bluuebunny/crossref_metadata_2025 huggingface dataset:
Intensive medical treatment of severe acute pancreatitis
Authors: Creutzfeldt Werner , Lankisch Paul G.
Published: May 2005

Therapeutic measurements for acute pancreatitis depend on the severity of the disease and its complications. Since complications of acute pancreatitis may develop at any time, patients should be admitted to an intensive care unit for assessment (and frequent reassessment) of the severity of the disease and of the development of complications; they should remain in the intensive care unit for the first 48 hours at least, even if no signs of shock are apparent. The only exceptions to this rule are mild cases without signs of peritonitis. Basic therapy should include relief of pain, total fasting, nasogastric suction, parenteral replacement of fluids, electrolyte, albumin, and blood, and antibiotics. Hyperglycemia should be corrected and heparin should be given in cases of disseminated intravascular coagulation. In renal insufficiency, peritoneal dialysis is important, and in respiratory complications, humidified oxygen or artificial ventilation including positive end expiratory pressure therapy should be applied. Although the effect of peritoneal dialysis has been proven only in animal experiments and in retrospective studies in man, it is recommended in severe cases for shock therapy and for correction of electrolyte imbalance when ascites is present, even before anuria occurs.
Conservative surgical treatment of acute pancreatitis
Authors: Ranson John H. C.
Published: May 2005

The influence of early management on morbidity in 133 patients with severe acute pancreatitis has been reviewed. Patients with severe pancreatitis (33% mortality rate) were separated from those with mild pancreatitis (0.9% mortality rate) by early objective prognostic signs. Early management (days 0–7) included intra‐abdominal operation in 31 patients and there were 20 deaths (65%). No early intraabdominal surgery was undertaken in 102 patients and there were 18 deaths (18%). Early intra‐abdominal surgery was limited to placement of catheters for peritoneal lavage in 10 patients, and nonoperative management included peritoneal lavage by catheters placed percutaneously in 23 patients. In these 33 patients, there was 1 early death (days 0–10). In contrast, 43% of deaths in nonlavaged patients occurred during this period primarily from cardiovascular or respiratory causes. Overall mortality was slightly reduced in some groups of lavaged patients but the improvement was disappointing.

Early intra‐abdominal surgery may be required for diagnosis but it is associated with an increased mortality rate. Peritoneal lavage is an effective adjunct to the management of early complications of severe pancreatitis, but does not prevent the late sequelae of peripancreatic necrosis.
Role of total pancreatectomy in the treatment of necrotizing pancreatitis
Authors: Alexandre Jean ‐Henri , Guerrieri M. T.
Published: May 2005

The place of pancreatic resection in the treatment of acute pancreatitis is still much debated. Because of the bad results after insufficient resection, such as recurrence of extensive pancreatitis and infection, we decided to perform gastroduodenopancreatectomy (GDP) if more than 75% of the gland was necrotic.

We have performed 52 operations for acute necrotizing pancreatitis since 1972 in the Surgical Clinic of Broussais Hospital; of 20 GDP patients, 8 are still alive. All have easily controlled diabetes,S were able to resume work, and 3 retired. After study of the deaths of the other patients, we conclude that it is important to carry out operative excision early, resecting all areas of necrosis before the lesions become the focus of uncontrollable infection. Four categories of patients are described on the basis of creatinine level, blood culture, appearance of the pancreas, and spread of necrosis. According to the gravity of the lesions treated with this method (necrosis of more than 75% of the pancreas), the death rate is usually 90% or higher. We believe that GDP offers the possibility of improvement.
Experimental basis and first application of clinical lymph vessel transplantation of secondary lymphedema
Authors: Baumeister Rüdiger G. H. , Scifert Jürgen , Wiebecke Baldur , Hahn Dietbert
Published: May 2005

Lymphedemas due to a blockage of the lymph vessels in the root of the extremities were treated experimentally and clinically by autotransplantation of lymph vessels under the operating microscope. In experimental lymphedema of the hind leg of 10 dogs, an increased circumference of about 50% was reduced to 10% within 7 weeks by lymph vessel transplantation. After removal of the transplants, the circumferences returned to pre‐transplantation values. The pre‐transplantation elevated intralymphatic pressure of 12.5 torr (controls: 2.5 torr) was reduced to the normal range of 3.5 torr after the transplantation. In 8 of 10 dogs, the patency of the transplants could be demonstrated by inspection, lymphography, and isotope injections. In all 10 dogs, patency could be proved by histologic examination. The data indicate that lymph vessel transplantation can restore the diminished lymph‐transporting capacity brought on by lymphedema.

