Surgical treatment of late postgastrectomy syndromes.

An analysis of the experience at the University of California Hospital, San Francisco, with the diagnosis and treatment of fifty-nine postgastrectomy syndromes shows that stomal obstruction (sixteen patients), the most common syndrome, was best treated by total reconstruction rather than stomal revision. Disappointment with the results of other procedures for the dumping syndrome (50 per cent improvement) has convinced us of the need to adopt the use of reversed jejunal interposition for surgical treatment of this condition. Because a precise etiologic diagnosis of bilious vomiting is often elusive, the preferred procedure is isoperistaltic jejunal interposition, since it eliminates the afferent loop and prevents bile from entering the stomach. All five patients with malabsorption were improved by conversion from BII to BI. Four of five patients with diarrhea were improved by various procedures (not including a reversed segment of intestine in the midjejunum). Three patients with reflux alkaline gastritis were improved by Roux-en-Y gastrojejunostomy or isoperistaltic jejunal interposition. Either is effective. Thus, in our experience if an unquestionable diagnosis of stomal obstruction, malabsorption, or reflux alkaline gastritis can be established, there is ample justification for an optimistic outlook regarding surgical therapy.     

Management of thyroid nodules in the elderly

Eleven malignant thyroid tumors were found in 100 consecutive patients more than sixty years old having thyroid operations. Based on preoperative findings, these 100 patients could be separated into two groups according to high and low risk for malignancy. Clinical manifestations in the high risk group were presence of a discrete cold thyroid nodule, hoarseness, dysphagia, an enlarging mass, or palpable ipsilateral cervical adenopathy; and in the low risk group, asymptomatic multinodular goiter, diffusely enlarged glands with elevated antithyroid antibody titers, and a family history of goiter. All eleven patients with malignant thyroid tumors were found in the sixty-six patients considered at high risk, whereas no malignant lesions were found in the low risk patients. Six of the malignant thyroid tumors were undifferentiated and in three of these a thyroid nodule had been present for more than fifteen years. There were no operative deaths and only one significant complication, a recurrent laryngeal nerve injury. Thyroidectomy is indicated for elderly patients with thyroid nodules who have features of the high risk group, whereas patients in the low risk group can be safely followed.     

Clinical utility of CAT body scans.

The results of 202 computerized axial tomography (CAT) body scans performed on hospitalized patients were analyzed for their accuracy and clinical utility. The sensitivity (80 per cent), specificity (70 per cent), and accuracy (77 per cent) were high but not superior to ultrasound examinations of the same area. The results of the CAT body scan affected patient management in 16 per cent of patients and affected the success of treatment in 1 per cent of patients. We conclude that for many abdominal conditions ultrasound scans are equally as accurate and substantially more cost-effective than CAT body scans, and that the clinical value of CAT body scans needs support from controlled clinical trials.     

Significance of lymph node metastasis in differentiated thyroid cancer

In age-matched patients with differentiated carcinoma of the thyroid, the tumor recurred in 32 per cent of those with lymph node metastases and in 14 per cent of those without lymph node metastases. Twenty-four per cent of patients with nodal involvement at the initial examination died of thyroid cancer, whereas only 8 per cent of those without nodal involvement died of thyroid cancer. In patients less than forty years old, there were no deaths in those without nodal metastases bu there were three deaths (11 per cent) in patients with nodal metastases. In patients more than forty years old, nine (41 per cent) iwth nodal metastases died of tumor, and four (15 per cent) without nodal metastases died of tumor. In the presence of positive nodes the death rate was substantially greater in the older than in the younger patients. Nodal involvement has an adverse effect on prognosis, but appears to be less important than the age of the patient.     

Technical accuracy and clinical efficacy of thoracic computed tomography

The technical accuracy and clinical efficacy of thoracic CAT scans in 302 surgical patients were retrospectively reviewed. We conclude that thoracic CAT scans should be ordered selectively since the technical accuracy of existing radiographic studies in detecting disease is equally high (greater than 90 percent) and the clinical efficacy does not differ substantially (less than 16 percent). The accuracy of CAT scans in staging carcinoma (the extent of the lesion or nodes) is only 58 percent. The technical limitations of these scans include (1) a lack of specificity because of the high incidence of false-positive lymph nodes, (2) a low or unreliable yield from needle aspiration, and (3) unreliable findings due to altered anatomy by previous treatment or associated disease. Surgical treatment regarding operability and resectability should not be solely based on CAT scans. These scans appear to be a useful screening test for chronic vascular disease and localization of obscure thoracic infections.     

