bluuebunny/crossref_metadata_2025 huggingface dataset:
Early cancer of the stomach
Authors: Murakami Tadashige
Published: May 2005

Definition, macroscopic and histologic classification, diagnosis, surgical treatment, and prognosis of early gastric cancer are described. The definition and macroscopic classification were agreed upon by endoscopists, pathologists, radiologists, and surgeons at the meeting of the Japanese Gastroenterological Endoscopy Society in 1962. Early gastric cancer was grossly classified into 3 major types, based solely on surface characteristics in order to make the classification usable for radiologists and endoscopists. Since most early gastric cancers are asymptomatic, mass survey examinations are of value. Patients with a suspicious lesion or symptoms should undergo a thorough diagnostic workup that includes x‐ray studies, endoscopy, and biopsy for histologic examination. The aim of surgery is complete eradication of cancer cells. Since peritoneal dissemination and liver metastases are rare, surgery is directed at removing regional lymph nodes with possible metastases and not leaving any cancer cells at the gastric suture line. Although the incidence of metastases to regional lymph nodes is reported to be about 5% and of lymphatic permeation to be about 12%, 5‐year survival rates ranging from 89 to 95% have been achieved.
The role of lymphadenectomy in curative surgery for gastric cancer
Authors: Soga Jun , Kobayashi Kiyoo , Saito Juichi , Fujimaki Masao , Muto Terukazu
Published: May 2005

A total of 530 cases of gastric cancer treated by curative surgery was analyzed with regard to lymph node metastases and survival rate. During this period, curative resections made up 75.9% of all resections (530/698) for gastric cancer, and the 5‐year survival rate was 50.6% (268/530). A total of 15,739 regional lymph nodes (an average of 30 per specimen) removed at surgery were examined histologically for metastases, and 16.0% were found to be positive. Of 339 patients with advanced, transmural cancers, 74.9% had lymph node métastases; those with negative nodes had a 5‐year survival rate of 63.5%, while those with positive nodes had a 5‐year survival rate of 29.9%. The 5‐year survivors with positive nodes made up 58.5% of all 5‐year survivors. The almost complete removal of at least the primary and secondary lymph node groups draining a gastric neoplasm is an essential part of the curative surgical treatment of gastric cancer. For lesions in the upper and middle portions of the stomach that invade the serosa of the posterior wall, total gastrectomy with a caudal hemipancreatectomy and splenectomy should be aggressively performed, so as to accomplish complete en bloc removal of the lymph nodes in these regions.
Indications and contraindications for surgery in gastric carcinoma
Authors: ReMine William H.
Published: May 2005

Operation for gastric carcinoma should be undertaken in the presence of known or probable carcinoma of the stomach, in the absence of clear contraindications. These contraindications include serious disease elsewhere (such as cardiac insufficiency, advanced pulmonary disease, and pronounced renal failure), definite objective evidence of distant metastases, and evidence of local extension beyond the point of resectability. To deny a patient the potential benefits of exploratory laparotomy is to eliminate the chance of cure. After thorough exploration of the abdomen, curative resection of gastric cancer involves radical subtotal gastrectomy for lesions restricted to the distal 2/3 of the stomach, and total gastrectomy with splenectomy for lesions in the upper 1/3. When there is local extension of the cancer, resection of adjacent organs should be performed if it appears that the growth can be completely removed. When curative resection is not possible, palliative resection or gastroenterostomy is often indicated to relieve symptoms.
Treatment of gastric cancer with combined surgery and intraoperative radiotherapy
Authors: Tobe Takayoshi , Hikasa Yorinori , Matsuda Susumu , Kaneko Iwao , Mori Kenjiro , Abe Mitsuyuki
Published: May 2005

In order to increase the cure rate of stomach cancer, we have used intraoperative radiotherapy in which resectable lesions are removed surgically and the remaining cancer nests sterilized with a single massive dose of irradiation during laparotomy. In cooperation with surgeons, radiologists, and anesthesiologists, effective doses of irradiation of 3,000–4,000 rads were administered in 85 patients with advanced cancer. After resection of the stomach and removal of regional lymph nodes, and before gastrojejunostomy, the region of the celiac axis was irradiated in order to destroy regional microscopic metastasis that could not be removed surgically. The survival rates were 0 of 8 patients with nonresectable lesions, 3 of 15 with absolutely noncurable resectable tumors, 6 of 11 with relatively noncurable resectable cancers, and 48 of 51 with absolutely or relatively curable resectable lesions. In the latter group, insufficient time has elapsed to calculate the 5‐year survival rate. No serious complications occurred except for an increase of serum amylase. These results, as well as experimental radiotherapy of the dog pancreas, are discussed.
Palliative operations for incurable gastric cancer
Authors: ReMine William H.
Published: May 2005

