bluuebunny/crossref_metadata_2025 huggingface dataset:
How do clinical results after proximal gastric vagotomy compare with the Visick grade pattern of healthy controls?
Authors: Muller C. , Engelke B. , Fiedler L. , Marrie A. , Mühe E. , Schmitz‐Harbauer W. , Zumtobel V.
Published: May 2005

Recently, the 5‐year results of a multicenter trial on proximal gastric vagotomy (PGV) have been reported. Symptomatic results in 415 duodenal ulcer patients, according to the Visick grading, were as follows: grade 1, 64%; 2, 28%; 3, 4%; and 4, 4%. It appears that one‐third of the patients are symptomatic, and the question arises as to which standard such a Visick grade pattern should be compared.

Five hundred sixty‐one healthy controls (blood donors), without history of peptic ulcer or previous gastric operation, have been examined according to a standard questionnaire identical to that used for follow‐up interrogation in the PGV trial. The control group was matched for sex and age with the trial population. Answers to 3 screening questions were compared with the result of detailed interrogation. The control group's Visick pattern was as follows: grade 1, 64.5%; 2, 28.9%; 3, 6.4%; and 4, 0.2%. Symptoms most frequently encountered were those of dyspepsia (pain, epigastric fullness) and gastroesophageal reflux. Dumping (2%) and diarrhea (4%) were also noted. Our conclusions are these: (1) The Visick grade pattern 5 years after PGV is almost identical with that of healthy controls. (2) Dull pain, epigastric fullness, and reflux symptoms are not specific signs after PGV. (3) Screening questions are misleading and follow‐up examinations must be based on a standard questionnaire to provide valid information. (4) The separation between Visick grade 1 and 2 should be abandoned, as it has no clinical importance. (5) PGV has virtually no specific long‐term sequelae except recurrence.
Infection of hepatic cysts following kidney transplantation in polycystic disease
Authors: Bourgeois Nadine , Kinnaert Paul , Vereerstraeten Pierre , Schoutens André , Toussaint Charles
Published: May 2005

Infection of hepatic cysts is not considered a classic complication of polycystic liver disease. In the rare cases reported in the literature, diagnosis was always made postmortem. We observed recurrent septicemic episodes due to infected hepatic cysts in a patient with hepatorenal polycystic disease (HRPD) who had been transplanted with a cadaver kidney. Aggressive surgical treatment, intensive antibiotherapy, and interruption of azathioprine treatment were required in order to cure the patient. With increased life expectancy of patients with HRPD because of hemodialysis and kidney transplantation, this complication is likely to occur more often in the future.
Prediction of healing time as an aid to the management of open granulating wounds
Authors: Marks Joseph , Hughes Leslie E. , Harding Keith G. , Campbell Hubert , Ribeiro C. Donald
Published: May 2005

The healing rates of 2 groups of patients were studied. Forty patients had laparotomy wounds that were left open to granulate because of overt or suspected infection, and 29 were from a series of pilonidal sinus excisions left unsutured as a matter of policy. The linear regressions of healing time against wound size were determined, the dimension chosen for wound size being either the breadth or depth, whichever was greater. From the results obtained, it was possible to calculate a “predicted” healing time for each wound corresponding to its size and to see how this differed from the observed time. The deviations found were used for statistical analysis relating to possible etiological factors; for example, the significance of infection as a cause of delayed healing.

Prediction of the healing time for individual wounds allows the patient to be given information about the likely duration of wound healing. More importantly, it enables delay in wound healing to be recognized and investigated at an early stage and facilitates analysis of factors having a possible bearing on the process.
Intramuscular pressure changes during and after revascularization of the femoral arteries in humans
Authors: Christenson J. T. , Qvarfordt P.
Published: May 2005

Intramuscular pressures in the anterior tibial compartments of the lower extremity were measured by the wick catheter technique in 5 patients undergoing revascularization of the femoral arteries by bifurcation grafting, because of occlusive arteriosclerotic disease. The intramuscular pressure at rest was within a normal range preoperatively (9.1±4.5 mm Hg), but rose significantly to a maximum level 4–6 hours after blood flow was reestablished (22.4±5.0 mm Hg), followed by a gradual decrease over 5 postoperative days, and reached the preoperative value on the 5th postoperative day (8.7±5.1 mm Hg). Changes in calf circumferences reflect the changes in intramuscular pressure. No significant changes in intramuscular pressures were seen when measured at different times during the day. Addition of thoracic epidural anesthesia did not affect the intramuscular pressures as compared to a combination of balanced anesthesia alone.

During occlusion of the aorta (clamping), no changes in intramuscular pressures were seen, but the pressure rose significantly immediately after declamping. The intramuscular pressures in the anterior tibial compartment correspond well with the findings on metabolic events seen after declamping, suggesting an incomplete ischemia of the leg muscles with insufficient tissue perfusion.
Combined fluid and corticosteroid therapy in septic shock in puppies
Authors: Connors Robert H. , Coran Arnold G. , Drongowski Robert A. , Wesley John R.
Published: May 2005

The optimal treatment of septic shock remains controversial. In order to evaluate the efficacy of fluid resuscitation and corticosteroid administration, the following experimental study was undertaken. Forty‐five puppies (1.6–5.4 kg) were randomly divided into 9 groups generated by combining 3 different fluid regimens and 3 different timings for steroid administration. Arterial, venous, and pulmonary artery catheterization allowed continuous hemodynamic and metabolic monitoring. Septic shock was achieved by a slow bolus infusion of 109/kgEscherichia coli organisms. Methylprednisolone (30 mg/kg) was administered either 30 min before bacterial infusion, at the time of shock, or 30 min after shock. When cardiac output dropped to less than 50% of control values, 1 of the 3 following fluid resuscitation regimens was begun: 5% albumin in lactated Ringer's (LR) at 35% of the estimated blood volume (EBV), LR at 105% EBV, or 5% albumin in LR at 105% EBV.

