Agenesis of the dorsal mesentery without jejunoileal atresia (“apple peel small bowel”)

Agenesis of the dorsal mesentery with apple peel or Christmas tree deformity but without small-bowel atresia can occur beyond the neonatal period. The recognition of this entity is imperative as it is also associated with a marginal artery which may be the only blood supply to the majority of small bowel. Preservation of this vessel is necessary to avoid catastrophic bowel death.     

Jejunal atresia with agenesis of the dorsal mesentery. ("apple peel small bowel")

Our surgical experience with five newborn infants with atresia of the jejunum associated with agenesis of the dorsal mesentery suggests that improved survival of these infants was possible with careful surgical technique and the addition of hyperalimentation to their management.     

Early and late obstruction of the small bowel after abdominoperineal resection.

A series of patients with early or late obstruction of the small bowel after abdominoperineal resection is studied. Immediate intervention is recommended in patients with early obstruction; adhesions and defects of the pelvic floor are the most common etiologic factors in this group. Recurrent pelvic carcinoma with associated obstruction of the small bowel is the primary etiologic factor in patients with late obstruction. Bypass operation provides the best palliation. Simple adhesions continue to be a significant etiologic factor. No obstruction related to spaces created by colostomy was encountered.     

Primary tumors of the small bowel

Primary tumors of the small bowel are uncommon, representing less than 6 per cent of all gastrointestinal tumors and less than 2 per cent of all malignant gastrointestinal tumors. This report concerns a twenty-five year survey of our clinical records from 1946 to 1971 which revealed 140 primary small bowel tumors, excluding periampullary tumors. Fifty-two of the neoplasms (37 per cent) were benign; eighty-eight (63 per cent) were malignant and included twenty-eight adenocarcinomas (31.8 per cent), twenty-four lymphosarcomas (27.3 per cent), nineteen carcinoids (21.6 per cent), and ten leiomyosarcomas (11.4 per cent). The average age at the time of diagnosis was 56.9 years for patients with benign tumors and 55.9 years for those with malignant tumors. The illusive and obscure nature of small bowel tumors is illustrated by the fact that 63.3 per cent of patients with benign lesions and 47.6 per cent of those with malignant lesions had symptoms for more than six months before the diagnosis was made. Bleeding was the most common present complaint in patients with benign neoplasms (52.9 per cent) whereas patients with malignant lesions more often had symptoms of obstruction (50.6 per cent). Most of the benign lesions were located proximally in the small bowel (duodenum, 34.6 per cent; ileum, 11.5 per cent), and most of the malignant lesions were located distally (duodenum, 17.0 per cent; ileum, 61.4 per cent). Treatment of patients with malignant lesions was radical excision whenever possible. Adjunctive radiation therapy was used for those with lymphoma. A second benign or malignant tumor occurred in 42.9 per cent of the patients with primary small bowel tumors. The average period of survival after diagnosis of a malignant small bowel tumor was 5.03 years: for patients with adenocarcinoma, 3.6 years; lymphosarcoma, 1.3 years; carcinoid, 6.8 years; and leiomyosarcoma, 8.3 years.     

Transmesenteric small bowel plication or intraluminal tube stenting. Indications and contraindications.

Controversy exists as to the efficacy of transmesenteric intestinal plication or long tube stenting of the small bowel in the treatment of severe intestinal adhesions and in late small bowel obstruction.We reviewed our experience with these procedures over a 12 year period with complete follow-up data on 92 per cent of the patients. There were 28 modified Childs-Phillips plications and 37 intraluminal tube decompressions and stenting. For comparison we reviewed 107 cases of small bowel obstruction treated by simple lysis of adhesions.Three deaths and one small bowel fistula were associated with the modified Childs-Phillips procedure; none was directly related to the plication. Three patients required reoperation within the 1st postoperative week for technical reasons. No late operations for recurrent small bowel obstruction were required.One death and one reoperation for bowel obstruction were associated with but not directly related to the Baker tube stenting.Four deaths were associated with simple lysis. Seven patients required reoperation for late recurrent small bowel obstruction.Modified Childs-Phillips transmesenteric plication using nonabsorbable sutures is recommended in cases of severe visceral and parietal peritoneal damage but not in cases of distention and severe ileus of the small bowel or acute generalized peritonitis.Baker tube jejunostomy with decompression and splinting of the small bowel is recommended with massive distention and ileus of the small bowel. Peritonitis is not a contraindication. In our experience fewer short-term complications have occurred after long tube decompression and stenting than after modified Childs-Phillips plication. Measures to avoid these complications are presented. With proper indications, modified Childs-Phillips plication and intraluminal tube stenting are safe and efficient in preventing reobstruction.     

