Endoscopic retrograde cholangiopancreatography and gray-scale abdominal ultrasound in the diagnosis of jaundice.

Fifty-five patients with suspected obstructive jaundice were studied with both ERCP and abdominal ultrasound. Biliary tract obstruction was documented in 49 patients and parenchymal liver disease in 7. A definite cause of jaundice was demonstrated by ERCP in 45 of 49 patients with biliary tract obstruction but in only 28 of 49 patients by ultrasound. Bile duct dilatation, where present, was detected by ERCP in only 33 of 42 patients. ERCP was particularly effective in patients with common duct stones; common duct calculi and a dilated common duct were detected in 15 of 16 such patients. Dilated bile ducts where present were detected by ultrasound in 22 of 42 patients. Ultrasound was particularly helpful in patients with pancreatic cancer in whom a dilated common duct could not be opacified during ERCP. ERCP and abdominal ultrasound together provide a rapid and safe method of diagnosis in the jaundiced patient with suspected bile duct obstruction.     

Importance of common bile duct stricture associated with chronic pancreatitis: Diagnosis by endoscopic retrograde cholangiopancreatography

Twenty-one patients with common bile duct strictures associated with chronic pancreatitis are described in whom ERCP was the principal diagnostic method used. In 5 of the 11 patients who had had previous pancreatic or biliary surgery, a common bile duct stricture was overlooked. Nine patients had one or more attacks of cholangitis, which were severe in seven and caused death in one. Endoscopically aspirated bile cultures showed heavy gram-negative infection in four patients with previous cholangitis. Two patients developed stones above the strictures, and in one this led to obstruction of a previous cholecystjejunostomy. Although strictures may be discovered at an asymptomatic stage, there should be careful follow-up to detect the appearance of any symptoms or objective signs of stricture progression, when surgery should be offered without delay. Direct biliary-enteric anastomosis is the procedure of choice when possible to relieve symptoms and prevent the potentially life-threatening complications of cholangitis and septicemia.     

Rhythm abnormalities of the biliary and pancreatic sphincters: diagnosis by endoscopic manometry

Abnormal phasic wave activity was noted in the biliary duct sphincter, pancreatic duct sphincter, or both in 43 patients. This abnormality consisted of a tachyrhythmia in 40 patients and absent phasic wave activity in 3 patients. Tachyrhythmia was encountered in patients with elevated basal sphincter pressures. In four patients with tachyrhythmia, administration of intravenous naloxone failed to modify phasic wave activity. Three patients with normal basal sphincter pressures had absent phasic wave activity. This abnormality occurred in two patients with cirrhosis and in one patient with suspected cirrhosis. In one patient with cirrhosis, administration of intravenous morphine did not induce phasic wave activity.     

Preoperative combination chemotherapy for advanced stage head and neck cancer. Promising early results

We treated 19 consecutive patients with cisplatin, bleomycin, and methotrexate before definitive surgery or radiation therapy. Fourteen patients (74 percent) had partial or complete tumor regression after chemotherapy. With a minimum follow-up time of 27 months, none of the 4 patients who had a major histologic response relapsed, and only 2 of the remaining 15 patients continued disease-free. The achievement of a complete histologic response after preoperative chemotherapy may correlate with long-term disease-free survival after surgery and radiation therapy for head and neck cancer.     

Femoropopliteal bypass in elderly diabetic patients.

The records of sixty-nine consecutive elderly diabetic patients over age 70 years who underwent femoropopliteal bypass at the New England Deaconess Hospital from 1966 to 1975 were reviewed and analyzed statistically. Grafts were classified as patent only if the patient had a palpable distal pulse postoperatively. No hospital deaths occurred. The patency rate declined with decreasing runoff below the knee. Patients receiving insulin had a patency rate of 7 per cent, compared with a rate of 35 per cent in patients treated with diet or oral agents (p < 0.05). Cross analysis disclosed no other significant difference between these two groups. No benefit from Dextran was demonstrable in our series. Graft closure carried a 36 per cent risk of above knee amputation. Life table analysis of patients who underwent autogenous vein graft (fifty-seven patients) showed one and three year patency rates of 72 and 56 per cent, respectively. Conversely, grafts of Dacron had one and three year patency rates of 48 per cent and less than 10 per cent, respectively. In a favorable subset of twenty-six patients who (1) were receiving insulin, (2) had either previously successful bypass or no previous vascular surgery, (3) had arteriographic evidence of one or more vessel runoff, and (4) had autogenous vein grafts, the one and three year patency rates were 91 and 82 per cent, respectively. Our experience shows that femoropopliteal bypass is safe and effective when patients are carefully selected. We strongly discourage the use of Dacron materials in elderly diabetic patients.     

Surgical management of chest wall tumors

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.     