When all the groups were combined, early steroid treatment was more effective than delayed therapy, yielding respective survival rates of 47% and 7% at 180 min. Similarly, the large‐volume resuscitation groups achieved a 43% survival rate compared to 13% for the smaller fluid protocols. Neither early steroid therapy nor large volume fluid therapy was shown by itself to increase survival, however. Despite steroid pretreatment, none of the puppies given the lower‐volume infusion survived. Also, despite large‐volume fluid resuscitation, there were no survivors when this was combined with steroid treatment that was delayed 30 min. Only by combining early steroid administration with large‐volume fluid therapy was a markedly increased survival rate achieved: 60% with simultaneous steroid treatment, and 70% with steroid pretreatment.

A definite increase in animal survival has, therefore, been shown in the acute period of severe septic shock using a combination of high‐volume fluid resuscitation and the early administration of steroids.
Metastasis to the funiculus spermaticus as the first sign of renal cell carcinoma
Authors: Marković Bogoljub , Oprić Miroslav , Prica Vladimir , Čolović Vidosav , Mandić Ratko , Jeremić Aleksandar
Published: May 2005

A patient who had renal cell carcinoma metastatic to the funiculus spermaticus is reported. On the basis of the detailed physical, radiological, and laboratory examinations, it was concluded that the tumor in the funiculus spermaticus represented a metastasis of clear cell carcinoma of the left kidney. The patient also had adenoma of the prostate. Surgery was performed in 2 stages. In the first stage, pannephrectomy and ablation of tumor from the funiculus spermaticus were performed. In the second stage, adenomectomy by a retropubic approach was performed 6 months following the first intervention. Histological sections of the renal tumor and of the funiculus spermaticus tumor showed clear cell carcinoma (Carcinoma lucidocellulare), while sections of the prostatic tissue showed adenomyomatosis of the prostate.
Subcutaneous brachial vein arteriovenous fistula for chronic hemodialysis
Authors: Koontz Paul G. , Helling Thomas S.
Published: May 2005

While the subcutaneous arteriovenous fistula is the ideal method for creating vascular access for chronic hemodialysis, it is not suitable for all patients. Other methods such as polytetrafluoroethylene grafts have proven satisfactory but have been fraught with problems in some cases. In these situations, we have employed the brachial vein arteriovenous fistula as a means of providing continuing vascular access.

The brachial vein is dissected free from surrounding structures in the upper arm and anastomosed to the distal brachial artery in end‐to‐side fashion. The arterialized vein is then placed in the subcutaneous position for easy access.

We have performed this procedure in 12 patients. All have had previous access problems. Follow‐up has extended from 1 to 34 months. There have been 3 failures and 7 complications. Nine patients have maintained patency of their fistulas through the follow‐up period, until transplanted, or until death.

We feel that the brachial vein fistula is a reasonable alternative in patients who have encountered problems with standard wrist arteriovenous fistulas or with prosthetic grafts.
The management of severe hyperthyroidism
Authors: Mieny C. J. , Franz R. C. , Venter I. D.
Published: May 2005

Either subtotal thyroidectomy or ablation of the gland with131I will lead to a permanent cure of hyperthyroidism. In choosing between these 2 modalities of treatment, several factors should be taken into account, such as the type of goiter, the severity of hyperthyroidism, the size of the gland, age, fitness, and preference of the patient. It is our practice to perform a subtotal thyroidectomy on the young patient with a large gland and severe hyperthyroidism. In the preparation of these patients, thionamides, beta‐blockade, and Lugol's iodine are used together until the patient is euthyroid. Preparation with beta‐blockade alone led to the only instances of impending storm after surgery in our experience.
Management of symptomatic hypercalcemia and hypocalcemia
Authors: Purnell Don C. , van Heerden Jonathan A.
Published: May 2005

Symptomatic hypercalcemia is a medical emergency. Knowledge of the alteration in the factors that control normal calcium homeostasis permits selection of a plan of treatment, which includes general supportive measures along with therapeutic agents directed at the specific alteration in calcium homeostasis. The rationale for the selection of various modes of treatment and treatment schedules and the untoward side effects of the therapeutic agents are reviewed.

Acutely developing hypocalcemia often requires emergency treatment. Relief of symptoms can be achieved with intravenous calcium preparations. Knowledge of the underlying cause permits selection of appropriate medications when long‐term treatment is required. When vitamin D is needed, measurement of serum calcium and phosphate at regular intervals is essential. Hypoparathyroidism may be temporary after thyroid or parathyroid surgery, and efforts should be made 6 to 12 months after operation to determine whether the abnormality is permanent.
Management of the patient presenting as an emergency with hypergastrinemia
Authors: Harris Nigel W. S. , Osborne D. Henry , Carter David C.
Published: May 2005