Primary neoplasms of the small bowel

The treatment of thirty-one malignant and eleven benign neoplasms of the small intestine is reported. The most common symptom was abdominal pain followed by vomiting, diarrhea, weight loss, constipation, and gastrointestinal bleeding. In four cases small bowel perforated. Intestinal obstruction occurred in 31 per cent of patients. Preoperative diagnosis was made in 19 per cent of patients. All eleven patients with benign neoplasms were curatively treated by resection and primary anastomosis. Eighteen of the thirty-one patients with malignant tumors had curative resection, five had palliative resection, and eight had laparotomy and biopsy only. The most common benign tumor was leiomyoma. The most common malignant tumor was lymphoma (67 per cent) followed by adenocarcinoma (16 per cent), carcinoid (10 per cent), and leiomyosarcoma (3 per cent). Twenty-four patients were available for follow up; thirteen remain alive and eleven died, seven within one year and four within two years.     

Congenital colonic atresia and stenosis.

Five more cases are added to the 88 reported cases of successfully treated newborns with congenital colonic atresia and stenosis. Because colonic atresia and stenosis are lethal conditions when untreated, early diagnosis and operative treatment are major requisites for survival. A two-stage procedure consisting of an emergency colostomy for decompression as the first stage and an elective resection with anastomosis a few months later is recommended. The need for thorough exploration of the abdomen is emphasized because atresias may be multiple or may be associated with additional gastrointestinal anomalies.     

Fistulas of the gastrointestinal tract. Experience with eighty-one cases.

Eighty-one cases of gastrointestinal fistulas are reported. Sixty-seven of these fistulas occurred postoperatively, all of them external, and fourteen occurred spontaneously, all but one internal. Fifty-two patients were treated conservatively and twenty-nine underwent operation, with an overall mortality rate of 23.4 per cent. It is noted that the presence of severe intraperitoneal infection and a high location of the fistula were associated with an unfavorable prognosis, with mortality rates of 31.4 per cent and 48 per cent, respectively.     

Radiation therapy for malignant melanoma of the head and neck.

Thirty-one patients with melanoma of the head and neck received split-course radiation therapy (5,000 to 6,000 rads/30 fractions) for loco-regional disease. There was no difference in survival in patients with gross tumors versus patients with no clinical evidence of disease at the start of radiation therapy. The prognosis was notably worse in patients with recurrence in the irradiated field.     

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.     

Expanded polytetrafluoroethylene as a small artery replacement: A preliminary report

Recent laboratory and clinical investigations have demonstrated a specific configuration of polytetrafluoroethylene (PTFE) to be a superior biocompatible material for small artery replacement. Twenty such vascular grafts have been implanted in eighteen patients. Grafts were placed in the femoropopliteal or femoral posterior tibial or anterior tibial positions in fifteen patients and in the aortorenal position in three patients. The early results have been satisfying as judged by follow-up angiography and/or clinical examination. There has been no aneurysmal formation in this series of Impragrafts. No infections have been noted. We believe that Impragraft may offer a logical substitute for the inadequate or surgically absent saphenous vein autograft.     

