Hepatocellular carcinoma. A 5 year institutional experience

Liver cancer is the most common of all malignancies worldwide, its incidence reaching almost epidemic proportions in some countries. However, its significance in North America has generally been underemphasized. In a 5 year period, hepatocellular carcinoma was diagnosed in 35 adult patients in our institution. Preexisting liver inflammation was present in 27 of the patients (77 percent). Although most patients had symptoms, they included only poorly defined pain or cachexia in most cases, and 10 patients (29 percent) were totally asymptomatic at the time of diagnosis. Five patients presented with hemoperitoneum due to intraabdominal tumor rupture. Examinations useful in confirming the diagnosis included alpha-fetoprotein determination, liver scan, and computerized tomographic scanning. Eight patients (23 percent) had associated visceral or other malignancies. The outlook was poor, with a mean survival of 5 months, and only two patients survived more than 1 year. Hepatocellular carcinoma is uncommon but not at all rare in the Pacific Northwest. It arises from chronic liver inflammation, is diagnosed late, and has a grim prognosis. Prevention of various forms of chronic liver inflammation, and mass serial screening of populations at high risk for the development of hepatocellular malignancy will probably have the greatest role in reducing the lethality of this disease.     

Percutaneous drainage of abscesses in the postoperative abdomen that is difficult to explore

We have evaluated our experience with computerized tomography and ultrasonography guided percutaneous drainage of extrahepatic abdominal fluid collections in a group of 22 patients. The most common goal was to avoid or delay surgery on abdomens in which reoperation would be difficult, mainly in high-risk patients. Drainage of pancreatic fluid collections or abscesses was also attempted in a small number of the patients. Percutaneous drainage was curative in 69 percent of those with nonpancreatic abscesses but in only 33 percent of those with abscesses associated with the pancreas. There were no complications attributable to the procedure or to delays in subsequent surgical drainage. Two patients died from problems not directly related to the use of percutaneous drainage. Percutaneous catheter drainage of nonpancreatic abdominal abscesses can play a useful role in patients who are carefully selected because they possess a complex abdominal anatomy distorted by previous surgery and infection or they are at high risk if surgical exploration is carried out.     

Enhanced survival in patients with variceal bleeding after elective portal decompression

In a retrospective study of 49 patients who had bled from esophageal varices but who survived and did not require emergency portal decompression, 24 patients were discharged without surgical consultation and 25 underwent portal decompression using a small-stoma portacaval shunt. Shunted and nonshunted patients were similar both demographically and in clinical and chemical criteria for preoperative hepatocellular function. Among nonshunted patients, survival was 33 percent during a follow-up period of up to 39 months, whereas shunted patients had an 83 percent survival during a follow-up period of up to 43 months. This difference in survival was statistically significant (p = 0.03). Shunted patients showed a 10.5 percent incidence of hepatic encephalopathy. We conclude that survival after variceal hemorrhage may be significantly increased by a portacaval shunt procedure, especially if it is carried out semielectively in stable patients.     

The role of peritoneal lavage in the management of stab wounds to the abdomen

In a 2 year period, 237 patients presented with stab wounds to the lower chest and anterior abdomen. Ninety-six patients were discharged from the emergency room after negative findings on wound exploration. There were no apparent missed injuries but two wound infections in this group for an overall morbidity of 2.1 percent. One hundred forty-one patients underwent exploratory laparotomy. Seventy-seven required emergency laparotomy because of hemodynamic signs of blood loss or peritonitis. Sixty-four patients whose only indication for laparotomy was penetration of the anterior abdominal wall fascia by local wound exploration underwent peritoneal lavage before laparotomy. If 50,000 red blood cells/mm³ in the lavage fluid had been used to select patients for observation, the incidence of negative laparotomy would have been reduced from 58 to 3.2 percent, and only one significant visceral injury would have been missed.Peritoneal lavage in properly selected patients, used in combination with local wound exploration and careful clinical observation, can be a useful diagnostic modality both in predicting significant visceral injury and in lowering the incidence of negative findings at laparotomy in patients with stab wounds to the abdomen.     