The emergency management of patients presenting with the Zollinger‐Ellison syndrome (ZES) consists of medical measures to control acid‐pepsin hypersecretion; emergency surgery should be confined to urgent complications of ulceration or tumor growth and spread. Operation for ulcer complications should be restricted to conventional surgical procedures with biopsy of suspicious lesions. Emergency total gastrectomy or resection of pancreas and duodenum is contraindicated. Once the emergency has been controlled, the diagnosis of ZES can be confirmed by basal serum gastrin measurements and the secretin provocation test. Other endocrine adenopathies should be excluded. An attempt is then made to localize the tumor(s) and any metastases. With techniques such as selective portal venous sampling, it may be possible to define the small group of patients with lesions amenable to surgical cure. For the remainder, continued control of gastric secretion can be achieved by H2‐receptor antagonists, but elective total gastrectomy or the combination of vagotomy with pharmacological blockade offer valid alternatives in long‐term management. Effective medical or surgical control of the peptic ulcer diathesis means that tumor progression is now the major cause of death in ZES patients, and advances in the fields of chemotherapy and radiotherapy are urgently required to control this aspect of the disease.
The management of the hypoglycemic patient
Authors: Kennedy Terence
Published: May 2005

Organic hypoglycemia may be caused by an insulinoma. This is a rare tumor, multiple in about 10% and malignant in about 10% of cases. Multiplicity is particularly likely when insulinoma occurs as part of the MEN 1 syndrome. When a patient exhibits Whipple's triad, synchronous blood sugar and insulin estimations must be made, and repeated during fasting. Diagnosis depends on the finding of inappropriately high insulin levels in the presence of low blood sugars. Many stimulatory tests are available but none are as reliable as prolonged starvation, and probably should be abandoned.

Measurement of proinsulin and C‐peptide are of particular value in the diagnosis and in elimination of factitious hypoglycemia.

Preoperative localization is most useful and can be achieved in up to 90% of patients by skillful selective angiography. Percutaneous portal venous sampling has been used and is particularly indicated in patients after a fruitless first exploration.

Tumors of the body and tail are usually treated by distal pancreatectomy, those of the head by enucleation. There is a risk of pancreatic fistula, and duct damage can be unmasked by secretin injection. Occult tumors and hyperplasia may require “blind” progressive distal resection with blood sugar monitoring until the hypoglycemia is controlled, but this is something of a desperation measure. In malignant tumors, hypoglycemia may be controlled by diazoxide or somatostatin. Streptozotocin may control the syndrome and lead to prolongation of life. Like other malignant apudomas, these tumors are usually slow growing and relatively benign.
The Radiologist's role in acute endocrine problems
Authors: May Gerald R. , James E. Meredith , Johnson C. Michael
Published: May 2005

Ultrasound and computed tomography have had an enormous impact on the imaging procedures used in the detection of tumors of the parathyroids, pancreas, and adrenals. Ultrasound is now the examination of choice in localizing parathyroid adenomas in the neck prior to cervical exploration or after unsuccessful exploration. Its role as a screening test in patients without biochemical confirmation of hyperparathyroidism awaits further study. Computed tomography is useful in identifying mediastinal parathyroid adenomas in patients who have had unsuccessful neck explorations and islet‐cell tumors of the pancreas if they are sufficiently large (greater than 2 cm). Angiography remains the most accurate method of localizing insulinomas prior to surgery. Computed tomography scanning has become the procedure of choice in localizing adrenal tumors and has sufficient sensitivity to be used as a screening test in patients without biochemical confirmation of an adrenal abnormality.
The management of the patient with catecholamine excess
Authors: Wheeler Malcolm H. , Chare Michael J. B. , Austin Thomas R. , Lazarus John H.
Published: May 2005

The key to the diagnosis of pheochromocytoma is a high index of suspicion on the part of the clinician. Confirmation of the diagnosis and localization of the tumor have been rendered relatively straightforward by advances in biochemistry, nuclear medicine, and radiology. Close cooperation and team effort between a physician, anesthetist, and surgeon possessing expertise in this field will ensure optimal preoperative, operative, and postoperative care, particularly for the small group of patients seriously ill with “acute” catecholamine excess.
Management of acute hypercortisolism
Authors: Thompson Norman W. , Allo Maria D.
Published: May 2005

An occasional patient with Cushing's syndrome may require urgent management primarily because the chronic ravages of hypercortisolism have caused the patient to be in a precarious metabolic condition. The side effects of prolonged excess corticosteroids increase the risk of operations in such patients and must be considered in overall management. Among the many effects of hypercortisolism to be considered are hypertension, diabetes, ocular hypertension, myopathies, dermatologic changes including skin infection, pancreatitis, osteoporosis, pathological fractures, peptic ulcers, renal calculi, coagulopathies, hypokalemia, poor wound healing, and increased susceptibility to infection. The most effective way to avert these complications is by earlier diagnosis and definitive treatment of Cushing's syndrome. The present report includes a review of the etiology and diagnosis of Cushing's syndrome and the management of problems associated with hypercortisolism.
The management of patients with primary aldosteronism
Authors: Granberg P. ‐O. , Adamson U. , Cohn K. H. , Hamberger B. , Lins P. E.
Published: May 2005

The diagnosis of primary aldosteronism is based upon low plasma renin and elevated unsuppressible aldosterone. Computerized tomography and selective venous sampling are the most accurate methods of localization. In patients with an aldosteronoma, unilateral adrenalectomy is performed preferably via the posterior or flank approach. Patients with bilateral adrenal hyperplasia are treated with spironolactone rather than surgery, although controversy exists regarding the management of patients with macronodular hyperplasia.
Primary hyperparathyroidism in children, adolescents, and young adults
Authors: Allo Maria , Thompson Norman W. , Harness Jay K. , Nishiyama Ronald H.
Published: May 2005

Primary hyperparathyroidism (HPT) is considered a rare disease in children and an uncommon one in adolescents and young adults. Until 1975, only 60 children under the age of 16 years had been reported with proven HPT. Most had symptoms of weakness, irritability, anorexia, and weight loss. Severe hypercalcemia (serum calcium>15 mg/ 100 ml) and radiologic evidence of bone changes were common findings, and suggested delayed diagnoses.

