Gestational macromastia

Gestational macromastia is a rare entity. Causes are many and include excess hormonal production, hormonal imbalance, and decreased hormonal catabolism. Documentation of elevated serum prolactin levels and tissue hormonal receptor levels brings new light to this pathologic condition. Pharmacologic measures are not recommended because of lack of effectiveness and possible teratogenic side effects. Primary therapy should consist of local measures, such as breast support, bed rest, and analgesics. If this fails and progression is inevitable, we recommend total mastectomy with provision made for reconstruction and nipple banking. Skin flaps must be thin, and all breast tissue must be removed, otherwise the pathologic condition will continue during the ensuing months of the pregnancy and will recur with each successive pregnancy. Abortion is feasible, but this leaves the patient in need of a reduction or total mastectomy at a later date, and thus is not recommended as a primary line of therapy. If the patient progresses to delivery without complication, a reduction mammoplasty can be considered but only if no future pregnancies are planned.     

The Penrose drain: a safe, atraumatic colostomy bridge

Because of the problems associated with the large, bulky bridges presently used for construction of loop ostomies, particularly complications of leaks and skin excoriation, we have studied the use of the Penrose drain as an alternative. This method has been time-tested on 45 patients and has been found to be safe, reliable, and inexpensive and has gained popularity among patients and ostomy nurses. The bulky colostomy bridge should no longer be accepted as a standard of care.     

Hypercalcemia in epidermoid carcinoma of the head and neck.

Hypercalcemia occurs rarely at the time of diagnosis in patients found to have epidermoid carcinoma of the head and neck. It is particularly unlike in those patients who present with potentially curable lesions. Only 2 of our 307 patients who presented with potentially curable lesions were hypercalcemic at the time of diagnosis. Two hundred thirty-eight of these patients were followed up for two years or until death. Of the 139 who did not remain free of disease, hypercalcemia of clinical significance developed in ten (7.2 per cent). Pseudohyperparathyroidism was the suspected cause in seven of twelve patients. Debilitating symptoms were present in all patients with serum calcium levels greater thn 12.0 mg/100 ml. Treatment, when given, was effective in alleviating gastrointestinal and central nervous system problems. Although usually temporary, symptomatic improvement was appreciated by most patients and family members.     

Metastatic cancer of the liver resulting in obstruction of the extrahepatic bile duct

A case is described of a sixty-five year old man with metastatic cancer of the liver originating in cancer of the colon. The flow of necrotic tissue into the bile duct resulted in obstructive jaundice.     

Gastrografin-induced hypertonicity. The pathogenesis of a neonatal hazard

Operative mortality in meconium ileus approaches 50 per cent. Recently, operation has been obviated by the administration of high Gastrografin enemas. However, the nonoperative therapy causes hypertonicity, manifested by rising hematocrit and serum osmolality and a decreased cardiac output and pulse rate. The suggested mechanism for hypertonicity is the attraction of plasma water into the gut by the concentrated “nonabsorbable” material. An alternate explanation involves absorption into the vascular system of osmolar active substances from Gastrografin. The purpose of this study is to clarify the pathogenesis of acute hyperosmolality.High Gastrografin enemas were administered to twenty-one neonatal puppies and serial blood studies were performed. A disproportionate rise in measured osmolality as compared to the calculated osmolality suggested significant absorption of the contrast material or its components through the puppy's intact gut wall. The results indicate that the hyperosmolar state is due to a combination of agent absorption and plasma water decrease.     

Cancer of the bile duct: the occult malignancy.