Sensitivity and specificity of serum ribonuclease in the diagnosis of pancreatic cancer

The serum levels of a poly-[C]-specific acid ribonuclease (RNase) found in the pancreas was measured in 40 normal persons and 137 patients with pancreatic cancer, other cancers, obstructive jaundice, acute pancreatitis or chronic pancreatitis. Serum RNase increased by as much as 800 percent above normal in 69 percent of patients with pancreatic cancer. Analysis of the serum isoenzymes of RNase by isoelectric focusing did not reveal any unique RNases produced by the tumors. In contrast, serum RNase rose in only 8 percent of patients with other cancers, 11 percent of other patients with obstructive jaundice and in no patients with chronic pancreatitis. These data suggest that the finding of increased serum RNase is of adjunctive value in the diagnosis of pancreatic carcinoma and may be particularly helpful in distinguishing it from other causes of biliary obstruction and from chronic pancreatitis.     

The urgency of diagnosis and surgical treatment of acute suppurative cholangitis.

Twenty patients with suppurative cholangitis were seen at the Massachusetts General Hospital over a nine year period. Fifteen patients had acute obstructive suppurative cholangitis due to complete obstruction of the common duct, many with coma, hypotension, and positive blood cultures. Sixty per cent of patients were older than seventy years, and most had a history of biliary tract disease. Although most had jaundice, abdominal pain, and fever, clinical symptoms were variable. The diagnosis of cholangitis was made in only 30 per cent of patients before autopsy or surgery. Eighteen patients had calculi in the common duct, and two had primary fibrosis of the ampulla. Patients explored less than 24 hours after admission or deterioration died less often than those operated on after some delay. Most patients underwent common duct exploration and four had a concomitant sphincterotomy. In one instance, cholecystostomy only was performed and this patient died because of ongoing sepsis. The overall mortality was 40 per cent; of those subjected to operation, 25 per cent died in the hospital. Recovery was dramatic among most survivors, and calculous disease did not recur, except for two patients with retained stones. Prophylactic cholecystectomy is recommended to prevent the occurrence of this subtle and highly dangerous syndrome.     

Late results in patients with schatzki rings undergoing destruction of the ring and hiatus herniorrhaphy

Thirty-six patients with symptomatic Schatzki rings were treated by rupture of the ring and repair and followed up an average of 6 years. Thirteen (37 percent) had no recurrence of symptoms; 8 (23 percent) had recurrence of mild symptoms; 14 (40 percent) had recurrence of symptoms as severe as those experienced preoperatively. Failure was associated with recurrence of the ring and hernia in some. In others, stricture with or without recurrence of the hernia was noted. Analysis of the procedures did not suggest a means of improving results.     

Is pulmonary angiography essential for the diagnosis of acute pulmonary embolism?

The records of 158 patients who underwent pulmonary angiography for the presumed diagnosis of acute pulmonary embolism were retrospectively reviewed. Of the 111 patients in the category of high probability for pulmonary embolism based on clinical impression, 60 patients (54 per cent) had a positive pulmonary angiogram. Of the forty-seven patients in the low probability group, ten (21 per cent) had a positive angiogram. Forty-eight of the seventy-three patients (66 per cent) with a high probability lung scan had a positive pulmonary angiogram. Eleven of twelve patients (92 per cent) with a high probability ventilation-perfusion scan had a positive pulmonary angiogram, and two of eight patients (25 per cent) with a low probability ventilation-perfusion scan had a positive pulmonary angiogram. The mean PO2 of patients with a positive pulmonary angiogram was 64 mm Hg, and the mean PCO2 30 mm Hg. The mean PO2 of patients with a negative pulmonary angiogram was 63 mm Hg and the mean PCO2 34 mm Hg. Based on these data, we believe that the accuracy of pulmonary angiography in diagnosing acute pulmonary embolism is much higher than that of the clinical impression, arterial blood gas determinations, and lung scanning technics.     

Conservation of pancreatic tissue by combined gastric, biliary, and pancreatic duct drainage for pain from chronic pancreatitis

In patients with chronic pancreatitis, the sclerosing process of the pancreas may constrict not only the pancreatic duct for also the bile duct and duodenum. This study analyzes the prevalence of these obstructive lesions in 58 consecutive patients with chronic pancreatitis requiring surgery for either pain (57 patients) or for painless jaundice (1 patient). There was significant biliary obstruction in 21, 4 of whom also had symptomatic duodenal obstruction. All 21 patients with biliary and duodenal obstruction were among the 38 with a dilated pancreatic duct suitable for pancreaticojejunostomy (modified Puestow procedure). None of the 20 patients with small duct pancreatitis had biliary or duodenal obstruction. Pseudocysts were distributed evenly between the two groups (9 of 38 patients with a dilated duct versus 4 of 20 patients with small duct pancreatitis). Pancreaticojejunostomy combined with choledochoenterostomy and gastrojejunostomy in appropriately selected patients provided good to excellent long-term (mean 3.6 years) relief of pain in 30 of 36 patients (83 percent). There was no correlation between successful relief of pain and development of pancreatic exocrine or endocrine insufficiency or calcification. Stenosis of the bile duct developed some years subsequent to pancreaticojejunostomy in four patients and required a second operation for choledochoenterostomy in three. Three other patients required secondary pancreatic resections due to failure of the pancreaticojejunostomy to relieve pain. It is often possible to effect excellent relief of symptoms with maximal conservation of remaining pancreatic functions despite sclerotic obstruction of multiple organ systems.     

