bluuebunny/crossref_metadata_2025 huggingface dataset:
The effect of varying levels of vagotomy on postprandial lower esophageal sphincter pressure and pancreatic polypeptide
Authors: Olinde Andrew J. , Maher James W. , McGuigan James E.
Published: May 2005

Feeding produces a sustained increase in lower esophageal sphincter pressure (LESP) that is impeded by vagolytic blockade with atropine. This study determines the effect of varying levels of vagotomy on postprandial LESP and hormones known to stimulate LESP. Six dogs had measurement of fasting and postprandial LESP at 15‐min intervals after a 60 g beef meal. Blood was drawn for gastrin and pancreatic polypeptide (PP). The animals then had proximal gastric vagotomy (PGV) and subsequently, truncal vagotomy and pyloroplasty (TVP). The studies were repeated after recovery. Feeding produced a marked increase in LESP during the control period (p < 0.001) that was not affected by PGV (p > 0.6). In contrast, TVP completely abolished the LES response to feeding (difference from controls and PGV significant atp < 0.01). Gastrin response to feeding was accentuated by PGV, but this response normalized after TVP. Pancreatic polypeptide increased postprandially during the control period (p < 0.001). These increases were not affected by PGV (p > 0.6), but were completely abolished by TVP (difference:p < 0.001). Truncal vagotomy abolishes the postprandial rise in both LESP and pancreatic polypeptide. This suggests that vagal influences may play a role in the normal postprandial rise in LESP, possibly by release of pancreatic polypeptide, a hormone known to increase LESP.
Papillary cystic neoplasm of the pancreas: A curable pancreatic tumor
Authors: Kaufman Steven L. , Reddick Robert L. , Stiegel Mark , Wild Ronald E. , Thomas Colin G.
Published: May 2005

Pancreatic neoplasms are common and a leading cause of death from malignant disease. Their aggressiveness as well as the poor results of treatment has led to a somewhat nihilistic attitude in their surgical management with an emphasis on palliation rather than cure. Papillary cystic neoplasm of the pancreas, although rare, is frequently confused with more malignant tumors which are less successfully treated by pancreatic resection. This neoplasm arises from ductular epithelium, usually occurs in young women, and often remains asymptomatic until it becomes manifest as an abdominal mass or by a complication, e.g., rupture, hemorrhage, or secondary infection. Because of lack of familiarity with the tumor as well as its unusual presentation, the diagnosis is infrequently made at the initial operation. Our experience with 3 young females with papillary cystic neoplasms of the pancreas is reported. Included is a review of the literature indicating the unique characteristics of the tumor. Although locally invasive, these tumors appear to have limited malignant potential and rarely metastasize. An aggressive surgical approach seems fully justified.
Comparison of sonography, computed tomography, angiography, and percutaneous transhepatic portography in detection of portal tumor thrombus in hepatoma
Authors: Igawa Sumito , Sakai Katsuji , Kinoshita Hiroaki , Hirohashi Kazuhiro , Inoue Tadashi
Published: May 2005

We operated on 108 patients with hepatocellular carcinoma between July 1980 and July 1985. Eighteen (16.7%) had a tumor thrombus in the portal branch. The sensitivity of detection of these thrombi was 11.1% (2/18) by computed tomography, 22.2% (4/18) by transarterial portography, 50% (9/18) by sonography, and 70.6% (12/17) by percutaneous transhepatic portography. The outcome of hepatocellular carcinoma in the patients with such a tumor thrombus was poor. We think that percutaneous transhepatic portography should be done before operating for hepatocellular carcinoma to see if there is a tumor thrombus in the portal branch.
Gallstones and gastric cancer: A matched case‐control study
Authors: Sarli Leopoldo , Gafa Matteo , Lupi Marco , Sansebastiano Giuliano , Longinotti Ernesto , Peracchia Anacleto
Published: May 2005

A matched case‐control study was carried out in order to verify the association of gastric neoplasms and lithiasic biliary disease and to clarify the nature of this association in 157 patients operated on for gastric cancer. Each patient was examined for previous cholecystectomy. Concomitant cholelithiasis was identified by ultrasonographic and intraoperative exploration. A statistically significant incidence of concomitant cholelithiasis (p<0.01) was found in patients affected by cancer of the antropyloric region (27% versus 11.7%), in female patients (24.7% versus 11.8%, p<0.05), and in patients over the age of 65 (32.2% versus 17.2%, p<0.05). No association with cholecystectomy was revealed in any of the cases. On the basis of these results, it may be concluded that the association found is not to be attributed to well‐known risk factors that are common to both diseases or to alterations in the bile composition caused by lithiasic disease. It appears that cholecystectomy has a protective effect as regards the increased risk of gastric cancer in patients with cholelithiasis.
Isolated splenic vein thrombosis
Authors: Moossa A. R. , Gadd Michele A.
Published: May 2005

Isolated splenic vein thrombosis is being recognized more frequently as a complication of pancreatic disease and as the cause of gastrointestinal hemorrhage in patients without liver disease. The increased incidence reflects advances in diagnostic radiology and a higher index of suspicion for the diagnosis.

Splenic vein thrombosis should be suspected in: (a) a patient with a history of pancreatitis and gastrointestinal blood loss; (b) a patient with splenomegaly in the absence of portal hypertension, cirrhosis, or hematologic disease; and (c) in the setting of isolated gastric varices.