Clinical predictors of the adult respiratory distress syndrome

One hundred thirty-six patients meeting our criteria for one or more of eight clinical conditions were prospectively observed for the development of the adult respiratory distress syndrome. A high risk population was identified, including those with sepsis syndrome (38 percent), documented aspiration of gastric contents (30 percent), multiple emergency transfusions (24 percent), and pulmonary contusion (17 percent). The risk from multiple major fractures appeared low but contributed to the risk from other factors. The risk associated with just one factor (25 percent) was compounded by the presence of two (42 percent) and three (85 percent) simultaneous factors, and this finding was more predictive of ARDS than the injury severity score or initial arterial oxygenation. Of the ARDS cases, 76 percent occurred in the initial 24 hours after meeting the criteria. ARDS did not occur after 72 hours unless there was late development of sepsis (3 of 136 patients).     

Role of intraoperative pancreatography in patients with injury to the pancreas

Over a 10 year period, 54 patients presented with pancreatic trauma. During the first 5 years of the study, when pancreatography was not utilized for the assessment of pancreatic duct injury, 55 percent of the patients had major pancreatic complications. During the subsequent 5 years, suspected proximal duct injury was evaluated by intraoperative pancreatography. This resulted in a decrease of postoperative morbidity to 15 percent. In addition, there were no postoperative deaths during this period. The reduction in adverse sequelae after pancreatic trauma leads us to support the following principles of treatment: early recognition of pancreatic injury with immediate surgical intervention, complete exploration of the pancreas with the liberal use of intraoperative pancreatography to determine the presence of major duct injury, and the use of techniques which ensure control of duct disruption.     

Gastric pH monitoring as a prognostic indicator for the prophylaxis of stress ulceration in the critically III

Previous studies have documented the efficacy of prophylaxis in the prevention of stress ulceration and bleeding in critically ill patients. In an effort to determine whether all critically ill patients require prophylaxis, 144 patients admitted to an intensive care unit were monitored by continuous indwelling nasogastric or gastrostomy tubes. Any patient with a measured gastric pH of less than 4 was treated with prophylactic cimetidine or antacids to maintain a pH of 4 or greater. One hundred twenty-three (85 percent) met this criterion. The gastric pH of 21 patients (15 percent) never fell below 4 during continuous monitoring for 26 ± 4.2 hours. There was a significantly lower incidence of hypotension and respiratory failure in this group (p < 0.05). Mortality was higher in the patients who required prophylaxis (15 percent) than in those who did not (0 percent). No bleeding was encountered in any patient in either group. These data suggest that patients who do not require prophylaxis may be determined by continuous monitoring of intragastric pH. If, within 24 hours, intragastric pH does not fall below 4, minimal indications for prophylaxis exist. Intragastric pH monitoring is a simple, effective tool in the care and management of critically ill or traumatized patients.     

A bacteriologic study comparing closed suction and simple conduit drainage

Over a 6 year period, 10 patients underwent pancreaticoduodenectomy for trauma. This was reserved for proximal pancreatic duct or ampulla injuries at locations that precluded reconstruction and combined devascularization injuries of the pancreas and duodenum. This was thought to be the most conservative indication for the procedure. All patients are alive an average of 3.5 years after injury, and only two continue to require some form of long-term medical therapy. Ninety percent of the patients have returned to functional activity. When confined to strict criteria for resection, pancreaticoduodenectomy is a viable option. The long-term complications of this procedure are minimal and can be well controlled.     