This report is based on the clinical and laboratory findings in 53 young patients with proven primary HPT (range: 1–30 years of age) from 1971 to 1980, treated in one hospital. There were 29 male and 24 female patients, 26 of whom developed symptoms before age 18. Common symptoms included hematuria and renal colic (50%), renal calculi (50%), and hypertension with (6%) and without (3%) severe headaches. Although 64.2% of patients had adenomas, only 54% of patients under 18, and as many as 77.8% over 18, had them. The incidence of hyperplasia was markedly increased in the patients under 18 (38%) as compared to the patients over 18 (18.5%) or the group taken as a whole (30.2%). The following associated diseases were identified: MEA I syndrome (4); MEA II syndrome (4); von Recklinghausen's neurofibromatosis; papillary carcinoma of thyroid; craniopharyngioma; and multiple metaphyseal chondromatosis. One child had hereditary neonatal parathyroid hyperplasia.

Primary hyperparathyroidism is more common than previously suspected in young people. Symptoms of renal stones, hypertension, persistent headaches, unexplained anorexia, and weight loss should prompt evaluation for primary HPT. If hyperplasia is found, the patient and family should be investigated for associated endocrinopathies.
Parathyroid cysts
Authors: Asfar Sami , Smith George , Krukowski Zygmunt H.
Published: May 2005

From a review of the world literature, 91 cases of parathyroid cysts have been identified. The majority present as asymptomatic lumps in the lower part of the neck to the right or, more frequently, the left of the midline and are diagnosed as thyroid nodules before surgery. The 4 cases discussed in this article were all derived from the left lower parathyroid gland or left upper pole of the thymus. Three are the largest on record, 2 of which produced pressure symptoms and one, scabbarding of the trachea.
A mechanical suturing method for the gastrointestinal tract: Clinical experience with a new stapling instrument
Authors: Pimenta Amadeu P. A. , Cardoso Valdemar M. B. , Rodrigues Joaquim S.
Published: May 2005

The results obtained clinically with a new circular stapling clamp for end‐to‐end, end‐to‐side, or side‐to‐side anastomosis are described. This clamp is especially indicated for esophagogastric, esophagojejunal, esophagocolonic, or enteroenteral anastomoses. The instrument creates an anastomosis that is held by a double, staggered row of stainless steel wire staples. It is extremely easy to use, saves time and, creates better anastomoses than those achieved with hand suturing.
The role of gastric stasis in the genesis of gastric ulceration following fundoplication
Authors: Maher James W. , Cerda James J.
Published: May 2005

Gastric ulceration is a cause of significant morbidity in approximately 3% of patients undergoing fundoplication. The etiology of this complication remains unsettled. A patient who presented with gastric ulceration following fundoplication is described. Gastric emptying of solids was markedly delayed (28% retention at 120 minutes; normal range, 3–17%). The integrated gastrin response to 180 g of lean meat (368%) demonstrated marked derangement of the antrat gastrin mechanism (normal, 44±8%). Metoclopramide therapy resulted in normalization of gastric emptying (13% retention at 120 minutes), while the integrated gastrin response showed a decided decrease (257%). This patient clearly implicates gastric stasis and hypergastrinemia secondary to vagal dysfunction as a contributing factor in the etiology of gastric ulceration following fundoplication. The question as to whether this vagal dysfunction is a preexisting condition or the result of operative manipulations remains unresolved.
A simple technique for the treatment of ureteral stenosis after kidney transplantation
Authors: Kinnaert Paul
Published: May 2005

An intraperitoneal approach has been used successfully in 3 patients for surgical correction of ureteral stenosis after kidney transplantation. Although the procedure cannot be used if the kidney has been transplanted in the homolateral iliac fossa, in the majority of cases it avoids the difficult dissection of the renal hilum. Thus, blood loss is minimal and the duration of the surgical procedure is shortened.
Ileal bypass for hyperlipidemia
Authors: Buchwald Henry , Fitch Laurie , Varco Richard L.
Published: May 2005

Partial ileal bypass (PIB) is a safe, effective, and lasting therapy for the reduction of lipids and lipoproteins in patients with hyperlipidemia. Following PIB, circulating plasma and low‐density lipoprotein (LDL) cholesterol fall markedly, while high‐density lipoprotein (HDL) cholesterol rises. The average plasma cholesterol lowering is 25% after diet, with a 40% reduction in the LDL‐cholesterol fraction; concurrently, the HDL‐cholesterol rises about 8%. These effects have been demonstrated to be maintained for up to 20 years. Currently, PIB is being used in the Program on the Surgical Control of the Hyperlipidemias (POSCH), a randomized controlled clinical trial designed to assess the effects of lipid reduction on mortality and morbidity in a postmyocardial infarction population with arteriographically demonstrated coronary atherosclerosis.
Small bowel transplantation
Authors: Pritchard Timothy J. , Kirkman Robert L.
Published: May 2005