Celiac angiography has replaced splenoportography as the definitive diagnostic tool for splenic vein thrombosis and is indicated prior to operation for suspected portal hypertension or for complications of pancreatitis. The importance of making the diagnosis lies in differentiating the lesion from the more common case of hepatic and extrahepatic portal hypertension. The treatment of choice is splenectomy.
Splenic trauma in children and techniques of splenic salvage
Authors: Buntain William L. , Gould Howard R.
Published: May 2005

The increased risk of sepsis after splenectomy applies to any age for any reason. Splenic injuries consequently are now managed when possible by salvage procedures or nonoperative observation. This is not without controversy and in an attempt to define these injuries more appropriately and so predict optimal management, a quantitative and qualitative classification of presence and severity is presented, based on computed tomography. Type I injuries consist of localized capsular disruption or subcapsular hematomas, without significant parenchyma injury. Type II injuries consist of single or multiple capsular disruptions, with parenchymal injury that does not extend into the hilum or involve major vessels, with or without intraparenchymal hematoma. Type III injuries consist of deep fractures, single or multiple, that extend into the hilum and involve major vessels. Type IV injuries are those in which the spleen is completely shattered, fragmented, or separated from its normal blood supply. Added to this is the subclassification A for splenic injuries without associated intra‐abdominal injuries; B for splenic injuries with associated intra‐abdominal injuries, B1 for injuries involving a solid viscus, B2 for injuries involving a hollow viscus; and E for splenic injuries with associated extra‐abdominal injuries.

Surgical techniques for splenic salvage consist of the application of topical hemostatic agents or omentum with or without simple capsular sutures, direct suturing of capsule and parenchyma, ligation of individual or segmental vessels, partial splenectomy, application of an absorbable net or ladder, and large entire organ through‐ and‐through sutures. These techniques are illustrated and alternatives to salvage are discussed.
Splenic abscess
Authors: Gadacz Thomas R.
Published: May 2005

Splenic abscess is an unusual disease and may be present either as a localized area of infection in the spleen or as a part of generalized sepsis. There are no specific clinical findings for a splenic abscess; the symptoms and signs of sepsis should arouse a suspicion of splenic abscess. Computerized axial tomography (CAT) scan probably offers the most direct way of evaluating the spleen and making an early diagnosis. Although gram‐positive cocci are most frequently reported in splenic abscesses, there is enough variation of organisms that specific combination of antibiotics cannot be recommended. Antibiotic selection should be based on positive blood cultures and intraoperative cultures. The preferred treatment is splenectomy, although occasionally external drainage may be required. A successful outcome is dependent on an early diagnosis and prompt treatment by splenectomy. When splenic abscess is part of an overall septic process, the prognosis is generally very poor.
Splenectomy for thrombocytopenia
Authors: Schwartz Seymour I.
Published: May 2005

The effects of splenectomy in 49 thrombocytopenic patients managed since 1979 were assessed and compared with our previous experience of 174 patients. Idiopathic thrombocytopenic purpura (ITP) constitutes a common indication for splenectomy, which effects a cure in 86% of these patients. The platelet count rises above 100,000/mm3 by the eighth postoperative day in 88% of responders. Urgent splenectomy is indicated for patients with thrombotic thrombocytopenic purpura (TTP) because it is associated with the highest cure rate. Splenectomy in patients with myeloproliferative disorders causing thrombocytopenia effectively raises the platelet count but has been followed by the greatest incidence of complications among the hematologic disorders studied. In patients with chronic lymphatic or hairy cell leukemia, splenectomy almost always returns platelet counts to normal levels and there is an impressive improvement in the quality of life. A wide variety of disorders characterized by thrombocytopenia is responsive to splenectomy. Accessory spleens have been removed in 17% of ITP patients and are often present in patients with myeloproliferative disease, but only rarely noted in other patients with thrombocytopenia.
Splenectomy for myeloproliferative disorders
Authors: Wilson Richard E. , Rosenthal David S. , Moloney William C. , Osteen Robert T.
Published: May 2005

Splenectomy is highly successful in reversing hypersplenism associated with myeloproliferative disorders (MPD). Significant improvement in leukocyte, platelet, and erythrocyte counts usually occurs within 1 week of splenectomy. Relief of symptoms associated with progressive splenomegaly seen with these entities is also achieved by splenectomy. Splenectomy, however, does not affect the inexorable course of these MPD, which appear to be caused by repeated damage to the pluripotential hematopoietic stem cell population. Hypercellular and hypocellular responses to this bone marrow injury result in a variety of disease states. A review of 50 patients treated with splenectomy for MPD from 1967 to 1980 demonstrated that the operation can be performed with a low mortality rate and minimal morbidity. About 15% of those patients presenting with MPD required splenectomy. Preoperative radionuclide ferrokinetic and sequestration studies, while good predictors of hematological response to splenectomy, do not provide information that impacts on the eventual outcome of splenectomized patients. Selection of patients with MPD for splenectomy is best made on clinical grounds.
Splenectomy for splenomegaly and secondary hypersplenism
Authors: Coon William W.
Published: May 2005

