Dieulafoy's lesion

We have presented six instances of Dieulafoy's lesion, two of which were diagnosed endoscopically preoperatively. Endoscopic electrocoagulation was used in two instances, one with success, and this may have a place in the treatment of these lesions. Oversewing alone of the lesion seems to be sufficient surgical treatment, if nonoperative measures, such as selective arterial embolization or endoscopic electrocoagulation fail or are unavailable.

Spontaneous rupture of the stomach: a rare complication of Nissen's fundoplication

Spontaneous rupture of the stomach may occur in cases of abnormal distension and reduced emptying capacity, either by normal peristalsis or by vomiting, of the stomach. We present a case of spontaneous rupture of the stomach in which the dilatation was due to apple fermentation and gas formation in the stomach. Peristalsis was inadequate for stomach emptying due to impaction of apple skins in the duodenum. The inability to vomit was due to a Nissen fundoplication performed 18 months earlier.

Appendix mass: conservative management without interval appendectomy

Forty-nine patients had conservative treatment of an appendix mass without interval appendectomy. Five were lost to follow-up within 6 months, and 44 patients were followed for between 6 months and 22 years. In nine patients (20 percent) recurrent appendicitis developed, and six (14 percent) suffered chronic pain not thought to be due to appendicitis. Of the recurrences, 66 percent occurred within 2 years of the initial attack. Barium examination of the cecum was successful in diagnosing two of three additional patients in whom a right iliac fossa mass was not due to appendicitis. The morbidity and expense of routine interval appendectomy was thus eliminated in 80 percent of the patients.

Prospective controlled vagotomy trial for duodenal ulcer: results after five years

A prospective, randomized, controlled trial was performed to study truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV) and parietal cell vagotomy (PCV) as elective treatment for duodenal ulcer. Five years postoperatively, 233 patients were available for study: 73 TV, 81 SV and 79 PCV. The ulcer recurrence rates were 13.6, 19.8 and 30.4 per cent respectively. The incidence of severe dumping was 4.9, 10.9 and 1.9 per cent; of severe diarrhoea 4.9, 6.3 and 1.9 per cent; of severe pain/dyspepsia 3.3, 6.3 and 3.8 per cent and of severe nausea/vomiting 0, 1.6 and 0 per cent respectively. Women suffered more postvagotomy symptoms than men. After treatment of recurrences and postvagotomy symptoms, more patients after PCV achieved excellent results than after TV and SV, as recurrences were easier to treat than severe postvagotomy symptoms. The only factor found contributing to the high ulcer recurrence following PCV was the large number of surgical trainees operating in the trial.

Quantitative analysis of reflection spectra of the surface of the guinea pig brain

For a nearly constant light scattering coefficient a method is presented which allows the quantitative analysis of reflection spectra of the brain using a nonlinear multicomponent analysis ( NLMCA ).

Tube cecostomy and staged resection for obstructing carcinoma of the left colon

Over a 17-year period, all patients presenting with acute obstruction of the left colon due to carcinoma were treated by emergency tube cecostomy. There were 57 patients aged between 35 and 93 years. After the decompressive procedure, eight died, 34 had complications, and eight were left with permanent cecostomies. Forty-one underwent secondary procedures of which 35 had resections. Seven patients died postoperatively and 15 had complications. Of the 34 survivors, in 23 the cecostomy closed spontaneously, and 11 had operative cecostomy closure. Of the latter, four died postoperatively, and nine had complications. Thus, 30 survived the entire treatment program. Reasons for the high morbidity and mortality are discussed. Comparison is made with other forms of treatment in the literature. A treatment program is suggested, using tube cecostomy for poor-risk patients and primary resection without anastomosis for patients in better condition.

Unsuccessful experience with closure of Jaboulay gastroduodenostomies in the treatment of post-vagotomy dumping and diarrhea

Eight patients after vagotomy and Jaboulay gastroduodenostomy had their gastroduodenostomy closed to treat dumping and diarrhea. Eight gastroduodenostomies were closed once and four were closed twice, a total of 12 procedures. Of these, ten were "simple" closures (direct suture of the opening into the duodenum via a gastrotomy) and two were "formal" (gastroduodenostomy formally dismantled). Among those gastroduodenostomies closed "simply," the closure remained intact for 2 to 9 months, relieving the patients' symptoms. Thereafter, the suture line broke down, leaving the patient with a patent gastroduodenostomy and recurrent symptoms. The two patients closed "formally" developed severe complications: one patient's stomach failed to empty permanently after the procedure and the second developed a duodenal leak. In addition to these major complications, another four of the 12 procedures were followed by transient gastric retention, and five of the 12 procedures were accompanied by minor pulmonary and wound complications. A satisfactory result was not achieved in any patient.

[CT-guided celiac plexus block with ventral approach]

A modified procedure for infiltrating the coeliac plexus for the treatment of chronic pain syndromes is described. The injection of the analgesic is made through a fine needle introduced via a transabdominal approach under CT guidance. The advantages of this technique, compared with the dorsal approach, are a more accurate placement of the solution and the ability to carry out this procedure in very sick patients. No complications have been observed.

Comparative studies on thrombin inhibitors in experimental microthrombosis

The influence of thrombin inhibitors, which differ both in their chemical structure and type of inhibition on thrombin-induced microthrombosis was studied in rat lungs. The antithrombotically effective doses and blood levels of the compounds correlated with their kinetic constants for inhibition of thrombin. In preventing microthrombosis, some of the synthetic inhibitors tested surpassed the effectiveness of heparin and approached that of the naturally occurring inhibitor hirudin.

Rectal temperature in the diagnosis of acute lower abdominal pain

The accurate diagnosis of acute lower abdominal pain continues to be a problem. In Israel, a diagnostic sign often sought as indicating pelvic peritonitis is a rectal temperature of greater than 1.0 C higher than the simultaneous oral temperature. We established that in each of the 20 emergency rooms surveyed both oral and rectal temperatures are measured as part of the admission procedure for patients with acute lower abdominal pain. The charts of three groups of 100 patients with acute lower abdominal pain were studied retrospectively. A rectal temperature of greater than 1.0 C higher than the oral was found in about 10% of each group. Both oral and rectal temperatures were raised in 56, 69 and 37% of each group, respectively. The rectal temperature alone was elevated in 8.5% of patients with appendicitis or pelvic inflammatory disease (PID), as well as in 6% of patients with undiagnosed abdominal pain. Oral temperatures alone were elevated in 4.5% of patients with acute appendicitis or PID and also in 13% of patients with undiagnosed abdominal pain. These differences were not significant. We conclude that the common Israeli practice of measuring both rectal and oral temperatures in patients with acute lower abdominal pain gives no more information than the measurement of either one.

Antrectomy for recurrent ulcer after parietal cell vagotomy

The results of antrectomy for recurrent ulcer after parietal cell vagotomy are reviewed. Eighteen patients underwent precise antrectomy between 6 months and 7 years after their primary operation. Fourteen patients were reconstructed with a gastroduodenostomy and 4 with a gastrojejunostomy. Eighteen patients were available for follow-up of between 18 months and 10 years. One patient (6.25 per cent) developed a recurrent ulcer 1 year after antrectomy. There was no operative mortality. Six patients (33 per cent) had minor complications in the immediate postoperative period, and one (5.5 per cent) had a major complication. According to Visick grading, 75 per cent had good or excellent results and 25 per cent poor results. Antrectomy following parietal cell vagotomy can be achieved with a low operative mortality, a low ulcer recurrence rate and a satisfactorily low incidence of post-gastrectomy problems.