The experiences of 206 patients who underwent palliative operations for advanced gastric carcinoma have been reviewed to evaluate the effect of treatment. Gastroenterostomy for obstruction alleviates vomiting for most patients, but significant palliation followed operation in only 1/3 of cases. The procedure was accomplished with an acceptable mortality rate, and the average period of postoperative hospitalization was 13 days. The results of palliative partial gastrectomy for patients having obstructive symptoms preoperatively were only slightly better than those following gastroenterostomy. Approximately 1/3 of the patients lived in relative comfort for more than a year. The poor progress of 6 patients who received total gastrectomy supports the opinion that total gastrectomy is not a satisfactory palliative operation. Palliative esophagogastrectomy for patients with dysphagia gave results similar to, or possibly better than, palliative resections for distal lesions. Although the results following the use of prostheses for inoperable malignant stricturing of the esophagogastric junction were disappointing, the procedure had significant advantages when compared with the marked limitations and disadvantages of jejunostomy and the transient relief afforded by transesophageal dilatation. Review of the records of patients who had had a feeding jejunostomy confirmed the general opinion that this procedure seldom is indicated in the management of advanced gastric carcinoma.
Clinical experience with a new method of gastric replacement following total gastrectomy
Authors: Kieninger G. , Koslowski L. , Durst J. , Kummer D. , Wolf K. ‐J.
Published: May 2005

Since 1972 we have used a new type of gastric replacement following total gastrectomy that was developed experimentally in our laboratory. The reconstruction is done by end‐to‐end interposition between the esophagus and duodenum of a proximal 25 cm isoperistaltic jejunal segment and a distal 10 cm antiperistaltic (reversed) jejunal segment. The reversed segment acts as a substitute for the pylorus, causing delayed and intermittent emptying of the above proximal isoperistaltic segment. To date we have performed this operation in 31 patients, with only 1 postoperative death and nonfatal anastomotic leakage at the esophagojejunal junction in 4 patients. The longest postoperative observation period has been more than 4 years. The function of the gastric substitute has been found to be very satisfactory by cineradiography, endoscopy, and fat absorption tests. Based on our encouraging experimental and clinical experience, it is concluded that this new method of gastric replacement has many advantages over other methods. The quality of life of patients treated in this way has been better, since digestion and absorption have been improved and many of the typical postgastrectomy sequelae have been reduced or eliminated. This type of reconstruction is now being used routinely in our clinic in curative resections for gastric cancer.
The development of endocrinopathies in the prospective screening of two families with multiple endocrine adenopathy, type I
Authors: Friesen Stanley R.
Published: May 2005

The majority of the members of 2 families afflicted with genetic manifestations of the multiple endocrine adenopathy (MEA) type I syndrome have been prospectively studied. The slow and insidious onset of endocrinopathies in these high‐risk relatives was preceded by chemical and humoral abnormalities which could be surgically treated early in the course of the endocrinopathy. The predominant pathologic process in those patients diagnosed prospectively was that of hyperplasia with some benign adenomatous developments; malignancy was not observed except in those studied retrospectively. Screening protocols for the detection of multiple endocrinopathies in the symptomatic patient with one endocrinopathy, as well as in asymptomatic family relatives, appear to yield endocrinopathies at an earlier stage of development. Antral G cell hyperplasia was observed on endoscopic mucosal biopsy to be associated with the development of clinical endocrinopathies; it is not known yet whether this is of predictive value. The pathogenesis of multiple APUD cell abnormalities, though not known, apparently involves an embryologic programming of cells from the neuroectoderm, as well as a genetic pleiotropic factor and environmental influences.
Precise antrectomy
Authors: Jensen Hans ‐Eric , Badskjaer Jørn , Andersen Bent Nyboe , Johansen Aage
Published: May 2005

A follow‐up study of 108 patients 2–8 years after precise antrectomy for gastric ulcer showed no ulcer recurrences. The frequency of complications was similar to that following conventional resections. Biopsies taken at gastroscopy at the time of follow‐up showed permanent removal of all functioning antral mucosa; no gastrin‐producing cells could be recovered from any part of the gastric remnant. There was a close relationship between gastric acid secretion and the incidence and spreading of chronic atrophic gastritis in both resected specimens and biopsies. Following precise antrectomy alone, acid secretion was reduced considerably 3 months postoperatively, and the reduction was unchanged at the time of follow‐up. In patients with a high preoperative insulin‐stimulated acid secretion, precise antrectomy plus vagotomy reduced acid secretion significantly more than precise antrectomy alone. Besides producing a decrease in acid secretion, the advantage of precise antrectomy appears to be that the target area for recurrent gastric ulcer is permanently removed.
Correction of common bile duct stricture by onlay patch of duodenum
Authors: Senning Åke
Published: May 2005

A simple method to correct iatrogenic common bile duct strictures is presented. The stenotic bile duct is incised longitudinally and a large T‐tube inserted, the ends extending proximal and distal to the incision. The rim of the incision is sutured to the posterior duodenal wall, and this is used as a serosal patch for roofing. The T‐tube is removed after 3–6 months. Use of this technique in 2 patients was successful.
Surgical treatment of hypopharyngeal and cervical esophageal cancer
Authors: Silver Carl E.
Published: May 2005

