Operative cholangiography in uncomplicated biliary tract surgery. Review of 354 cholangiography studies in patients without indication of common duct pathology.

The literature of the past ten years is replete with articles on “routine” cholangiography, with particular reference to the overlooked or “unsuspected” stone. Many series do not differentiate between T-tube cholangiograms performed after common duct exploration and those performed on patients with and without the usual clinical or operative indications for common duct exploration. We present a pure operative cholangiographic study of 354 patients with apparent uncomplicated biliary tract disease; a significant incidence of unsuspected pathologic features are demonstrated. Can a convenient and innocuous procedure like routine operative cholangiography continue to be ignored, even in the most routine of cases?     

Portal hypertension in infants and children with histiocytosis X.

Histiocytosis X describes a disease characterized by histiocytic infiltration of the reticuloendothelial system, skin, bones, and pituitary gland. The disseminated form frequently occurs in infants and children. Chemotherapy has significantly improved the prognosis in this disorder. Sixty-three per cent of survivors, however, have some residual disability related to fibrosis of tissues previously infiltrated by histiocytes. In instances of liver involvement, healing by fibrosis may result in cirrhosis with portal hypertension and bleeding esophageal varices. Clinical findings include hepatosplenomegaly, jaundice, ascites, hypoalbuminemia, prolonged prothrombin time, and Bromsulphalein retention. Histologic examination of the liver shows a characteristic dense "macronodular" periportal cirrhotic pattern. Three children with portal hypertension and bleeding varices due to healed histiocytosis X were sucessfully managed by portosystemic shunt procedures. Portacaval, mesocaval, and central splenorenal shunts were equally effective in relieving poral hypertension. These children had neither recurrence of bleeding nor evidence of encephalopathy. Two children remain well whereas in one patient a primary hepatoma developed fourteen years posthung and he died of pulmonary metastases. Portosystemic shunt procedures effectively relieve the threat of potentially fatal variceal hemorrhage and improve the opportunity for long-term survival in children with cirrhosis and portal hypertension due to healed histiocytosis X.     

The use of stroma-free hemoglobin solution for partial exchange transfusion in aortic resection in dogs

Vascular surgery involves multiple transfusions with their concomitant hazards. At the start of each vascular procedure, 20 per cent of each patient's blood (approximately 1,000 of 5,600 ml) is removed and replaced with colloid and crystalloid and the withdrawn blood returned at the end of surgery. Theoretically, if 40 per cent of the blood volume (2,000+ ml) could be withdrawn, essentially no banked blood would be required for a major vascular procedure. Therefore, 40 per cent (900+ ml) of the blood volume of twenty greyhounds was withdrawn under anesthesia and replaced with stroma-free hemoglobin solution (SFHS). Abdominal aortic resection and graft replacement was performed, and any blood lost during the procedure was replaced with SFHS. After surgery the withdrawn blood was returned to the dog and excess volume removed with postoperative hemodilution diuresis. The study included a battery of twenty tests for monitoring during the procedure and at intervals from this project that in greyhounds 40 per cent or more of the blood volume may be removed and replaced with SFHS and major vascular surgery done without undue risk and with unaltered kidney function.     

Chondrosarcoma of the hand

Chondrosarcoma is a rare tumor that involves the fingers. The treatment of choice is early diagnosis and amputation of the involved finger.     

Transplantation in the military: I. Guidelines for cadaver organ donation

The military system, which is suited for long distance, rapid transportation of personnel, provides a unique method for national and international organ sharing. Use of the system requires establishment of official guidelines and open lines of communication within the military. Furthermore, cooperation with civilian agencies increases the recipient pool and enhances the opportunities for successful use of viable organs.     

Detection and treatment of recurrent cancer of the colon and rectum

A series of 177 patients with recurrent colorectal cancer treated at the Massachusetts General Hospital is examined retrospectively. Two thirds of recurrences were observed by the second postoperative year, and 15% of patients were asymptomatic. Pelvic recurrences were usually attributable to rectal or sigmoid tumors, whereas right-sided carcinomas frequently spread to the liver. The commonest methods of clinical discovery of recurrence included findings of abdominal and pelvic masses, hepatomegaly, and positive chest films. The average survival after discovery of recurrence was only eleven months, but 23 patients having reresections for cure lived an average of thirty-three months. Seven patients (30%) undergoing reresection for cure represented probable cures. Chemotherapy with intravenous 5-FU provided poor palliation, but radiotherapy gave satisfactory relief of symptoms in approximately 50% of patients, particularly those with rectal or low colon lesions. A program of follow-up is offered since there is evidence that even the symptomatic patient may be well palliated or even cured by surgical resection of the recurrence or palliative therapy.     