Small bowel transplantation may offer a future alternative to patients with short bowel syndrome. However, currently available immunosuppressive regimens are not adequate to prevent rejection of small bowel allografts. Recent experimental studies using cyclosporine have provided improved results, especially in rats; but there are relatively few long‐term survivors in large animal models. Graft‐versushost disease may result from lymphoid tissue in the small bowel transplant but is less troublesome than rejection. Seven patients have undergone small bowel transplantation; the longest survivor died at 6 months. Clinical application of small bowel transplantation must await further refinements in immunosuppression.
Recurrent adhesive small bowel obstruction
Authors: Jones Peter F. , Munro Alexander
Published: May 2005

Adhesive obstruction of the small bowel complicates about 5% of laparotomies; of these, 5–10% have recurrent attacks. The etiology of adhesions is incompletely understood and attempts to prevent their formation are of unproven value. Patients with recurrent acute obstruction that threatens strangulation, or that fails to subside, require laparotomy. If numerous adhesions have to be divided, it is worth considering a procedure to encourage fresh adhesions to form in a favorable pattern. Suture plication of the bowel by Noble's technique has a high incidence of complications and recurrent obstruction, and transmesenteric plication cannot be used in the presence of sepsis. Splinting of the entire small bowel by intraoperative passage of a long tube, which is left indwelling for 2–3 weeks, appears to be effective and safe. We have used this method in 140 patients without associated complications; of these, 17 had recurrent intestinal obstruction after 1–5 previous laparotomies for adhesions. A meticulous adhesiolysis followed by transluminal splinting through a jejunostomy has been followed by freedom from recurrence during 103 patient‐years of follow‐up.
Small bowel fistulas
Authors: Sansoni Baldasarre , Irving Miles
Published: May 2005

Most external small bowel fistulas follow surgical operation, but a few develop spontaneously. Seventy percent will close with conservative treatment including vigorous nutritional support and elimination of sepsis. Internal fistulas involving the small bowel always result from extension of disease in the bowel or in adjacent viscera, and they virtually never close spontaneously. Our 11‐year experience of 71 Crohn's fistulas confirms 2 types. Type 1 (n=49) results from spontaneous extension of active bowel disease, while type 2 (n=22) follows leakage of an anastomosis. The former virtually always requires surgical closure, which can usually be achieved without mortality and with minimal complications. Most type 2 fistulas will close with parenteral nutrition, but staged surgery with exteriorization of bowel ends may be required. Our 4 deaths were all among type 2 cases. High‐output fistulas with severe associated sepsis should be managed in specialized intestinal failure units. In just under 4 years, 51 patients with complicated intestinal fistulas have been treated in this department, with a 23.5% mortality rate.
The management of duodenal and other small intestinal trama
Authors: Donohue John H. , Crass Richard A. , Trunkey Donald D.
Published: May 2005

One hundred sixty‐three patients were treated for blunt and penetrating trauma of the duodenum and small bowel over a 41/2‐year period at a major trauma center. Blunt injuries, mostly a result of vehicular trauma, comprised 17% of the cases, while stabbing and firearm injuries made up the remainder. Laboratory data, including white blood cell count, amylase, and abdominal x‐rays, were unreliable in predicting the presence of intestinal injury. Although only obtained in a few patients following blunt injury, computerized tomography (CT scan) of the abdomen was sensitive to intraperitoneal findings suggestive of or diagnostic for gastrointestinal injury. Speedy operative management is of the utmost importance; 63% of these patients were operated on in less than 2 hours from the initiation of medical treatment. The majority of intestinal damage can be repaired by simple closure or resection. Because of anatomic and physiologic considerations, complex operative procedures are required for the correction of some duodenal lesions. Our treatment of these injuries included frequent utilization of pyloric exclusion, as well as occasional diverticulization of the duodenum and pancreaticoduodenectomy. Delay in treatment and the magnitude and number of associated injuries contributed to increased morbidity and mortality, which was much higher in blunt trauma (21% versus 4% for penetrating injuries), especially when the duodenum was involved (36% mortality). Complications were also more common in the patients following blunt trauma and with multiple injuries. Infectious complications were the most frequent, with postoperative ileus or obstruction, hemorrhage, and iatrogenic complications occurring less often. In the majority of small bowel injuries, the management is straightforward and consists of operative repair as soon as possible. A high index of suspicion and reliance on diagnostic aids, such as CT scan, will speed the diagnosis of occult blunt intestinal injuries. Sound surgical judgment and facility with a variety of repairs is needed in the treatment of complex duodenal injuries.
Enteric adenoma and adenocarcinoma
Authors: Cooper M. J. , Williamson R. C. N.
Published: May 2005

The small bowel comprises 75% of the length of the gastrointestinal tract but is a rare site of neoplasia. An unselected retrospective review of Bristol patients between 1969 and 1983 revealed only 25 small bowel carcinomas: an incidence of 1 per 450,000 of population per annum. Distribution was 10 duodenal, 6 jejunal, and 9 ileal carcinomas; 5 patients had other associated diseases. Twenty‐one of the 25 patients underwent a surgical resection, of whom 17 survived (operative mortality 19%). Survival was 60% at 1 year and 40% at 2 years; no patient has survived 5 years although 3 remain alive and well.

