Leaks and obstruction after gastric resection.

Postoperative gastric retention may be minimized by avoiding the use of the Billroth I reconstruction when a large duodenal ulcer must be retained. Postoperative gastric retention is more likely to remit with conservative therapy if the procedure was a Billroth I reconstruction with a vagotomy. In other instances where there is difficulty in gastric emptying, a mechanical cause should be strongly suspected.

The impact of demographic trends on hospital surgical care.

The projected increase in numbers and percentages of elderly people has great potential impact on health services generally. Only rarely, however, has the impact of age of patients on a surgical service been quantitated. Two hundred fifty-five consecutive laparotomies performed in men older than 65 years of age were compared with 174 consecutive laparotomies in men younger than 65 years of age, all from a Veterans Administration Medical Center experience.

Early urgent relaparotomy.

We analyzed the indications for and implications of reoperation in 113 patients who required early urgent relaparotomy. Infection with intact organs was the most common indication, causing the most diagnostic difficulties, and presenting the most varied findings. Suture-line leaks and dehiscence were next in frequency.

Associated lung lesions in patients with primary head and neck carcinoma.

From a 9-year Veterans Administration Medical Center experience, 34 patients were identified who had synchronous or metachronous pulmonary lesions in association with primary head-neck carcinoma. Evaluation of the pulmonary lesions included bronchoscopy, mediastinoscopy, and thoracotomy. Lung lesions were felt to be metastatic lesions from head and neck primary in 12 patients, primary lung carcinoma in 20 patients, and metastases from subdiaphragmatic primary neoplasms in two patients.

Role of infection in increased mortality associated with age in laparotomy.

Mortality in patients undergoing laparotomy increases with age of the patient. Concomitantly other morbid perioperative factors also are increased, including number and grade of associated system diseases, preoperative infections, severity of disease, emergency operations, post-operative infectious and noninfectious complications, organ failures, and forced secondary operations. All these and other factors may play a role in mortality but two patterns of death are predominant.

Iatrogenic ureteral injury. Options in management.

Twenty-five patients sustained 27 iatrogenic ureteral injuries during various operative procedures. Injuries were managed by ureteroureterostomy in 11 injuries, ureteroneocystostomy in 11, nephrectomy in two, ureteral stent in one, cutaneous ureterostomy in one, and reimplantation into an ileal conduit in one. Four of 25 patients died, three as a result of the failure of ureteral repair and intra-abdominal sepsis.

Applications of choledochoduodenostomy in biliary tract obstruction.

Forty-three patients each underwent choledochoduodenostomy for distal biliary obstruction. The results were satisfactory for those patients with benign obstructions. Choledochoduodenostomy was complicated by recurrent biliary obstruction in five of 19 patients with obstructing neoplasms, and is generally a poor choice in those circumstances.

Gangrene of the gallbladder: a complication of acute cholecystitis.

Eighteen cases of gangrenous cholecystitis were reviewed to better define causes of morbidity and mortality. All patients in the series presented with signs and symptoms of acute cholecystitis. Cholecystectomy was done as an emergency procedure in 12 patients, while in six patients cholecystectomy followed a failure of nonoperative therapy.

Surgery in elderly patients.

Operations on patients over 65 years old are increasing steadily in number and complexity. Demographic trends indicate that future increases will be even greater. We reviewed patients having operations of diverse type and magnitude to determine results, with emphasis on the influence of age.

Systemic prophylactic antibiotics: need the 'cost' be so high?

To assess compliance with accepted principles, the use of prophylaxis with systemic antibiotics in selected specialty procedures was examined. The operations reviewed were aortofemoral bypass, pulmonary resections, open-hip procedures, and head-neck cancer procedures that involve the oropharyngeal cavity. Of all patients, 74% received antibiotics preoperatively and 79% received prophylaxis with antibiotics longer than 24 hours postoperatively.

Empyema of the gallbladder: a complication in the natural history of acute cholecystitis.

Empyema of the gallbladder was identified in 34 patients. Patients undergoing early operation without attempts at nonoperative treatment had less infectious morbidity and mortality. Delayed operative intervention, extrabiliary abscess, perforation of the gallbladder and common duct exploration are factors that contribute to increased risks in these patients.