Surgery of left paraduodenal hernia

The clinical presentation, embryologic and etiologic factors, and repair of left paraduodenal hernia are presented. A new operative procedure for cure of left paraduodenal hernia is presented that deals effectively with the sac and predisposing arch containing the inferior mesenteric vein without section of the vein. Repair is based upon the embryologically normal anatomy with restoration of the inferior mesenteric vein to its normal retroperitoneal position. This procedure has been successfully utilized in a case in which the paraduodenal hernia of small bowel was encountered concomitantly with a perforated duodenal ulcer.     

Release of vasoactive intestinal peptide in the central nervous system in man.

Recent work has shown that vasoactive intestinal peptide (VIP), one of the many candidate hormones of the gut, also occurs widely in neurones. To determine whether the neuronal peptide may have a neurotransmitter function, we studied changes in immunoreactive VIP in dog plasma and human cerebrospinal fluid after the infusion of choline esterase inhibitors (neostigmine and physostigmine, respectively). Immunoreactive VIP was released in both situations. The systemic changes (in VIP levels) were enhanced five weeks after portacaval shunting in dogs. Our results demonstrate that the immunoreactive VIP level increases as a result of choline esterase inhibitors. The plasma "release" may originate either from peripheral peptidinergic nerve terminals or from APUD cells of the gastroenteropancreatic system. The increase in immunoreactive cerebrospinal fluid VIP may very well originate from central neurons, since the peptide does not apparently cross the blood-brain barrier.     

Multiple jejunal diverticulosis and small bowel volvulus

A case of diverticulosis of the jejunum with volvulus of the small intestine is reported. A brief discussion of the common clinical features and the principles of treatment is given. A review of twelve cases of jejunal diverticulosis with small bowel volvulus is presented.     

Fournier's syndrome: Synergistic gangrene of the scrotum

Progressive spread of necrosis in the skin and subcutaneous tissues of the scrotum is the key feature of idiopathic scrotal gangrene. The disease may present initially as an acute abdomen, but laparotomy should be avoided. Usually an anaerobic Streptococcus is found, acting in synergism with aerobic, frequently gram-negative, bacilli. As in other synergistic gangrenes, wide debridement with drainage of all sinus tracts is required.Although the testicles are frequently bared, they are usually not necrotic and should not be amputated. Once the infection has resolved, a surprising amount of skin coverage, including coverage of the testicles, can often be obtained from the scrotal remnants.     

Surgical management of patients with primary operable colorectal cancer and synchronous liver metastases

The surgical results were analyzed of 217 patients who had undergone operation for primary colorectal cancer and were found to have synchronous liver metastases. It is recommended that patients with primary operable colorectal cancer who are found to have synchronous liver metastases should at least have an adequate resection of the primary lesion. If the primary lesion is resectable for cure and there are solitary hepatic metastases, then excision of these seems warranted. In most cases this can be accomplished by simple excision or wedge resection, although occasional cases may require lobectomy.     

Effect of vagal innervation on the secretory responses of canine gastric pouches exposed to bile.

The changes in the secretory response to a meat meal, after preliminary exposure of vagally innervated and vagally denervated fundic pouches to ox bile at pH 7 and pH 2, have been defined. In the innervated pouches, exposure to bile at both pH levels caused transient inhibition of gastric acid secretion. In both types of pouch, the output of Na+ in the gastric juice was presistently increased due to enhanced exchange diffusion. The changes were more pronounced after exposure to bile at pH 2 than after exposure to bile at pH 7. After exposure to bile, exchange diffusion was more increased in the innervated pouches than in the denervated. The results suggested that the innervated mucosa was more susceptible than was the denervated mucosa to the injurious effects of bile.     