Numerous methods have been employed for esophageal replacement after total pharyngolaryngectomy‐esophagectomy. These have included the use of skin, as well as free transplantation or transposition of various abdominal viscera. The history and technical aspects of the procedures that have been used on the author's service are reviewed and results of 32 reconstructive operations are presented. Lower mortality and morbidity rates were obtained and palliation more consistently achieved with visceral transposition procedures than when the esophagus was reconstructed with skin. The 3‐year cure rate of patients undergoing resection for cancer was 21%. Gastric transposition after extrathoracic total esophagectomy is the preferred procedure for suitable patients with post‐cricoid and cervical esophageal carcinoma. Skin flaps are preferred for high hypopharyngeal tumors and in the poorest risk patients. Reversed gastric tube esophagoplasty and esophagocoloplasty are best employed for secondary rather than primary reconstruction.
Pharyngogastric anastomosis following pharyngolaryngoesophagectomy. Analysis of 157 cases
Authors: Lam K. H. , Wong J. , Lim S. T. K. , Ong G. B.
Published: May 2005

During the last 14 years, pharyngogastric anastomosis following pharyngolaryngoesophagectomy was performed in 157 patients, among whom 67 had carcinoma of the hypopharynx, 7 had carcinoma of the cervical esophagus, and 83 had carcinoma of the larynx involving the hypopharynx. The operative procedure was that described previously by Ong in 1960, and modified in 1971. The overall hospital mortality was 31%, which in the last 2 years of the study had fallen to 18%. It was found that the mortality was higher in patients with poor cardiopulmonary status and in patients whose tumors had extended into the vallecula, thus requiring resection of the posterior third of the tongue. Previous failed radiotherapy increased the risk of leakage of the anastomosis. The immediate results of the operation can be improved if the surgeon ensures that a healthy stomach is prepared, a secure anastomosis is performed, and the vulnerable blood vessels are protected. Postoperative function in terms of swallowing ability was good, but rehabilitation of speech was poor. The 5‐year survival rate was 17.8%. The longest surviving patient is still alive 10 years after the original operation. The most common cause of long‐term failure was the development of metastatic disease. Improvement in survival results may require the use of adjuvant therapy to operative treatment.
Resection of midesophageal carcinoma with esophagogastric anastomosis
Authors: McKeown Kenneth C.
Published: May 2005

This report is based on 432 cases of cancer of the oesophagus, 154 of which involved the middle third. There were 82 men and 72 women, ranging in age from 42 to 81, average 62. Operative mortality was 15.7%. The philosophic objectives were to restore promptly the ability to swallow, to obtain a worthwhile survival period, and to avoid the miseries associated with oesophageal carcinoma.

Preoperative preparation, operative techniques including errors and safeguards, postoperative management, and overall results are specified. The stomach is preferred to jejunum or colon as a means of restoring continuity of the alimentary tract following resection of oesophageal carcinoma.
Surgery for carcinoma of the lower esophagus and cardia
Authors: Ellis F. Henry , Maggs Peter R.
Published: May 2005

Esophagogastrectomy with esophagogastrostomy is the treatment of choice for patients with cancer of the lower esophagus and cardia. The Lahey Clinic experience with the surgical management of this disease between January, 1970 and March 1, 1980, consists of 68 patients, 58 of whom (85.3%) had resections. Forty‐three had stage III disease, and the remainder (25) were equally divided between stages I and II. Esophagogastrectomy and end‐toside esophagogastrostomy is performed through a left thoracotomy without the use of clamps and without tension.

One patient died postoperatively of a myocardial infarction‐an overall hospital mortality rate of 1.7%. With few exceptions, all of the hospital survivors were able to swallow without difficulty throughout the follow‐up period. Long‐term survival was rare, but of the 22 patients operated on 5 or more years ago, 4 survived from 5 to 8 years; the 5‐year survival rate was 50% for patients with cancer developing in the lower esophagus but only 11.1% for those with disease arising at the cardia.

The low mortality and morbidity rates and the excellent palliation afforded patients with cancer of the lower esophagus and cardia by esophagogastrectomy with esophagogastrostomy justify its continued use in the management of patients with lesions in this location.
Intubation in the treatment of carcinoma of the esophagus
Authors: Angorn I. Barnett
Published: May 2005

Intubation for the palliation of dysphagia due to squamous carcinoma of the esophagus has been analyzed in a series of 1,135 patients treated over a 5‐year period. Tumors involving the upper thoracic esophagus in 1,045 patients were intubated with the Procter‐Livingstone tube using a pulsion technique. The hospital mortality rate in this group was 16%, with 80% of patients intubated swallowing satisfactorily on discharge. Tumors of the lower esophagus in 90 patients were intubated with the Celestin tube, using a traction technique. The hospital mortality rate was 20%, with 73% of patients swallowing an adequate diet on discharge. In 184 patients with malignant esophago‐respiratory fistulas, pulsion intubation successfully palliated symptoms in 75% of patients. Objective evaluation of the nutritional status of patients following intubation demonstrated correction of protein‐calorie malnutrition.
The Kirschner bypass operation—A palliation for complicated esophageal carcinoma
Authors: Roeher Hans D. , Horeyseck Guenter
Published: May 2005

The original technique and modification of the Kirschner gastric bypass operation are described. This procedure provides an alternative to the Celestin tube in restoring oral food intake in case of complete neoplastic obstruction of the esophagus in an unresectable stage. The superiority of this procedure primarily concerns esophagobronchial fistulas of benign and malignant origin. Operative mortality rates between 10 and 33% and survival times of 3–6 months are approximately equal for the bypass procedure and tumor intubation.
Results of the Kirschner operation
Authors: Wong John , Lam K. H. , Wei W. I. , Ong G. B.
Published: May 2005

Between 1964 and 1979, a total of 1,536 patients with carcinoma of the thoracic esophagus were treated at this center. Of these, 142 patients with unresectable tumor underwent the Kirschner operation for palliation. In this operation, esophageal obstruction is bypassed by subcutaneous or retrosternal gastric esophagoplasty, and the thoracic esophagus defunctionalized by a long Roux‐en‐Y jejunal loop to the abdominal esophagus. Dysphagia is thus relieved and aspiration of esophageal and gastric contents into the respiratory tract avoided.