Acalculous cholecystitis in critically III patients

Acute acalculous cholecystitis is a treacherous and potentially fatal complication of severe trauma and prolonged intensive care. The present study reviews seventeen patients seen between June 1974 and August 1977. Although specific causes have been suggested—transfusions, fractures with immobilization, central hyperalimentation, respirators, and “refeeding”—there was no common denominator among our patients. Refeeding was a feature in 30 per cent of our cases, 50 per cent received more than 10 units of blood, 65 per cent had prolonged gastric suction, and 60 per cent had mechanical ventilation. Thus, although all suggested causes were seen, no single factor was dominant.Clinical presentation in this civilian group resembles that of other reports, but differs in remarkable areas. Only 65 per cent of our group presented with one or more of the classic symptoms of cholecystitis—pain, tenderness, or mass. Sixty-five per cent of patients had elevated bilirubin levels. However, the same incidence of hyperbilirubinemia was seen in another group of traumatized patients who did not develop acalculous cholecystitis. The smoldering and nonclassic presentation frequently delayed diagnosis for several days. It was correctly made in 65 per cent, discovered at autopsy in one patient, and found at laparotomy for “sepsis” in the rest. The present report is unique because 88 per cent of the patients had cholecystostomy as initial therapy. Although five patients who underwent operation ultimately succumbed, cholecystitis could be implicated in only one. This patient died of sepsis at 24 hours but also had multiple unrelated intraabdominal abscesses at surgery. Clinical presentation is more complex than previously reported and simple cholecystostomy is an effective mode of therapy in these critically ill patients.     

Pyogenic osteomyelitis of axial bones following civilian gunshot wounds.

A series of forty-five patients with low velocity gunshot wounds to the spine and pelvis were followed up for at least eight weeks to determine the incidence of pyogenic osteomyelitis and the role of debridement and fragment removal in its prevention. Four cases of osteomyelitis were found, and although debridement was not frequently done, the incidence of osteomyelitis was higher following debridement than it was without debridement. The most important cause appeared to be spread of contiguous intraabdominal abscesses into the injured paravertebral muscles and spine. If an intraabdominal abscess did not develop, the presence of gastrointestinal injury did not predispose the patient to osteomyelitis. Based on this study, we can conclude that debridement and fragment removal of the spine and pelvic bones are unnecessary for low velocity missile wounds.     

Prehospital cardiopulmonary resuscitation of the critically injured patient

Prehospital cardiopulmonary resuscitation combined with endotracheal intubation, vigorous fluid resuscitation, and rapid transport can be effective in resuscitating trauma patients in cardiopulmonary arrest. Survival does not correlate with the injury severity score or transport time once the patient has arrested but does correlate with the mechanism of injury, endotracheal intubation, and placement of intravenous lines.     

Laser scalpel for solid organ surgery

Hemostasis remains a major technical problem in surgery of the liver and spleen. A high power neodymiumdoped yttrium aluminum garnet (Nd:YAG) laser has been coupled with a fiberoptic delivery system and quartz blade designed to yield maximal hemostasis and minimal tissue injury. In a series of experiments we were unable to demonstrate a significant advantage of its use in partial hepatic lobectomy.     

Indications for transluminal angioplasty: A surgical view

Twenty-two patients had transluminal angioplasty by catheter dilation of arteriosclerotic arterial stenoses. Follow-up of 3 to 32 months and changes in ankle blood pressure data are used to discuss the role of this controversial procedure from the perspective of the vascular surgeon.     

Inflammatory tissue reaction in rabbit bowel injected with Crohn's homogenates.

Homogenates from the terminal ileum of a patient with Crohn's disease with granulomas were prepared as snap-frozen or fresh and were injected into the ascending colonic walls of New Zealand white rabbits. Control animals were injected with 1 per cent bovine serum albumin alone. The rabbit bowel was examined after 1 year, and lesions were noted in each of the rabbits injected with Crohn's disease homogenate, irrespective of the type of tissue preparation. The observed lesions were diffuse and occurred both at the injection site and in the terminal ileum. These changes were not noted in the control group. This work confirms earlier results in the same animal model and suggests that either fresh or snap-frozen homogenates will produce the intestinal lesion but that bovine albumin alone will not.     

