bluuebunny/crossref_metadata_2025 huggingface dataset:
Hemodynamic and metabolic impairment in acute pancreatitis
Authors: Di Carlo Valerio , Nespoli Angelo , Chiesa Roberto , Staudacher Carlo , Cristallo Marco , Bevilacqua Giuseppe , Staudacher Vittorio
Published: May 2005

Twenty‐one patients with acute pancreatitis underwent evaluation of cardiovascular function and oxygen consumption; 5 of those who were critically ill had a further study of hormonal metabolism. The evaluation of hemodynamic parameters was made using a computer‐based cardiovascular program developed by Siegel et al. During the initial phase of the disease a reduction in vascular tone (relating cardiac index with total peripheral resistance) represented the basic abnormality seen in all patients, while a depression in ventricular function (relating left ventricular stroke work with central venous pressure) was observed in more than 40% of patients. With the progression of pancreatitis, cardiovascular monitoring identified a time, 5 days after admission, in which a clear deterioration of the hemodynamic parameters occurred. Beyond 5 days, all patients developed a hyperdynamic state with mild to severe deficiency of oxygen extraction. In the most seriously ill patients, oxygen consumption fell and peripheral shunting increased in a similar manner to that observed in septic and cirrhotic patients. At this time a Survival Index permitted recognition of those patients at high risk of rapid deterioration who might benefit from emergency surgical therapy. In 5 patients who developed a hyperdynamic unbalanced state, a marked reduction in oxygen consumption was associated with significantly increased serum levels of insulin, glucagon, aromatic amino acids, octopamine, and phenylethanolamine. While false neurotransmitters may be invoked in explanation of peripheral vascular abnormalities, the cause of impairment in oxygen extraction remains unclear.
Role of surgery in the management of acute pancreatitis
Authors: Hollender L. F. , Meyer C. , Marrie A. , da Suva E. Costa J. , Castellanos J. Garcia
Published: May 2005

Three important aspects of the surgical therapy of acute pancreatitis are discussed: the time at which operation appears to be indicated, the procedure to be chosen (in accord with operative findings), and the results. After initial medical treatment, the timing of intervention should be based on clinical and biological information. Classification of acute pancreatitis in 3 degrees of severity may facilitate the decision. When edematous pancreatitis is found, irrigation and drainage are indicated. For distal necrosis, a left or subtotal pancreatectomy should be carried out. Necrotic lesions of the isthmus should be excised locally; if necessary, local isthmus excisions may be combined with left pancreatic resection. Resections of the head of the pancreas have been abandoned because of their high mortality rate; intervention is now limited to local excision of necrotic tissue (necrosectomy), with drainage and irrigation. In all cases, complementary biliary drainage by choledochostomy or at least cholecystostomy, drainage of areas of necrosis, and gastric suction are also mandatory. Forty‐nine patients who were operated upon according to these principles with a mortality rate of 36.7 % are discussed.
Importance of peritoneal irrigation after surgical treatment of hemorrhagic, necrotizing pancreatitis
Authors: Gebhardt Christoph , Gall Franz P.
Published: May 2005

This is a report of 139 patients with hemorrhagic, necrotizing pancreatitis, 135 of whom were operated upon. The poorest results (mortality rate of 64%) were found in patients with total necrosis of the gland, while partial necrosis of the pancreas had a better outcome (33% mortality rate). The most favorable form of therapy was either local excision of necrotic pancreatic tissue (necrosectomy), or left resection of the pancreas, combined with postoperative irrigation and sump drainage of the peritoneal cavity. With this technique, the mortality rate of 72% seen with drainage of the peritoneal cavity alone was reduced to 33%.
Management of complications after operations for acute pancreatitis
Authors: Kümmerle Fritz , Neher Manfred
Published: May 2005

After early operation in 49 patients and delayed operation in 114 patients, all with acute hemorrhagic‐necrotizing pancreatitis, 65% of patients developed local or general complications. Local complications were abscesses, peritonitis, bleeding, gastrointestinal fistulae or stenoses, and external pancreatic fistulae. Their cause can be traced to the large wound cavity with the tryptic wound surface as well as residual necrosis. The general postoperative complications were shock, acute renal failure, cardiorespiratory insufficiency, gastrointestinal bleeding, ileus, coagulopathy, and sepsis. These may have resulted from the local complications, or may even have been present before operation. If local septic complications do not respond to conservative treatment, they require reoperation. For gastrointestinal fistulae or stenoses, or for pancreatic fistulae, a “wait and see” attitude is recommended. Generalized complications call for aggressive intensive medical care.

Despite the frequency of postoperative complications, the total mortality rate in our series was 30% in patients with partial pancreatic necrosis operated on early, and in patients who received delayed operations for acute hemorrhagic‐necrotizing pancreatitis. The 74% mortality rate in early operations of subtotal and total pancreatic necroses was admittedly high. Operative results in those patients who were under our care from the beginning, however, were more encouraging (mortality rate of 50%) and demonstrate that the correct treatment for severe acute hemorrhagic‐necrotizing pancreatitis is surgery.
The natural history of chronic leg ischemia
Authors: McGrath Michael A. , Graham Antony R. , Hill David A. , Lord Reginald S. A. , Tracy G. Douglas
Published: May 2005

The onset of leg ischemia may be sudden or gradual, occurring over a wide age spectrum and as a result of multiple causes. The clinical outcome is extremely variable, and only about 1 patient in 8 will progress to the stage of ischemic gangrene. Many patients have the capacity to show marked clinical improvement, or to maintain a comfortable life with claudication that is not severely disabling.