Any patient who was not discharged from the hospital for any reason and eventually died in the hospital is counted as a mortality. The hospital mortality for these 142 patients was 41.5% (59 patients). In recent years, there has been a reduction in mortality rate. The most common cause of death was progressive bronchopneumonia (72.9%). Leakage of anastomosis occurred in 67 patients (47.2%), but most healed on conservative treatment. The ability to eat normally was restored in 69% of survivors, and another 28% were able to tolerate a soft diet. Although temporary postoperative aspiration was occasionally encountered when the patient started oral feeding, once swallowing was established, tracheobronchial aspiration did not occur.

The mean survival of the discharged patients was 5.0 months. Malignant cachexia from growth of the primary tumor accounted for 61.4% of late deaths; metastatic disease, 10.8%; and cardiopulmonary insufficiency, the remainder. One patient is alive more than 5 years after operation, and presumably was cured by postoperative radiotherapy.

Although the mortality rate of the Kirschner operation is substantial, other forms of treatment also have significant mortality rates but with less palliative potential. Therefore, we would recommend this operation for the palliation of unresectable carcinoma of the esophagus.
The utility of fine needle aspiration biopsy cytology in the management of thyroid tumors
Authors: Varhaug Jan E. , Segadal Elsa , Heimann Peter
Published: May 2005

This report is a retrospective survey of our experience with fine needle aspiration biopsy cytology in the evaluation of thyroid tumors in the years 1974–1978. The method was used as a routine procedure with 17 surgeons involved in the sampling and 4 cytopathologists involved in analyses of the smears. In 264 patients treated surgically, the preoperative cytopathologic diagnoses have been compared to the postoperative diagnoses. In 43 patients (16%), the biopsies were not representative. In patients with representative biopsies, a preoperative benign cytologic diagnosis was obtained in 112 of 160 patients with benign postoperative histology (70%), and a malignant or suspected malignant preoperative cytologic diagnosis was found in 52 of 61 patients (85%) with carcinomas. In 9 patients, the preoperative cytologic diagnoses were false‐negative (4.1% of the representative biopsies). No false‐positive cytologie diagnosis occurred. Sampling of adequate cellular material was the major problem in our experience. The high diagnostic reliability from representative material makes fine needle aspiration biopsy cytology a useful method in planning operations and in selecting patients for surgery. Due to the risk of false‐negative biopsies, a clinical suspicion of malignancy must not be ruled out by this method.
Calcitonin studies in the rhesus monkey
Authors: Geelhoed Glenn W. , Becker Kenneth L. , O'Neill William , Snider Richard H. , Moore Charles F. , Silva Omega L.
Published: May 2005

This study evaluates the utility of the rhesus monkey (Macaca mulatta) as a model for calcitonin (iCT) dynamics in humans. Two different anticalcitonin antisera were used, each having different region specificities for the hormone. Basal levels of iCT in both serum and urine were lower than those encountered in humans, whether measured with midportion (Ab‐IIIb) or carboxyl terminal (Ab‐IV) antisera. The totally thyroidectomized monkey continues to have detectable serum iCT while, in contrast to humans, urine iCT is undetectable by direct assay but measurable after concentration. Immunoperoxidase studies revealed a relatively larger concentration of C cells in the thyroid of the monkey, with, as in humans, a distribution in the central region along the median axis of the lateral lobes. Extraction of iCT from the thyroid gland demonstrated a higher concentration in the monkey than in humans. Many extrathyroidal tissues of the monkey contained iCT, which did not differ immunochemically from that in thyroid; this finding is also true of comparable human tissue. The very high concentration of iCT in liver decreased markedly after thyroidectomy, suggesting that hepatic iCT may be receptor‐bound hormone of thyroid origin. Other extrathyroidal sources of iCT persisted after thyroidectomy in the monkey, with the highest concentrations being found in thymus and in lung. The demonstration of the presence of extrathyroidal iCT may have important implications for its function as a tumor marker and for its presumed role in calcium metabolism. These studies demonstrate that the rhesus monkey, regardless of some differences from man, is nonetheless a useful animal model for the investigation of the pathophysiology of calcitonin.
Emergency decompression of bile duct in acute obstructive suppurative 3 cholangitis by duodenoscopic cannulation: A lifesaving procedure
Authors: Ikeda Seiyo , Tanaka Masao , Itoh Hideaki , Kishikawa Hideki , Nakayama Fumio
Published: May 2005