A prospective study of carotid endarterectomy with and without shunt.

The extent of cerebral protection necessary during carotid endarterectomy for ischemia is controversial. In 147 carotid endarterectomies, carotid backflow was estimated and, in later years, these clinical impressions were correlated with stump pressure. These estimates or values, modified particularly in early years by the extent of contralateral disease and (inversely) of ipsilateral occlusion, were used to determine the need for a shunt at the time of carotid clamping.

Pseudoaneurysms and related complications of aortic bypass grafts.

During a recent five-year period 14 patients had pseudoaneurysms as late complications of aortic bifurcation grafts. Severe atherosclerosis had been present at the time of the aortic grafts, and subsequent progression of arterial disease appeared to be the usual cause of the pseudoaneurysms which occurred from two to 14 years later. Nineteen of the 23 pseudoaneurysms in the 14 patients were in the groin.

Clinical considerations in unusual colonic obstructions.

Colonic obstructions of uncommon cause may present challenging diagnostic problems that require prompt and correct treatment. Fifty such patients were studied and illustrate the problems that may be encountered. Clinical observations of importance include the need to distinguish a prostatic cancer obstructing the rectum, the mimicking of inoperable cancer by various benign processes, the need to decompress an enlarging cecum even in paralytic ileus, and the occasional inadequacy of sigmoidectomy as the elective treatment of sigmoid volvulus.

Occult diverticulitis, a cause of retroperitoneal fibrosis.

A case is reported in which extensive mesocolonic and retroperitoneal granulomatous and fibrotic disease were apparently due to occult diverticulitis. The patient later had a good result from aggressive but limited operation for obstructions of the ureter and colon.

Results of corrective surgery for alkaline reflux gastritis.

Reflux alkaline gastritis and esophagitis have been incriminated as a source of symptoms in achlorhydric patients afer operation for duodenal ulcer. Documentation of such pathologic findings has increased due to widespread use of fiberoptic endoscopy. As reported in the literature, results of remedial operations have ranged from encouraging to excellent, and evaluations have been uniformly laudatory.

Recurrence of volvulus after sigmoidectomy.

Three patients had recurrences of left-sided colonic volvulus after allegedly total resections of redundant sigmoid loops. All three patients had chronic, acquired megacolon. Other instances of late recurrence of volvulus after sigmoidectomy are documented in the literature.

Rectal obstruction secondary to carcinoma of the prostate.

The records of 13 patients with symptomatic rectal obstruction secondary to prostatic carcinoma have been critically reviewed to provide criteria for identifying this atypical presentation. The site of obstruction varied from the anal verge to 17 cm by sigmoidoscopy. Significant clinical findings were ureteral obstruction on excretory urography in 12 of the patients, elevated acid phosphatase in eight, intact mucosa over the obstructing mass in seven and osteoblastic bone metastasis in six.

Interposition mesocaval shunt for bleeding esophageal varices: clinical, hemodynamic, and metabolic changes.

Twenty-three patients bleeding from varices had mesocaval H-grafts using Dacron prosthetic material. There were 21 men and two women with ages ranging from 37 to 60 years. There were 11 elective and 12 emergency procedures.

Management of aortic bypass graft thrombosis: utility of thrombectomy.

The condition of many patients with early or late thrombosis after an aortic bypass operation can be improved by appropriate secondary operations. Late thromboses generally occur in patients with impaired arterial outflow. Restoration or establishment of good outflow is the most critical part of most secondary operations.

Freezing an extremity in preparation for amputation.

Patients requiring a major amputation for ischemia are frequently gravely ill. Physiologic amputation obtained by freezing the leg, usually with a tourniquet, will permit delay and intensive preoperative therapy. In an efficient, safe, and convenient method which we have developed and used in 46 patients, a pump circulates antifreeze solution through a specially constructed boot.

A technic for freezing an extremity in preparation for amputation.

Freezing of an extremity permits delay in amputation, and the time gained can be devoted to such intensive therapy as may be indicated. A safe, efficient, and convenient technic is described.