Evaluation of the results of external choledochoduodenostomy for retained, recurrent, or primary common duct stones.

Twenty-five patients were treated for retained, recurrent, or primary common duct stones by permanent drainage of the biliary tract with external choledochoduodenostomy. Twenty-one patients had common duct stones which became evident two to fifty years after the initial biliary tract procedure and which may represent stones formed in the common duct. Three recent patients had a clinical history of primary common duct stones, had stones which were soluble in chloroform-methanol solution, and had hepatic bile which was lithogenic as determined by evaluating the molar percentage of cholesterol, phospholipid, and bile salt in bile samples obtained at the time of choledochoduodenostomy. These data suggest that further stone formation is possible and that permanent bypass of the sphincter of Oddi is indicated to prevent recurrent bile duct obstruction. Long-term evaluation of the results of external choledochoduodenostomy indicates that the procedure is safe and effective in the prevention of recurrent biliary tract calculi.     

Metabolic responses of the heart in acute myocardial infarction in man

Acute myocardial infarction evokes a characteristic neurohumoral response: Catecholamine release is increased, plasma contents of free fatty acids and glucose are elevated and glucose tolerance is diminished. To what degree the myocardium participates in this stress response was evaluated by sampling coronary sinus and arterial blood in 50 patients with acute transmural infarction. Studies were initiated an average of 8 hours after the clinical onset of infarction and were continued for up to 60 hours. A total of 173 separate metabolic studies were analyzed. Forty-one percent exhibited a pattern of predominant myocardial free fatty acid uptake (mean extraction ratio 24 percent) in the presence of elevated plasma free fatty acid and glucose contents (respective means 1,181 μmol/liter and 210 mg/100 ml). Myocardial extraction ratios for glucose, lactate and pyruvate were low (respective means 1.1, 4 and 11 percent). Twenty-one percent of the studies revealed normal myocardial metabolism and 18 percent showed enhanced carbohydrate uptake, as evidenced by increased myocardial extractions of lactate and pyruvate (respective means 42 percent) and of glucose (mean 5 percent). Plasma contents of glucose and free fatty acids were lower than in the predominant free fatty acid group (respective means 156 mg/100 ml and 743 μmol/liter). The remaining 20 percent of studies showed high plasma substrate contents and low myocardial substrate uptake suggesting metabolic breakdown. The free fatty acid metabolic pattern was observed in more than 50 percent of the studies performed at the time of or close to the occurrence of important clinical complications. Propranolol, 0.1 mg/kg intravenously, shifted myocardial substrate utilization from free fatty acids toward carbohydrates. The myocardial respiratory quotient increased from an average of 0.79 to 0.88 (P < 0.01).The study demonstrates that the metabolic patterns of the myocardium are influenced by the systemic response to stress. Beta adrenergic blockade changed substrate utilization of the myocardium, supporting the hypothesis that adrenergic activation plays an important role in these metabolic responses.     

Extrathoracic esophagectomy in the treatment of esophageal cancer

Extrathoracic esophagectomy has the potential of improving the results of resectional therapy for carcinoma of the esophagus by eliminating the need for thoracotomy and decreasing postoperative pulmonary complications. This report compares the operative and functional results of blunt extrathoracic esophagectomy and substernal reversed gastric tube reconstruction in patients with esophageal cancer to results in 10 consecutive nonrandomized control patients treated by standard esophagogastrectomy. Extrathoracic esophagectomy was associated with greater pulmonary dysfunction than standard esophagogastrectomy. While there was no significant difference in survival in the two groups, three patients in the standard esophagogastrectomy group (mean survival 9.0 months) and none in the extrathoracic esophagectomy group (mean survival 7.4 months) developed anastomotic recurrence. Extrathoracic esophagectomy evidently does not afford patients with esophageal carcinoma better palliation than standard esophagogastrectomy.     

Multiple primaries among gynecologic malignancies

Seventy-eight synchronous or metachronous tumors among 2362 patients followed by the Downstate Gynecologic Tumor Registry are reviewed. Significant synchronous tumor pairs include cervix (invasive and in situ)-ovary, cervix (in situ)-uterus, cervix (in situ)-kidney, endometrium-ovary, endometrium-rectosigmoid and ovary-breast. Significant metachronous pairs include cervix (invasive and in situ combined)-lung, cervix (invasive and in situ combined)-upper alimentary tract, and cervix (invasive)-rectosigmoid. In the case of in situ and invasive cervical cancer-lower genital tract, significance was determined for both synchronous and metachronous pairs. Long survival is an important factor in the appearance of a second tumor as demonstrated in patients with cervical carcinoma. Synchronous data prove to be valuable in assessing risk of second primaries in patients surviving for short periods. The roles of cigarette smoking, hormones, immunosuppression, radiotherapy, and screening are discussed.     

Primary transitional cell carcinoma of the fallopian tube associated with primary carcinomas of the ovary and endometrium

A patient with primary transitional cell carcinoma of the fallopian tube, primary endometrial adenocarcinoma, and primary endometrioid carcinoma of the ovary is reported. The clinical picture was similar to that of adenocarcinoma of the fallopian tube, but the mode of spread was somewhat different and more aggressive. The patient was treated with surgery and a combination of internal and external radiotherapy.