Acute obstructive suppurative cholangitis is a life‐threatening condition characterized by abdominal pain, jaundice, spiking fever, shock, and central nervous system depression. Biliary calculi are by far the most common obstructing mechanism. This entity carries an almost 100% mortality unless early decompression of the obstructed common bile duct is performed. With recent progress in duodenofiberscopy, this can be accomplished by endoscopic cannulation using a large‐calibre stiff catheter. Three consecutive patients recently treated in the Kyushu University Hospital are presented. All were female and a stone was the cause of the obstruction in all. The stones impacted at the distal common bile duct of these patients were dislodged by endoscopic cannulation, resulting in a release of purulent bile and a dramatic improvement in the symptoms and signs. Endoscopic decompression is a quick, safe, and effective procedure for emergency treatment of acute obstructive suppurative cholangitis.
Operation‐sequel carcinoma of the stomach. Experimental studies of surgical techniques with or without resection
Authors: Langhans Peter , Heger Ralph A. , Hohenstein J. , Schlake Werner , Bünte Hermann
Published: May 2005

Several etiopathogenetic factors responsible for carcinogenesis in the operated stomach have been proposed in the literature, but exact proof is still lacking. An experimental assay was planned to determine the pathogenetic roles of surgical trauma, of duodenogastric reflux, and of carcinogen application and its effects. Five different techniques of gastric surgery were performed on a collective of 466 Wistar rats: Billroth I resection, Billroth II resection, Billroth II plus gastroenterostomy with Roux‐en‐Y technique, Billroth II plus Braun's anastomosis, and gastroenterostomy without resection. Forty‐two animals were left unoperated as controls. The appropriate date for autopsy was determined by general clinical observation and random endoscopic and radiologic examinations, and eventually fixed on the 56th postoperative week.

Carcinomas developing in the resected stomach were found in animals with and without carcinogen exposure. The actual rate of carcinoma incidence was strongly dependent on the surgical procedure chosen for the respective group. The lowest carcinoma incidence (0%) was found in gastroenterostomy without Roux‐en‐Y anastomosis, the highest rate (70% without carcinogen, 50% with carcinogen application) in gastroenterostomy alone.

Tumor development was found to be connected with alterations of the physiological environment induced by the surgical intervention; a direct association between duodenogastric reflux and tumorigenesis can be postulated. The results of the present study are interpreted with an emphasis on reflux‐preventing techniques for gastric surgery that should be included in clinical routine.
Urgent surgery for ulcerative colitis: Early colectomy in 132 patients
Authors: Albrechtsen Dagfinn , Bergan Anstein , Nygaard Knut , Gjone Egil , Flatmark Audun
Published: May 2005

In accordance with a policy of early colectomy for severe ulcerative colitis, urgent/emergency surgery was performed in 132 patients during the last decade. The indication for surgery was toxic megacolon (45 cases), massive hemorrhage (6 cases), and fulminating colitis not responding to medical treatment within 4 days (81 cases). The operations performed were proctocolectomy (9 cases, mostly of hemorrhage), colectomy plus ileorectal anastomosis (3 cases), and abdominal colectomy plus ileostomy plus proctostomy (CIP) (120 cases, including 45 of toxic megacolon). Secondary proctectomy (SP) was later performed in 113 CIP cases.

A major distinction of this series is a colonic perforation rate of only 3% (9% in toxic megacolon). Mortality after urgent/emergency colectomy was 5.3%. Total mortality within 2 years (including SP) was 6.8%. Two of 4 patients with colonic perforation died, as did 1 patient with colonic cancer. Postoperative complications occurred in 40% of the patients after urgent/emergency colectomy, and in 52% after all surgery combined (including SP). Mortality and morbidity were higher in toxic megacolon and in patients older than 60 years. Late complications, mostly persisting perineal sinuses, were seen in 31%.

We believe that the low colonic perforation rate, and the subsequent favorable mortality and morbidity, are the results of our policy of early colectomy. Also, this study lends support to the choice of abdominal colectomy plus ileostomy plus proctostomy (and subsequent secondary elective proctectomy) when urgent/emergency surgery is indicated for severe ulcerative colitis.
Rectocolic familial polyposis; a study of 32 cases
Authors: Bigay D. , Plauchu H. , Berard Ph. , Robert J. M. , Guillemin G.
Published: May 2005

Thirty‐two cases of diffuse rectocolic polyposis, with a more or less marked hereditary character, have been analyzed. The homogeneity of the series, derived from the same surgical source and with the cooperation of a genetics department for the familial survey and detection, allowed precise observations on the evolution and treatment of the disease. Besides the imperative indications for removal of the rectum in those cases determined by endoscopy to be either locally degenerate or uncontrollable, a surgical protocol designed to meet more precisely the diagnostic needs must be developed, based on the preservation of the rectum and resulting in its unlimited supervision.
Studies in the healing of intestinal anastomoses
Authors: Ravitch Mark M. , Brolin Robert , Kolter Joseph , Yap Simon
Published: May 2005