In 2 patients, it was possible to prepare lymph collectors about 25 cm long. After the transplantation, the circumferences diminished. By isotopes improved lymphatic transport could be demonstrated after the operation. Autologous transplantation of lymph vessels is a promising method for the treatment of secondary lymphedema especially in the early stages.
Significance of hemorrheology in the management of the ischemic limb
Authors: Dormandy John A.
Published: May 2005

Clinicians have become interested in hemorrheologically oriented treatment of limb ischemia because of the increasing evidence that (a) hemorrheological abnormalities play an important role in the pathophysiology of circulatory diseases, and (b) such treatment may also be useful in the management of ischemia due to other causes. Possible hemorrheological approaches to management of limb ischemia can be classified according to the primary hemorrheological determinant being treated: the red cell concentration, plasma proteins, or the flow properties of individual red cells. Hemodilution, difibrinogenation with an oral agent, and the use of drugs to improve red cell deformability represent possible therapeutic approaches. The feasibility, advantages, and shortcomings of each of these treatment modalities are explored.
The choice of operation in aortoiliac reconstructions for intermittent claudication
Authors: King R. Barry , Myers Kenneth A. , Scott David F. , Devine Terence J.
Published: May 2005

This report describes the results of 290 aortoiliac reconstructions performed for intermittent claudication and particularly analyzes the results for different techniques of operation and their indications. The accumulative patency rate for all operations was 79% at 5 years in surviving patients. The patency rate was significantly better in patients who stopped smoking after the operation. Dacron® grafts had a significantly higher patency rate than endarterectomy in men. Dacron® grafts and endarterectomy had equal patency rates in patients who had patent superficial femoral arteries, but Dacron® grafts had a significantly higher patency rate than endarterectomy if the superficial femoral arteries were occluded or severely stenosed. If the success rate for relieving intermittent claudication is considered rather than the patency rate, then Dacron® grafts gave even better results than endarterectomy in patients with severe superficial femoral artery disease. Limited unilateral extraperitoneal operations gave satisfactory long‐term results in selected patients, as did extra‐anatomical operations in patients in whom conventional reconstructions seemed inappropriate.
Objective analysis of factors contributing to failure of tibial bypass grafts
Authors: Ricco Jean‐Baptiste , Flinn William R. , McDaniel Martha D. , Yao James S. T. , Bergan John J.
Published: May 2005

A retrospective study of 204 femoro‐tibial bypass procedures performed from 1979 through 1982 is reported. The effect of various parameters—patient age, graft material, type of bypass, bypass outflow, presence or absence of pedal arterial arches, and degree of preoperative ischemia as judged by the ankle—brachial index‐on tibial bypass patency was examined. The only obvious factor in graft failure was the type of graft material utilized, with autogenous saphenous vein grafts faring much better than the polytetrafluoroethylene (PTFE) grafts.
Prostaglandin therapy in severe limb ischemia
Authors: Pardy Bruce J. , Eastcott H. H. G.
Published: May 2005

The use of prostaglandin E, and prostacyclin in the treatment of severe limb ischemia is evaluated and the literature reviewed. Conclusions are the following: PGE1 is easier to administer than PGI2. PGE1 does not require buffering to an alkaline pH, is more stable, has a less critical dose rate, and has less serious and more easily managed side effects. PGE1 8–10 ng/kg per min intravenously for 72 h increases terminal phalangeal blood flow in severe Raynaud's phenomenon. Healing will occur after antibiotic therapy, PGE1 intravenously for 72 h, and surgical debridement during general anesthesia of all necrotic and septic tissue from the fingers of patients with severe Raynaud's phenomenon. When nail‐related sepsis and necrosis is recurrent, removal of the nail and nail bed has prevented recurrence of terminal phalangeal sepsis and ulceration. Patients with severe Raynaud's phenomenon who have not suffered finger amputation, and who have no history of finger necrosis or severe sepsis, are unlikely to be helped by PGE1. Upper limb sympathectomy provides short‐term enhancement of digital blood flow which may tide a patient over an acute episode of severe ulceration, sepsis, or necrosis, but the duration of benefit is short. Conversely, lumbar sympathectomy may provide prolonged symptomatic relief. The thromboxane synthetase inhibitor dazoxiben is currently being investigated in Raynaud's phenomenon. In Buerger's disease, foot pain is usually relieved by intravenous PGE1, provided the popliteal pulse is palpable and closed sepsis is not present. Toenail removal in Buerger's disease after intravenous PGE1 may not result in rapid healing. The more favorable response of Buerger's disease compared with arteriosclerosis may be related to the nature of the disease or to the more distal site of arterial occlusion in Buerger's disease. Prostaglandin therapy may not be effective in diabetic patients with lower limb ischemia. Long‐term (weeks or months) intra‐arterial infusion of PGE1 may promote healing after minor amputation in critical atherosclerotic lower limb ischemia in the nondiabetic patient, and prevent the need for major amputation. While prostaglandin therapy is associated with many side effects, complications are almost nonexistent. Clinical trials are very difficult to design. When reporting results, distinction should be made between diabetic and nondiabetic patients with arteriosclerosis, between those with and those without a palpable popliteal pulse, and between those who do and those who do not have extremity closed sepsis.
Surgical aspects of thyroid autonomy in multinodular goiter
Authors: GemsenjÄger E. , Heitz P. U. , Staub J. J. , Girard J. , Barthe P. , Benz U. F.
Published: May 2005