Of over 2,000 patients referred to a vascular unit, only about 30% required operative intervention. Rigorous conservative measures should be given a trial for at least 3 months in all patients except those whose limbs are severely threatened, since that period of time is necessary to judge the capacity for spontaneous improvement, before the patient is subjected to the invasive technique of aortography.

A flow chart of management decisions is suggested for patients with intermittent claudication.
Limb ischemia caused by small artery disease
Authors: Porter John M. , Taylor Lloyd M.
Published: May 2005

The pathophysiology and clinical manifestations of limb ischemia due to small artery diseases are reviewed, based on records from over 400 patients who were examined since 1971. Details of prospective clinical, laboratory, and angiographic evaluation and long‐term follow‐up are presented. The predilection of small artery diseases for the upper extremity remains unexplained. Preliminary results with the use of nifedipine for chronic treatment of vasospastic symptoms are reported.
Acute lower limb ischemia: Pathogenesis and management
Authors: Lusby Robert J. , Wylie Edwin J.
Published: May 2005

Acute lower limb ischemia continues to be a problem both in diagnosis and management. The high mortality rate appears to be related to the metabolic consequences of ischemia, a function not only of time, but also of severity. The etiology of acute ischemia is reviewed along with the pathophysiological response. The management of the patient centers on diagnosis of cause and estimation of the severity of ischemia. Correction of metabolic disturbances and early restoration of flow is the preferred treatment, although there remains a place for late operative intervention in patients with less severe symptoms. Despite improved diagnostic and operative techniques, the thrombotic and metabolic changes that occur in the small vessels and muscular tissues appear to limit the success rate, with mortality rates remaining around 25%.
Surgery or cimetidine? I. Comparison of two plans of treatment: Operation or repeated cimetidine
Authors: Andersen Daniel , Amdrup Erik , Sørensen Finn Hanberg , Jensen Kurt Birger
Published: May 2005

The aim of this study was to compare the effect of 2 different treatment plans on the definitive treatment in a group of duodenal ulcer patients with symptoms severe enough to indicate surgery after pre‐cimetidine criteria.

The patients were randomized to either 8 weeks of cimetidine 1 g per day followed by operation in case of symptomatic recurrence, or to repeated 8‐week courses of cimetidine 1 g a day in case of recurrence. Many patients wanted to change their treatment plan, which was allowed and used as evidence of their value judgments.

After 3 years the cumulative operation rate was 74% in the Full dose/Stop cimetidine group and 60% in the Repeated cimetidine group. During the first year the probability of operation was highest in the group with only 1 course of cimetidine, but after this time the patients came to surgery with equal probabilities. Eight percent of the patients had no relapse and, therefore, had not undergone surgery after 3 years.

The study suggests that patients with severe ulcer disease usually have to undergo surgery, even after the advent of cimetidine, but surgery is delayed. It makes little difference whether cimetidine is offered once or in several courses. The economic consequences of the 2 schemes are very similar. Intermittent treatment with cimetidine, thus, cannot be expected to have much influence on the indications for surgery in severe duodenal ulcer disease. All patients should have 1 course of cimetidine, but additional courses make no material difference in the end result and usually can be avoided.
Surgery or cimetidine? II. Comparison of two plans of treatment: Operation or cimetidine given as a low maintenance dose
Authors: Andersen Daniel , Amdrup Erik , Sørensen Finn Hanberg , Jensen Kurt Birger
Published: May 2005

The aim of this study was to compare the effect of 2 therapeutic schemes on the final treatment of patients with duodenal ulcer disease severe enough to indicate surgery. One group was randomized to cimetidine 1 g/day for 8 weeks and operation was suggested in case of symptomatic recurrence. The other group was given a prophylactic dose of cimetidine 400 mg at night after the full‐dose course and operation was suggested in case of symptomatic recurrence during the maintenance treatment.

The study showed that cimetidine on a long‐term basis substantially reduced the tendency to symptomatic recurrence of duodenal ulcer. The effect on the operation rate, however, was rather modest and was in essence a postponement rather than a prevention. In regard to ability to reduce the number of patients operated on, the result of maintenance therapy was very similar to the result seen in a previous study on intermittent courses of cimetidine.