Intraluminal pCO2: a reliable indicator of intestinal ischemia

A reliable, objective method to determine small bowel ischemia intraoperatively has not been developed. These experiments examined the relationship between intraluminal pCO2 (IL pCO2), intestinal blood flow, and degree of ischemic mucosal injury. IL pCO2 was measured with a clinical mass spectrometer using Teflon catheters calibrated in tissue mode; transmural intestinal blood flow was measured with radioactive microspheres. Anesthetized rabbits (N = 24) were cannulated for microsphere injections and mass spectrometer catheters were placed in the lumen of the small bowel. Blood flow was determined prior to superior mesenteric artery occlusion and then at 30, 60, or 180 min after occlusion. In control animals the superior mesenteric artery was not clamped. Intestinal biopsies were taken at the time of each blood flow determination and microscopic injury was graded from 1 (normal) to 4 (complete epithelial slough). There was a strong linear correlation between the IL pCO2 and the histologic grade of injury (r = 0.778, P less than 0.001). These results show that intestinal ischemia due to superior mesenteric artery occlusion causes a rapid, sustained rise in small bowel IL pCO2 that correlates with the degree of mucosal injury. These experiments suggest that this technology may provide a superior method to assess intestinal perfusion.     

Evaporative water loss of adult surgical patients in Greece

Daily evaporative water loss was studied in seventy-two adult surgical patients in Greece. It was found to average 1,480 ml in preoperative patients and 1,751 ml in postoperative ones. It is concluded that the daily amount of water given to surgical patients for replacement of evaporative water loss in temperate climates should be 1,500 to 2,000 ml.     

Operative risk in coronary revascularization of patients with ventricular dysfunction

The initial sixteen month experience in patients undergoing simple revascularization of coronary arteries shows that 81 per cent of these patients were either Class III or Class IV on the basis of the New York Heart Association scale preoperatively; 57 per cent had some degree of ventricular dysfunction on left ventricular cineangiography, 50 per cent had elevated left ventricular graft dysfunction at rest, and 57 per cent had elevation post angiography. The hospital mortality was 1.6 per cent in the first 252 patients, and 2 per cent of the patients had a definite perioperative myocardial infarction and a further 6 per cent had a possible myocardial infarction. The total number of patients operated on between January 1971 and March 1974 now exceeds 1,000 with a total over-all hospital mortality of ten patients or 1 per cent. We believe that mortality and morbidity are essentially unchanged and that the flow study instances of myocardial infarction, pericarditis, and arrhythmia are representative of our over-all experience. Whenever significant valvular disease or ventricular aneurysm is associated with occlusive coronary artery disease, we believe that revascularization is necessary to achieve lower mortality and that ventricular dysfunction per se in patients undergoing revascularization is only a relative contraindication to revascularization.     

Chemical antroneurolysis

Chemical antroneurolysis in dogs with alcohol-hyaluronidase solutions depressed food-stimulated gastric secretion, reduced gastric hypersecretion induced by antral transplantation into the colon, increased survival rates, reduced ulcer formation in animals subjected to Exalto-Mann-Williamson procedures. The antroneurolysis did not alter gastric emptying nor significantly modify the gross and microscopic appearance of the gastric antrum.     

Quantitative microbiology: Its application to hand injuries

Quantitative microbiologic analysis of civilian hand injuries has been accomplished in thirty-four patients. Most traumatic soft tissue injuries exhibited an insignificant level of contamination. The number of bacteria recovered from most of those wounds was comparable to that encountered in clean elective surgical hand cases. We now view most civilian hand wounds as clean wounds carrying a very low risk of infection.Our patients with traumatic hand injuries are considered candidates for immediate reconstruction, which includes vascular, bony, or neural repair as well as immediate implantation of Silastic rods in preparation for subsequent tendon grafting.     

Evaluation of peritoneal closure at laparotomy.

Laparotomy closure was performed in rats with and without peritoneal suture. Both paramedian and midline incisions were used. The incidence of adhesions to the parietal peritoneum was significantly higher when the peritoneum was sutured, more so with catgut. The peritoneal surface reperitonealized in 7 days when peritoneum was not sutured. The tensile and bursting strength was studied on the 7th and 14th day, and was found to be similar in both midline and paramedian incisions whether or not the peritoneum had been sutured. The same results were obtained whether continuous or interrupted sutures of the muscle sheath with monofilament nylon was used. We believe that the peritoneum should not be sutured at laparotomy closure and that a midline incision with rectus sheath closure using monofilament nylon should be used as it is less time-consuming and provides sufficient strength to the abdomen.