In a prospective study of 217 consecutive patients with multinodular goiter selected for surgical treatment, 43% had significant autonomous thyroid hormone secretion as evidenced by TRH unresponsiveness [TSH<1.0 ΜU/ml after intravenous (200 Μg) or oral (40 mg) TRH], with normal values of the FT4‐Index and FT3‐Index (preclinical hyperthyroidism) in 74%, and with hyperthyroidism in 26% of these cases. The amount of autonomous thyroid hormone secretion increased with the mean goiter weight and age of patients. Nodular goiter growth is considered a further manifestation of escape from normal TSH dependence, namely, with respect to follicular epithelium cell replication. Goiter recurrence may, therefore, not only be TSH dependent, but it may also evolve from autonomously growing goiter tissue left behind. This implies a selective nodular goiter resection instead of the uniform subtotal resection leaving remnants at the hilus. Prospective results of this operative tactic and technique are presented: (a) operative morbidity was low; (b) in TRH‐unresponsive patients, the postablative autonomous thyroid hormone secretion was usually low. The thyrotropic and TSH‐mediated thyroid function recovered within 2–4 months; (c) no hypothyroidism occurred, but slightly elevated TSH secretion resulted in 40% of the patients; and (d) follow‐up of 76 selected patients during a mean of 3.5 years revealed the occurrence of TSH‐dependent and of autonomous recurrences, developing in nonresected lobes. Selective goiter resection is advocated on the basis of newer pathophysiological concepts in benign multinodular goiter and on the basis of refinement of the thyroid surgical technique.
Elevated plasma levels of noradrenaline in duodenal ulcer
Authors: JÄrhult J. , Angerås U. , Farnebo L. ‐O. , Graffner H. , Hamberger B.
Published: May 2005

The changes in plasma catecholamine and gastrin concentrations and gastric acid secretion in response to modified sham feeding were investigated in 7 duodenal ulcer (DU) patients before and 6 weeks after highly selective vagotomy (HSV). Both basal and peak acid secretion in response to modified sham feeding were significantly reduced by HSV. Basal plasma noradrenaline concentrations were elevated in DU patients but fell to normal values after HSV. Plasma adrenaline concentrations were within the normal range and did not change after HSV. Basal gastrin concentrations were significantly higher after HSV than before. Modified sham feeding caused no significant changes in plasma catecholamine and gastrin concentrations either pre‐ or postoperatively. It is concluded that noradrenaline is involved in, or reflects, DU disease.
Ultrasonic examination during surgery for abdominal abscess
Authors: Machi Junji , Sigel Bernard , Beitler Julio C. , Coelho Julio C. U. , Donahue Philip E. , Duarte Bernardo , Nyhus Lloyd M.
Published: May 2005

Real‐time B‐mode high resolution ultrasound scanning was employed during 12 operations for abdominal abscess. These included: 5 hepatic, 2 splenic, 2 pancreatic, 2 retroperitoneal, and 1 intraperitoneal abscesses. In most instances, operative ultrasonography was considered to be helpful in operative management of abdominal abscesses. Ultrasound was valuable in: (a) localizing abscesses before tissue dissection; (b) establishing the diagnosis which had not been made preoperatively; (c) excluding the presence of abscesses suspected on preoperative studies or at operative exploration; (d) identifying adjacent structures such as blood vessels, biliary and pancreatic ducts, and intestines; and (e) guiding the needle for aspiration of abscess. Operative ultrasonography is a safe and simple technique, providing the surgeon with accurate information during surgery which may reduce the re‐drainage and mortality rates of abdominal abscess.
Inguinal hernia repair with silk or polyglycolic acid sutures: A controlled trial with 5‐years' follow‐up
Authors: Burcharth Flemming , Hahn‐Pedersen Jan , Andersen Bjørn , Andersen Jens R.
Published: May 2005

Polyglycolic acid and silk sutures were used for repair of 321 direct inguinal hernias in 302 patients in a triple‐blind randomized trial. A standardized McVay repair was used. A total of 28 recurrent hernias were diagnosed. The cumulated recurrence rate increased gradually to 6.5% after 2 years and to 10.4% after 5 years. No difference was found between polyglycolic acid and silk sutures.

It is concluded that repair of direct inguinal hernias may be performed with the same safety with polyglycolic acid as with silk sutures.
Therapeutic action of fructose‐1,6‐diphosphate in traumatic shock
Authors: Markov Angel K. , Oglethorpe Nicole , Grillis Michael , Neely William A. , Hellems Harper K.
Published: May 2005

Traumatic shock was induced in 130 rats by tumbling them in a Noble‐Collip drum for a total of 600 revolutions at 40 rotations/min. The experimental protocol was designed to evaluate the therapeutic effectiveness of fructose 1,6‐diphosphate (FDP) in reducing the mortality rate when given both prior to and following the trauma, or only following the trauma. In the first group (n=50) in which the treatment was given prior to and after trauma, the animals were randomly assigned to 3 subgroups as follows: 20 rats received 350 mg/kg of FDP prior to and an additional 350 mg/kg after trauma; 20 other rats received in the same manner equal amounts of glucose; and 10 rats received no treatment. In the group treated only after inflicting the injury (n=80), 35 rats received 350 mg/kg of FDP after trauma; another 35 received glucose; and 10 received no treatment. The rats from the different subgroups were tumbled at the same time.

Survival rates in the pretreated subgroups were 85% for those receiving FDP, 30% for glucose‐treated animals (p< 0.005), and 20% for the nontreated ones. In the animals that were treated after trauma, there was also a significant increase in survival rate for the FDP‐treated ones (66%), while for those receiving glucose it was 31% (p<0.01), and 20% for the nontreated ones.