This and our earlier study suggest that operative treatment will still be the choice of the majority of patients with severe duodenal ulcer disease, and that neither intermittent nor continuous cimetidine treatment will radically change this. An important effect of cimetidine is that some patients can be treated without operation because of very long remissions, and that other patients in a high‐risk group can be kept on cimetidine. The value judgment of patients may, however, change with time, because medical treatment will decrease the symptomatic strain on the future ulcer patients as compared to patients remaining from the precimetidine era.
An interim report of a prospective, randomized, controlled study of adjuvant chemotherapy in operable gastric cancer: British stomach cancer group
Authors: Fielding J. W. L. , Fagg S. L. , Jones B. G. , Ellis D. , Hockey M. S. , Minawa A. , Brookes V. S. , Craven J. L. , Mason M. C. , Timothy A. , Waterhouse J. A. H. , Wrigley P. F. M.
Published: May 2005

A prospective, randomized, controlled study of adjuvant chemotherapy in operable gastric cancer was commenced in 1976. Four hundred and eleven patients have been randomized into 1 of 3 treatment groups. Group A received a placebo injection of intravenous normal saline (10 ml) at 3‐week intervals. Group B received a 5‐day induction course of 5‐fluorouracil (5‐FU), vincristine, cyclophosphamide, and methotrexate followed by 3‐week intravenous injections of 5‐FU and mitomycin C (MMC). Group C received 3‐week intravenous injections of 5‐FU and MMC. The treatment was to be given for 2 years. Patients were stratified for age, sex, preoperative duration of symptoms, and clinicopathological stage prior to randomization. At this interim analysis, preoperative duration of symptoms and clinicopathological stage were statistically significant prognostic factors (p=<0.05 and <0.001, respectively).

At the time of this analysis, there has been no significant improvement in survival in either of the treatment groups compared to the control group. While treatment could begin at any time during the first 3 postoperative months, survival at 1 year was significantly improved (p=0.013) by treatment C in those who started treatment within 1 month of surgery; however, this benefit of treatment was not maintained at 3 years. Of the 279 deaths, 16 (5.7%) have been drug‐related, 11 resulting from renal toxicity associated with this therapeutic regimen.

This study has confirmed the poor prognosis of gastric cancer, and the early results demonstrate that there is no place for the use of cytotoxic agents in this disease outside prospective controlled studies.
Determinants of optimal results after ileoanal anastomosis: Anal proximity and motility patterns of the ileal reservoir
Authors: Schraut Wolfgang H. , Rosemurgy Alexander S. , Wang Chen‐Hwu , Block George E.
Published: May 2005

End results after ileoanal anastomosis with a proximal ileal reservoir range from defecatory frequency to obstruction. To define the physiological (reservoir compliance, motility) and anatomical (reservoir design, anal proximity) determinants of the varying clinical outcome, we placed an S‐shaped (SS‐R) or double‐barreled (DB‐R) reservoir in comtinuity with the anus in dogs, either directly or via 2‐cm or 6‐cm ileal conduits.

Because of increased compliance, either reservoir provides for fecal storage, prolongs intestinal transit time, and alleviates the defecatory frequency seen after direct ileoanal anastomosis. Electromyography and manometry revealed that repetitive, simultaneous peristaltic contractions of the 2 and 3 ileal limbs forming the DB‐R and SS‐R, respectively, are required to generate the intraluminal pressure waves necesssary to promote complete reservoir evacuation. Such simultaneous contractions occur less often in the SS‐R than in the DB‐R. Therefore, the SS‐R develops into an inert, obstructing viscus within 6 months, which is not seen with the peristaltically stronger DB‐R. Ileal conduits facilitate reservoir placement; but, when longer than 2 cm, they impede reservoir evacuation and predispose to obstruction.

We conclude that, in contrast to the SS‐R, the DB‐R has physiological characteristics (compliance yet contractility) that allow normal bowel habits, but only if it is placed in anatomical proximity to the anus.
Thromboembolic complications from central venous catheters: A comparison of three catheter materials
Authors: Efsing Hans Olof , Lindblad Bengt , Mark Joakim , Wolff Tomas
Published: May 2005

In this comparative study of catheter materials used in central venous catheterization (CVC) into large veins, the overall frequency of CVC‐induced thrombosis was 12%. A 20% incidence of CVC‐induced thrombosis with siliconized polyethylene catheter, 9% with Teflon® catheter, and 6% with heparinized polyethylene catheter was seen. Thrombosis thus was significantly less common with Teflon® and heparinized polyethylene than with siliconized polyethylene (p<0.05). Repeat arm phlebography was performed in 15 patients and revealed no late formation or progression of thrombosis. Pulmonary embolism appeared in 2 patients and was fatal in one of them.
A unifying concept of polymorphonuclear neutrophil function in acute bacterial infection
Authors: Krukowski Z. H. , Smith G.
Published: May 2005

Alteration in neutrophil function during bacterial infection has been variously reported as either increased or decreased depending on the parameter measured, the technique used, and the nature of the infection. The chemotaxis, phagocytosis, and intracellular killing of neutrophils from 2 groups of patients were studied in an attempt to clarify the possible changes during bacterial infection. Chemotaxis was measured with the “leading front” modification of the Boyden micropore technique, and phagocytosis and intracellular killing with a simplified scheme for the interpretation of bactericidal activity. Patients with moderate bacterial infection had increased chemotaxis, phagocytosis, and intracellular killing. Patients with severe infection and toxic changes in the neutrophils had decreased chemotaxis, phagocytosis, and intracellular killing. A unifying concept for the explanation of the observed changes in neutrophil function is proposed.
Recurrence after proximal gastric vagotomy for gastric, pyloric, and prepyloric ulcers
Authors: Heberer G. , Teichmann R. K.
Published: May 2005