Primary malignant lesions of the bile duct system are almost always discovered at a late stage, and largely because of this, the prognosis with this disease is poor. Despite this bleak prognosis, many of these lesions are well differentiated and relatively slow growing. In contrast to periampullary lesions, which may be polypoid or papillary with a relatively good prognosis, bile duct cancers are almost always of the infiltrative type and are often scirrhous. Metastases to lymph nodes occur in the majoirty of patients, about half have liver metastases, direct invasion of the liver occurs frequently, extension into the wall of the bile duct often occurs early, periductal involvement often precludes resection, and perineural invasion frequently extends far beyond the limits of resection. The early periductal spread of these lesions along with the anatomic barriers, that is, the portal vasculature, often prevents wide excision of tumors in the supraduodenal portions of the bile ducts. These lesions are difficult to detect accurately and, because of this, often are nonresectable when definitive diagnosis is established. To detect these tumors more frequently during exploration of the extrahepatic biliary system, especially during cholecystectomy, biopsy specimens of any indurated area should be taken. The discovery of white bile in the common duct is highly suggestive of malignant disease, scrapings of indurated areas may establish the diagnosis, and perhaps the interior of the ductal system should be visualized directly with the optical instruments currently available. However, since most intraductal malignant lesions resemble fibrous strictures, direct visualization may not allow distinction between the two; moreover, biopsy may not establish the diagnosis of malignant disease since often the lesions are extensively fibrotic. Retrograde cholangiography with the duodenoscope probably will be used increasingly in the study of various problems in the bile ducts, including malignant disease. It is unlikely, however, that this method will contribute to the discovery of lesions confined to the mucosa, since carcinoma at this stage seldom produces symptoms and duodenoscopy would rarely be carried out in a patient without significant biliary symptoms.     

Occult injuries of the liver, bile duct, and pancreas after blunt abdominal trauma

Blunt trauma to the abdomen may produce a wide range of intra-abdominal injuries. Subcapsular hematoma of the liver, disruption of the common bile duct, and subcapsular disruption of the pancreatic duct are three injuries discussed; all are rare, isolated injuries frequently accompanied by minimal initial abdominal signs and symptoms. Each injury, however, has serious potential late complications. The diagnosis and treatment of these conditions are discussed with a view toward preventing or minimizing the late complications.     

Refractory primary common bile duct stone disease

Thirty-seven cases are reported of primary common bile duct stones considered typical of primary stone disease with an asymptomatic period of at least 2 years after cholecystectomy and stones of a soft brown, easily crushable characteristic. Two other groups with a total of 57 cases closely related to those in the first group are reported, for a total of 94 cases. These three groups have similar patient ages, large common bile ducts averaging 19 mm in diameter, ampullas easily open to a no. 6 Bakes dilator and a high incidence of recurrent or overlooked stones despite the use of operative cholangiography in at least half of the procedures. The use of a duct anastomosis in ducts over 11 mm in diameter is mandatory for a satisfactory result. In smaller sized ducts a generous sphincterotomy or sphincteroplasty must be carried out in addition to choledocholithotomy. The exact indication for endoscopic papillotomy in the treatment of this condition has not been settled. Other conditions associated with primary duct stones include traumatic and nontraumatic strictures, sclerosing cholangitis, oriental cholangiolitis, congenital cystic disease, Caroli's disease and congenital hepatic fibrosis. More information is needed to explain the soft stone syndrome, such as data on the bacteriologic and chemical characteristics of the bile and on the physiologic features of common bile duct emptying.     

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.     

Understanding the bowel obstruction problem.

