Primary carcinoma of the gallbladder

The clinical records of thirty-three patients treated at the University of Missouri Medical Center for carcinoma of the gallbladder have been studied retrospectively. Eighty-five per cent of these patients were over sixty years of age and all but three were female. The most common symptom was abdominal pain. Gallstones were present in 75.8 per cent. The most common histologic type of tumor encountered was adenocarcinoma, but 12.1 per cent of the tumors were adenoacanthoma. The mean survival time after operation was 2.95 months.On the basis of current information and knowledge, early cholecystectomy in all patients with calculous disease appears to offer the best hope for decreasing the distressingly high mortality associated with carcinoma of the gallbladder.     

Traumatic arteriovenous fistula. Clinical evaluation and intraoperative monitoring with the doppler ultrasonic flowmeter

The Doppler ultrasonic flowmeter is a relatively inexpensive device with which the surgeon may audibly study the hemodynamics of the vasculature transcutaneously and atraumatically. It is of great value in the study of vascular anomalies and in the evaluation of peripheral arterial occlusive disease. It is of even greater value when used intraoperatively to ascertain vascular patency during arterial reconstruction and to determine the obliteration or repair of arteriovenous malformations whether they are congenital or traumatic in origin. The use of the Doppler flowmeter to follow up patients in the clinic is readily accepted by the patient, as the process is atraumatic and results in a saving of time and money to both the patient and the hospital.     

Burn wound biopsy bacterial quantitation: a statistical analysis.

Sequential paired punch biopsy samples were taken from three separate locations on each of four burn patients and were quantitated for the number of viable bacteria per gram of tissue. The range (log10 0.02 to log10 1.51) and the standard deviation (log10 0.67) were determined for each pair. The 95 per cent confidence interval based on any single observation, x, was determined to be x +/- 1.31. It is concluded that the burn wound biopsy is a reliable procedure for quantitating organisms in a burn wound and that changes in sequential samples give an indication of the dynamics of infection in the burn patients.     

The effects of streptokinase on ischemic flaps

Prolonged ischemic periods may inhibit success in microsurgical procedures. Impairment of fibrinolytic activity could be a factor contributing to this problem. Ischemic epigastric flaps in the rat were used as a model to measure the potential of streptokinase to improve blood flow and tissue survival. A moderate but statistically significant improvement in flap survival was observed and is felt to be due to the enhancement of fibrinolytic activity previously impaired by ischemia. Saline irrigation alone in control animals was found to be detrimental to flap survival. Streptokinase might prove beneficial when dealing with an ischemic replant or free flap.     

Spectrum of Pulmonary Sequestration

Bronchopulmonary sequestration was diagnosed in 17 patients ranging in age from newborn to 64 years. The sequestration was intralobar in 14 patients and extralobar in 3. The spectrum of symptoms could be divided into three patterns: no symptoms (6 patients), respiratory problems (8 patients), and cardiovascular problems (3 patients). Cardiovascular problems usually manifest themselves in the first few weeks or months of life and often have a respiratory component. In older patients the sequestration is first manifested by recurrent pulmonary infections or, if it remains uninfected, an asymptomatic density on chest roentgenogram.The definitive diagnostic study is arteriography. Operative treatment for the intralobar variety consists of segmental resection or, if the inflammatory process is more extensive, lobectomy. An extralobar sequestration may simply be excised.     

Peripheral blood T and B lymphocytes in patients with burns. I. Test parameters and clinical evaluation of the rosette assays

Rosetting techniques identifying receptors for sheep red blood cells, for Fc in antigen-antibody complexes (EA) and C₃ in antigen-antibody-complement complexes (EAC) were employed in the sequential evaluation of 10 normal individuals over an 8-week period and in the testing of burn patients' blood samples. Mean values with standard deviations were 59 ± 7 per cent or 959 ± 260 E rosettes, 34 ± 6 per cent or 500 ± 186 EA rosettes and 41 ± 7 or 657 ± 214 EAC rosettes. Variations in percentage results were attributed to the handling of rosetted cells for counting. Variations between samples from the same individual were similar to variations between samples from different individuals. Lymphocyte preparation of peripheral blood samples from burn patients resulted in red cell contamination of the separated lymphocytes. Ox red cell rosette assay and E and EAC percentages were used to evaluate samples from burn patients for non-rosetting cells or possible multiple reactive cells to explain diverse results obtained from these samples relative to normal control samples.     