Splenomegaly and secondary hypersplenism may be associated with acute and chronic infections, autoimmune states, portal hypertension or splenic vein thrombosis, and a number of infiltrative and neoplastic conditions involving the spleen. Our experience and that of others with these various conditions demonstrates that the decision to perform splenectomy should be based on well‐defined and often strictly limited indications. Except for idiopathic splenomegaly, the presence and severity of secondary hypersplenism or severely symptomatic splenomegaly should be well documented. In each case, the potential for palliation and known mean duration of expected response must be weighed against the increased morbidity and mortality of splenectomy (as compared to operation for “primary” hypersplenism).
Staging laparotomy with splenectomy for Hodgkin's disease: The Stanford experience
Authors: Taylor Mark A. , Kaplan Henry S. , Nelsen Thomas S.
Published: May 2005

The results of 825 staging laparotomies performed by surgeons at Stanford University Hospital are presented. The clinical stage was changed as a result of laparotomy in 43.2% of cases. Preoperative lymphangiography proved accurate in 78–80% of cases. In 321 patients (38.9%) the test results for the spleen were positive, and in161 (50.2%) of these, the spleen was the only positive tissue sampled. Major complications occurred in 9.6% of cases; most were wound and upper respiratory infections. The results of laparotomy have identified a subgroup of stage NIA patients who benefit from early systemic chemotherapy. Staging laparotomy with splenectomy has proven to be a useful and safe clinical research tool and has been one of the major factors in increasing survival from Hodgkin's disease.
Partial splenic embolization: Experience in 136 patients
Authors: Jonasson Olga , Spigos D. G. , Mozes Martin F.
Published: May 2005

We report our experience with transcatheter partial splenic embolization (PSE) in 136 patients; 124 patients were treated in association with renal allograft protocols, 8 patients for hematologic disorders, and 4 patients for portal hypertension and esophageal varices. A total of 15 patients have died over the 1–8 year follow‐up period. Three deaths were a direct result of the procedure. Long‐term follow‐up for up to 8 years of the patients who underwent transplantation has revealed good renal allograft survival and no apparent increased mortality from late septic episodes. Seventeen major complications have occurred including pancreatitis (2), pseudocyst formation (2), splenic hematoma (1), pleural effusion (10), and splenic abscess (2). Fever, atelectasis, leukocytosis, pain, and hyperamylasemia were commonly seen and resolved rapidly. Children withβ‐thalassemia major, spherocytosis, andα1‐antitrypsin deficiency were benefited by PSE with no serious morbidity and no mortality. Two patients with splenic vein thrombosis and one with alcoholic cirrhosis were successfully managed by sequential PSE, as was 1 patient with massive splenomegaly from myelofibrosis. We conclude that PSE is a relatively safe and effective procedure in the management of certain patients with hypersplenism and portal hypertension, and that the long‐term risks of postsplenectomy sepsis may not be incurred.
Tumors of the spleen
Authors: Morgenstern Leon , Rosenberg James , Geller Stephen A.
Published: May 2005

Splenic tumors are uncommon lesions that can be divided into two main categories: nonlymphoid and lymphoid. The most common nonlymphoid tumors are the vascular tumors, which include benign and malignant hemangiomas, lymphangiomas, and hemangioendotheliomas. The remaining nonlymphoid tumors, such as fibrosarcoma and lipoma, are so uncommon as to be only anecdotally reported. Of the lymphoid tumors, Hodgkin's lymphoma may rarely occur as a primary splenic tumor, but more commonly is seen as part of disseminated disease. The same is true of histiocytic lymphoma and plasmacytoma. Rare benign lymphoid lesions may simulate lymphoid tumors. Of the metastatic tumors to the spleen, melanoma, breast, and lung are the principal lesions, but metastases from many other neoplasms occur. Metastases to spleen are less common than to other parenchymatous organs for reasons yet unknown. The surgical approach to splenic tumors should conform to the principles of good tumor surgery with good access, extirpation without rupture, and correct handling of tissue for study. Partial splenectomy is an acceptable procedure for benign splenic cysts, and possibly for polar hamartomas.
Is choledochoduodenostomy in the treatment of stones in the common bile duct an obsolete technique?
Authors: Cubillos Lorenzo , Fiallo Rodrigo , Rodríguez Jorge
Published: May 2005

The complex pathogenesis of bile duct stones, the anatomical properties of the biliary tree, the patient's age, associated diseases, as well as the technical devices available, may explain the great variety of procedures and preferences of different groups in the treatment of choledocholithiasis. Since no technique is infallible or free of complications, it seems unfair to argue that procedures whose efficacy has been proven by many authors are obsolete. This is the case of choledochoduodenostomy (CDS) in the treatment of common bile duct (CBD) stones. The complications associated with CDS, (ascending cholangitis, and “sump” syndrome) have been overemphasized and have led CDS to be rejected by many surgeons. Our experience with this technique is good and concurs with that of Madden and others.

