mucosal pH and blood flow

The effects of cimetidine inhibition of acid secretion on gastric mucosal blood flow and the intramural pH of gastric mucosa were assessed in a canine model ex vivo. Intravenous infusion of histamine at 1.0 microgram/kg per minute resulted in brisk acid secretion, which was associated with an increase in total gastric and mucosal blood flow and the intramural pH of gastric mucosa. The increased blood flow and mucosal alkalinity may be compensatory mechanisms of the stomach to enhance its tolerance of luminal acid. Cimetidine inhibition of acid secretion was associated with a reduction in mucosal alkalinity and total gastric and mucosal blood flow. These adverse effects of cimetidine on blood flow and mucosal pH, two important factors in the stomach's self-defense against acid injury, may explain the inefficacy of cimetidine in the prevention of stress ulcers.     

Palliative intubation in the management of esophageal carcinoma

Intubation for unresectable esophageal carcinoma has been analyzed from a collective review of 2,459 patients covering the period of 1960 to 1971.The overall hospital mortality (including a technical mortality of 4.5%) was 13.9%. For the two most commonly used pull-through tubes (Celestin and Mousseau-Barbin) the hospital mortality was 23.5% and the technical mortality 6.6%. For the push-through tube, mortality was, in general, less and was least for the Souttar tube; hospital mortality ranged from 3.6 to 11%, and technical mortality was less than 2%.The overall complication rate was 25.4%. The most common complications were tube dislodgment and tube obstruction. Dislodgment occurred most frequently with the Souttar tube. The average survival period was 4.2 months after intubation. Though not perfect, this mode of treatment provides satisfactory palliation for patients whose survival is limited. The best results were recorded for the Celestin and Souttar tubes.     

Hereditary polypoid diseases of the gastrointestinal tract: A working classification

Almost all published cases of hereditary intestinal polypoid diseases can be meaningfully classified into a relatively few distinct syndromes including familial polyposis of the colon, Peutz-Jeghers syndrome, and juvenile polyposis.Familial polyposis is characterized by the development of numerous adenomatous polyps of the colon and subsequent development of colorectal carcinoma in nearly all patients. Extracolonic manifestations are common but do not influence the premalignant nature of this syndrome.Peutz-Jeghers syndrome is identifiable by a combination of circumoral melanin pigmentation and hamartomatous polyps. These polypoid lesions have an unusually wide distribution and may occur in the respiratory, gastrointestinal, or genitourinary tract. There is a small but definite increased incidence of gastrointestinal cancer in these patients.Juvenile polyposis presents a more variable spectrum. In one form there is extensive intestinal involvement leading to diarrhea, inanition, and increased susceptibility to infection. Another form is limited to the colon and easily confused with familial polyposis. With the third form, there is involvement of the stomach, intestines, and colon, which makes it easily mistaken for the Peutz-Jeghers syndrome.     

Primary adenocarcinoma of the vermiform appendix

The surgical management of adenocarcinoma of the appendix is discussed. Seven cases of this entity together with a review of the literature are presented. The incidence, classification, pathophysiology of the symptom complex, treatment, and results are reviewed. To obtain the best prognosis, we recommend that right hemicolectomy be performed for invasive adenocarcinoma of the appendix, either at the initial operation or subsequently.