Pseudoaneurysm of the dorsalis pedis artery

Two cases of post-traumatic pseudoaneurysm of the dorsalis pedis artery are presented. Both were managed by resection and vascular reconstruction with a successful result. It is suggested that this, rather than resection and ligation, is the preferred treatment in these cases.     

A simple operation for correction of chronic lateral instability of the ankle

Twenty-two patients underwent a simple operation for correction of chronic lateral instability of the ankle. During the procedure the function of the peroneus brevis was preserved and the anterior talofibular ligament was reconstructed. At follow-up only one patient reported that the ankle still felt unstable.     

A practical approach to the treatment of burn shock in childhood

A simple method of evaluating and treating burn shock has been used with very good results and low mortality.The amounts of fluids given in a specific time and the type of fluids given are dependent upon the evaluation of a few simple observations. We believe that shock is a treatable condition and that ‘shock kidney’ is preventable.We stress the difficulty of trying to compare the results of two different burn units.     

Use of a stapling technique in closure of perforation of the esophagus

A case of rupture of the esophagus is presented. Closure of the perforation was achieved using an Auto Suture stapler, with excellent results.     

Modification of the haemonetics cell saver for optional high flow rate autotransfusion

Intraoperative autotransfusion is a technique well-suited to major vascular surgery. It is most effective when salvage and reinfusion of shed blood can be accomplished at flow rates compatible with the degree of hemorrhage encountered in both elective and emergency procedures. Appropriate equipment modifications can render commercially available autotransfusion devices safer and more effective in the management of intraoperative blood loss. The Cell Saver, a device which concentrates and washes salvaged red blood cells, is limited in its potential as an autotransfusion device because of its slow reinfusion rate. A modification was devised which expands the flow capabilities of the Cell Saver and allows rapid reinfusion of autologous whole blood. The modified blood circuit has been employed in 10 major vascular cases with favorable results, thus demonstrating its efficacy in the management of massive hemorrhage during vascular repair. Guidelines for the safe and effective use of the modified unit are stressed.     

Resection versus pericystectomy in the treatment of hydatidosis of the liver

The surgical treatment of 87 hepatic cysts from Echinococcus granulosus in 42 patients has been presented. The importance of determining the features of the cysts in each patient (age, number, location, and relation with vasculobiliary structures) in order to carry out the most appropriate treatment was stressed. Radical surgery was preferred because marsupialization, a conservative technique still widely used, has a high complication rate (60 percent in this study) and a prolonged recovery time. Arguments for and against cystopericystectomy and hepatic resections have been discussed. It is noteworthy that excellent results have been observed after hepatic resection when it was performed in selected patients.     

Choledochoduodenostomy in the treatment of benign biliary tract disease

During the 15 year period 1965 through 1979, sixty patients underwent choledochoduodenostomy for benign obstructive lesions of the biliary tract. Patients with traumatic and iatrogenic common duct strictures were excluded. Eighty-two percent of the patients were in the seventh to ninth decades of life. Twenty-seven patients (45 percent) had undergone a total of 40 previous biliary tract surgical interventions. Thirty-three patients (55 percent) in the older age group (average age 75 years) were subjected to choledochoduodenostomy as a primary procedure during the first surgical intervention on the biliary system. Cholangitis recurred in only one patient (in whom the sump syndrome was the culprit), while all other patients have been free of abdominal complaints, cholangitis and pancreatitis during follow-up of 1 to 15 years. There was no operative mortality; morbidity was 26 percent. Hospital stay averaged 15 days. These favorable results mark choledochoduodenostomy as a safe, simple and effective procedure in the treatment of benign biliary tract disease, particularly in aged and high risk patients.     

Choledochoduodenal fistula: An unusual complication of duodenal ulcer disease

Choledochoduodenal fistula in the absence of primary biliary disease is an unusual complication of duodenal ulcer disease. A case seen recently at the Johns Hopkins Hospital is reported and the literature on Choledochoduodenal fistula secondary to penetrating duodenal ulcer is reviewed. Treatment should be individualized according to the clinical situation. The elderly or poor risk patient, in the absence of complications, can be treated with an intensive medical regimen of antacids or cimetidine, or both. Surgical therapy is indicated in patients with a history of intractability or complications of duodenal ulcer disease. Exclusion-type gastrectomy is optimal. An attempt at division of the fistula itself is hazardous and unnecessary since long-term complications are rare.     

Adjunctive arteriovenous fistula with tibial and peroneal reconstruction for limb salvage

Arteriovenous fistulas were constructed as an adjunct to femoral peroneal and tibial bypasses in 13 patients threatened by imminent limb amputation. Previous attempts at conventional vascular reconstructive procedures had failed in nine patients. Deficient or absent pedal arches were noted in all patients, as were poor quality or small crural arteries. Graft patency was achieved in 11 cases and limb salvage in 10. There was no mortality. A steal phenomenon occurred in one patient and was successfully treated by secondary popliteal vein ligation. These preliminary results clearly indicate that an adjunctive arteriovenous fistula can maintain patency in a femoral tibial or peroneal bypass graft while preserving flow into the markedly diseased distal circulation.     

Interaction of chenodeoxycholic acid and dietary cholesterol in the treatment of cholesterol gallstones

Standard doses of chenodeoxycholic acid (15 mg/kg/day) fail to dissolve gallstones in 30 to 50 percent of patients with radiolucent gallstones in a functioning gallbladder. In humans, increasing dietary cholesterol produces increased biliary secretion of cholesterol. Restriction of dietary cholesterol reduces the minimum effective dose of chenodeoxycholic acid and speeds gallstone dissolution. In this study we investigated the interaction of dietary cholesterol and chenodeoxycholic acid in the prevention of gallstones in the prairie dog gallstone model. In animals fed a moderately lithogenic diet, standard doses of chenodeoxycholic acid failed to prevent gallstones. Reduction of the cholesterol stimulus or doubling the dose of chenodeoxycholic acid prevented the formation of gallstones. These findings support the hypothesis that the formation and dissolution of cholesterol gallstones are an expression of the relative strengths of saturating and desaturating stimuli. Therefore, rational therapy for cholesterol gallstone dissolution and prevention requires both reduction of lithogenic stimuli and optimal titration of chenodeoxycholic acid.     