Clinical Experience with Permanent Atrioventricular Sequential Pacing

In a 23-month period, we implanted 26 permanent atrioventricular (AV) sequential pacing units in 11 women and 15 men ranging from 37 to 85 years old (mean, 68 years). Indications for pacing were complete heart block in 12 patients and sick sinus syndrome in 14 patients.Cardiac index, using standard thermodilution techniques, was determined in 9 patients during ventricular pacing and AV sequential pacing at constant heart rate. Atrioventricular sequential pacing was superior in all patients, with a mean increase in cardiac index of 22% (p < 0.01). Complications of AV sequential pacing included the need to revise two pulse generator pockets due to the large size of the pulse generator. One transvenous atrial lead displacement occurred in a patient who had previously undergone right atrial appendage ligation at open-heart operation. No failures of pacing or sensing occurred during 279 patient-paced months.The theoretical hemodynamic advantage of AV sequential pacing has been confirmed in this clinical trial. Experience with electrode placement and improvements in pulse generator design should aid in eliminating complications with this pacing modality.     

Studies of pathologic vasoconstriction (vasospasm) in microvascular surgery

Characterization and resolution of microvascular spasm were investigated in 170 studies with the use of tail or femoral arteries of the rat. Topical epinephrine reliably produced vasospasm and topical vasodilators which included 2% and 20% lidocaine (Xylocaine) and 0.75% bupivacaine (Marcaine) were applied to resolve the vasoconstriction. Extensive vessel dissection was necessary to obtain significant resolution of vasospasm, and adventitial stripping was associated with even more impressive results. Local anesthetics appear to have a concentration dependent ability to resolve vasospasm, and 20% Xylocaine is the most effective agent yet studied.     

Surgical therapy of advanced esophageal cancer. A critical appraisal

Thirty-five patients with advanced esophageal carcinoma underwent esophagogastrectomy. Of these, 13 patients underwent esophagogastrectomy through midline celiotomy and right thoracotomy incisions (Group 1), and 20 patients underwent extrathoracic esophagectomy with either reversed gastric tube (Group 2) or isoperistaltic tube reconstruction (Group 3). Morbidity was significantly greater in patients who underwent extrathoracic esophagectomy due to more severe pulmonary complications and anastomotic fistulas. Because of these complications, a longer interval to solid food ingestion occurred in the extrathoracic esophagectomy group. Long-term survival was not affected by the operative procedure utilized. Extrathoracic esophagectomy with cervical anastomosis is associated with more complications than an intrathoracic anastomosis, resulting in inferior palliation for patients with advanced esophageal carcinoma.     

Peripheral blood T and B lymphocytes in patients with burns. II. Sequential rosette analyses considering burn severity and pseudomonas sepsis

Lymphocytes have been enumerated by E rosette assay for T lymphocytes and by EA and EAC rosette assay for B lymphocytes in 49 burn patients sequentially for 30 days following thermal injury. Severity of burn was used as a classification in a separate analysis of patients. Significant depressions in T lymphocyte percentages and counts per mm³ were seen in the early post-burn period, the magnitude of which increased with increasing severity of burn. There was a trend towards elevated levels of EAC rosetting cells in mild to moderate injury but there was an absolute depression in severe injury.Extreme depressions of T lymphocytes have been consistently seen in patients who coincidentally developed clinically evident pseudomonas sepsis.     

Major complications of median sternotomy

Major sternal infections developed in eleven of 1,550 patients undergoing median sternotomy for operations on the heart. Nine patients had myocardial revascularization, six with internal mammary artery as the conduit. Seven of these patients have been salvaged by aggressive local wound management and systemic support. These survivors have a good outlook for treatment of their basic cardiac disease.     

Mesenteric venous thrombosis in two women taking oral contraceptives

2 cases of mesenteric venous thrombosis in women taking oral contraceptives (48-year old gravida 5 taking norethindrone with mestranol for 10 years, a 33-year old gravida 2 taking Enovid and C-Quens since 1962 followed by norethindrone with mestranol 1 month prior to admission) were treated at the Jewish Hospital of St. Louis. Both patients had acute abdominal pain, vomiting, and bloody and diarrheal stools. In order to remove nonviable portions of the bowel which are viable at initail operation, 2 operations are necessary in the treatment of mesenteric venous thrombosis. Both of these patients underwent 2 operations and both had extensive segments of bowel removed. The post-operative courses of both patients were long (85 and 40 days respectively) and difficult. No predisposing or etiologic factor could be determined in either patient. A relationship of mesenteric venous thrombosis to oral contraceptives is suggested, but no definite causal relationship can be established.     

Evaluation of choledochoduodenostomy in the treatment of malignant obstruction of the biliary tree.

The results of direct decompression of the common duct for malignant obstruction of the distal biliary tree by side-to-side choledochoduodenostomy are presented. Thirty-three patients were treated with twenty-four (73 per cent) having carcinoma of the pancreas. Seventy-two per cent of the patients had had previous cholecystectomy or cholelithiasis whereas the common duct was utilized in preference to cholecystojejunostomy in six patients. The operative mortality was 12 per cent and six patients had complications. No deaths could be attributed to the choledochoduodenostomy, and complications did not significantly affect palliation. Mean postoperative survival was 10 +/- 0.9 months. Two patients had obstruction of the anastomosis as a terminal event. This study suggests that appropriately applied choledochoduodenostomy is a simple, effective means to decompress the common duct obstructed by tumor.     

