Biliary atresia before and after the introduction of the Kasai-type procedure

The apparent cure rate of infants with biliary atresia is compared before and after the introduction of the Kasai-type procedure. While the operation has been criticized for many of its postoperative problems, it still compares favourably in terms of the apparent cure rate, i.e. an improvement from 4.5% to 35.3%.

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.

Surgical management of benign oesophago-pleural fistula

Three cases of oesophago-pleural fistula are presented. Two resulted from foreign body perforation of the oesophagus and one followed left lower lobectomy for bronchiectasis. All three presented late; the time lapse ranged from 6 days to 2 months. An initial course of conservative treatment was given to all three patients. Alimentation via nasogastric tube feeding, gastrostomy or total parenteral nutrition was carried out. The pleural fluid grew the anaerobe, Bacteriodies melaninogenicus, in all three cases. Gram-negative aerobes, Escherichia coli and Proteus mirabilis, were also cultured. Closed intercostal drainage and a course of appropriate antibiotics were instituted. The patients were subjected to surgery after the infection had been brought under control. Simple repair was performed in two patients. Exclusion of the oesophageal leak with drainage and later reconstruction was carried out in the third patient. Although all three patients recovered, the morbidity was considerable. The duration of hospital stay ranged from 2 to 4 months.

Analysis of mortality of extradural haematoma in a general surgical unit

Extradural haematoma complicating head injury still has a formidable mortality despite recent advances in neurological surgery. The experience of 60 cases of extradural haematoma treated in a general surgical unit was reviewed retrospectively. The mortality was 35%. Analysis of the 21 deaths showed that 13 (62%) of them were possibly avoidable. Lack of index of suspicion, delay in instituting surgical treatment and inadequate surgical intervention were the main causes of the avoidable mortality.

Tracheostome construction during laryngectomy--a method to prevent stenosis

A new technique for construction of the tracheostome at the time of total laryngectomy is described. It involves making an X-shaped incision on the lower skin flap and four slits on the divided trachea. The result is a serrated suture line at the tracheocutaneous junction. The incidence of stenosis in 116 patients who did not have this method of construction was 31%. Sex difference and previous irradiation was not found to be related to the occurrence of stenosis. Of 25 patients who had the new method of tracheostome construction, only one patient had to wear a tube until she died at 7 months. The rest, followed up for at least 9 months, did not have stenosis. It is concluded that this new method of tracheostome construction will reduce the incidence of stenosis.

Percutaneous sump drainage: a palliation for oft-recurring intracranial cystic lesions

Eleven cystic lesions comprising four craniopharyngiomas, six astrocytomas, and one pinealoma, which at operation were presumed to be unamenable to radical excision, were treated by partial resection, insertion of a sump drainage, and postoperative radiotherapy. As a consequence of this relatively simple operative procedure there were no serious complications, and every patient recovered fully from preoperative neurologic deficit. Whenever the symptoms recurred the subcutaneous reservoir provided a readily available access for needle puncture to relieve the raised intracranial pressure. On each occasion, after aspiration of the accumulated cyst fluid, each patient showed marked improvement within 48 hours. Pertinent literature is reviewed and possible other applications of sump drainage are discussed.

Oestrogen receptor status and survival in Chinese females with breast cancer

Oestrogen receptor assay was performed on one hundred and sixty-eight patients with proven breast cancer. Fifty-two per cent were positive for receptors; there was a lower incidence of positives in both the pre- and postmenopausal women, when compared with corresponding figures for American women. Patients were randomized into different modes of treatment. It was found that oestrogen receptor positive patients fared better than the negative ones irrespective of the stage of the disease or the treatment received, and this difference was statistically significant in patients with early disease (stages one and two). In patients assigned to some form of endocrine manipulation, 77% of receptor positive, and 7% receptor negative patients showed a response to treatment; in those receiving chemotherapy, receptor negative patients fared better than the positive ones, though the difference was not statistically significant.

Caseating regional lymphadenitis complicating BCG vaccination: a report of 6 cases

Six infants had caseating regional lymphadenitis complicating BCG vaccination. There was a delayed onset and a lack of immediate vaccination complications. Three infants had frank abscesses. Additional affected nodes undetected clinically were found at operation in all cases. All lymph nodes contained tubercles, 3 showing acid-fast bacilli, 2 of which grew Mycobacterium bovis. Complete excision followed by antiuberculous chemotherapy produced satisfactory results.