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 percent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.     

Simple reconstruction of anteromedial rotational knee stability

A technically simple operation for the restoration of anteromedial rotational knee stability is described. It involves suturing under tension the posteromedial capsule of the knee joint to the semimembranosus tendon at its insertion into the tibia, with the leg held in full internal rotation and with the knee flexed to 60 °. This, in combination with the conservative treatment of meniscal injuries and with tightening of the soft tissue structures over the medial aspect of the knee, restored full or almost full anteromedial stability in the knee in 15 out of 16 young men, observed for an average of 19 months after the operation.     

Acute cholecystitis and cholestasis as a complication in hip surgery

Four patients who developed jaundice and acute cholecystitis following operations on the hip are reported. These complications occurred over a period of 6 years. In 3 cases no gallstones were found. Two subjects underwent cholecystectomy; one of them died on the fourteenth day after operation. The other 2 were treated conservatively without further complications.     

Surgical treatment of gastroesophageal reflux with esophageal stricture in infancy and childhood

During the past 5 years, 26 infants and children with gastroesophageal reflux were operated on. The results have been highly satisfactory and unattended by serious complications or mortality. Barium fluoroscopy was the most reliable diagnostic method. The indications for operation were persistent vomiting with failure to thrive, recurrent aspiration pneumonia, gastrointestinal bleeding and peptic stricture of the esophagus, not relieved by medical treatment. The high incidence of peptic stricture of the esophagus (50 percent) may reflect delay in diagnosis and medical treatment, which is successful in 60 to 87 percent of the infants with gastroesophageal reflux. Surgical treatment consisted of Nissen fundoplication combined with gastrostomy in cases of esophageal stenosis where dilatations were indicated. Complications related to the operation were minimal. In a follow-up period of 9 months to 5 years, all patients had obtained relief of symptoms of reflux and had excellent nutritional status and normal growth.     

Primary closure of the contaminated wound: Closed suction wound catheter

Primary closure of the contaminated wound using a closed suction catheter and antibiotic or povidone-iodine irrigation is a cost-effective and convenient alternative to standard open wound care with delayed primary closure. Antibiotic irrigation appeared more effective than povidone-iodine in this study, but the total number of patients studied was too small to be statistically significant.     

Mandatory laparotomy for gunshot wounds penetrating the abdomen

A 4 year experience with 245 patients with isolated lower thoracic or anterior abdominal gunshot wounds was reviewed. Twenty-three (16 percent) of the 144 abdominal injuries were clinically superficial and all were managed successfully nonoperatively. Of the remaining 121 patients, 115 were confirmed to have peritoneal violation at laparotomy and 111 (96 percent) of these had significant visceral injuries. Of the 101 patients with lower chest wounds, 47 had peritoneal violation and 45 (96 percent) had intrabdominal injuries. Twenty-six (17 percent) of the 156 patients with intraperitoneal trauma had unimpressive physical signs on admission. These findings support a policy of routine exploration for gunshot wounds violating the peritoneum. When depth of penetration is uncertain, diagnostic peritoneal lavage should be used. Only those patients with unequivocally superficial injuries warrant observation.     

Surgical treatment of anorectal melanomas

Thirty cases of anorectal melanoma have been recorded in Israel from 1960 to 1981. The frequency of the disease doubled in the last decade (from 10 to 20 cases). A clear predominance has been noted among Jews of European descent (18 patients) as opposed to Sephardic Jews (9 patients) or Arabs (3 patients). From this series, the emerging conclusion is that in most cases radical surgery (abdominoperineal resection) is seldom indicated. It is doubtful whether this form of treatment increases the survival while affecting considerably the quality of life. Survival correlated well with the stage of disease at the time of diagnosis. No such correlation could be established with the type of treatment employed.     

Aggressive surgical management of popliteal artery aneurysms

One hundred fifty-nine patients with 244 popliteal aneurysms underwent 167 reconstructive procedures. Patients were divided into those with asymptomatic aneurysms, those with acute ischemia secondary to thrombosis or embolism, those with claudication secondary to chronic thrombosis or embolism, and those with local symptoms referable to the aneurysm itself. Patients who underwent successful revascularization were considered to have good early results. Patients with asymptomatic aneurysms had uniformly good results (97.2 percent) as opposed to those presenting with acute (70.7 percent) or chronic symptoms (83.8 percent). Similar statistically significant differences were seen when patients with thrombosis (71.7 percent) or embolism (81.3 percent) were compared with asymptomatic patients. Analysis of late results indicates that if an initial good result was obtained, the late patency rate was independent of type of presentation. Late results were affected by type of conduit employed where life table analysis showed the superiority of saphenous vein over Dacron prosthesis. At 5 year follow-up, 77.2 percent of all saphenous veins were patent whereas only 29.5 percent of Dacron prostheses remained patent.     

Simplified method for the detection of choledochal stones

Intraoperative cholangiography is an essential part of cholecystectomy. Visualization of choledochal stones can be difficult when dealing with small calculi and a nondilated common bile duct. A simple method to detect such small stones is described. The method was used in 120 patients undergoing cholecystectomy, and in 5 of them calculi not visualized on operative cholangiography were detected.