Secretory state of gastric mucosa and its resistance to aspirin injury.

The influence of the secretory status on gastric mucosal tolerance to aspirin injury was assessed in a canine ex vivo model, which provided two segments of mucosa supplied by a single vascular pedicle in the same dog. Acid secretion was stimulated by intravenous infusion of histamine in one mucosa, whereas the secretory response to histamine was significantly impaired by topical treatment with 16,16-dimethyl prostaglandin E2 in the other. As expected, the secreting mucosa exhibited a twofold greater blood flow than the inhibited mucosa. Exposure of both mucosae to 20 mM aspirin for 30 minutes resulted in the appearance of small multiple superficial erosions. The degree of mucosal injury was not significantly different between the secreting and inhibited mucosae. The extent of mucosal damage was similar to that seen when aspirin in acid was placed on resting mucosa in the same model. These data do not support the hypothesis that histamine-stimulated acid secretion and accompanying increase in gastric mucosal blood flow protects the stomach against aspirin injury.     

Correction of rheumatoid swan-neck deformity by lateral band mobilization

Fifty-seven digits in 18 hands of 14 patients with rheumatoid disease were retrospectively evaluated after surgical correction of swan-neck deformity. Release of each hyperextension deformity was done via a previously described lateral band mobilization technique with temporary pin fixation of the proximal interphalangeal (PIP) joint and primary skin closure. Extension block splinting was used for 1 month after pin removal. Follow-up averaged 24 months. Twenty-two percent of the patients were enthusiastic about their results, 56% were satisfied, 22% were equivocal, and none were dissatisfied. Maximum active flexion at the PIP joint averaged 55 degrees, and maximum extension averaged--10 degrees. The average distance from fingertip to distal palmar crease was 32 mm. Average grip strength was 10 kg of force in men and 4 kg in women. Step-cut lengthening of the central slip was associated with the development of a boutonniere deformity and an unsatisfactory result in three digits. Even with narrowing of the PIP joint or articular erosions, which were found on 91% of roentgenograms, lateral band mobilization to correct swan-neck deformity can predictably improve the function and cosmesis of rheumatoid hands.     

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.     

Acidification of arterial blood enhances gastric mucosal injury induced by bile salts in dogs

The influence of intraarterial infusion of hydrochloric acid on gastric mucosal injury induced by topical bile salts was assessed in a canine ex vivo model. Exposure of the gastric mucosa to 5.0 mM sodium taurocholate in acid bathing solution alone resulted in a slight but not significant reduction in intramural pH of gastric mucosa and mild mucosal damage. When hydrochloric acid (0.1 N) was infused directly into the artery perfusing the stomach of the dogs, the intramural pH of gastric mucosa markedly decreased. The mucosal acidification was associated with severe ulcers in all test dogs that received intraarterial infusion of hydrochloric acid. The deleterious effect of intraarterial infusion of hydrochloric acid was not due to ischemia since the gastric blood flow remained relatively unchanged. The severe mucosal ulcerations were perhaps caused by the decrease in the ability of gastric blood to buffer the incoming luminal acid induced by topical bile salts. These results suggest that (1) the pH of arterial blood perfusing the stomach may also be an important determinant in the ability of the gastric mucosa to protect itself against acid injury, and (2) better management of systemic acid-base balance may contribute to a lower incidence of stress ulcers in critically ill patients.     

Comparative evaluation of selective and nonselective peripheral portosystemic shunts for treatment of variceal hemorrhage

There is currently available a variety of operative techniques that, by shunting of portal blood into the systemic circulation, decompress esophagogastric varices. Continued evaluation of when to employ a specific type of portosystemic shunt is indicated. This report compares experience with nonselective peripheral portosystemic shunts with selective distal splenorenal shunts. Twenty-nine patients were divided into two operative groups. All patients were operated on for variceal hemorrhage. The two patient groups were similar preoperatively in all parameters evaluated except that the patients having nonselective peripheral shunts had more ascites and four were operated on for acutely bleeding varices, whereas the selective shunt patients had minimal ascites and none were operated on for acute bleeding. Rebleeding rates, incidence of encephalopathy, and long-term survival were not significantly different between the two groups. Eight of 14 (57 percent) patients discharged from the hospital with selective distal splenorenal shunts were alive with a mean follow-up interval of 19 months. Eight of 11 (72 percent) patients discharged with nonselective peripheral shunts were alive with a mean follow-up interval of 34 months. These results suggest that if technical or clinical conditions preclude the performance of a selective distal splenorenal shunt, a nonselective peripheral shunt will produce comparable results and can be used with confidence.