Primary malignant tumors of the small intestine: A twenty-two year experience with thirty patients

A review of thirty cases of primary malignant small bowel tumors is presented. Chronic obstruction was the presenting symptom most frequently encountered, with an acute abdomen from perforation of the tumor next in frequency. Adenocarcinoma and carcinoid were about equally encountered, and more than half of all tumors were found in the ileum. Three patients are alive and well, two are alive on chemotherapy, and all others are dead. Five of these died of other causes. Of twenty-seven patients explored for symptomatic small bowel cancers, only one is alive free of tumor. Malignant small bowel tumors are difficult to diagnose early and have a poor prognosis.     

Shortened small bowel syndrome: Mackby's operation

Intestinal infarction is a condition with a high rate of mortality. Progress in the fields of anesthesia, maintenance of electrolyte balance, and intensive postoperative care has made survival possible in a number of patients subjected to extensive resection of the small intestine. Many of these patients, however, later succumb to the effects of malabsorption.In this paper we report on a patient who has undergone massive intestinal resection, because of venous intestinal infarction, and Mackby's operation, with favorable results twelve months postoperatively.     

A controlled clinical trial of whole gut lavage as a method of bowel preparation for colonic operations.

In a prospective randomized clinical trial, whole gut lavage was evaluated against conventional mechanical cleansing for colonic operations. The lavage took less time to perform, was better tolerated by patients, and resulted in more satisfactory preparation as judged by frequency of collapsed intestines. There was no difference in the outcome in the two series as measured by wound infection rate and length of hospitalization. It is concluded that whole gut lavage is as good as conventional mechanical cleansing but surpasses the latter in logistic advantages.     

Role of selective venous catheterization of the small thyroid veins as a diagnostic study in hypercalcemic states

Previous studies of selective venous catheterization stress its value in localizing hyperfunctioning parathyroid tissue in patients with an established diagnosis of hyperparathyroidism. Our study presents our experience with selective venous catheterization as a diagnostic aid in the differential diagnosis of hypercalcemia. In our four patients, an extensive metabolic work-up did not resolve the differential diagnosis of hypercalcemia, and selective venous catheterization provided the ultimate data that led to the correct diagnosis of hypercalcemia in each patient. Selective venous catheterization can be an important diagnostic study in carefully selected patients with hypercalcemia.     

Inflammatory tissue reaction in rabbit bowel injected with Crohn's homogenates.

Homogenates from the terminal ileum of a patient with Crohn's disease with granulomas were prepared as snap-frozen or fresh and were injected into the ascending colonic walls of New Zealand white rabbits. Control animals were injected with 1 per cent bovine serum albumin alone. The rabbit bowel was examined after 1 year, and lesions were noted in each of the rabbits injected with Crohn's disease homogenate, irrespective of the type of tissue preparation. The observed lesions were diffuse and occurred both at the injection site and in the terminal ileum. These changes were not noted in the control group. This work confirms earlier results in the same animal model and suggests that either fresh or snap-frozen homogenates will produce the intestinal lesion but that bovine albumin alone will not.     

Low anterior resection with anastomosis by endorectal pull-through. Another look at Black's operation.

The type of endorectal pull-through described by Black was evaluated as an alternative method of anastomosis in 11 anterior resections in which anastomosis from above was impossible. The method is attractive from the standpoint of function because it preserves the distal rectum and leaves the anus intact. Technical points important to success are complete mobilization of the descending colon to allow the distal descending colon to be used for the pull-through and prophylactic dilatation of the early stenosis, which is characteristic of this type of anastomosis.     

Mortality and prognosis of obstructing carcinoma of the large bowel.

In a series of 760 patients with adenocarcinoma of the colon and rectum, 103 patients presented with acute obstruction requiring urgent surgical decompression. Obstructed patients were slightly older and had slightly more advanced tumors than the total group. Obstructing lesions of the left colon treated primarily by staged procedures had relatively low mortality and five year survival figures comparable to unobstructed cases. Obstructing lesions of the right colon had a much poorer absolute five year survival rate, mainly because of the high operative mortality associated with primary resection in our institution. Five year survival after curative resection in patients with obstructing tumors of the right colon was considerably less than in patients with nonobstructing tumors. A suggestion is made for consideration of proximal external bowel decompression in association with resection of the right colon.