Tools to cope more effectively with the bowel obstruction problem have been gradually evolving over the past four decades. It is possible to recognize most varieties of acute intestinal obstruction early enough to salvage the patient from the threat of a disorder that a few decades ago commanded a forbidding mortality. Great intestinal distention does not loom as difficult a problem today as it did four decades ago.The large residual mortality of intestinal obstruction today concerns primarily strangulating varieties. In fact, more than half the deaths from intestinal obstruction derive from the profession's failure to deal promptly with strangulated hernias and with internal strangulations before the bowel becomes nonviable. The current achievement with intussusception contrasts strikingly with our failure to deal competently with other strangulating varieties of intestinal obstruction. So similarly, the accomplishment with congenital intestinal atresia bespeaks the finesse of modern-day surgeons in coping with anastomoses of small tubular structures.The profession needs to take a more serious interest in intubation technics in dealing with intestinal distention, to which developments my colleagues, Doctors Arnold Leonard and Richard Edlich, have made significant contributions.The team approach to the problem of intestinal obstruction is essential. Every hospital with an interest in intestinal obstruction should have on its Bowel Obstruction Team an intestinal intubator with both interest and expertise. Leonard and Edlich and others who have achieved striking success with intestinal decompression by per oral intubation have a responsibility to train intubators and to transmit their expertise to others who can carry on. The problem in many respects is not unlike the history of utilization of gastroscopy for diagnosis. Only within the past decade have most American hospitals enjoyed ready access to competent gastroscopists, despite the fact that Mikulicz's first effort with gastroscopy traces back more than a century. It is important to preserve the skill and expertise that experienced intubators have acquired. Their lessons and experience will be lost unless transmitted to younger professional associates.Early diagnosis, prompt surgical management of all strangulated hernias, and per oral decompression of the distended small bowel prior to and/or at operation in all simple obstructions are fundamental criteria for success in any plan of treatment. When the obstruction is complete, after operative decompression, the obstructing mechanism must be removed surgically. For incomplete simple obstructions of the small intestine following adequate decompression, operation may not be necessary. Most instances of paralytic ileus, not septic in nature, respond favorably to conservative management. In colic obstructions, early decompression proximal to the obstruction is indicated. Effective intestinal decompression, preserving the sterility of the peritoneal cavity lies at the root of the matter.This recounting of a long experience in attempting to understand the bowel obstruction problem suggests that clinical observation, reinforced by experimental studies, is a useful tool in lending a forward thrust to improved accomplishment.     

Jaundice in patients with acute cholecystitis: Its validity as an indication for common bile duct exploration

Our study demonstrates that (1) mild to moderate jaundice is frequently seen in patients with acute cholecystitis; (2) severe degrees of jaundice were seen in two patients without the presence of common duct stone or recognizable obstruction of the common bile duct; (3) only one of forty-one patients with acute cholecystitis had common bile duct stone; (4) jaundice does not appear to be a compelling reason for choledochotomy; and (5) less invasive technics such as intravenous and intraoperative cholangiography should suffice to exclude the possibility of common bile duct stone in patients with acute cholecystitis.     

Pancreatic duct obstruction by a benign polypoid adenoma of the ampulla of vater

An unusual presentation of polyp of the ampulla of Vater is described. The patient initially had a chronic relapsing pancreatitis. Pancreatocholangiography revealed a tumor in the main pancreatic duct that proved to be a pedunculated polyp of the ampulla of Vater by operation. Transduodenal excision and sphincteroplasty may cure the lesion and relieve the symptoms of this disease.     

Management of locally recurrent breast cancer adjacent to prosthetic implants

Local recurrence of breast cancer around prosthetic implants has largely the same significance as local recurrence in a nonreconstructed chest wall. It tends to be a harbinger of systemic metastases, and this fact should influence patient management. It was not necessary to remove any implant either for local control of recurrent breast cancer or for complications of treatment.     

Granular cell myoblastoma involving the common bile duct.

Three cases of granular cell myoblastoma involving the large bile ducts are reported. Two of the patients were proved to have multifocal tumors. These tumors may clinically simulate sclerosing adenocarcinomas. Technical difficulties with these tumors for the consulting pathologist are discussed.     

Immediate oophorectomy and adrenalectomy in the treatment of stage III breast carcinoma: A ten year follow-up study

One hundred twenty-two patients with stage III breast carcinoma had radical mastectomy with or without adjunctive radiation therapy, chemotherapy, or steroids. Thirteen randomly selected persons in the group had immediate bilateral oophoroadrenalectomy. Survival ranged from 10 to 147 months (median, 68.0) with seven of thirteen patients (53.8 per cent) alive five years and three of thirteen (23.0 per cent) alive ten years or longer. No statistical difference in survival or disease-free intervals with respect to menopausal status was observed in the nine patients of this group who died.One hundred and nine patients treated by conventional therapy without endocrine ablation had shorter five year (37.6 per cent) and ten year (15.6 per cent) survival intervals. The difference in survival intervals was statistically significant at p <0.01. This study suggests that immediate endocrine ablation may prolong survival in patients with stage III breast carcinoma.