Data on 125 patients with CBD stones treated with CDS between 1968 and 1982 are analyzed. Sixty‐eight of them were female and the mean age was 61.4 years; 73.6% were more than 50 years old. There were frequent accompanying diseases, especially cardiovascular ones. More than half of the patients had a previous operation on the biliary tree. The duct diameter was always greater than 20 mm and it was frequently associated with stenosis of the distal choledochus. Floercken's technique of CDS was the most frequently used, after Kocher's maneuver had been performed. There was no intraoperative mortality. Postoperative mortality was 3.2% and is analyzed in detail. The incidence of postoperative complications was 42.4%. Most were septic complications or those ascribed to accompanying diseases. Late operative cholangitis was present in 1.6% of patients, comparable with reports of other authors. We encourage the use of CDS in the treatment of CBD stones provided that: (a) careful attention is paid to its clinical indications, considering that the patient may benefit from alternative techniques, for example, duodenoscopic papillotomy; and (b) choledochal dilatation is greater than 20 mm in diameter and the choledochal and duodenal walls are normal. We specifically recommend CDS as the primary operation for patients with “choledochal funnel syndrome.” The operation is simple, restores normal digestive function, and almost always resolves the problems of CBD stones in high‐risk patients.
Total repair of annulo‐aortic ectasia with composite graft and reimplantation of coronary ostia: A consecutive series of 41 patients
Authors: Inberg Markku V. , Niinikoski Juha , Savunen Timo , Vänttinen Esko
Published: May 2005

Replacement of the ascending aorta and the aortic valve with a composite graft, including reimplantation of the coronary ostia, was carried out in 41 consecutive patients with annulo‐aortic ectasia from 1975 to 1984. Thirty‐seven patients were operated on electively and 4 of these had a chronic dissection. Four patients underwent an emergency operation, 1 for a ruptured aneurysm and 3 for an acute dissection. The operative procedure was identical in each case. The aortic valve and the aneurysm were resected, the coronary ostia were dissected free, mobilized, and then implanted to the tube prosthesis. There was no hospital mortality. Re‐sternotomy was done in 3 patients for excessive postoperative bleeding. Two patients required a permanent pacemaker owing to a total atrioventricular block. No pseudoaneurysms at the coronary ostia or the distal aortic anastomosis were observed at control aortography carried out in each patient 6 months after surgery. One patient died 3 months after the operation because of multiple emboli. All the other patients have been symptom free during follow‐up. It is concluded that total repair using the technique described is feasible in all patients with annulo‐aortic ectasia and gives good early and late results.
Total parathyroidectomy and parathyroid autograft for renal osteodystrophy: Analysis of the cause of failure
Authors: Kinnaert Paul , Vanherweghem Jean ‐Louis , Fuss Michel , Schoutens André , Bergmann Pierre , Dratwa Max , Van Geertruyden Jean
Published: May 2005

Between September, 1979, and December 31, 1983, thirtyone patients with renal osteodystrophy and high serum immune parathyroid hormone (iPTH) levels underwent total parathyroidectomy with parathyroid autograft. Three failures (10%) were due to residual parathyroid tissue. In 2 of these patients, 4 and 6 glands respectively, had been removed. This indicates the need for thorough dissection of the neck even when 4 glands have been found. Painful symptoms and vitamin D3 intolerance persisted after surgery in 3 other patients (10%), although iPTH levels dropped significantly. Further work‐up disclosed aluminum intoxication.
Hepaticojejunostomy using the left biliary trunk for iatrogenic biliary lesions: The French connection
Authors: Hepp Jacques
Published: May 2005

This paper deals with the utilization of the left main hepatic trunk in secondary repair of the bile ducts which was described by the author 28 years ago following the anatomic works of Couinaud. The reasons for choosing this duct are discussed: usual anatomic integrity, extraphepatic disposition of the trunk, and ease of location by intraoperative cholangiogram (which is considered indispensable by the author). The technical details of the operation are given: subcostal S‐shaped incision, lowering of the left trunk after a transverse incision of Glisson's capsule, opening of the trunk, instrumental exploration in the search for intrahepatic stones, and Roux‐en‐Y hepaticojejunostomy usually without a transanastomotic stent. Precise technical modifications are given for involvement of the bifurcation or morphological variations of the liver.
Complications of cyclosporin therapy
Authors: Kahan Barry D. , Flechner Stuart M. , Lorber Marc I. , Jensen Chris , Golden Debbie , Van Buren Charles T.
Published: May 2005

Cyclosporin (CsA) therapy has improved the outcome of allotransplants. Because of a relatively selective action on T lymphocytes, CsA therapy causes fewer immunosuppressive complications of infection or malignancy compared to previous chemical agents, which were relatively nonspecific in their spectrum of action on lymphoid versus nonlymphoid cells. Gastrointestinal complaints after oral administration and vasomotor reactions after intravenous administration represent pharmacologic toxicities rarely of major clinical import. Drug‐induced complications involve primarily the neuroectodermal, or the mesenchymal hepatic and renal, systems. While the former group of complications are rarely severe, mesenchymal nephrotoxicity poses a major limitation of drug therapy. On the one hand, reductions by 33% of normal renal function in patients treated with CsA for autoimmune disease appear to be reversible on discontinuance of therapy. On the other hand, severe renal dysfunction occurs in transplant recipients, particularly in the presence of concomitant therapy with nephrotoxic drugs. In the kidney transplant setting, numerous factors exacerbate the druginduced injury, including adverse donor procurement conditions, prolonged graft storage, and allograft rejection. Since the clinical and histologic findings in CsA nephrotoxicity tend to be pleiomorphic, no single diagnostic or therapeutic strategy has emerged. However, insights gained through pharmacologic monitoring of renal allograft recipients suggest that the group at increased risk for nephrotoxicity can be identified by elevated serum drug trough levels, increased area under the plasma time concentration curve, prolonged elimination half‐life, and heightened pharmacodynamic sensitivity to CsA. Analysis of pharmacologic data in conjunction with clinical results should provide drug regimens of maximal therapeutic index with minimal risk of complications.
Renal transplantation in the diabetic
Authors: Rohrer Richard J. , Madras Peter N. , Sahyoun Anthony I. , Monaco Anthony P.
Published: May 2005