The results of the present study and those obtained in other etiological types of shock indicate that FDP has profound antishock therapeutic activity. This action appears to be metabolically mediated by augmenting the endogenous energy production via glycolysis.
Axillary transpleural sympathectomy: Indication, technique, and results
Authors: Linder F. , Jenal G. , Assmus H.
Published: May 2005

The indications and operative technique for high thoracic sympathectomy by the transaxillary approach are demonstrated. The late results and complications are referred to in a retrospective analysis of 159 patients on whom 193 sympathectomies have been performed over the last 15 years for peripheral vascular occlusive disease, vasospastic diseases such as Raynaud's phenomenon, and hyperhidrosis of the upper extremity.
Recurrent peptic ulcers
Authors: Johnston David , Blackett Richard L.
Published: May 2005

This article is concerned mainly with recurrent ulceration (RU) after vagotomy [truncal (TV), selective (SV), or highly selective (HSV)]. RU may be symptomatic or asymptomatic. Since few surgeons routinely perform endoscopy on asymptomatic patients, it is symptomatic RU that is being discussed.

After all 3 types of vagotomy, without antrectomy, median incidences of RU are about 10% after 5–10 years, but there is wide variation, from 1% to 30%. There is no convincing evidence that TV denervates the parietal cell mass more effectively than does SV or HSV, or that it has a lower incidence of RU than SV or HSV. Claims that SV and HSV lead to fewer incomplete vagotomies and less RU than TV are, however, not convincing. Since SV + P (pyloroplasty) or gastrojejunostomy (GJ) carries the same risk of RU as HSV, but has more side effects because of loss of the pylorus, it has been abandoned. The choice of elective operation for duodenal ulcer (DU) thus lies among TV + D (truncal vagotomy + drainage procedure), HSV, and V + A (vagotomy + antrectomy).

The results of 5 controlled trials suggest that HSV yields better overall clinical results than V + A, even though the incidence of RU is 1% after V + A compared with 10% after HSV. Even for patients with hypersecretion of acid, V + A should not be employed in preference to HSV, because incidences of RU after HSV are no higher among hypersecretors of acid than among normal secretors. Gastrin cell (G‐cell) hyperplasia and “antral dominance” are concepts still too nebulous to influence the choice of elective operation for DU.

After complete vagotomy (TV, SV, or HSV), as shown by the Burge, Grassi, or Hollander tests, the incidence of RU is 2–5%. High incidences of RU are not related to any characteristic of the patient, the level of acid output, or the ulcer, but are related to the surgeon who operates. They are thus related to operative technique, and are preventable.

Despite the advent of H2‐receptor antagonists, elective vagotomy (preferably in the form of HSV) still has a place in the management of DU because it is more effective than H2‐blockers in lowering intragastric acidity permanently and in preventing recurrent ulceration.
Bleeding gastroduodenal ulcers: Nonoperative treatment
Authors: Laurence B. H. , Cotton P. B.
Published: May 2005

Early endoscopy is now standard diagnostic practice in most institutions for assessment of patients with acute upper gastrointestinal bleeding. Definition of the cause of bleeding facilitates management, and the precise appearance of the lesion may give additional prognostic information about the risk of rebleeding.

Many endoscopic tools have now been developed for use in attempts to stop bleeding directly, or to reduce the risk of rebleeding. This article reviews the methods that have been described, which range in expense and complexity from lasers, through diathermy and heater probes, to simple injection needles. Despite the difficulties in assessment and a relative lack of controlled trials, it is clear that most methods can be effective, but also that the experience of a team is probably more important than the choice of probe. Guidelines for selection of patients will continue to evolve. The concept of high‐risk patients with high‐risk lesions provides a valuable framework for stratification.

Endoscopic hemostasis is simply a new way of applying surgery. Close collaboration between gastroenterology and surgical teams is essential for future progress in this field.
Bleeding gastroduodenal ulcers: Choice of operations
Authors: Herrington J. Lynwood , Davidson Jesse
Published: May 2005

Management of upper gastrointestinal tract hemorrhage continues to present a challenge in surgical judgment. Endoscopy is the mainstay to precise diagnosis and, although some authorities feel that this modality has not reduced overall mortality, it has, however, played an important role in overall patient management. A bleeding patient may be classified into 1 of 3 separate categories and the algorithms outlined in this article are useful in selecting patients for nonoperative and operative treatment. For the good‐risk patient with a massively bleeding duodenal ulcer (DU) who is hemodynamically stable, truncal vagotomy‐antrectomy, Billroth I reconstruction is our procedure of choice if the inflammatory process in the duodenum is conducive to a safe resection. Our operative method is described along with variations in technique which are used when conventional end‐to‐end gastroduodenostomy is not feasible. Closure of the duodenal stump and Roux‐en‐Y reconstruction or placement of a Roux limb on a severely diseased duodenum following resection is employed in highly selected cases. The Billroth II type of reconstruction is rarely used today in our experience. Truncal vagotomy and pyloroplasty (TV‐P) is reserved for the high‐risk patient who is bleeding massively. An increasing number of these patients are currently encountered as transfers from our intensive care units with associated multiple organ disease and organ failures. Proximal gastric vagotomy with ulcer undersewing has limited application, in our judgment, when faced with the massively bleeding patient. Gastric resection with or without vagotomy along with ulcer excision is our choice for the massively bleeding gastric ulcer (GU) located in the distal 50–60% area of the stomach. For the high‐risk patient with GU, ulcer excision followed by TV‐P is indicated. For the rarely encountered giant GU, gastric resection may be the only option even though the patient is high risk.