Results after proximal gastric vagotomy (PGV) with ulcer excision for gastric ulcer type I (according to Johnson) show recurrence rates similar to those for duodenal ulcer. In the European Multicenter Trial with 71 patients, symptomatic recurrence was 7.9% at 5 years and the total recurrence (including asymptomatic recurrences) was 17.5%. Recurrent ulcers are mainly gastric ulcers. Treatment of recurrence is, initially, always conservative with antacids or H2‐receptor blockers. From 19 patients with recurrent ulcer after PGV with ulcer excision for gastric ulcer type I reported from 3 prospective trials, 12 were managed conservatively. The operative procedure of choice for recurrence was partial gastric resection with a Billroth I or Billroth II reconstruction. Favorable results for this type of gastric ulcer after PGV may be explained by maintenance of gastric continence for solids, reduction of duodenogastric reflux and of postoperative gastritis. Preoperatively and intraoperatively, malignancy has to be excluded by multiple biopsies and frozen sections. Combined gastric and duodenal ulcers (gastric ulcer type II) may also be treated by PGV in controlled trials so that more data will be available for that rare type of ulcer. Recurrence rates after PGV for pyloric and prepyloric ulcers (gastric ulcer type III) are significantly higher than those for gastric ulcer type I or duodenal ulcers. After 5 years, recurrence rates of 16.4–35% are reported. This may be due to gastric retention, which is a common feature in patients with prepyloric ulcers. In fact, selective gastric vagotomy and drainage or vagotomy and antrectomy give significantly better results. The operation rate for recurrent ulcers after pyloric and prepyloric ulcers following PGV is about 25% because of pyloric stenosis. It is concluded that PGV and ulcer excision seem to be suitable for gastric ulcer type I and probably for type II. Pyloric and prepyloric ulcers should no longer be treated by PGV alone because of high recurrence rates. A drainage procedure should be added. In general, the operation should be performed by experienced surgeons since recurrence rates depend on the number of surgeons involved in clinical trials.
Bleeding gastroduodenal ulcers: Selection of patients for surgery
Authors: Hunt Phillip S.
Published: May 2005

In a prospective study of bleeding peptic ulcer from 1980 to 1985, endoscopic findings were found to be inferior to shock on admission in the prediction of further bleeding in the hospital. According to management policy, 40 patients (age greater than 50 years on admission) from a total of 376 cases were treated by emergency surgery for shock. Endoscopic methods of treatment were not used during this period of study. In the remaining 336 cases, 83 (25%) bled again in the hospital and 62 patients in this group underwent urgent surgery. Endoscopic findings were classified into 3 groups: active bleeding (including visible vessel), evidence of recent bleeding, and no stigmata of hemorrhage in the upper gastro‐intestinal tract. In patients who bled again in the hospital, there was no significant difference between the number of cases with active bleeding (44%) and those with signs of recent bleeding (30%). Visible vessel was an unusual finding, present in 4% of cases, but was associated with a risk of further bleeding of 38%, an incidence comparable to active bleeding on endoscopy. The incidence of further bleeding was low (7%) without stigmata and comparable to that found in 33 cases with prepyloric ulcer (10%). Shock on admission was associated with a significantly greater incidence of rebleeding in 70% of cases. The combination of shock on admission and active bleeding on endoscopy was no better a predictor of further bleeding than was shock alone. Age was a poor discriminator as the incidence of further bleeding was the same comparing those under and over 50 years. Active bleeding on endoscopy was a less common finding with gastric ulcer than with duodenal ulcer, but was associated with a significantly greater incidence of rebleeding of 58% of cases compared to 42% for duodenal ulcer.
Pyloric stenosis complicating duodenal ulceration
Authors: Ellis Harold
Published: May 2005

Pyloric stenosis would be better termed gastric outlet obstruction but popular usage favors the former title. The most common cause in adults is a stenosing chronic duodenal ulcer, but differential diagnosis must be made clinically, radiologically, and endoscopically from other causes, particularly carcinoma of the gastric antrum. Metabolic disturbances due to fluid and electrolyte loss are not common but, if present, require correction by intravenous replacement therapy.

The condition is becoming less common due to the overall decline in incidence of duodenal ulcer in the Western world and the more effective medical treatment of duodenal ulcer with H2antagonists. It is still common, however, in many parts of the Third World.

Treatment is invariably surgical but medical preoperative preparation is required. Vagotomy combined with drainage gives excellent results.
Giant gastric and duodenal ulcers: A population‐based study with a comparison to nongiant ulcers
Authors: Gustavsson Sven , Kelly Keith A. , Hench Victoria S. , Melton L. Joseph
Published: May 2005

Among 454 operations done for peptic ulcer between 1956 and 1985 on residents of Rochester, Minnesota, U.S.A. in whom ulcer size could be determined accurately, 50 operations (11% of the total) were performed for giant ulcers and 404 (89%) for nongiant ulcers. The annual operation rate per 100,000 residents for giant ulcer did not clearly decline during the 30‐year period in contrast to the dramatic fall in operation rates for nongiant ulcers. Nonetheless, the ratio of operation rates for giant ulcer compared to nongiant ulcer changed relatively little. Giant ulcers required emergency operation for massive bleeding more often than nongiant ulcers. Also, giant ulcers presented with unusual and severe complications such as gastrocolic fistula. Survival after surgery for giant ulcer was poorer than survival after an operation for nongiant ulcer. We conclude that giant ulcers are operated on somewhat less often today than in the past, while operations for nongiant ulcers are much less frequent. The giant ulcers that are operated on, however, are more prone to massive bleeding and are associated with poorer postoperative survival than their nongiant counterparts.
The influence of remnant size, antithyroid antibodies, thyroid morphology, and lymphocyte infiltration on thyroid function after subtotal resection for hyperthyroidism
Authors: Jörtsö Erik , Lennquist Sten , Lundström Björn , Norrby Klas , Smeds Staffan
Published: May 2005

