Penetrating wounds of the cervical esophagus

To determine trends in management, twenty-two years' experience with penetrating wounds of the cervical esophagus in thirty-nine patients has been evaluated. There were three deaths, all as a result of delayed operative repair. Experience gained from the earlier years of this study led to a marked reduction in mortality in the later years as a result of an increased index of clinical suspicion, coupled with an aggressive operative approach with primary closure and adequate drainage. A nonoperative approach has been suggested by others for small esophageal perforations after endoscopy and perforation from foreign objects. For penetrating injuries of the esophagus, operation and definitive repair is mandatory.     

Origin of gastrin in gastric juice

Four dogs were prepared with an isolated, innervated antral pouch, a Heidenhain pouch, and a gastric fistula. Gastric secretion was stimulated by perfusion of the antrum with a suspension of liver powder or by betazole injection. Both methods of gastric stimulation increased acid and gastrin output from the gastric fistulas and Heidenhain pouches. There was a significant direct correlation between these two variables in the gastric juice of the gastric fistulas and Heidenhain pouches. We conclude from this study that gastrin in the gastric juice originates in the antrum or some extragastric source and is cleared from the blood by the fundic mucosa. Its rate of appearance in the gastric juice is directly related to the secretory activity of the parietal cells.     

Management of upper abdominal vascular trauma

Advances in the management of penetrating and blunt cardiovascular trauma have paralleled developments in the operative treatment of acquired vascular disease. Nevertheless, upper abdominal vascular trauma still presents a challenge to the surgeon in terms of control of hemorrhage, operative exposure, and multiple organ injury.Between January 1969 and December 1973, forty-six patients were seen with injuries to the upper abdominal aorta, vena cava, portal vein, or proximal few centimeters of the celiac axis or superior mesenteric arteries. Eighty-seven per cent of the patients presented in shock. Control of arterial hemorrhage was achieved by approaching the aorta from a posterolateral position after reflection of the viscera. Vena caval injuries were controlled by utilizing extensive liver mobilization as well as both transthoracic and transabdominal intracaval shunts. Dacron prostheses were employed successfully in the suprarenal position of both the aorta and vena cava.Through prompt resuscitative management, rapid assessment of intra-abdominal injuries, systematic approach to organ involvement, and adaptive exposure, control of upper abdominal vascular trauma was achieved with a reduced requirement for blood replacement and lower mortality. Adjunctive measures of intraoperative autotransfusion and microfiltration of homologous blood further improved survival in these patients with complex injuries.     

Traumatic injuries of the pancreas

Traumatic injuries of the pancreas have evolved from an uncommon encounter of even wartime wounds to a relatively common injury of today's civilian strife. A review of 448 patients sustaining pancreatic trauma demonstrated that the pancreatic injury alone contributes little to immediate or late mortality but is frequently a source of postoperative morbidity. Complications of pancreatic injury comprise almost half of those observed after trauma in such patients, but for the most part are self-limited and easily cared for. Survival among patients sustaining pancreatic injury depends mainly upon the degree of success with which the multiple associated injuries can be managed.     

Vagotomy of the fundic gland area of the stomach without drainage. A definitive treatment for perforated duodenal ulcer.

Twelve patients in Sweden and thirteen patients in Houston underwent selective proximal vagotomy or parietal cell vagotomy, respectively, for the treatment of perforated duodenal ulcer. A drainage procedure was performed in four of the former and in none of the latter group of patients. There were no operative complications and no operative deaths. Twenty-two of the patients were followed from six months to four years. No patient has recurrent ulcer, dumping, diarrhea, or other significant gastric symptoms during the follow-up period. At the time of their last follow-up, the results were considered excellent or good in all twenty-two patients. The results of this study suggest that SPV or PCV without drainage may be the method of choice for the definitive treatment of all patients with perforated duodenal ulcer who have no obstruction and no contraindications to an operative procedure of greater magnitude than simple closure.     

Clinical experience with the Teflo disposable membrane oxygenator.

A simple, inexpensive, highly efficient disposable membrane oxygenator with low priming volume and a microporous membrane recently has become available. Animal and clinical investigations of its use have been most satisfactory, and clinical experience now has been extended to include 285 patients. Its primary advantage has been the ability to control oxygenation and carbon dioxide separately. Disadvantages have included the somewhat increased complexity of the system as compared with bubble oxygenator systems, the necessity of converting pumps for its use, and excessive condensation of water vapor in the gas phase of the oxygenator unless certain precautions are followed.     