The choice of the proper operative procedure for the individual patient with massive gastric or duodenal hemorrhage should rest on the experience and the judgment of the surgeon.
Perforated duodenal ulcers
Authors: Boey John , Wong John
Published: May 2005

The incidence of perforation, complicating about 5% of duodenal ulcers, has not decreased proportional to the overall decline in peptic ulcer disease. To define the role of immediate definitive surgery, we conducted several prospective studies to identify risk factors that increase operative mortality as well as predictive factors associated with relapse after simple closure. Among 613 consecutive patients, major medical illnesses, preoperative shock, and perforations exceeding 24 hours' duration were found to be determinant variables that allowed stratification of patients into different risk groups. Definitive surgery or simple closure in the absence of any risk factor had a mortality rate of less than 0.7%, whereas even closure alone incurred a mortality rate of 86.7% when all 3 risk factors were present.

The need for definitive surgery was assessed by comparing relapse rates after closure in patients who differed in respect to the chronicity, age at onset, and family history of their ulcer disease. Multivariate analysis revealed chronicity and a positive family history to be the most useful independent predictors of the likelihood of relapse after closure. The benefits of definitive surgery for perforations in chronic lesions were corroborated by a prospective controlled trial in which proximal gastric vagotomy with closure or truncal vagotomy with gastric drainage each proved as safe as closure alone but significantly more effective in reducing the frequency of relapse after operation.

Immediate nonresective definitive surgery is indicated in fit individuals who have perforations in chronic duodenal ulcers; however, closure alone is more prudent in patients who have any risk factor.
High gastric ulcer
Authors: Jensen Hans‐Eric , Hoffmann Jack , Wille‐Jørgensen Peer
Published: May 2005

Fifty‐six patients with high gastric ulcers were studied retrospectively. There were 38 women and 18 men. The mean age was 66 years. Findings were: 25% had ulcer histories of more than 5 years; 45% had illnesses in other systems making them poor operative risks; 34% were taking ulcerogenic drugs, and 36% were on antiulcer treatment prior to surgery; 43% presented with severe bleeding, 16% with perforation, and 2 patients had simultaneous bleeding and perforation; 38% had deeply penetrating ulcers and many ulcers were very large; 7 patients had ulcers in hiatus hernias. Sixty‐three percent of the procedures were emergencies. Half of the operations were nonresective, with or without vagotomy. The other half were gastric resections of various types. The overall mortality rate was 18%, but the mortality rate was 24% for emergency procedures and 9% for elective ones. The highest mortality rate, 45%, occurred after emergency resective procedures. Vagotomy did not increase postoperative mortality when added to a nonresective procedure. Beside the 10 patients who died, 6 others developed severe postoperative complications, usually respiratory failure or suture line leakage. Follow‐up of between 6 months and 12 years (average 3 years) was possible in 55% of the patients. Two developed recurrent ulcers and 2 had overlooked gastric carcinomas. An approach of management for high gastric ulcer is outlined recommending a Pauchet operation for good‐risk patients, and vagotomy and drainage for old and frail patients. Medical treatment should be pursued as long as possible to avoid an often hazardous operation.
Pyloric and prepyloric ulcers
Authors: Muller Claude , Liebermann‐Meffert Doris , Allgöwer M.
Published: May 2005

In a prospective multicenter trial, 560 patients with peptic ulcer were treated with proximal gastric vagotomy (PGV) without drainage. Four hundred ninety‐three patients had duodenal ulcer (DU), 35 pyloric (PU), and 32 prepyloric ulceration (PPU). Actuarial 5‐year recurrence rates were 14%, 35%, and 33%, respectively, and were significantly higher in PU and PPU than in DU. In a separate study, thickness of the pyloric and antral wall was assessed in the resection specimens of patients with similarly defined ulcer types and in controls. There was significant thickening of the muscular layer of the pylorus and antrum in patients with PU and PPU compared to those with DU and controls. It appears that this muscular hypertrophy and fibrosis could be one factor responsible for the failure of PGV without drainage in PU and PPU. Preliminary results indicate a possible beneficial effect of adding a drainage procedure to PGV when treating pyloric channel ulcers. Our results emphasize that pyloric channel ulcers must be considered as a particular entity of peptic ulcer disease and should no longer be assigned to the duodenal ulcer group.
Peptic ulcer complications in high‐risk patients
Authors: Stabile Bruce E. , Tzu‐Ming Chang , Hiatt Jonathan R. , Passaro Edward
Published: May 2005

Distinct groups of patients at high risk for the development of peptic ulceration of the stomach and duodenum have been identified. As newer forms of treatment for critical illness evolve, it seems probable that other high‐risk groups will be described. The etiology of the ulcerations appear to be different for each group. The presence of intraluminal acid is correlated with the incidence of bleeding. Acid‐reducing therapy, whether intraluminal or intravenous, is effective in decreasing the risk of bleeding to variable degrees among the high‐risk groups but does not prevent or reduce the incidence of ulceration. When surgical therapy is needed, no operation is superior.
Assessment of the Angelchik prosthesis for treatment of symptomatic esophageal reflux
Authors: Starling James R. , Hamilton John W. , Reichelderfer Mark , Yamato Dennis T. , Pellet John R. , Belzer Folkert O.
Published: May 2005