Parathyroid cysts

Cystic neck masses may be accurately diagnosed by sonography, and some nonfunctioning parathyroid cysts can be cured by percutaneous aspiration. Primary hyperparathyroidism should be considered in all patients with cystic neck masses. Parathyroid cysts can often be recognized from the characteristics of the cyst fluid which is usually clear and colorless, contains elevated parathyroid hormone levels and normal or low thyroid hormone levels, and may contain parathyroid cells. Parathyroid cysts may be multiple; all four parathyroid glands should therefore be identified and appropriately removed or hyperparathyroidism may persist.     

Experimental gastric carcinogenesis in the rat: Effects of hypergastrinemia and acid secretion

The present experiments examined in rats the influence of chronic hypergastrinemia and the resulting gastric hyperacidity on induction of gastric adenocarcinoma by N-methyl-N′-nitro-N-nitrosoguanidine (MNNG). Three groups of animals were studied: (A) control rats (no operation, normogastrinemia); (B) rats with antrectomy and Billroth II (normogastrinemia); and (C) rats with implantation of the antrum into the colon and Billroth II (hypergastrinemia). All rats were fed MNNG, 83 μg/ml, in drinking water for 6 months and were observed for 6 more months before being killed. The number, location, and histology of malignant gastric neoplasms were recorded.The incidence of tumors in the proximal gastric remnant of the Billroth II antrectomy rats was 88 percent, significantly greater than the incidence in the proximal gastric remnant (excluding the implanted antrum) of Billroth II antral implant rats (50 percent) or in control rats (50 percent). In addition, 19 gastric neoplasms were found in the 12 antra implanted into the transverse colon.Thus antrectomy Billroth II predisposed the animals to tumors, which was at least partially offset by hypergastrinemia. This suggests that gastric mucosa is more vulnerable to carcinogens after antrectomy and Billroth II, and the effects of hypergastrinemia (or acid secretion and mucosal growth) reduce this vulnerability. Hypergastrinemia did not protect the antrum from tumor induction when the antrum was removed from exposure to acid. These data suggest that in rats (1) antrectomy Billroth II predisposes to carcinogenically induced gastric cancer, (2) hypergastrinemia directly or indirectly decreases this predisposition, and (3) in the presence of hypergastrinemia and after removal from the acid stream, the antrum is highly vulnerable to the carcinogenic effects of MNNG.     

Infection in vascular prostheses. Clinical manifestations and surgical management

The clinical manifestations and results of management in twenty-seven patients treated for infected vascular prostheses are reviewed. The mortality of 37 per cent and a loss of limb rate of 37 per cent are testimony to the serious nature of the problem. The over-all incidence of infection in our series of prosthetic grafts is 2.5 per cent; however, grafts inserted between 1966 and 1973 have an infection rate of 1.5 per cent as compared to that of grafts inserted prior to 1966 when the infection rate was 4.1 per cent. The most likely explanation for this lowered rate of infection was a corresponding change in prophylactic antibiotic management.     

Extrathoracic repair of branch occlusions of the aortic arch.

Thirty extrathoracic operations in twenty-six patients with occlusive disease involving the primary branches of the aortic arch were reviewed. Spanning a fourteen year experience, these operations included carotid-subclavian artery bypass, retrograde common carotid artery thrombectomy, carotid-carotid artery bypass, and femoral-axillary artery bypass. Dacron bypass grafts were used primarily for reconstruction, but saphenous vein bypass and endarterectomy were also employed. Indications for operation, the presence of concomitant cardiovascular disease, surgical technics, patient survival, and late patency of the reconstructions were reviewed. One patient died postoperatively (3.85 per cent). All Dacron grafts were patent on late follow-up examinations. Low mortality and excellent late functional results make extrathoracic repair the approach of choice in the management of occlusive disease of the branches of the aortic arch.     

Hashimoto's thyroiditis and thyroid cancer: Indications for operation

This study demonstrates that patients with Hashimoto's thyroiditis can be separated into those at low risk and those at high risk for cancer. Patients with solitary or dominant cold thyroid nodules have about a 25 percent chance of thyroid cancer, whereas the vast majority of patients who have diffusely enlarged glands or nodular goiters without a dominant nodule are unlikely to have thyroid cancer.     

Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy

We analyzed the course of 50 consecutive patients with recurrent biliary stricture (at least one previous repair) to determine the pattern of recurrence and the outcome of additional treatment. The presenting manifestations included cholangitis in 40 percent of the patients, jaundice in 30 percent, and pain in 17 percent. Sixty-seven percent had become symptomatic within 2 years of their previous repair and 90 percent within 7 years. Ten (20 percent) patients were treated by end-to-end anastomosis of the bile duct, and 40 (80 percent) patients by bilioenteric anastomosis (hepaticojejunostomy in 32 patients and hepaticoduodenostomy in 8). Two patients (4 percent) died postoperatively. After repair of recurrent stricture, 38 (76 percent) patients had no further symptoms. In 11 (22 percent), another recurrence developed: 6 (55 percent) of the 11 did well after another operation and in 4 (36 percent), a third recurrence developed which was successfully treated by a fourth operation in 3 of the patients. Thus, two thirds of recurrent strictures were evident by 2 years and 90 percent by 7 years. The chance of another recurrence was about 25 percent after treatment of a first recurrence. There was no evidence that prolonged stenting contributed to a good result. Treatment of recurrent stricture should consist of anastomosis between the duct and the intestine, usually a hepaticojejunostomy.     

Bilirubin and alkaline phosphatase values before and after surgery for biliary obstruction

From a study of 178 patients who underwent operation for biliary obstruction, we found that preoperative bilirubin values above 14 mg/dl and alkaline phosphatase values over 5 times normal meant that common duct stones were an unlikely cause of the obstruction. Jaundice for more than 4 weeks before operation, bilirubin values greater than 10 mg/dl and the presence of significant fibrosis in the portal spaces indicated a lower than average chance of postoperative resolution of jaundice. After successful biliary surgery, the rate of decrease in serum alkaline phosphatase was haphazard and of little diagnostic value. The postoperative rate of decrease in the bilirubin values followed first-order kinetics and averaged 8 percent/day. This rate was not significantly influenced by the disease process, the length of preoperative clinical jaundice or the absolute height of the preoperative serum bilirubin level.     

Usefulness of diagnostic tests for biliary obstruction

We studied the value of tests commonly used in diagnosing obstructive jaundice in 178 patients operated on for biliary obstruction. Ultrasonography had a diagnostic accuracy of 87 percent for gallbladder stones, 82 percent for dilated ducts, and 80 percent for pancreatic masses. Computed tomography was 93 percent accurate in diagnosing dilated ducts, and 93 percent accurate in diagnosing a pancreatic mass. Intravenous cholangiography gave useful information in only 4 of 21 patients. Among 45 patients, endoscopic retrograde cholangiopancreatography was technically successful in 91 percent and gave accurate diagnostic information in 86 percent and partially diagnostic information in 7 percent; it detected all cases of common duct stones and had a 91 percent sensitivity for detecting pancreatic cancer. Among 75 patients, transhepatic cholangiography was technically successful in 95 percent and provided accurate diagnostic information in 90 percent and partially diagnostic information in 3 percent; it detected all cases of common duct stones and 95 percent of cases of benign strictures. With persistent jaundice, ultrasonography should be the first test because it is less costly than computed tomography and provides similar information. If more information is needed, transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are equally accurate; transhepatic cholangiography more often opacifies the proximal biliary tree and endoscopic retrograde cholangiopancreatography provides direct access to the ampulla of Vater and the pancreatic duct.     

Effects of lumbar sympathectomy on skin capillary blood flow in arterial occlusive disease

Thirteen patients undergoing lumbar sympathectomy had skin blood flow measured preoperatively and postoperatively in the lower extremity by ¹³³xenon clearance. Eleven of 15 sympathectomized extremities showed an increase in nutritional blood flow when compared to preoperative measurement. The unsympathectomized extremity was used for control measurements. The clinical symptom that was most improved was rest pain.This measured increase in skin capillary blood flow after sympathectomy supports the continued use of this operative technique for ischemic skin conditions of the lower extremity.     

The use of fresh tissue arterial substitutes in infected fields.

An experiment, designed to test the efficacy of arterial bypass in the presence of infection using fresh autograft and allograft arteries in comparison to knitted Dacron grafts is presented. Three months following implantation of these conduits in infected femoral wounds, 11 out of 12 autografts, and 10 out of 12 allografts were found to be sterile, while 7 out of 8 Dacron grafts were infected. The results of this study suggest that fresh, live arterial autograft and allograft arteries are suitable materials for arterial reconstruction in infected fields since they function as a vascular conduit and allow the clearing of the infectious process by conventional antibiotic therapy.     