Penetrating injuries to the iliac arteries

Despite advances in the management of traumatic truncal and peripheral vascular injuries, penetrating trauma to the iliac arteries carries a high mortality. Among more than 600 patients with arterial trauma seen at the Ben Taub General Hospital between January 1958 and December 1977, eighty-three had penetrating injury to the iliac arteries. Thirty-two patients (39 per cent) died within thirty days of injury, none of these dying within 48 hours of injury. Injuries were managed by resection and end-to-end anastomosis (36 per cent), lateral arteriorrhaphy (27 per cent), ligation (20 per cent), and prosthetic interposition (10 per cent). Three perigraft infections occurred with ultimate removal of the graft and ligation of the common iliac artery.Among patients with penetrating injuries who arrive alive at a hospital, iliac artery wounds result in massive intraperitoneal blood loss, in contrast to aortic injuries which frequently have a protective tamponade for a period of time. Delay in surgery, irreversible shock, dilutional bleeding diathesis, and respiratory insufficiency result in a high mortality. A high index of suspicion and prompt aggressive surgery are necessary to improve chances of survival of patients with this highly lethal injury.     

Early evacuation of clotted hemothorax

Thoracotomy is infrequently required for penetrating or blunt thoracic trauma. Complications of thoracic trauma, such as clotted hemothorax and empyema, significantly increase morbidity, mortality, and length of hospitalization. Among approximately 9,000 patients with blunt or penetrating thoracic trauma seen during a recent eleven year period, 33 per cent (3,000 patients) presented with hemothorax or pneumohemothorax. The average length of hospitalization in the patient with uncomplicated thoracic trauma was less than six days. Among the 3,000 patients with hemothorax or pneumohemothorax, 2,600 (85 per cent) were treated with a drainage procedure. Among this group, clotted hemothorax or posttraumatic empyema developed in 85 (3.3 per cent). Among ten patients undergoing evacuation of a clotted hemothorax within five days of admission, there was zero mortality and an average hospital stay of ten days. Forty-one patients undergoing decortication more than five days after injury had a 2.4 per cent mortality, with the average period of hospitalization being twenty-five days. Thirty-four patients requiring decortication and drainage of empyema had a 12 per cent mortality and an average hospital stay of forty-one days. Among those patients in whom empyema developed, the most frequently associated injuries were enteric. These complications occurred due to inadequate evacuation of the original hemothorax, nonfunctioning tube thoracostomy, physician delay in recognition of the pathologic process, and bacterial contamination of the hemothorax. When complications secondary to tube thoracostomy dysfunction occurred, early operative evacuation of clotted hemothorax decreased the mortality, morbidity, and hospital stay and prevented the development of empyema.     

Mycotic aneurysm of the inferior mesenteric artery

This is the first reported case of successful management of a mycotic aneurysm of the inferior mesenteric artery. The only helpful clinical manifestations were episodes of previous abdominal pain and a history of bacterial endocarditis. The surgical management involved simple excision without revascularization of the inferior mesenteric artery.     

Major complications of percutaneous subclavian vein catheters

New and reportedly safer techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature 55–59 yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.     

Intravascular migratory bullets.

The estimated course of a penetrating missile provides some clues to planning intraoperative priorities and management. However, missiles which become intravascular emboli present diagnostic and therapeutic dilemmas. Twenty-eight patients have been seen with bullet emboli. Five patients had emboli to the lungs, two of which were removed. Two large bullets embolized from a right heart injury down the inferior vena cava, one to a hepatic vein and one to the right renal vein. Fourteen patients had arterial bullet emboli, four originating in the heart, four in the thoracic aorta, and six in the abdominal aorta. Two patients died, one of cerebral infarction secondary to bullet embolus to the right carotid artery and one of an unrecognized traumatic intracardiac defect. Complications were secondary to associated injuries rather than a result of removal of bullet emboli.     

An improved mitral valve prosthesis

A Dacron velour–covered, Teflon-disc mitral valve prosthesis was developed in an effort to reduce thromboembolic complications of mitral valve replacement. A 12- to 28-month follow-up of 202 patients receiving these prostheses demonstrated only a 4.5% total incidence of such complications. However, a continuing search has been made for more durable materials. The most promising of these has been Pyrolite carbon, which now has been used for both the disc and the struts. Sacrifice of calves at intervals up to 12 months with scanning electron microscopical studies has demonstrated a disc and strut wear curve projecting 140 years prior to penetration of the Pyrolite carbon coating. Orifice and frustum areas of all sizes have been enlarged without change in mounting diameter. Clinical investigations of this prosthesis in several centers have been associated with as low an incidence of thromboembolic complications as that achieved with the Teflon-disc prosthesis. This improved prosthesis now has been released for general use.     

Renovascular trauma

One hundred fifty-four patients with renovascular injuries were analyzed to gain insight into the mortality, morbidity and indications for immediate nephrectomy versus arterial revascularization. Arterial revascularization is seldom indicated in patients with a normal contralateral kidney who have multiple associated injuries, hilar injuries, long segmental arterial injuries or prolonged renal ischemia. An attempt at renal artery revascularization is justified with bilateral injuries, when only one kidney is present or when a solitary artery injury can be repaired by simple lateral arteriorrhaphy.     