During a recent 5‐year period, 74 patients were fitted with an Angelchik antireflux prosthesis for symptomatic reflux esophagitis. Seventy‐five percent of 28 patients in the initial series (series 1) have had excellent to very good response to the prosthesis, as indicated by a clinical follow‐up of 36–60 mo. The main cause of failure in this series was prosthesis disruption (4 of 28 patients). Ninety‐two percent of 46 patients in the more recent series (series 2) have had excellent to very good response to prosthesis placement. The new prosthesis design, which includes a circumferential strap, has completely eliminated prosthesis disruption. Of the total series of patients, 19% of patients experienced transient dysphagia. This complication was no longer significant by 6 mo postoperatively, and no prostheses have had to be removed because of this complication. There have been no instances of erosion of the prosthesis. In addition to clinical data, lower esophageal sphincter measurements and recently, 24‐hr ambulatory pH monitoring have demonstrated a physiological effect of reflux protection after prosthesis placement. In our experience, the Angelchik prosthesis has been especially useful in high‐risk patients, patients who have recurrent esophagitis after previous antireflux or foregut surgery, and patients who would probably not have been referred for conventional antireflux surgery. In view of our data, we believe that the Angelchik prosthesis should continue to be commercially available as a surgical option for treating selected patients with medically refractory reflux esophagitis.
Bronchial carcinoids: An analysis of 91 cases
Authors: MÅrtensson Hans , Böttcher Gerhard , Hambraeus Göran , Sundler Frank , Willen Helena , Nobin Anders
Published: May 2005

Ninty‐one patients with bronchial carcinoids operated on during a 30‐year period were retrospectively studied regarding age, symptoms, diagnosis, tumor size and extent, treatment, and survival. In addition, an immunocytochemical study was performed on 69 tumors.

The mean age at the time of diagnosis was 50 years with a slight predominance of women (64%). Common symptoms were cough, singular or recurrent pneumonias, and hemoptysis. Thirty‐one patients were discovered by chance at health control or investigation for other reasons. They were totally asymptomatic. Patient delay was insignificant, while doctor's delay exceeded 1 year in 30% of the cases. Bronchoscopy was performed in 83 patients but tumor was seen only in 60%. Biopsy from these tumors was positive in 82%. The tumor was solitary in 89 patients and was usually 10–30 mm in size. At the operation, 1 patient had lymph node metastases and 1 had a disseminated disease. The immunocytochemical analysis showed 5‐hydroxytryptamine in 37, peptide in 41, and no immunoreactive cells in 19 tumors. Gastrin‐releasing peptide was the most common peptide (21 tumors), followed by adrenocorticotropin hormone (19), human pancreatic polypeptide (17), calcitonin (15), metenkephaline (4), vasoactive intestinal polypeptide (1), and somatostatin (1). Endocrine symptoms were present only in 1 patient who suffered from a carcinoid‐like syndrome. Only 5 patients died from their endocrine tumor while 18 died from an intercurrent disease.
Iatrogenic bile duct injuries
Authors: Mathisen øystein , Bergan Anstein , Flatmark Audun
Published: May 2005

During a 25‐year period (1959–1984), 42 patients with iatrogenic bile duct damage were referred. Before referral, 11 patients had no attempt at reconstruction, while 31 had undergone 41 operations to repair the damage. At admission, 4 patients had secondary biliary cirrhosis, 1 had portal vein thrombosis, and 1 had sepsis. The entire extrahepatic duct system had been resected in 1 patient, and operative treatment includes 41 patients. Fifty‐two operations have been performed, and 34 patients (83%) have had an excellent long‐term result, median 13 years. Five patients had 4 operations or more (before and after referral), and 3 are alive in good condition. Various methods of repair were employed, and 8 patients (20%) had recurrence of stricture. Restricture was lowest for hepaticojejunostomy Roux‐en‐Y (15%), in particular when no stent was used across the anastomosis (8%). The hospital mortality rate was 2 (5%) of 41 and overall mortality, 7 (17%) of 41. The lowest mortality rate (9%) was associated with hepaticojejunostomy Roux‐en‐Y. Low rate of recurrence and mortality are correlated to early referral. Patients who had restricture or died were referred a median 5 and 7 months, respectively, later than those who did well. Mortality was also related to serious complications at the time of referral and lack of follow‐up. Patients with iatrogenic bile duct injury should be referred early to a competent center, where adequate treatment of infection, reconstruction with a hepaticoje‐junostomy Roux‐en‐Y without stenting, and lifelong follow‐up can be performed.
Supernumerary parathyroid glands: Implications for the surgical treatment of secondary hyperparathyroidism
Authors: Edis Anthony J. , Levitt Michael D.
Published: May 2005

Of 20 patients who underwent parathyroidectomy for secondary hyperparathyroidism between 1978 and 1985, recurrent hypercalcemia occurred in 4. Three of the 4 patients had initially undergone total parathyroidectomy with autotransplantation (TP‐A) and the fourth had been subjected to removal of 3 parathyroids with autotransplantation of a portion of 1 of these glands. None of the 5 patients treated by subtotal parathyroidectomy (STP) developed recurrence. One of the 3 cases of recurrent hyperparathyroidism after TP‐A was due to graft overgrowth. Another was caused by supernumerary parathyroids subsequently removed at the time of reexploration of the neck. The third remains hypercalcemic after autograft excision and presumably still has a supernumerary gland in situ. The patient who developed recurrent hypercalcemia after removal of only 3 glands and autotransplantation remains hypercalcemic even after radical graft excision and reexploration of the neck and mediastinum.