The practices and recent results from a transplant center servicing a large proportion of uremic diabetics were reviewed to highlight modern management issues. The focus is taken off the diabetic as a “high‐risk” renal transplant recipient and brought to bear on the laborintensive aspects of his or her management. With special attention to perioperative cardiovascular status, operative mortality (30 day) can be less than 3.5% and morbidity minimized. Living related donors continue to offer advantages in terms of organ availability, early postoperative function, and most likely long‐term function, but in the cyclosporin era cadaver renal transplants have evolved competitive 1‐year patient survival rates of 96% and 1‐year graft survival rates of 88%. Still, the proportion of graft losses due to death of the patient from nonimmunologic causes, chiefly cardiac and cerebrovascular events, remains relatively high in the diabetic at 35.8%. Rehabilitation of the diabetic post‐transplant is less complete than that of the nondiabetic transplant recipient, but is clearly superior to that of alternative modes of therapy for the uremic diabetic.
Prospects for pancreatic islet transplantation
Authors: Gray Derek W. R. , Morris Peter J.
Published: May 2005

It is over a decade since the first description of cure of experimental diabetes in rats by transplantation of isolated adult islets of Langerhans. Despite a remarkable number of experimental studies, clinical islet transplantation is still not a reality, raising questions about the feasibility of this approach. Experiments in rodents have demonstrated the potential of isolated islet transplantation. It is possible to cure experimentally induced diabetes and restore normal glucose metabolism with prevention or even reversal of diabetic complications. The problem of allograft rejection, while formidable, is not insurmountable and a number of techniques are now available to achieve this aim.

Studies in animals larger than the rodent have been less successful and no repeatable method for isolated islet transplantation has so far emerged. Attempts at clinical purified islet transplantation have also proven unsuccessful. Transplantation of unpurified dispersed pancreatic tissue has been used successfully in dogs, but the technique has proven dangerous and inefficient when applied clinically. These disappointing results suggest, superficially, that the prospects for clinical islet transplantation are bleak. In reality, the problem in all the studies conducted in large mammals and humans has been the lack of an efficient method for separation of viable purified islets from the human and large mammalian pancreas. The recent description of more efficient islet separation methods allows new hope for clinical transplantation.
Cancer of the gastric stump: Analyses of 819 patients and comparison with other stomach cancer patients
Authors: Viste Asgaut , Eide Geir E. , Glattre Eystein , Søreide Odd
Published: May 2005

The clinical characteriscics and prognosis of 819 patients with cancer in a previously resected stomach are described. The data were obtained from the Cancer Registry of Norway from the period 1970–1979. Median age was 69.2 years (range 31–91), with a male‐to‐female ratio of 4.4:1. The predominant symptoms were general weakness, abdominal pain, and dyspepsia; the majority of patients had a short duration of symptoms. The median cime interval from the primary operation to cancer diagnosis was 28.7 years. Twenty‐one percent of the patients had localized disease; 25%, regional disease; and 39%, distant metastatic disease. In 15% of the patients the stage of the disease could not be ascertained. The resectability rate was 41%, with a postoperative mortality rate of 11%. The overall 5‐year survival was 10%, but 40% for patients with localized disease having a resection. Pacients younger than 40 at the primary operation had a 5‐year survival of 14% as compared to 7% for those older than 40 (p< 0.001). Pacients younger than 70 at cancer diagnosis had a 5‐year survival of 13% as compared to 7% for those older than 70 (p< 0.001). Analyses showed that the apparent poor prognosis for patients with stomach stump cancer relacive to patients with other stomach cancer was due to differences in patient characteristics, and when corrected for these variables, the 2 populations had the same prognosis.
Adenocarcinoma of the cardia: A 10‐year regional review
Authors: Allum W. H. , Roginski Claudia , Fielding J. W. L. , Jones B. G. , Ellis D. J. , Waterhouse J. A. H. , Brookes V. S.
Published: May 2005

Adenocarcinoma of the gastric cardia has the worst prognosis of all sites, and treatment is often palliative. This study has reviewed 736 patients with carcinoma of the cardia registered with the Birmingham Cancer Registry during 1960–1969. Fifty‐eight percent of the patients presented with advanced disease. Radical resection was accomplished in 265 (36%). The age adjusted 5‐year survival for all patients was 4.5% and 9.8% for those undergoing radical resection. In patients with advanced disease, palliative resection was associated with a longer survival than for those treated by intubation (p < 0.001) and this difference was maintained even in the presence of liver or peritoneal metastases. There was no difference in the 30‐day mortality rates for those undergoing palliative resection or intubation and it is suggested that resection be undertaken whenever possible.
Rapid turnover proteins as nutritional indicators
Authors: Cavarocchi Nicholas C. , Au Francis C. , Dalal Fram R. , Friel Karen , Mildenberg Budd
Published: May 2005

Many of the commonly employed nutritional parameters are inadequate indices of malnutrition since they are relatively nonspecific, focused on depletion, have limited validity, and do not always reflect improvements after repletion. Recent studies have focused on the rapid turnover proteins (RTP), particularly thyroxin‐binding prealbumin (TBPA) and retinol‐binding protein (RBP) as more sensitive indicators of malnutrition. Twenty patients with protein‐calorie malnutrition who were given total parenteral nutrition were evaluated by routine nutritional parameters and rapid turnover protein assays for comparison.