Surgical intervention in acute necrotizing pancreatitis

Thirty-eight patients with acute pancreatitis were treated with an operation that included cholecystostomy, gastrostomy, feeding jejunostomy, and sump drainage of the peripancreatic lesser sac. Of eleven patients judged to be dying of fulminant pancreatitis in the first forty-eight hours of treatment, nine improved immediately and seven survived. Of eighteen patients who underwent operation because of persistent or increased signs of inflammation two weeks after admission, seven had an immediate favorable response, mainly due to drainage of abscesses, necrotic pancreas, or pseudocysts, and twelve survived. Nine patients with pancreatitis of lesser severity received no apparent benefit from the operation.Gastrostomy and jejunostomy were used for prolonged treatment of intestinal dysfunction in nine patients. In six patients the cholecystostomy helped to control bacterial cholangitis. In seven patients the peripancreatic sumps provided tracts for the late drainage of abscesses, pancreatic fistulas, and sloughed pancreas.The major problem after surgery was the development of intra-abdominal abscesses in sixteen patients. Of the thirteen deaths, ten were directly related to these abscesses. An aggressive approach to re-exploration and drainage of late pancreatic abscesses in patients with necrotizing pancreatitis should improve still further the survival rate of patients.The survival of patients with severe pancreatitis resistant to standard medical measures appears to be improved by this operative approach.     

Recent experience in the management of cancer of the colon and rectum

A review is presented of 1,566 cases of cancer of the colon and rectum at the Massachusetts General Hospital in the ten year period 1961 to 1970. Comparisons are made with similar numbers of patients treated at this institution during the two previous decades. Although there were striking improvements in mortality and five year survival rates from those of the years 1937 to 1948 to those of the years 1949 to 1960, no further progress was evident in the last ten years covered by this study.Comparisons are made between the groups of patients treated during the last two periods. Little difference was found in the length of delay from onset of symptoms to treatment, sex of the patient, type of symptoms, location of the tumor in the bowel, or details of operative technic. Although the patients in the more recent series are somewhat older, the resectability rate remained the same and the operative mortality was actually lower after both curative and palliative resection.It is emphasized that until other modalities of detection and treatment of cancer become available, the details of past surgical management must be assiduously practiced.     

Management of the upper extremity with absent pulses after cardiac catheterization

Thirty-one patients had a delayed loss of brachial artery and radial artery pulse after cardiac catheterization; eleven of the patients had early embolectomy or a vein patch graft and 82% of these had immediate restoration of pulse and remained asymptomatic. Early surgery failed in two patients, requiring late vein bypass grafting for claudication. Twenty patients did not have early surgery, eleven (55%) remaining asymptomatic and nine (45%) developing ischemic symptoms. Five of these nine patients (25%) required late vein bypass grafting for severe claudication. Of the fifteen patients who lost their pulse and did not undergo surgery, the average Doppler forearm pressure immediately following the occlusion was 50 mm Hg (pressure index=0.46). The average Doppler pressure measured at the time of follow-up was 80 mm Hg (pressure index = 0.61). Early local surgery is highly successful in patients who lose their radial artery pulse after cardiac catheterization. Conservative nonoperative therapy may be successful but often results in late ischemic symptoms that may require late vein bypass grafting.     

Acute fulminating transmural ileocolitis after small bowel bypass for morbid obesity

A personal series of small bowel bypass operations for morbid obesity is presented. The importance of careful considerate follow-up by the operating surgeon is stressed. The development of acute fulminating transmural ileocolitis, Crohn's disease, in a patient twenty-two months after such surgery is reported and considered merely a dangerous coincidence, combining an acute colonic disease with a short small intestine.     

Limited surgical excision as the basis of a comprehensive therapy for cancer of the breast.

A comprehensive program of therapy has evolved with collaborating roles for surgery, pathology, radiotherapy, and chemotherapy. Our experience includes 131 patients with breast cancer treated at the Massachusetts General Hospital since 1956 by limited excision of the cancer. The tumors of 10 patients were noninvasive or sluggishly so; the patients received no further therapy. Because of the invasive character of their tumor, 121 patients received heavy postoperative irradiation. In 12 of these 121, the irradiation has been followed by immediate and prolonged chemotherapy. It is too soon to judge the effect of the chemotherapy, but survival rates of those treated by limited excision and primary irradiation compare favorably with those of patients treated by radical mastectomy.