Diagnosis and treatment of gastric emptying disorders: Clinical usefulness of radionuclide measurements of gastric emptying

We studied 53 patients with severe gastrointestinal symptoms thought to be due to a gastric motility disorder. Sixty-six percent had had a previous operation on the stomach, and 21 percent had insuli-ndependent diabetes mellitus. Based on clinical, radiographic, and endoscopic findings, 48 patients were thought to have gastroparesis, 3 were thought to have dumping, and 2 had no diagnosis. Measurement of gastric emptying of solids showed that gastric emptying was normal in 12 patients, rapid in 15 patients, and slow in 26 patients. Further evaluation showed that half of the patients with normal gastric emptying, and one third of those with rapid gastric emptying had other diseases of the gastrointestinal tract that responded well to surgery. Of those patients with dumping, diet modification was effective in 40 percent, and half of those who did not respond to dietary manipulations did well after reoperation. Nineteen patients with delayed gastric emptying were treated with metoclopramide. Sixty percent of those without previous gastric surgery responded, whereas only 25 percent of those with previous gastric surgery had good results. The rate of gastric emptying improved following reoperation in 9 (90 percent) of 10 patients with delayed gastric emptying (4 who had not responded to metoclopramide). Gastric emptying was measured again in 15 patients after treatment. The changes after treatment paralleled the clinical response.These studies indicate that gastroparesis cannot be reliably diagnosed on the basis of clinical findings and standard tests. Gastric emptying studies are essential to diagnose and treat patients thought to have gastric motility disorders, and to evaluate the results of therapy.     

Composition and morphologic and clinical features of common duct stones

No systematic study of the composition of common duct stones has been carried out to date. In this study, we assessed the chemical composition and morphologic characteristics of common duct stones from 115 patients, and compared them with gallbladder stones in 67 patients who had both. Visually and chemically, common duct stones could be divided into two groups: cholesterol stones and pigment stones. Cholesterol common duct stones contained 83 ± 1 percent cholesterol, 2.3 ± 0.4 percent bilirubin, and 5.5 ± 1 percent insoluble pigment residue. Pigment common duct stones contained 7 ± 1 percent cholesterol, 24 ± 2 percent bilirubin, and 38 ± 3 percent pigment residue. There were two subgroups of pigment stones: one with large amounts of bilirubin and one with large amounts of pigment residue. A high proportion (46 percent) of common duct stones were composed of pigment. Patients with pigment common duct stones were more likely to have cholangitis and pancreatitis than were patients with cholesterol stones. It was not possible to distinguish primary from secondary stones on morphologic grounds.In 65 of 67 patients (97 percent), gallbladder stones and common duct stones were of the same chemical type. Morphologically, cholesterol common duct stones were very similar (3.6+ on a scale of 0 to 4+) to their counterparts. Pigment common duct stones and gallbladder stones were less similar (2.4+). Chemically, cholesterol common duct stones were identical to their gallbladder counterparts. Pigment common duct stones regularly contained a greater fraction of bilirubin and less pigment residue than associated gallbladder stones (p < 0.05). Earthy common duct stones were associated with earthy gallbladder stones, and were chemically indistinguishable from other pigment stones.These data suggest that all cholesterol common duct stones, and when the gallbladder is present, most pigment common duct stones, are secondary. The latter stones, however, probably grow after entering the duct, adding pigment with a high proportion of bilirubin relative to pigment residue.     

Splenectomy for massive splenomegaly

Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.     

Surgical treatment of chronic pancreatitis

We studied the course of 100 consecutive patients who underwent surgery for pain or biliary obstruction from chronic pancreatitis or both between 1958 and 1982. Patients with pancreatic pseudocysts were excluded. Ten patients had pancreatic resection after previous pancreatic surgery had failed to control pain. Ten of 47 patients (21 percent) studied between 1972 and 1981 had bile duct entrapment from chronic pancreatitis and required biliary bypass operations. The results of longitudinal pancreaticojejunostomy were good in 67 percent of the patients, fair in 18 percent of the patients, and poor in 15 percent of the patients. The results of partial pancreatectomy were good in 60 percent of the patients (all with disease limited to the tail), fair in 20 percent of the patients, and poor in 20 percent of the patients. The results of subtotal pancreatectomy were good in 31 percent of the patients, fair in 37 percent of the patients, and poor in 32 percent of the patients. The results of pancreatic resection in patients with previous unsuccessful surgery for pain relief were good in only 10 percent of the patients. Biliary obstruction is present in many patients with chronic pancreatitis and must be treated surgically to prevent the development of biliary cirrhosis. Hemipancreatectomy is useful in patients with disease limited to the tail. The results of subtotal pancreatectomy are discouraging, especially in patients with a previous unsuccessful operation for pain. When the pancreatic duct is dilated, however, longitudinal pancreaticojejunostomy gives long-lasting relief of pain in most patients.