Results show statistically significant increases in mean values of TBPA (p < 0.001) and RBP (p < 0.0001) when compared in negative versus positive nitrogen balance (NB). Serum albumin levels decreased (p < 0.03), while transferrin (p < 0.03) and total lymphocyte count (p < 0.3) demonstrated less significance when compared in negative versus positive NB. Overall RBP and TBPA levels increased 2.8–3‐fold from negative to positive nitrogen balance. In mildly malnutritioned patients TBPA levels increased from 6.14 (±3.84) mg/100 ml to 22.42 (±9.62) mg/100 ml (p < 0.001); in moderately malnutritioned patients the TBPA increased from 7.2 (±6.68) mg/100 ml to 23.6 (±16.59) mg/100 ml (p < 0.04); and in severe forms, TBPA increased from 6.0 (±4.58) mg/100 ml to 18.66 (±7.37) mg/100 ml (p < 0.06). No such correlation could be found with the other routine nutritional parameters.

We conclude that TBPA and RBP levels can be used as serum markers of mild to severe malnutrition and that there exists a numerical range of values for TBPA and RBP which correlates with negative and/or positive nitrogen balance.
Factors affecting quality of life with a conventional ileostomy
Authors: McLeod Robin S. , Lavery Ian C. , Leatherman Judith R. , Maryland Patricia A. , Fazio Victor W. , Jagelman David G. , Weakley Frank L.
Published: May 2005

Two hundred seventy‐three patients with inflammatory bowel disease and permanent conventional ileostomies were surveyed to determine which factors affect the health and quality of life of the ileostomate. Physical and emotional health were considered good or excellent by 79% and 78%, respectively. Only a small number of patients (approximately 20%) felt they were more restricted with the ileostomy with regard to diet, clothing selection, leisure and work activities, and travel than they were preoperatively. Despite these restrictions, 74% stated they led normal, unrestricted lives; 23% experienced some restrictions and had some difficulties psychologically but were glad they had surgery. Only 3% regretted having surgery. Only one factor, function of the ileostomy, affected patients' physical and emotional well‐being, ability to perform work and daily activities, and their overall outlook on life. Other factors such as age, sex, duration of the disease preoperatively, duration since surgery, and disease etiology and activity seemed to make no difference. Thus, it appears that the surgeon plays an important role in determining the well‐being and quality of life of the conventional ileostomate.
Nodular goiter: Effects of surgery and thyroxine medication
Authors: Westermark Kerstin , Persson C. Peter A. , Johansson Henry , Karlsson F. Anders
Published: May 2005

In a prospective investigation, thyroid function was studied in 43 patients before and after surgery on a nontoxic nodular goiter. Prior to surgery, 11 patients displayed a flat thyroid‐stimulating hormone (TSH) response to thyrotropin‐releasing hormone (TRH), suggesting subclinical hyperthyroidism. Thyroid autoantibodies (microsomal/thyroglobulin) were found in low titers in 7 of 43 patients, and in no patient were TSH‐receptor antibodies found. Three months following surgery, 32 patients were chemically euthyroid and 11 patients had elevated TSH values. Seven of the latter had additional signs of hypothyroidism and were given continuous thyroxine substitution. Starting 3 months after surgery, increasingly higher doses of thyroxine were administered to patients with a normal TRH test until an abnormal TSH response was observed. Four patients had a flat TSH response to TRH without administration of thyroxine and in 9 patients a daily dose of only 0.1 mg resulted in such a response. The 32 euthyroid patients developed flat TSH responses at an average dose of 123 μg of thyroxine. The data indicate that following surgery, the thyroid hormone production from the nonnodular thyroid remnant has low suppressibility, suggesting that, in nodular goiter, tissue with abnormal hormone production is widely distributed within the gland. It appears then that thyroxine medication in nodular goiter has a place mainly in patients developing hypothyroidism following surgery.
Treatment of unresectable hepatocellular carcinoma : Results of a randomized controlled trial
Authors: Lai Edward C. S. , Tong S. W. , Ong G. B. , Wong John
Published: May 2005

Most patients with hepatocellular carcinoma present late with unresectable disease and, to date, an effective and safe palliative treatment has not been found. From December 1971, to December 1981, a randomized controlled trial was conducted to evaluate the following treatments against a control group receiving only symptomatic therapy (group I) : hepatic dearterialization (group II), hepatic artery ligation and cannulation for infusion of chemotherapeutic agents (group III), hepatic artery ligation and portal vein cannulation for chemotherapeutic agents infusion (group IV), and external irradiation (group V). Response to various treatments was assessed with respect to symptomatic relief and duration of survival. A total of 166 patients with histologically confirmed tumor confined to the liver were studied. All patients had similar preoperative general status and biochemical findings. Patients in group IV had the best symptomatic improvement; 58.6% responded to some degree. Hepatic artery ligation intraportal infusion (group IV) offered significantly longer survival than infusion via the intra‐arterial route (group III) (p= 0.023). However, when compared with the control group, the survival times in the 4 treatment groups were not significantly different. Hepatic dearterialization (group II) had the highest 7‐day mortality rate, 33.3%. The results of this trial suggested that none of the modalities of treatment studied offered patients with unresectable hepatocellular carcinoma any better survival and symptomatic palliation than did symptomatic treatment alone.
Repair of bile duct defect with full‐thickness vascularized jejunal patch
Authors: Bengtsson Henrik J. O. , Broomé Albert E. A. , Rimér Ulf
Published: May 2005