We have assessed the security of anastomoses made by a variety of techniques, and under various circumstances. (a) In small bowel, inverting and everting silk anastomoses and stapled anastomoses give equivalent results. (b) With everting closures and anastomoses, healing is from the cut end, and not at the suture line. (c) Foreign material around an anastomosis produces leaks with any type anastomosis. (d) In the colon, inverting manual anastomoses and stapled anastomoses are equivalent, and superior to one‐layer manual everted anastomoses. (e) Induction of early intestinal action by Prostigmin® and castor oil has no adverse effect on inverted, or stapled anastomoses, at any level of bowel, but increases incidence of anastomotic leaks in silk everting anastomoses of colon. (f) Stapled anastomoses made in presence of 24‐hour perforative peritonitis, 48‐hour devascularized bowel, and 48‐hour intestinal obstruction are as secure as inverting anastomoses.
The kallikrein‐kinin system in circulatory and metabolic homeostasis
Authors: McConn Rita , Haberland Gert L. , Frölich J. C.
Published: May 2005

This review focuses on how the kallikrein‐kinin system may influence circulatory and metabolic homeostasis through its interrelationship with the renin‐angiotensin system and the prostaglandins. Biochemical and physiological aspects of each of these systems are described. Recent findings suggest that the kinins may play a role in the physiological processes of healthy individuals as well as in disease states. The major influence of kinins, both in tissue and plasma, on renal function and blood pressure homeostasis may be through their effect on prostaglandin synthesis rather than their effect on angiotensin II formation. Kinins also may play a role in metabolism since these oligopeptides were found to influence glucose uptake in the gut and in skeletal and cardiac muscle in normal and pathological conditions. The effects of these chemical mediators on renal function are presented in terms of their anatomical location, as well as the biochemical and physiological associations between these chemical mediators.
Combined arterial reconstruction and transluminal dilatation: Therapeutic teamwork to combat vascular insufficiency
Authors: Johansen Kaj , Ricketts Howard , Wales Lee R. , Morishima Michael
Published: May 2005

Percutaneous transluminal angioplasty (PTA) is a nonoperative method for dilatation of arterial stenoses. A burgeoning interest in PTA, fueled by its speed, ease, relative noninvasiveness, and diminished expense, has been marred by its rapid adoption without sufficient understanding of the biophysics of plaque dilatation, healing of the arterial injury thus incurred, or long‐term consequences of the technique. Further, it has too frequently been considered to be a competitor with surgical reconstruction in the management of limb or organ ischemia. Five illustrative cases demonstrate that PTA and arterial reconstruction may occupy complementary roles. Arterial dilatation has permitted limb‐saving arterial reconstructive surgery to be done in some severely ill patients, and has diminished the scope of such surgery in others. Arterial reconstructive surgery and PTA can be used effectively in synchronous or staged fashion to the benefit of well‐selected patients with arterial insufficiency.
The initial evaluation of the multiple trauma patient
Authors: Shaftan Gerald W.
Published: May 2005

The primary evaluation and resuscitation of the multiple trauma patient is based upon diagnosis and therapy of the failures of oxygen transport. The sequence is clearly ventilation, circulatory failure, and pulmonary failure. The secondary evaluation is related to intracranial, intrathoracic, intra‐abdominal, and extremity injuries. These 2 phases overlap. Thus, ventilation needs to be achieved without further compromise of spinal cord function while the control of external bleeding certainly aids circulatory function. In addition, effective cardiopulmonary resuscitation commonly greatly improves cerebral function. Thus, although discussed separately, evaluation and resuscitation is a complex endeavor that involves all of the injuries and all of the organs on a varying time scale in which the failures of oxygen transport are of first order importance because of the time scale that leads to death. Effective resuscitation demands a detailed knowledge of cardiopulmonary physiology and an aggressive personality so that the various possible mechanisms are evaluated and treatment is rapidly initiated. In general, the patient should have good cardiopulmonary resuscitation prior to being transferred to the radiographic unit. Thus, chest tubes may be placed on the basis of emergency room physical evaluation. The various pump failures are recognized by the failure of adequate circulatory response to blood volume support, usually accompanied by a rising right atrial pressure. Intra‐abdominal and intrathoracic bleeding are largely diagnosed by chest or peritoneal lavage tubes without x‐ray examination.
Traumatic shock in polytrauma: Circulatory parameters, biochemistry, and resuscitation
Authors: Messmer Konrad F. W.
Published: May 2005

Traumatic shock in multiple trauma patients essentially represents hypovolemic shock in association with the effects and sequelae of tissue damage. The primary factor rendering the patient at peril to develop multi‐organ failure is the persistence of impairment of the microcirculation. Resuscitation must take place efficiently to prevent shock if possible or to treat shock when manifest. Primary volume replacement with red cell‐free solutions, preferably with a long‐lasting colloid, is recommended as the most important single step in resuscitation. Sequential analysis of circulatory and biochemical parameters, together with evaluation of clinical symptoms, is needed to reverse traumatic shock as a prerequisite for surgical management.
Thoracic injury requiring surgery
Authors: Mattox Kenneth L.
Published: May 2005