A further 5 patients were found to have benign adenomas in the absence of malignancy: 3 duodenal and 2 jejunal. Duodenal lesions were treated endoscopically while the jejunal adenomas were removed by enterotomy. There were no complications of treatment.
Fine‐needle biopsy of the pancreas: Results of 204 routinely performed biopsies in 190 patients
Authors: Søreide Odd , Skaarland Elsa , Pedersen Ole M. , Larssen Trond B. , Arnesjø Bo
Published: May 2005

Two‐hundred and four fine‐needle aspiration biopsies of the pancreas have been performed in 190 patients during a 12‐year period. Sixty‐one of these were performed percutaneously guided by endoscopic retrograde cholangio‐pancreatography, percutaneous transhepatic cholangiography, angiography, or ultrasonography; and 143 were taken intraoperatively. In 77 (67%) out of 115 patients with pancreatic cancer, a correct cytological diagnosis was obtained. Two biopsies were reported as malignant in 1 patient who ultimately was found to have chronic pancreatitis (false positives). The frequency of “not representative” biopsies varied from 20.8% in patients with suspected cancer biopsied intraoperatively to 48.4% in patients biopsied preoperatively. A correct cytological diagnosis of malignancy was obtained preoperatively in 54.6% of patients with cancer, in 60.0% of patients evaluated without later operation, and in 71.1% of patients biopsied during laparotomy for suspected pancreatic cancer. The overall false‐negative rate was 9.8%. The predictive value of a positive test was almost 100%, whereas the predictive value of a negative test was only 69.6% (total material). Analyses may indicate that a more aggressive approach with multiple punctures may lower the not representative biopsy rate and increase the diagnostic accuracy in patients with pancreatic cancer.
Long‐term surgical results of carcinoma of the gastric remnant: A statistical analysis of 613 patients from 98 institutions
Authors: Kidokoro Tsutomu , Hayashida Yaso , Urabe Motomichi
Published: May 2005

Based on a survey questionnaire sent to the 98 member institutions of the Japanese Research Society for Gastric Cancer, 613 cases of cancer of the gastric remnant, after resection for a variety of benign and malignant conditions, were collected and reviewed. This study includes both recurrences and newly developed cancers, although only cases with an accurate diagnosis and careful follow‐up were selected. An analysis of the time intervals between initial gastrectomy for cancer and second operation suggests that recurrences usually occur within 10 years of the first procedure, while those cancers developing after 10 years are likely to represent new lesions. The cumulative 5‐year survival rates of 48.7% after subtotal and 28.9% after resection for carcinoma of the gastric remnant are no worse than those for cancer resections in the stomach previously untreated surgically. An active approach based on early detection and aggressive surgical therapy of these lesions is recommended.
Results of surgical treatment of necrotizing pancreatitis
Authors: Beger Hans G. , Krautzberger Wolfgang , Bittner Reinhard , Block Sylvia , Büchler Markus
Published: May 2005

In 205 patients with necrotizing pancreatitis, surgery was carried out following failure of medical treatment. Intraoperatively, according to the size of the necrotic area and the weight of the surgically removed necrotic tissue, 79 patients showed a limited pancreatic necrosis, and 126 patients an extended necrotizing process. In 40.4% of 138 patients with bacteriological reports, a bacterial contamination of the pancreatic necrosis was found. The main objective of surgical management was the removal of the necrotic tissue. This was performed with 2‐way drainage and postoperative continuous peritoneal and/or local lavage, in a smaller group of patients with inner drainage of the necrosis cavity, and in a few patients with drainage alone. The overall hospital mortality rate was 24.4%. The lowest mortality was achieved in patients treated with necrosectomy and postoperative continuous local lavage (6.0%). In patients with necrosis of approximately 30% of the pancreas, mortality was lower (7.6%) than in patients with a 50% necrosis (24.0%) or in patients with a subtotal/total necrosis (51.0%) (p<0.0001). Formation of extrapancreatic necrosis resulted in a significantly increased mortality rate (p<0.02). In patients with bacterially contaminated necrosis, a mortality rate of 32.1% was found, whereas in patients with a sterile necrosis, mortality was down to 9.8% (p<0.01). Based on the results of this study, we conclude that the clinical course of necrotizing pancreatitis depends essentially on the extent of the necrosis in the pancreas itself, the development of extrapancreatic necrosis, and the bacteriological status of the necrotic area. Adequate surgical management leads to a considerably increased survival rate of patients with necrotizing pancreatitis.
Histochemical demonstration of thyroxine, triiodothyronine, and thyroglobulin in the primary lesion of thyroid carcinoma, and its predictability for radioiodine uptake by metastatic lesions
Authors: Kodama Takaya , Fujimoto Yoshihide , Obara Takao , Ito Yukio , Kusakabe Kiyoko , Hirayama Akira
Published: May 2005

Although a total thyroidectomy followed by131I therapy is widely adopted for hematogenous metastatic lesions of thyroid carcinoma, they do not always take up enough131I for treatment. This work was undertaken to elucidate the predictive value of histochemical demonstration of thyroid hormones in the primary lesion for131I uptake by the metastatic lesions. A total of 27 patients with thyroid carcinoma underwent the above treatment during a 19‐year period (1966–1984). Metastases in either the lung, the bone, or both were found in 12, 9, and 6 patients, respectively. Five patients died of thyroid cancer 2, 4, 10, 10, and 20 years after the initial surgery. Five patients demonstrated negative131I uptake in the lung metastases, but one of them had simultaneous bone metastasis, which was positive for131I uptake. Sectioned specimens were stained by the peroxidase antiperoxidase method for thyroxine, triiodothyronine, and thyroglobulin, the presence of which was demonstrated in 15, 9, and 26 cases, respectively. All of the thyroxine‐ or triiodothyronine‐positive patients showed the ability to take up131I.131I uptake was not shown in 4 of 12 thyroxine‐negative or in 4 of 18 triiodothyronine‐negative cases. From these results, it may be concluded that131I uptake by metastatic lesions is predictable when thyroxine or triiodothyronine is demonstrated immunohistochemically in the primary lesion. In the absence of thyroxine or triiodothyronine, however, no prediction can be made.
The use of intercavernous sinuses phlebography in the diagnosis of ACTH‐secreting microadenomas
Authors: Merola B. , Lombardi G. , Lupoli G. , De Chiara G. , Colao A. M. , Finelli L. , Marzano L. A. , Iaccarino V. , Zarrilli L.
Published: May 2005