The use of a vascularized jejunal patch for the reconstruction of bile duct injuries is presented. The method has been used in 1 patient with a common bile duct stricture and in 1 patient with a noncircumferential bile duct defect. The procedure has the advantages of technical simplicity, primary mucosal coverage, lasting elasticity, and minimal risk for stricture formation.
Perioperative transfusions associated with colorectal cancer surgery : Clinical judgment versus the hematocrit
Authors: Tartter Paul Ian , Quintero Sandra , Barron Deborah
Published: May 2005

We prospectively studied 123 patients with colorectal cancer in order to identify determinants of perioperative blood transfusions and unnecessary transfusions. Transfusions were considered unnecessary if the preoperative hematocrit reading exceeded 36% or the discharge hematocrit level exceeded 33%. Age, sex, admission hematocrit reading, operative procedure, specimen length, duration of surgery, estimated blood loss, tumor size, tumor differentiation, nodal status, Dukes' staging, and attending surgeon were evaluated in relation to perioperative blood transfusion using stepwise logistic regression. Fifty‐one (41%) of the 123 patients in the study were transfused and 35 patients (28%) received at least 1 unnecessary unit of blood. Advanced age, low admission hematocrit reading, high estimated operative blood loss, prolonged procedures, and lengthy specimens were significantly related to the administration of blood. Excessive intraoperative transfusions and the practice of administering blood in pairs of units accounted for the unnecessary transfusions. This study indicates that factors that influence clinical judgment and thereby the decision to transfuse a patient are not accurate indicators of when blood should be given. Greater use of pre‐transfusion hematocrit testing, especially in the operating room and before transfusing a second unit of blood, will dramatically reduce blood usage in elective colorectal cancer surgery.
Fluid and electrolyte resuscitation of the thermally injured patient
Authors: Reaves Larry E. , Antonacci Anthony C. , Shires G. Thomas
Published: May 2005

Fluid and electrolyte management of thermal injury continues to undergo evolution. The goal of resuscitation is optimal maintenance of vital organ function, and during the first 24 hours after injury, resuscitation is best accomplished with isotonic balanced salt solution. Colloid‐containing solutions do not offer any advantage and may be deleterious. In the second 24 hours, fluid replacement should account for free water losses, maintaining serum sodium at 140 mEq/L. The use of colloid‐containing solution may be of benefit during this time period after capillary integrity is reestablished. Several formulae are available for initial guides, although clinical evaluation of adequate intravascular expansion is necessary. This is best accomplished using urine output as an indication of renal perfusion. Special attention is necessary in the resuscitation of children, the elderly, patients with inhalation or electrical injuries, and patients having a delay in initial resuscitation.
Acid‐base problems in surgery
Authors: Clark John , Walker William F.
Published: May 2005

The identification and treatment of various clinical states of acid‐base imbalance assume particular significance in major surgery and in patients with multiple organ failure. Metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis, and mixed disorders of acid‐base balance are described and a management plan for each entity is defined.
Effects of changes in endocrine function on water and electrolyte metabolism
Authors: Johnston Ivan D. A.
Published: May 2005

The effects of a number of hormones on fluid and electrolyte balance are reviewed, first under normal physiological conditions and then under pathological conditions associated with loss of function or with overactivity due to the presence of hyperplasia or functioning tumors. Some of the most pronounced changes may occur with ectopic hormone production by certain neoplasms of nonendocrine origin.
Denervation of the greater curvature in proximal gastric vagotomy
Authors: Martinez‐Ramos Carlos , Sanz Mario G. , Pardo Pilar , Nuñez Jose R. , Soriano Eduardo , Escobar Santiago T.
Published: May 2005

This report concerns a study of the role of the gastroepiploic nerves at the greater curvature in gastric acid secretion and the influence of its section in proximal gastric vagotomy (PGV) in the prevention of ulcer recurrence.

Thirty‐two patients who had surgery for duodenal ulcer were randomly divided into 4 groups. Group 1 had PGV; group 2, PGV plus section of the right gastroepiploic nerve; group 3, PGV plus section of the left gastroepiploic nerve; and group 4, PGV plus section of both gastroepiploic nerves. BAO and MAO values were determined in all patients pre‐ and postoperatively.

The statistical analysis of the results shows that the percent reduction of the BAO and MAO values obtained when performing a gastroepiploic nerve section, whether one of them or both, is not significantly different from those obtained when PGV alone is done. We have observed no differences in the rate of ulcer recurrence in the patients of the 4 groups; there was no ulcer recurrence after a minimum follow‐up time of 4 years.