This report concentrates on the 15% of chest injuries requiring thoracotomy. Eighty‐five percent of cases may be managed by a large‐bore chest tube placed in the midaxillary line. The indications for thoracotomy following placement of a chest tube are immediate egress of 1,500 ml of blood, continued bleeding at a rate of more than 100 ml/h, and large air leaks that prevent re‐expansion of the lung or that, on the ventilator, constitute a significant fraction of the tidal volume. Immediate thoracotomy is also indicated for the patient with a penetrating wound that may have reached the heart in association with acute loss of vital signs or shock that does not quickly respond to blood replacement. Emergency room thoracotomy may also allow salvage of blunt trauma patients with blood loss in the chest by allowing more effective control of blood loss, cardiac massage, and cross‐clamping of the aorta. A persistent diagnostic suspicion of the hidden injuries such as aortic rupture, esophageal injury, airway rupture, blunt cardiac injuries, and diaphragmatic rupture must be maintained, so that these injuries are properly diagnosed and treated. Sepsis following trauma to the chest is generally related to retained hematoma and damaged tissue. It is probably wise to resect the pulmonary parenchyma damaged by a high velocity gunshot wound. Chest tubes for hemothorax should be placed so that the blood is totally evacuated; otherwise, the clotted blood usually restricts pulmonary ventilation and commonly leads to an empyema which requires surgery.
Management of open fractures in the multiple trauma patient
Authors: Allgöwer Martin , Border John R.
Published: May 2005

The management of open fractures in the multiple trauma patient is discussed. It is concluded that operative stabilization of the open fracture both enhances the survival of these patients and reduces the complications of the fracture while enhancing extremity function. This procedure must be conducted so as to avoid devascularization of more tissue and especially bone fragments and so that adequate stability is provided. In general, all open fractures are left open with the degree of openness depending upon the magnitude of the soft tissue trauma. In grade I and II open fractures, stabilization can usually be achieved by internal fixation or by a combination of minimal internal fixation (usually lag screws) and external fixation. In grade III open fractures, stabilization is usually best achieved by external fixation. However, the external fixation must be carefully designed to allow the subsequent soft tissue coverage operations which are usually required in third degree open fractures. In general, the external fixator should be viewed as a device to gain sufficient stability for patient mobilization and soft tissue management and not as definitive fracture care. For this reason, in the tibia unilateral frames are usually best and bilateral or trilateral frames should be reserved for segmental defects and severe zonal comminution. Definitive fracture care is then administered after soft tissue healing by cast or internal fixation.
The metabolic response to trauma and sepsis
Authors: Hassett J. , Border J. R.
Published: May 2005

The metabolic response of the body to trauma and sepsis is the summed response of the organs. Net catabolism of the muscles of ambulation is particularly important in providing the other organs with a source of amino acids for protein synthesis and, therefore, anabolism. This net catabolism of muscle is based upon decreased physical activity, the net effects of the neuroendocrine system, and the consequences of local amino acid concentration changes within muscle, particularly of leucine. Secondary to these changes, previously healthy humans sustaining acute short‐term trauma of fairly major degree do not require exogenous supplies of amino acid even though the patient has a short‐term negative nitrogen balance.

In contrast, the septic patient has, in addition to the preceding changes, activation of phagocytosis with release of phagocytic factors that mobilize white cells, increase body temperature, and further modulate the metabolism of muscle and probably all other organs. Since these changes are induced by phagocytosis, which may be activated by retained dead tissues of all kinds, the basic attributes of the septic state may be activated in the absence of bacteria. The retained dead tissue makes bacterial growth much more likely. The septic state, therefore, has as its hallmark all of the changes of the trauma state, plus a prolonged enhanced catabolism of all amino acids, which leads to protein malnutrition with its overt manifestation of multiple systems organ failure. These patients require calories only 10 to 50% in excess of the requirement of normal humans, but a great increase in amino acid intake (up to 2.5% to 3 g/kg per day). This support will purchase more time in which to treat the underlying sepsis.
Nutritional support of the multiple trauma patient
Authors: Schmitz J. ‐E. , Ahnefeld F. W. , Burri C.
Published: May 2005

This report presents a brief review of currently relevant aspects of the parenteral nutritional support of the multiple trauma patient in intensive care. The decisive factors governing selection and application of an individually devised program of parenteral nutrition are the multiple trauma patient's energy turnover and nitrogen losses on the one hand, and the tolerance limits and viability of the traumatized organism on the other. It is possible nowadays to provide situation‐adapted nutritional support corresponding to the individual requirements of a seriously injured patient. However, further detailed studies are still necessary to come up with more definite answers to questions regarding requirement levels, turnover, and tolerance of the substrates applied in critical metabolic situations. This aside, adequate nutritional therapy at present represents without a doubt an integral feature of any long‐term post‐trauma therapeutic program.
Evaluation and management of the polytraumatized patient in various centers
Authors: Olerud S. , Allgöwer M.
Published: May 2005