The influence of thyroid remnant size, antithyroid antibody titre, thyroid morphology, and lymphocyte infiltration on postoperative thyroid function was studied in 179 patients undergoing subtotal thyroidectomy because of hyperthyroidism. The surgical procedure was strictly standardized and included determination of the thyroid remnant size. The preoperative medication used was beta‐adrenoceptor blocking agents in 101 patients and antithyroid drugs and thyroxine in 78. With remnant size adjusted to 6–10 g (or, in goiters less than 20 g, to 25–30% of initial gland weight), the overall recurrence rate after 2–8 years (mean 5.3±2.0) of follow‐up was 1.7% and the incidence of thyroid hypofunction was 29.6%.

In toxic nodular goiter (TNG; n=63), a significant negative correlation was found between TSH and remnant size after 12 months as well as a significantly lower remnant weight in patients developing postoperative hypothyroidism. In toxic diffuse goiter (TDG; n=116), there was no difference in remnant size between euthyroid and hypothyroid patients. For patients with TDG treated preoperatively with beta‐blockers, the incidence of autoantibodies against thyroid cytoplasm was increased in patients who postoperatively developed thyroid dysfunction. Within the group of TDG developing hypofunction, we found increased titre of autoantibodies and “presence of lymphoid tissue” more often in patients treated preoperatively with beta‐blockers compared to thyrostatics. In toxic nodular goiter, the remnant size was considered the parameter most helpful to the surgeon in predicting postoperative thyroid function.
Nuclear DNA patterns and survival in metastasizing ileal carcinoids
Authors: Nobin Anders P. , Erhardt Kerstin , Auer Gert , Falkmer Sture , MÅrtensson Hans
Published: May 2005

The prognostic value of assessing the tumor cell nuclear DNA pattern in metastasizing ileal carcinoids was evaluated in 22 patients. Eleven patients survived for 5 years or more after the diagnosis of the liver metastases, whereas 11 died within 3–4 years. Clinical data as well as histopathological and immunohistochemical tumor characteristics were studied. DNA measurements in single tumor cells were performed on histologic sections with a photographic cytophotometric method.

The number of aneuploid tumor cells was almost negligible in all tumor specimens. When the number of nondiploid cells was evaluated, however, a tendency was observed for more frequent nondiploidy in tumor cells from patients surviving less than 3–4 years. Histopathologically and immunohistochemically, there were no clear‐cut differences between the tumors of the 2 patient categories. Consequently, an assessment of the DNA pattern may help in determining the malignant potential of individual ileal carcinoids.
Is major surgery in hemophiliac patients safe?
Authors: Rudowski Witold J. , Scharf Romuald , Ziemski Jan M.
Published: May 2005

In the last 20 years, surgery in patients with hemophilia has been carried out with progressively less mortality and morbidity. Even extensive and major surgical operations can be carried out provided that the underlying coagulopathy is corrected and normal hemostasis restored.

We report the results of 196 operations performed in 147 hemophiliacs during the period 1961–1985 in the Department of Surgery, Warsaw Institute of Hematology. Our patients experienced, in this 25‐year period, 23% of hemorrhagic complications in hemophilia A and 12.5% in hemophilia B. In the last 5 years, however, the incidence of hemorrhagic complications was reduced to 5.2% in hemophilia A and 8.3% in hemophilia B. This correlates with the discovery of cryoprecipitate and with the development of concentrates of factor VIII and IX, respectively.

In all patients, deficient factor levels were determined before the operation. The replacement therapy was based on the policy of raising the level of factor VIII or IX above 60% of the normal value and maintaining this level above 30% in the postoperative period until final wound healing.

Problems discussed in this article include the principles of replacement therapy, its advantages and disadvantages, and the organization and degree of cooperation among surgeon, hematologist, and blood bank staff.
Effect of varying number and volume of transfusions on mortality rate following septic challenge in an animal model
Authors: Waymack J. Paul , Warden Glenn D. , Miskell Phil , Gonce Sara , Alexander J. Wesley
Published: May 2005

It is well established that transfusions given prior to transplantation diminish rejection, and recent reports suggest that transfused patients having surgery for cancer develop metastases more rapidly than do those not receiving transfusions. Recently, we have demonstrated in an animal model that allogeneic blood transfusions increase susceptability to infectious complications. To determine if this effect could be altered by changing either the number or the volume of transfusions, Lewis rats were given varying volumes of blood in both single and multiple dosages. A control group received only saline. These rats were subjected to a 30% total‐body surface area full‐thickness burn which was inoculated withPseudomonas aeruginosa1244 on postburn day one. The animals were then followed for 28 days to determine the mortality rates. Each group of transfused rats had an increased mortality rate compared to the saline group. There were no differences between the various transfusion groups. In conclusion, the increased susceptability to infections seen following transfusions does not appear to be influenced by the volume or the number of transfusions within the limits tested.
Pathologic changes secondary to radiation
Authors: Berthrong Morgan
Published: May 2005