One patient treated early in the series by total parathyroidectomy without autotransplantation now has measurable levels of serum immunoreactive parathyroid hormone, presumably due to a small residual supernumerary gland. There is, thus, at least presumptive evidence of supernumerary parathyroid glands in 3 (15%) of the 20 patients in this series. The implications of this finding are discussed.
Complications of radiation therapy and factors in their prevention
Authors: Cox James D. , Byhardt Roger W. , Wilson J. Frank , Haas Judith S. , Komaki Ritsuko , Olson Laird E.
Published: May 2005

Radiation therapy of most malignant tumors requires dose‐fractionation regimens near the tolerance of the surrounding normal tissues. With the exception of the bone marrow and the lung in which the morbidity may be minimized by reducing the volume irradiated, other structures require limitations of total doses to minimize adverse effects. In thoracic irradiation, the most sensitive normal structure is the lung, while the heart and esophagus do not frequently have serious late effects. Pelvic irradiation carries a much greater risk of morbidity, primarily to the fixed segments of small bowel and less frequently to the large bowel and bladder. Irradiation of the upper aerodigestive tract may be complicated by necrosis of soft tissues and bone, especially the mandible. Dental management greatly affects the risk of complications. Bones and soft tissues elsewhere in the body are rarely affected except in the growing child. The normal pituitary may be irradiated when tumors near the base of the skull are treated. The production of growth hormone may especially be compromised in children. Acute, subacute, and late effects of irradiation of the brain are well recognized. While transient radiation myelopathy is frequent and not serious, progressive radiation myelopathy is rare but extremely grave. Host factors, other diseases, and technical aspects of radiation therapy affect the risks and severity of adverse effects on normal tissues. Surgical procedures may be important in preventing complications as well as in managing them.
Radiation damage to the small intestine
Authors: Smith Daniel H. , DeCosse Jerome J.
Published: May 2005

Although radiation therapy has proven effective in both cancer control and cure, grave side effects may occur. Among the most serious treatment complications encountered by a patient with malignant disease is that of radiation injury to the small intestine. Patients with gynecologic malignancies are most often found to have these problems of therapy. The etiology of radiation damage at the cellular level is mostly molecular damage resulting in lethal cellular injuries. Accompanying vascular and connective tissue may also be altered and cause later complications. Because of the complex nature of the patient's malignant disease and treatment, diagnosis of radiation injury to the small bowel and other pelvic structures can be most difficult to determine. The management of acute manifestations of enteric radiation injury includes diet modification and drugs that affect intestinal motility. Long‐term manifestations of enteric radiation injury present more serious difficulties. Initially, the patient must be stabilized to reverse the effects of chronic malnutrition, sepsis, and electrolyte imbalance. Immediate surgery may be necessary in patients with suspected perforation. Most patients, however, require further studies for complete assessment of clinical damage. In patients with enteric fistulas, an operation is always necessary for fistula control. Complete enteric bypass utilizing minimally affected intestine is mandatory to ensure the least morbidity and mortality. Prevention of enteric radiation injury requires efforts to minimize postoperative adhesions, avoidance of excessive therapy to segments of fixed small bowel, and dosimetry alteration when complications arise during initial therapy.
Repair of the radiation‐induced vaginal fistula utilizing the martius technique
Authors: Boronow Richard C.
Published: May 2005

The radiation‐induced vaginal fistula is an extremely difficult rehabilitative challenge to the surgeon. Historically there has been a sense of frustration about prospects for success with these defects and many patients have been managed by either permanent colostomy or permanent urinary diversion. This report reviews a personal experience of 25 radiation‐induced vaginal fistulas in 22 patients utilizing the Martius bulbocavernosus‐labial fat flap technique. Successful closure was accomplished in 84.2% of the rectovaginal fistulas and 50% of the vesicovaginal fistulas. Only 1 patient required a second surgical effort for successful closure. There was no surgical mortality and no significant surgical morbidity. No patient with a rectovaginal fistula closure required subsequent colostomy for stricture. These results, coupled with the relative simplicity of the procedure, allow us to recommend this technique as firstline therapy for these difficult management problems. The majority of patients will be rewarded with successful rehabilitation.
Repair of chronic radiation wounds of the pelvis
Authors: Mathes Stephen J. , Hurwitz Dennis J.
Published: May 2005