The use of intercavernous sinus phlebography in the diagnosis of pituitary adenomas has enabled the collection of selective venous samplings of the inferior petrosal sinuses (IPS), where pituitary hormones can be measured before becoming excessively diluted in the systemic circulation. This approach has been particularly useful in patients affected by ACTH‐secreting microadenomas, whose diagnosis and preoperative localization can be very difficult. Five female patients, 30–53 years old, suffering from hyperadrenocorticism have been studied. The basal and dynamic hormonal assessment indicated an ACTH‐dependent hyperadrenocorticism, although the computed tomography of the sella turcica, performed in all the patients, was negative in 3 patients and doubtful in 2. The perihypophyseal phlebography showed a small left‐sided intrasellar expansive process in patient no. 1 and a right‐sided intrasellar mass in patients no. 2 and 3. The analysis of ACTH concentrations in the IPS and in the peripheral circulation showed the presence of a concentration gradient between the side of presumed adenoma and the contralateral side (2.7 times;p<0.01) and between the side of the presumed adenoma and the periphery (3.4 times;p<0.01). No significant difference was found between the ACTH concentration in the contralateral IPS and that of the periphery. Surgery confirmed the presumed diagnosis in all cases.
Studies on in vivo and in vitro release of intact parathyroid hormone using a new two‐site immunochemiluminometric assay
Authors: Aston J. Paul , Wheeler Malcolm H. , Brown Richard C. , Curley Ian R. , Woodhead J. Stuart
Published: May 2005

Basal parathyroid hormone (PTH) levels measured by a chemiluminescent immunoassay for intact PTH showed good discrimination between normal, n=82 (1.2–9.4 pmol/l), and hyperparathyroid subjects, n=55 (9–200 pmol/l). In malignant hypercalcemia, all PTH levels were within the normal range or suppressed (0.8–5.2 pmol/l). Dynamic studies of PTH release in response to intramuscular salmon calcitonin (100 u) showed no significant rise out of the normal range in controls, but adenoma patients demonstrated a mean rise at 120, 180, and 240 minutes of 22%, 22%, and 35%, respectively, and hyperplasia patients a mean rise of 44%, 63%, and 46%, respectively. The mean absolute rise in PTH concentration was 10.6±7.2 pmol/g parathyroid adenoma and 26.6±19.2 pmol/g hyperplastic parathyroid tissue; this difference being significant (p <0.01). In vitro studies were performed in which dispersed cells prepared from both parathyroid adenomas and hyperplastic tissue were exposed to low (0.5 mM) and high (2.5 mM) extracellular calcium. Intact PTH secretion was measured under these conditions and compared with the results obtained by a mid‐region (44–68) specific immunoassay for PTH. There was parallel secretion of intact and mid‐region hormone under all conditions, the secretion rate of hyperplastic cells being greater than that of adenomas. Suppressibility of PTH release by high extracellular calcium was significantly greater in hyperplasia than in adenomas. These differences in the behavior of adenomatous and hyperplastic tissues both in vivo, in response to calcitonin, and in vitro, in response to changes in extracellular calcium concentration, suggest that the underlying pathogenesis of hyperparathyroidism may be heterogenous at the cellular level.
Duplex scan‐derived thyroid blood flow in euthyroid and hyperthyroid patients
Authors: Hodgson Kim J. , Lazarus John H. , Wheeler Malcolm H. , Woodcock John P. , Owen Glynn M. , McGregor Alan M. , Hall Reginald
Published: May 2005

Using a high‐resolution real‐time scanner to locate the superior thyroid artery (STA), the absolute blood flow has been measured with a pulsed Doppler flow meter. The diameter of the vessel and the angle of inclination of the ultrasound beam to the axis of the vessel were measured from the real‐time image and the blood flow then computed in the on‐board computer. Vessel diameter measurements were performed by the computer to 1/10 mm and all examinations were performed under identical conditions.

In 24 randomly selected, clinically and biochemically euthyroid, preoperative, general surgical patients on no drugs (12 males, 12 females; age range, 18–65) the STA was located and blood flow measured in 46 arteries (96%). Mean blood flow was 18.3 ml/min ± 6.0 SD (range, 5.8–29.2). Bilateral measurements were made in 20 of 22 (5 males, 17 females; range 27–80 years) hyperthyroid patients. Mean blood volume flow was 73.0 ml/min±34.3 SD (range, 30–140), significantly higher (p < 0.01) than in the euthyroid group. No sex differences were seen. For euthyroid and thyrotoxic patients together, thyroid blood flow correlated with FT4 (r = 0.77,p <0.001), and, in the thyrotoxics, blood flow was significantly correlated with FT3 (r = 0.51,p <0.05), 4‐hr123I uptake (r =0.60,p <0.01), and 48‐hr123I uptake (r =0.63,p < 0.01), but not with FT4 (r = 0.40). The within artery coefficient of variation for volume flow was 17.4% for euthyroid subjects and 24.4% for hyperthyroid subjects. However, the mean comparable coefficient of variations for time‐averaged velocity were 9.2% and 13.8%, respectively.