Revascularization of the leg using polytetrafluoroethylene: Cumulative patency in patients with claudication and limb salvage

Of 196 polytetrafluoroethylene bypass grafts in the leg, 113 were placed in the femoropopliteal and 83 in the femorotibial or femoroperoneal position. Claudication was the indication for 31 percent of the grafts, and 67 percent were done for limb salvage. Cumulative patency rates calculated by the life-table method for the femoropopliteal grafts were 66 percent at 1 year, 53 percent at 2 years, and 49 percent at 3 years. Corresponding patency rates for the femorotibial or peroneal grafts were 48, 44, and 36 percent, respectively. An analysis of factors influencing graft patency indicated that the best results were obtained with femoropopliteal grafts done for claudication in the presence of good distal runoff and grafts placed in limbs without previously failed grafts. Graft occlusion was most likely in distal bypasses for limb salvage and limbs with previously failed grafts. It is concluded that alternatives to PTFE bypass should be considered in those patients at greatest risk for graft occlusion. In patients who lack a satisfactory saphenous vein but who must have a bypass graft, polytetrafluoroethylene is an acceptable arterial substitute; however, thrombectomy or revision will be required to maintain patency in a high proportion of cases.     

An inexpensive,versatile vein holder

A simple, versatile vein holder can be fashioned from metal stock and surplus surgical instruments. It is inexpensive, reusable, and easily constructed by the standard hospital machine shop. Because it is composed of two independent parts, it can be adjusted to any length of harvested vein.     

Colon ischemia accompanying ruptured abdominal aortic aneurysm

Myocardial, cerebral, and renal ischemia are recognized as serious sequelae in patients surviving repair of ruptured abdominal aortic aneurysms. Colonic ischemia, though a documented consequence of aortic reconstruction, has received less emphasis in these patients. In a 5-year review of a single hospital's experience, 50 patients underwent an emergency operation for ruptured abdominal aortic aneurysm. Ninety-six percent of the patients were in shock preoperatively. Of the 37 patients who survived the initial surgical procedure, 12 (32%) were subsequently found to have colon ischemia diagnosed by proctoscopy, repeat laparotomy, or autopsy. Among 20 of the initial survivors who later died at intervals up to 6 weeks after aneurysm repair 8 (40%) had colon ischemia as the sole or major contributing cause of death. Because of the high incidence of this serious but remediable problem in patients undergoing emergency operation for ruptured abdominal aortic aneurysm, we now routinely perform: (a) intraoperative Doppler examination of the colonic arterial tree, with consideration of mesenteric revascularization if necessary, (b) daily postoperative sigmoidoscopy and examination of the stool for blood, and (c) aggressive “second-look” laparotomy in patients exhibiting any signs or symptoms suggesting colonic infarction. Our experience suggests that large bowel infarction is a common, lethal, and underemphasized complication following successful repair of ruptured abdominal aortic aneurysms.     

Natural history of incidental appendectomy in patients with Crohn's disease who required subsequent bowel resection

The records of 20 patients with Crohn's disease who underwent incidental appendectomy and later required bowel resection were reviewed and the following conclusions ascertained. If the patient had had abdominal pain for less than 1 week, appendectomy is followed by minimal problems. If the patient has had abdominal pain for longer than 1 week, incidental appendectomy is followed by an 83 percent incidence of fistula or sinus tract, arising not from the appendiceal stump but from the terminal ileum. The natural history of patients with resection after appendectomy includes more medication and a higher symptom recurrence rate and perhaps operative recurrence rate than their counterparts who have not undergone incidental appendectomy.     

Intraoperative manometry: adjunct to surgery for esophageal motility disorders

Intraoperative manometry can provide an objective means of determining the correct length of myotomy in patients with esophageal motility disorders. Of the patients in this series who underwent primary repair, 94 percent were relieved of pain and dysphagia. One patient required repeat myotomy for vigorous achalasia. After a mean follow-up period of 33 months, gastroesophageal reflux had not developed in any patient, indicating that myotomy with intraoperative manometry eliminates the need for an antireflux procedure. Such a procedure in these patients with poor esophageal motility can lead to dysphagia and obstruction, which is a very difficult problem to correct. We recommend intraoperative manometric be used routinely with myotomy for esophageal motility disorders.