We conclude that the denervation of the greater curvature, which is recommended by some authors when performing a PGV, is of little importance in obtaining a satisfactory reduction of gastric acid secretion and in reducing the ulcer recurrence risk.
Pelvic recurrence rate after abdominoperineal resection and low anterior resection for rectal cancer before and after introduction of the stapling technique
Authors: Luke Michael , Kirkegaard Preben , Lendorf Axel , Christiansen John
Published: May 2005

Pelvic recurrence rates after abdominoperineal resection (APR) and low anterior resection with the EEA stapler (LAR) for rectal cancer were compared. Since a controlled trial is not possible, we have compared the pelvic recurrence rate over a 2‐year period before and after introduction of the EEA stapler. Before introduction of the stapler, standard treatment for midrectal tumors was APR while LAR has been the standard treatment of these cancers after introduction of the EEA stapler. A total of 164 patients underwent surgery for rectal cancer in this 4‐year period, 85 in the first 2‐year period and 79 in the last 2‐year period. No difference could be demonstrated in pelvic recurrence rate after APR and LAR in the 2 periods [22.7% (95% confidence limits: 10.1–39.1%) and 22.2% (11.5–37.8%), respectively]. The recurrence rate was highest among Dukes' C tumors, but was unrelated to the type of operation.

It is concluded that the increased use of low anterior resection for rectal cancer after introduction of the EEA stapler has not been followed by a higher pelvic recurrence rate.
A posterior approach to the presacral mass
Authors: Geelhoed Glenn W. , Kotz Herbert L.
Published: May 2005

Mass lesions in the presacral space are not readily accessible from the transabdominal approach. The posterior transcoccygeal technique is a nearly ideal approach to the presacral mass, and allows the combined use of abdominosacral resection for more extensive tumors.

Four patients with presacral mass, which later proved to be benign cystic teratomas, each had transcoccygeal operation for resection. The technique gave adequate exposure, satisfactory margins, minimal patient morbidity, and no recurrence of the primary presacral teratomas.

The diagnostic evaluation of the presacral mass and the operative technique of a modified Kraske approach are described with suggestions for resection technique. The utility, flexibility, and limitations of the posterior transcoccygeal approach are reviewed in application to the management of the presacral mass.
Transcaval posterocranial resection of the liver as treatment of the Budd‐Chiari syndrome
Authors: Senning Åke
Published: May 2005

In 3 patients with a Budd‐Chiari syndrome the suprahepatic caval vein was incised during extracorporeal circulation and the suprahepatic hindrance for the hepatic venous runoff abolished. By resection of the juxta caval hepatic tissue the thrombotically occluded parts of the main vein stems were removed and a free hepatic venous flow to the caval vein was established in 2 patients. In the third patient, who had a caval stenosis at the diaphragmatic level (web) and thrombosis of even smaller hepatic veins and a retrograde flow to the portal vein, the resection resulted in an abundant blood flow from the resected liver area. It is assumed that this flow originates not only from the smaller hepatic veins, but to a great extent from arterio‐ and portovenous shunting. Angiography has shown that such shunting can take place after resection.

The first 2 patients are healthy and working full‐time at 2 1/2 and 2 years postoperatively, respectively. Nine months postoperatively, the third patient is in good condition, jaundice has disappeared, and bleeding from esophageal varices has not occurred.
Fat and carbohydrate metabolism during and following hemorrhagic shock in puppies: A comparison of different resuscitation protocols
Authors: Coran Arnold G. , Connors Robert H.
Published: May 2005

Shock states continue to carry a high mortality rate in the pediatric age group. Using a puppy model, we measured the initial metabolic response to hemorrhagic shock and to 3 resuscitation regimens: whole blood 1∶1 (replacement∶shed), lactated Ringer's 3∶1, and 5% albumin in lactated Ringer's 1∶1. Despite the immature nature of the puppy's enzyme, cardiovascular, and nervous systems, responses very similar to those in adult animals were seen. Serum glucose and free fatty acids rose during shock and declined with resuscitation as cardiac output returned toward normal. Serum lactate levels rose similarly but continued to rise for a short period after resuscitation and were associated with a further fall in pH consistent with “hidden acidosis.” Only small changes were noted in triglyceride and cholesterol levels. The metabolic responses noted following each of the 3 resuscitation protocols were similar. This study suggests that the immature animal responds to hemorrhagic shock in ways similar to the adult. The better initial hemodynamic response to resuscitation with high‐volume lactated Ringer's or lactated Ringer's with 5% albumin was offset by the better buffering capacity of blood resuscitation. All 3 regimens were equally efficacious in providing initial metabolic recovery in this experimental hemorrhagic shock model.
Pituitary apoplexy—An endocrine emergency
Authors: Laws Edward R. , Ebersold Michael J.
Published: May 2005

Successful therapy for pituitary apoplexy depends on prompt recognition of the clinical syndrome, accurate anatomic evaluation of the lesion with the CT scan, intensive steroid replacement therapy, and effective transphenoidal decompression of the tumor. Successful long‐term management of patients who have suffered pituitary apoplexy requires recognition by the complex interrelationships of the pituitary with adrenal, thyroid, gonadal, pancreatic, and gut physiology. Such patients often require multiple medications for replacement therapy. Surgical treatment is often supplemented with radiation therapy, and prolactin‐ and growth hormone‐secreting adenomas may require long‐term management with bromocriptine. Careful follow‐up evaluations and appropriate post‐surgical therapy enable most of these patients to live normal lives.