It is concluded that this noninvasive Duplex scanning method for measuring thyroid blood flow is accurate, reproducible, suitable for examining this parameter in relation to thyroid disease and drug effects, and may have a role to play in the management of patients with hyperthyroidism.
Flow cytometric DNA measurements in benign and malignant Hürthle cell tumors of the thyroid
Authors: Ryan John J. , Hay Ian D. , Grant Clive S. , Rainwater Leslie M. , Farrow George M. , Goellner John R.
Published: May 2005

The prediction of outcome in the rare Hürthle cell tumor of the thyroid continues to present a problem to surgeons and pathologists. To better clarify the distinctions between benign and malignant tumors, we have measured DNA content by flow cytometry on isolated cell nuclei derived from archival paraffin‐embedded tissue blocks of 125 Hürthle cell tumors operated from 1943 to 1985 at the Mayo Clinic, Rochester, Minnesota, U.S.A. Nuclear DNA ploidy patterns were divided into 3 groups. A DNA normal (diploid) pattern was found in 55% of 75 Hürthle cell adenomas and in 26% of 50 Hürthle cell cancers; a DNA tetraploid/polyploid pattern was found in 11% of benign, and 14% of malignant tumors. An abnormal DNA stemline was detected in 34% of benign and 60% of malignant tumors. Hürthle cell cancer was the histologic diagnosis in 24% of the DNA normal, 47% of the DNA tetraploid/polyploid, and 54% of the DNA aneuploid tumors. None of the patients with adenomas developed tumor recurrence. However, 20% of the euploid and 40% of the aneuploid tumors developed local or distant recurrences. Survival to thyroid cancer death was significantly correlated with DNA ploidy status (p=0.02) but did not correlate with either tumor size or histologic grade. To date, deaths from thyroid cancer have been confined to patients whose tumors were DNA aneuploid. We would conclude that determination of DNA ploidy status may not aid the surgical pathologist in the diagnosis of Hürthle cell cancer. However, when a patient's Hürthle cell cancer is DNA aneuploid, there is significant risk of death from thyroid cancer.
Benign Hürthle cell tumors of the thyroid: A diagnosis to be trusted?
Authors: Grant Clive S. , Barr Darlene , Goellner John R. , Hay Ian D.
Published: May 2005

The ability to differentiate benign from malignant Hürthle cell thyroid neoplasms has provoked considerable controversy. This has significant therapeutic implications, since some have advocated total thyroidectomy for all of these lesions. The principal objectives of this study were: (a) to determine whether the histologic diagnosis of Hürthle cell adenoma could be reliably made, (b) to quantitate the risk of inappropriately labelling a Hürthle cell cancer as an adenoma, and (c) to ascertain whether the type of operative procedure affected the clinical course.

We reviewed 272 patients who had undergone thyroid resection for benign Hürthle cell neoplasms at the Mayo Clinic from 1960 to 1980. All pathologic sections were rereviewed. Postoperative follow‐up was available on 233 patients (86%), with a mean of 8.9 years. A minimum of 5 years of follow‐up was obtained on 10% of the patients. Nodules ranged in size from 0.3 to 11 cm; 195 (55%) were 2 cm or larger. Surgical resection was limited to one side in 137 (50%) patients and involved both sides in 135 patients. No total thyroidectomies were performed. Evidence of malignancy—a local recurrence—developed in only 1 patient, and she died of unrelated causes. None of the 272 patients died of thyroid cancer, and none showed evidence of metastases. Our data is in agreement with most published reports, with only 6 (0.9%) of 642 reported patients being diagnosed incorrectly. These tumors can be accurately separated into benign and malignant. Routine total thyroidectomy for Hürthle cell adenomas is not justified.
Improved differential diagnosis of hypercalcemia by hypocalcemic stimulation of parathyroid hormone secretion
Authors: Ljunghall Sverker , Benson Lars , Wide Leif , Åkerström Göran , Rastad Jonas
Published: May 2005

In vitro experiments have indicated that in primary hyperparathyroidism (HPT) the hyperfunctioning glands have a set point error, i.e., they are not autonomous but regulate serum calcium around a hypercalcémie value. In contrast, parathyroid function is suppressed in patients with hypercalcemia of causes other than HPT (e.g., malignancy or sarcoidosis). The basal measurements of serum parathyroid hormone (PTH) levels, however, cannot, alone, separate with precision HPT from other causes of hypercalcemia.

Lowering of calcium, in order to stimulate secretion of PTH, was, therefore, achieved by either infusion of Na2 EDTA (24 mg/kg per hr) for 1 hour, or intramuscular injection of 100 IU salmon calcitonin.

All 35 patients with primary HPT displayed a significant increase of serum PTH concentrations, evaluated by a midregion/intact hormone assay, during the EDTA infusion, which lowered plasma ionized calcium by an average of 0.16 mmol/l. The injection with calcitonin reduced the calcium concentrations by 0.10 mmol/l after 8 hours and caused a rise in PTH in 80% of HPT patients. With both tests, the secretory response by PTH to the reduction of plasma calcium was generally evident while the patients were still hypercalcemic.

In 32 patients with other causes for hypercalcemia, primarily malignancy and sarcoidosis, similar reductions of plasma ionized calcium were obtained. In contrast to the HPT patients, none of them raised their serum PTH values during the test. Thus, stimulation of PTH secretion by a moderate reduction of serum calcium considerably improves the differential diagnosis of hypercalcemia since a significant secretory response appears to be exclusive for HPT.