Epidermoid carcinoma of the anus

Twenty five patients with epidermoid carcinoma of the anus, representing 1.5% of all large bowel malignancies, were seen over a 33 year period. Most patients presented with an advanced lesion which gave rise to a fungating mass, bleeding or pain. Nearly all patients who received either palliative irradiation or refused treatment died within a year of diagnosis. Abdominoperineal resection in 12 patients yielded an encouraging five year survival rate of 68.5%. Therapeutic groin node dissection performed on six occasions led to only one late recurrence. The surgical literature on sphincter saving local excision and therapeutic radiotherapy is reviewed. Currently, radical resection remains the most appropriate treatment for the majority of patients with epidermoid anal cancer.

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.

Perforations in acute duodenal ulcers

To determine the clinical characteristics and outcome of perforated acute ulcers of the duodenum, we prospectively studied 60 patients, 28.3 per cent of all perforations, after closure only. Patients with acute ulcers were significantly older and had a higher hospital mortality than did those with perforated chronic ulcers. Within the first three years following closure, chronic ulcers recurred significantly more often than did acute ulcers. Nevertheless, relapses in patients with acute ulcers were usually symptomatic and, on occasion, necessitated reoperation for complications. Among the acute ulcer group, individuals who had perforated ulcers by the age of 30 years had a significantly increased risk of early recurrence. Due to the higher risk, we suggest that an immediate, definitive operation be evaluated in younger patients with a perforated acute ulcer of the duodenum.

Oesophagoplasty for malignant obstruction of the oesophagus following previous partial gastrectomy

The management of 19 patients with malignant obstruction of the oesophagus who previously had undergone partial gastrectomy was reviewed. With stomach unavailable for oesophagoplasty, the jejunum was used in 12 patients, and the colon in seven patients, for reconstruction or bypass. The technique recommended is jejunal oesophagoplasty. Surgical intervention to restore swallowing in this group of patients has been associated with a 52% hospital mortality and a considerable morbidity. Because of the late stage of the disease, survival beyond two-three years after a successful operation has not been possible so far.

Mucoepidermoid carcinoma of the bile duct

Three patients with mucoepidermoid carcinoma of the bile duct are described. In two patients the tumor arose from the common hepatic duct. Mucoepidermoid carcinoma of the extrahepatic bile duct has not been previously reported. The clinical features and pathologic behavior of this rare type of tumor are similar to the usual biliary adenocarcinoma. The coexistence of Clonorchis sinensis infestation and primary pyogenic cholangitis raises the possibility of an etiologic association.

Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery

A one-stage technique for the repair of urethral fistulae after urethroplasty for hypospadias is reported. A pedicle flap prepared from the facial layers of the scrotum is interposed between the urethra and the overlying skin. In the nine patients operated on, there was one failure, and it was due to postoperative hematoma formation. This technique is especially recommended for patients with multiple small urethral fistulae.

Extraperitoneal sphincteroplasty for residual stones: an update

Sphincteroplasty was done via the extraperitoneal transduodenal approach in 42 patients. The indications were residual stones in 34 patients, stricture at Oddi's sphincter in seven patients, and relapsing pancreatitis in one patient. Seven patients suffered operative complications, with one death. Sphincteroplasty was successfully performed in all patients, and the residual stones were removed in 31. Thirty-three of the 36 patients followed up for a mean of seven years were asymptomatic. Extraperitoneal sphincteroplasty has a role in supplementing endoscopic papillotomy and percutaneous extraction through the T-tube tract in the treatment of patients with residual stones.

Choledochojejunostomy in the treatment of primary cholangitis

Choledochojejunostomy was performed upon 128 patients with primary cholangitis with an operative mortality of 2.3 per cent. Evaluation of 106 patients at a median of eight years reveals that 78 patients or 73.6 per cent have good, 14 or 13.2 per cent have fair and 14 or 13.2 per cent have poor results. All 14 patients with poor results required reoperation, and the findings showed that the two most common causes of recurrent symptoms are the reformation of stones, despite a patent choledochojejunostomy and the stricturization of the choledochojejunostomy. When performed with the proper indications, choledochojejunostomy is a safe and effective procedure for managing patients with primary cholangitis.

Survival after surgery for advanced carcinoma of the stomach other than the cardia

The survival of 103 patients operated on for advanced carcinoma of the stomach other than the cardia was assessed. The median duration of survival for patients subjected to palliative partial gastrectomy, total gastrectomy, gastrojejunostomy, and biopsy only was 24, 22, 11, and 10 weeks, respectively. All of these patients had definite residual tumor. In the 27 patients with preoperative signs of incurable tumor, the high operative mortality rate (19 percent), the low rate of resectability (26 percent), and the short duration of survival in the patients who had resection (median 11 weeks) combined lead to the conclusion that exploration for the possibility of resection is not worthwhile.