In order to be effective in the treatment of disease, especially neoplastic disease, radiation necessarily needs to be given in large doses. When treating tumors with high radiosensitivity in tissue of relatively low radiosensitivity, few complications of therapy occur. Frequently, however, the differential of sensitivity to radiation between the neoplasm and normal tissues exposed is small and the incidence of radiation injury to normal tissues becomes significant. Nowhere is this more apparent than in treatment of neoplasms during which the alimentary canal is heavily radiated. The following discussion will describe the pathologic changes that occur in the various units of the exposed alimentary tract and in various components of those units during and especially months or years after radiation therapy. The usual rapid and effective regeneration of the rapid‐renewal cell system after injury will be noted. The serious delayed manifestations of injury to the fibrovascular tissues with resulting delayed complications of ulcerations, stenoses, fistula formation, and obstructing adhesions will be emphasized. Brief discussions of several other organ systems injured by radiation will be presented.

The development of second neoplasms as a result of radiation will be briefly mentioned and discussed from three standpoints: very low levels, low levels, and high levels of radiation.
Repair of radiation complications in the head and neck
Authors: Larson David L.
Published: May 2005

Complications attendant on the use of irradiation in the head and neck occurred in 72 of 128 patients at the M. D. Anderson Hospital. The author outlines a rational approach to the patient with head and neck cancer that can help in preventing undesirable sequelae. Dental status, tumor location, and patient compliance are major factors that bear on incidence of major complications of radiation. Recent advances in reconstructive surgery now permit safe transfer of tissue with its intrinsic blood supply‐not dependent, as in the past, on the local radiated area for its vascularity. When complications of radiation therapy occur, they are usually late and in some instances no treatment is indicated or desired. Clinical examples are used to identify specific areas of concern.
An approach to repair of radiation necrosis of chest wall and mammary gland
Authors: Sando William , Jurkiewicz M. J.
Published: May 2005

Chest wall reconstruction following radiation no longer need be a protracted sequence of multiple stage tissue transfer with potential necrosis of the flap at each step. Muscle flaps with or without the overlying skin provide very reliable and effective methods of single‐stage repair. For the anterior chest the latissimus dorsi, the rectus abdominis, and pectoralis muscles are the choices with omen turn as an alternative in salvage cases. For the posterior chest, choices are the latissimus dorsi or trapezius.

In selected patients, breast reconstruction can be offered. The use of either the rectus abdominis or latissimus dorsi musculocutaneous flap, singly or in tandem, is the current preferred choice.
The radiation‐damaged rectum: Resection with coloanal anastomosis using the endoanal technique
Authors: Cooke Stanley A. R. , Wellsted Michael D.
Published: May 2005

Fifty‐nine consecutive patients with a radiation‐damaged rectum were treated by subtotal rectal resection, continuity being restored by coloanal sleeve anastomosis using the endoanal suture technique. There were no deaths. Technical success was achievd in 55 patients (93%) with rectovaginal fistula, hemorrhagic proctitis, painful radiation ulcer, rectal stricture, or carcinoma developing in an irradiated rectum. An additional risk factor was present in all 4 technical failures, including a divided irradiated sphincter, previously divided marginal artery, diabetes, and persistent sepsis. Restorative surgery was attempted in all patients, irrespective of the severity of the radiation injury. Postoperative continence depended on anal sphincter function, with an improvement in full continence from 54% to 76% over the first postoperative year. Of the first 28 patients assessed at 1 year after operation, all 19 of those whose initial condition was well above the sphincter mechanism were fully continent, compared to only 2 of 9 with low fistulas extending down to the anal sphincter, which in these patients was histologically shown to be severely damaged by radiation. The functional status was assessed 1 year after surgery in 46 of the total 59 unselected patients treated. Thirty‐five were continent (76%), 7 incompletely continent (15%), and 4 incontinent (9%). Long‐term follow‐up was possible in 35 of the first 37 consecutive patients successfully treated before February, 1980, and followed for a mean of 5.1 years (range 1–8 years 9 months). Four died of recurrent cancer. Twenty‐four (77%) of the surviving 31 patients were fully continent at the time of final assessment, 4 incompletely continent, and 3 (9.7%) reverted to a colostomy because of incontinence or pelvic obstruction.
Resection and pull‐through for rectovaginal fistula
Authors: Cuthbertson Alan M.
Published: May 2005

Reconstruction of the rectum following irradiation injury may be achieved if the injury is localized. This type of injury may follow intracavity irradiation during which the rectum may have received an unexpectedly high dose. Heavily irradiated tissue heals poorly, and so a method that introduces nonirradiated tissue is necessary for a successful repair. Presacral infection following rectal resection is the other problem which determines the outcome. The pullthrough resection with delayed colorectal anastomosis fulfills these requirements. Four patients were treated by this operation successfully prior to 1975. Since then no further cases suitable for this type of repair have been seen due to modifications to the irradiation technique. The operation had been used in 223 patients with rectal cancer prior to 1975 with a mortality rate of 4.9%. The major cause of death was from failure of blood supply to the exteriorized colon, but with adequate mobilization of the left colon this complication can be avoided. Bowel function following pull‐through resection is slow to return, but after 12 months over 90% of patients have reached an acceptable level. The operation is, therefore, not recommended as a palliative procedure.
Functional results after postirradiation rectal reconstruction
Authors: Bricker Eugene M. , Kraybill William G. , Lopez Marvin J.
Published: May 2005