Radiation therapy is currently utilized for primary or adjuvant therapy for pelvic tumors. Although improvements in radiation delivery techniques have largely eliminated acute complications in the radiation field, occurrences of late wound complications persist and result in complex pelvic and perineal wounds. Since these wounds reflect underlying impaired local circulations secondary to obliterative endarteritis, local wound management frequently fails either to control secondary infection or to allow spontaneous wound closure. Twenty‐four patients with chronic pelvic wounds have recently undergone successful wound repair with use of muscle, musculocutaneous, and fasciocutaneous flaps. This review of these patients will demonstrate the physiologic basis for vascularized flaps for wound closure. Specific flap selection is based on the location of the pelvic radiation wound in the anterior pelvis and inguinal region, perineum and pelvic cavity, and sacrum. Well‐vascularized flaps must have an independent source of circulation distant to the site of radiation damage for reliable wound coverage. Muscle and skin fascial flaps are available based on reliable pedicles located in the anterior abdominal wall, anterior and posterior thigh, and posterior pelvic region with adequate arc of rotation to cover most pelvic defects. Flaps frequently utilized in this study included: rectus femoris, rectus abdominis, gracilis, and gluteus maximus muscle and musculocutaneous flaps, and the gluteal thigh skin fascial flap. Wound debridement and simultaneous coverage with well‐vascularized flaps have been established as a useful and reliable method to repair complex wounds of pelvic radiation necrosis.
Ramification of the intrahepatic portal vein identified by percutaneous transhepatic portography
Authors: Inoue Tadashi , Kinoshita Hiroaki , Hirohashi Kazuhiro , Sakai Katsuji , Uozumi Akira
Published: May 2005

We carried out percutaneous transhepatic portography (PTP) in 182 patients with liver, biliary tract, or pancreatic disease. With anterior and lateral views of selective portograms and stereoscopic x‐rays, we investigated the ramifications of the intrahepatic portal vein. There were 3 patterns of branching of the portal trunk and of the left branch of the portal vein. There were 8 such patterns for the right anterior branch, with either 4 or 5 major branches arising from it. Branching of the right posterior branch was classified into 4 patterns; simple branching into 2 (one, the posterior superior branch, the other, the posterior inferior branch) was found in only 97 of the 164 cases inspected. These results suggested that the liver cannot necessarily be divided into 8 segments. Branching of the intrahepatic portal vein is very complex; therefore, the pattern of ramifications of the portal vein must be ascertained anew for every patient for whom systematic segmentectomy is contemplated.
Liver resections in cirrhotic patients: A western experience
Authors: Bismuth H. , Houssin D. , Ornowski J. , Meriggi F.
Published: May 2005

Systematic screening for hepatocellular carcinoma (HCC) in cirrhotic patients by alpha‐fetoprotein and ultrasound permits the detection of small asymptomatic tumors. Owing to the small tumor size, more liver resections can now be performed than in the past. These resections are performed in a more economical way in terms of loss of functional parenchyma and in a more appropriate manner with regard to carcinology: surgical techniques of liver segmentectomy and use of intraoperative echography are mandatory. Favorable long‐term results obtained in Eastern countries by resecting such lesions are encouraging but remain to be confirmed in the Western hemisphere.
Endotoxin inactivation in plasma from septic patients: An in vitro study
Authors: Olofsson Pär , Olofsson Christina , Nylander Gunnar , Olsson Per
Published: May 2005

Patients with suspected septicemia were screened for endotoxemia with a quantitative chromogenic assay. In some patients endotoxin concentrations were within the range of healthy controls. Eleven of these were patients on intensive care with severe, culture‐verified, gram‐negative infections in blood or other foci. One possible explanation for this paradoxical absence of endotoxin is increased plasma inactivation. In order to test this hypothesis, endotoxin was added to platelet‐rich plasma from these patients to give a concentration of 100 ng/l, and serial quantitative determinations were made for 2 hours. Plasma from 11 healthy individuals served as controls. In the first sample, measured immediately after addition of endotoxin, a mean of 97.3 ng/l was recovered in plasma from healthy individuals and only 75.8 ng/l in the septic plasma (p<0.05). When kept on ice, these concentrations were maintained, while at +37‡C they decreased rapidly at rates that were equal in both septic and control plasmas. In a corresponding study in platelet‐free plasma, it was found that the platelets could not account for this inactivation. The results demonstrate the possibility of immediate endotoxin inactivation in plasma from patients with sepsis, probably caused by chemical binding.
Clinical reliability of perioperative fluorocholangiography
Authors: Reiss Raphael , Deutsch A. A. , Nudleman I. , Cohen M.
Published: May 2005

The use of mobile image intensifier and television monitor permits easy performance of direct visualization of the biliary tract during surgery (fluorocholangiography). The routine use of fluorocholangiography has certain advantages over the standard technique of operative cholangiography: rapid direct visualization permits proper positioning of the instrument and the patient, thus many pitfalls can be avoided (gas, air bubbles, superposition of bone structures); multiple exposures at varying angles can be obtained if suspicious areas are seen; the intrahepatic ducts can be fully visualized; the functioning of the sphincter can be evaluated under direct vision; and direct visualization permits considerable time savings. In this study, operative cholangiography was routinely performed on 1,600 consecutive operations on the biliary tract using this technique. The reliability of operative fluorocholangiography was evaluated and compared to other published forms of operative cholangiography. The principal conclusions of the authors are as follows: the false‐positive results of operative fluorocholangiography are 16.8% (57 of 339 common bile ducts explored, 57 of 1,600 cholangiographies); 22 retained stones were subsequently found in the 1,600 patients; the reliability of operative fluorocholangiography is, therefore, approximately 95%; and operative fluorocholangiography is superior to conventional cholangiography, and its routine use contributes significantly to the reduction of the rate of negative choledochal explorations and residual stones.