A questionnaire was sent to the following 6 trauma centers: University Hospital for Accident Surgery, Hannover, Federal Republic of Germany (Prof. H. Tscherne); University of Munich, Department of Surgery, Klinikum Grosshadern, Munich, Federal Republic of Germany (Prof. G. Heberer); Akademiska Sjukhuset Uppsala, Sweden (Prof. S. Olerud); University Hospital, Department of Surgery, Basel, Switzerland (Prof. M. Allgöwer); Hôpital de la Pitié, Paris, France (Prof. R. Roy‐Camille); and University of Texas Southwestern Medical School, Dallas, Texas, U.S.A. (Prof. B. Claudi). Their answers have been summarized in a few short paragraphs where tabulation was not possible, and then mainly in tabular form for convenient comparison among the various centers. There seems to be considerable international agreement on the main points of early aggressive cardiopulmonary management to prevent multiple organ failure and also, surprisingly, on the advantages of early internal fixation of major fractures.
Comprehensive regional trauma/Emergency Medical Services (EMS) delivery systems: The United States experience
Authors: Boyd David R. , Cowley R. Adams
Published: May 2005

The early 1970's, as an outgrowth of the American military experience, several pioneer regional trauma/EMS programs showed the way for better planning, organization, and resource deployment for trauma/EMS systems in the civilian community. The experience of the mid and late 1970's has brought an even wider implementation and modeling of trauma/EMS care systems with identification of specific patient problems, designation of trauma service centers, development of protocols, and professional teams on a regionwide basis. Currently, the acceptance of regionalized systems of care for trauma makes it a potentially manageable disease with greater prospect for developing even better systems of trauma care and control in the 1980's. The progressive impact on improving trauma care for this nation will in large part be due to the continued planning and development of regional trauma/EMS systems which have as a key focus the designation of an appropriate limited number of trauma service centers for geographic regions and the nation.

There should be little question today that hospitals having extensive experience with injured patients offer better care to these patients than hospitals receiving only an occasional trauma patient. Mortality and morbidity rates are lower in more experienced hospitals where interdisciplinary teams provide coordinated resuscitation, evaluation, and definitive operative management. The skills and teamwork employed in this complex task are improved by practice and repetition, which come only with a large volume of injured patients.
Prevention and management of infection in trauma
Authors: Molnar Joseph A. , Burke John F.
Published: May 2005

Examination of the causes of late mortality in multiple trauma patients reveals that as much as 78% of all deaths may be attributed to septic complications, suggesting the value of understanding the prevention and treatment of traumatic sepsis. In penetrating trauma, the protective features of the skin are eliminated, and systemic mechanisms of host defense are compromised. These changes in the host defense mechanism and the risk of infection influence the choice and technical features of wound closure and the use of antibiotics. Early diagnosis is imperative, but difficult.
Progress in the treatment of polytrauma over the past twenty years
Authors: Walt Alexander
Published: May 2005

Significant advances have been made over the past 20 years in the treatment of multiple trauma patients. An organized, preplanned, and intelligent network of people, transport, and facilities has been developed. Surgeons have come to appreciate the urgency of establishing the appropriate therapeutic priorities, both immediate and long term. The place of antibiotics in combatting sepsis in polytrauma has gradually been put into perspective. Technological developments and refinements in surgical skill as a result of experience and improved training are enabling more patients to survive post‐trauma emergency surgery. In addition, the care given in surgical intensive care units has improved as physicians become trained to view the patient as a series of integrated organ systems, the function of which may be observed and tracked in physiological terms.
Progress in the care of the victim of multiple injuries
Authors: London P. S.
Published: May 2005

Progress over the past 20 years in the care of victims of multiple injuries has been largely technical. These technological advances, which have made it possible to study both the structural and functional effects of injury on all organ systems, have also brought difficulties—increased septicemia from invasive measures, changes that result from the treatment that may themselves prove fatal, and life prolonged beyond any meaningful existence.

Progress, however, has also been made in therapy, in the understanding of the pathophysiology, and in the training and equipping of emergency room staff. It is these individuals who have played a large part in the progress in this field.
Progress in care and treatment of multiple trauma patients during the last twenty years
Authors: Sander E.
Published: May 2005

During the last 20 years, the increase in polytrauma has stimulated scientific development and brought about new activities in the field of patient can, Of these new activities, the early treatment of shock by first aid measures and intensive therapy are of greatest importance.

In the operative approach, the atraumatic method of operation with the help of new technical devices, instruments, and implants has stood the test of time. A remarkable development arose in the operative treatment of fractures, which plays a decisive role in polytrauma on account of the high rate of bone injuries as well as for reasons of general patient support. The operative treatment of abdominal, craniocerebral, and thoracic injuries was improved not so much by changing operative technics, but rather by vigorous treatment of shock and intensive medical support which have decisively changed the magnitude and timing of the surgery that can be performed to aid the patient. By this means, as well as by newly developed diagnostic possibilities, the necessary conditions for an effective operative treatment have been greatly improved. Thus, at present, more complete primary care of the injured may be carried out successfully in a large percentage of trauma victims.
Our experience with the changes in the care of the multiple trauma patient over the past twenty years
Authors: Rehn J. , Müller‐Färber J.
Published: May 2005

The experience of the Bergmannsheil in West Germany in treating multiple trauma patients is long and has reflected many of the advances in trauma care that have occurred, especially over the past 20 years. Constant confrontation with diagnosis and therapy of multiple trauma patients has resulted in an organizational regimen that reduces the time to commencement of effective treatment. Modern diagnostic equipment and procedures, prompt treatment, and a sequence of priorities for the medical care of multiple fractures and other injuries have all contributed to improved care for the multiple trauma patient.