The functional results obtained in 26 patients operated on for postirradiation rectovaginal fistula, stricture, or combination of fistula and stricture are reported in detail. Emphasis is placed on the degree of continence obtained. The operation consists of use of proximal nonirradiated colon to repair the damaged area without doing a rectal resection. It has been found that nonirradiated colon with a good blood supply can be expected to heal to irradiated colon or rectum and complete resection of the entire irradiated area is not necessary. The results of this operation have been excellent in 11, satisfactory in 8, and poor in 2; the procedure failed in 2 patients. One patient died as a consequence of the operation and 2 patients died of other causes before having closure of a temporary colostomy. It was found that the presence of radiation damage to the small intestine could influence the quality of the end result.
Pelvic complications after interstitial and external beam irradiation of urologic and gynecologic malignancy
Authors: Schellhammer Paul F. , Jordan Gerald H. , El‐Mahdi Anas M.
Published: May 2005

Pelvic malignancies comprise 19% and 28% of all malignancies in the female and male, respectively. The majority of gynecologic and urologie pelvic malignancies are treated with radiation therapy either alone or in combination with surgery either as definitive or palliative therapy. The pelvic organs, therefore, are at risk for injury by pelvic radiation. We have reviewed our experience and that of the literature with regard to the incidence of injury associated with pelvic irradiation and give recommendations for management. The most frequent and severe complications occur in association with cystectomy performed for carcinoma of the bladder that has failed definitive radiation therapy and in association with radiotherapeutic and surgical treatment of carcinoma of the cervix. We have found an 11% incidence of bowel injury following planned integrated preoperative radiation followed by cystectomy. In our experience, bowel and urinary complications secondary to external beam radiation or125I brachytherapy for definitive treatment of carcinoma of the prostate are very similar. The morbidity of external beam radiation therapy has been reduced using a triple‐course fractionated protocol. Rectal ulceration requiring colostomy has occurred in approximately 3% of patients treated with external beam or interstitial125I therapy. Surgical correction of rectal fistulas using vascularized flaps has been successful after125I injury but has not been possible after external beam injury. Urethral complications associated with definitive external beam radiation therapy for carcinoma of the prostate are most often associated with prior transurethral resection. They can be significantly reduced by withholding initiation of therapy for 4–6 weeks after completion of transurethral resection.
Partial hepatectomy for intrahepatic stones
Authors: Choi Tat K. , Wong John
Published: May 2005

Fifty partial hepatectomies were performed in 49 patients as the definitive treatment for symptomatic intrahepatic stones. The part of the liver containing the strictured ducts and stones was resected. In 39 patients, it was done as the primary procedure, and in 11, it was done when an initial procedure (including one left hepatic lobectomy) had failed. Partial hepatectomy was the preferred method of management when the patients had 1 or more of the following conditions: stones confined to one segment or one lobe of the liver; destruction of the portion of the liver harboring the stones from repeated episodes of obstruction and infection; and multiple strictures of the ducts in the involved portion of the liver. The operative mortality was 2%. Long‐term follow‐up on 44 patients at a median of 7 years showed that 82% were symptom free, 7% had occasional mild attacks of cholangitis, and 11% had severe cholangitis requiring surgical intervention. At reoperation for severe cholangitis, 2 were found to have sphincteroplasty strictures and 3 had stones and ductal strictures. The low operative mortality rate and the overall good results show that partial hepatectomy can be considered as the primary treatment of choice for selected patients with intrahepatic stones.
Hepatic resection for hepatocellular carcinoma associated with liver cirrhosis
Authors: Kinami Yoshio , Takashima Shigeki , Miyazaki Itsuo
Published: May 2005

Sixty‐three patients with hepatocellular carcinoma associated with cirrhosis received various kinds of treatment at our clinic during the past 21 years. Of these, 35 patients who underwent hepatic resection were divided into a large tumor group (tumors more than 5 cm in diameter) and a small tumor group (tumors less than 5 cm in diameter), and the operative results of both groups were studied. There was a difference in the average ages between the 2 groups (p <0.05), but there was no difference in the duration of illness or laboratory data. The resectability rate of the liver in 17 patients with small tumors was 89% and was significantly higher than that of 41% in 18 patients with large tumors (p<0.005). The overall operative mortality rate was 14% for both groups. Patients with tumors over 3 cm already exhibited the histological findings seen in advanced cancer. Cumulative 3‐year survival rates of the large and small tumor groups were 0% and 53%, respectively, and there was a significant difference in survival curves between the 2 groups (p<0.005). The above results suggest that hepatic resection for patients with small tumors is effective as a treatment for hepatoma associated with cirrhosis.
Determination of the extent of feasible hepatic resection from hepatic blood flow
Authors: Mimura Hisashi , Takakura Norihisa , Ohno Yasuhiko , Matsuda Tadakazu , Kin Hitoshi , Hamazaki Keisuke , Tsumura Makoto , Toda Satoshi , Hiraki Yoshio
Published: May 2005