Clinical experience with an improved mitral valve prosthesis

More than five years ago a Dacron velour-covered Teflon-disc mitral valve prosthesis was introduced in an effort to decrease thromboembolic complications of mitral valve replacement. Numerous reports have demonstrated an extremely low incidence of thromboembolic complications with this prosthesis. Efforts toward improving the prosthesis have been aimed at using more durable materials, and a Dacron velour-covered mitral prosthesis using Pyrolite carbon for both the disc and the cage legs now is available. Animal investigations with scanning electron microscopical wear analysis predicted 140 years of wear prior to penetration of the Pyrolite carbon coating. Clinical trials then were begun, and combined experience with this prosthesis in three centers now includes 175 cases. There have been no deaths related to the prosthesis, and only four thromboembolic episodes have occurred; the only fatal one was an embolus from the left atrial appendage that occluded the prosthesis. This improved prosthesis appears to offer significant advantages.     

Management of acute combined injuries to the aorta and inferior vena cava

Major abdominal vascular injuries present problems in diagnosis, exposure, and management. Combined injuries to the abdominal aorta and vena cava are particularly lethal due to extensive blood loss, difficulty in sequential exposure, and the high incidence of associated injuries. Between 1953 and December 1974, ninety-one patients required emergency operations for abdominal aortic trauma at our city-county charity hospital. Twenty-nine of these had combined injuries to the abdominal aorta and vena cava, ten of whom had either an audible bruit preoperatively or a palpable thrill at exploration suggesting acute fistulas. Twenty-three injuries were secondary to gunshot wounds. Ten were located in the suprarenal aorta and vena cava. Management involved a variety of technics including intravascular shunts, adaptive exposures, Dacron prostheses, and autotransfusion. Survival rate was 27 per cent. Sixty-two per cent of the deaths were a function of extreme difficulty in controlling hemorrhage and exposure. There were no late recurrences of arteriovenous fistulas. Successful management of acute traumatic injury to both the abdominal aorta and vena cava requires rapid, aggressive surgical management, adaptive sequential control maneuvers, and application of technics and principles developed for elective vascular surgery.     

Cholestasis due to compression of the common bile duct by pancreatic pseudocysts

We studied 10 patients with pancreatitis who had persistent cholestasis secondary to compression of the common bile duct by a pancreatic pseudocyst. Elevation of the serum bilirubin or alkaline phosphatase levels, or both, (sensitive indicators of cholestasis) was present in each of our patients. The diagnosis of a pancreatic pseudocyst is best made by CAT scan and ultrasonography. These techniques will delineate the small intrapancreatic pseudocyst that otherwise may be difficult to recognize on inspection at operation. Endoscopic retrograde cholangiography and pancreatography are desirable because they delineate the anatomic alterations of the pancreatic and common bile ducts and may contribute information pertaining to the possibility of common duct obstruction by pancreatic fibrosis. In our opinion, cholestasis secondary to bile duct compression by a pseudocyst is an indication for operation. Each of our 10 patients had drainage of their pseudocysts. Cystoduodenostomy, performed in seven patients, was the method most commonly used. If there is concern regarding the patency of the common duct after drainage of the cyst, intraoperative cholangiography should be performed. This was carried out in three patients. In each patient, the preoperative elevations of serum alkaline phosphatase and serum bilirubin levels returned to normal limits after operative decompression of a pancreatic pseudocyst alone without an accompanying or subsequent bilioenteric bypass being required.     

Surgery of the alimentary tract: An overview

An overview of surgery of the alimentary tract is presented in three parts. The first part is designed to give historical perspective, showing the relatively recent development of surgery of the alimentary tract compared with surgery of other systems. Three particularly important reasons for its slow development are medicolegal constraints, lack of educational materials and a high incidence of illiteracy among surgeons. Lessons to be learned include the following: (1) inappropriate legal constraints stifle progress; (2) mechanisms for prompt distribution of information are critical for rapid and steady progress; and (3) the distribution of knowledge does not insure its proper use.The second part on the present status of alimentary tract surgery discusses the development of specialty societies and particularly the Society for Surgery of the Alimentary Tract, noting that programs of this society have shown an increased percentage of papers devoted to animal and clinical experiments over the years.In the third section on the future of alimentary tract surgery, it is observed that among men in this country there are more abdominal operations per 1,000 persons than any other type of operation, despite the rapid increase in cardiovascular surgery and operations involving other organ systems. Presentations by previous presidents of the society have pointed out many challenging and fascinating areas of study. Thus for our generation and future generations of surgeons, the study and treatment of gastrointestinal disease makes surgery of the alimentary tract an exciting and challenging arena.     

Treatment of postradiation stricuture of the rectum by the modified Duhamel procedure.

Benign rectosigmoid stenosis secondary to pelvic radiation presents a difficult problem in management and is usually treated by permanent colostomy with its attendant discomfort and inconvenience. Other approaches include low anterior resection or even transsacral resection of the affected area of rectosigmoid, but they involve risk to rectal, bladder, and sexual function. The Martin modification of the Duhamel procedure is specifically designed to avoid these problems and was used successfully in the present case for treatment of rectosigmoid stenosis. The patient has been followed up 8 years and reports normal sensation and function of bladder and rectum and no disturbance of sexual function.