Blood flow in the residual liver after major hepatectomy is considered an important determinant factor of liver function. Presented here is a method of obtaining the whole and regional hepatic blood flow index from hepatic clearance of198Au‐colloid, which can predict the blood flow index of residual liver before operation and thereby prevent postoperative hepatic failure due to too large a resection. Hepatic resection was followed by a decrease of the hepatic blood flow index (KLAu) almost proportional to the amount of hepatic mass resected. An analysis of data from 34 patients who underwent hepatectomy showed that the preoperatively predicted value of the blood flow index in the unresected liver had a good correlation (r=0.9) with that measured 1 month after hepatectomy. It also correlated well with the risk of death from liver failure among those patients whose KLvalue of residual liver was under the critical level. Since 1981 the early death rate from liver failure after hepatectomy was reduced remarkably by preparing the resection boundary on the basis of the blood flow index of residual liver. With the use of our method in animal experiments, the hepatic blood flow index was found to be uninfluenced by reticuloendothelial system function and was considered to be a reliable indicator of blood flow in hepatic sinusoids.
Cytoprotection of the gastric epithelium
Authors: Moody Frank G. , Zalewsky Charlotte A. , Larsen Kenneth R.
Published: May 2005

The lining of the stomach of man is protected from its unique secretion, hydrochloric acid, by a variety of highly specialized characteristics. Foremost is its relative impermeability to hydrogen ions. The gastric surface epithelial cell which forms a continuous integument from the esophagus to the duodenum plays an important role in this barrier function. Disruption of the barrier by injurious agents, sepsis, or shock may lead to severe erosive gastritis when acid is present within the lumen of the stomach. This process is accelerated during periods of low mucosal blood flow. The relationship of the rate of back‐diffusion of hydrogen ions to mucosal blood flow appears critical. Factors which (a) inhibit acid secretion, (b) strengthen the barrier to H+ diffusion, or (c) increase mucosal blood flow will protect the stomach from injury. Prostaglandins of the A, E, and F series offer a level of protection in experimental erosive gastritis that is out of proportion to their effect on acid secretion and mucosal perfusion. The secretion or filtration of an alkaline secretion may be an important component of the cytoprotection which follows the topical exposure of gastric mucosa to 16,16‐dimethyl (PGE2). The role of mucus release in this situation requires further elucidation.
The pathophysiology of stress ulcer disease
Authors: Silen William , Merhav Aryeh , Simson Jay N. L.
Published: May 2005

Stress ulcers are superficial mucosal lesions located predominantly in the fundus of the stomach. They occur mainly in the victims of severe trauma and sepsis and are to be clearly distinguished from Cushing's ulcers, ulcers induced by drugs and from activation of a preexistent ulcer. It is generally agreed that mucosal ischemia is the major inciting event in the pathogenesis of acute stress ulceration of the stomach and that the presence of luminal acid and pepsin are required for overt ulceration to develop. Back‐diffusion of acid occurs in the absence of overt disruption of the gastric mucosal barrier, is closely related to the formation of ulcers, and may be enhanced by reflux of duodenal content into the stomach and by diffusion of blood urea into the stomach. Severe acidosis and base deficit together with depression of acid secretion and consequent lowering of alkaline tide are important contributing factors. A differential energy deficit in fundic mucosa as a result of ischemia probably contributes to mucosa damage by interfering with anion exchange (HCO3− for Cl−). The exact role of steroids and prostaglandins is controversial.
Role of gastric mucosal energy metabolism in the etiology of stress ulceration
Authors: Menguy Rene
Published: May 2005

It is generally agreed that mucosal ischemia of the gastrointestinal tract is one of the major consequences of the low‐flow state, be it due to blood loss, fluid loss, or sepsis. In the present paper, arguments are presented in favor of the hypothesis that stress‐induced mucosal injury which tends to occur preferentially in the proximal stomach, duodenum, and terminal ileum results from a mucosal energy deficit severe enough to cause cell death.
Drug‐induced gastric mucosal injury
Authors: Fromm David
Published: May 2005

Although there is much of anecdotal information about drug injury to the gastric mucosa, only a few agents (e.g., salicylates, nonsteroidal‐nonsalicylate antiinflammatory compounds, and alcohol) have been studied in detail. The presence of acid in the gastric lumen is required for an injurious drug to cause clinically significant injury. Injury occurs as a result of the ability of certain drugs to increase the permeability of the mucosa to its own secreted acid lying within the lumen. As the tissue becomes overwhelmed by the diffusing acid, cell death occurs. Drugs that increase the diffusion of acid also interfere with cellular metabolism, an effect that is independent of the ability of the drug to increase diffusion of acid from the lumen into the tissue. However, when metabolic processes of the mucosa are depressed, the ability of the tissue to buffer diffusing acid is impaired. Thus, the quantity of acid diffusing into the tissue is not as important as the buffering capacity of the mucosa. Most instances of drug‐induced injury are not clinically apparent, yet significant hemorrhage occurs in some patients. Even though the initial episode of hemorrhage may be severe, aggressive nonoperative treatment usually is sufficient, provided the mucosa is no longer exposed to the injurious agent. Only a few patients require operation, the extent of which is still controversial.