Intracystic papillary carcinoma of the breast

The occurrence of a breast carcinoma within a breast cyst is rare. These tumors are usually papillary adenocarcinomas arising from the wall of macrocysts of the breast. The clinicopathologic course in seven patients is reviewed. Modified radical mastectomy has provided satisfactory surgical management and is the recommended therapy.

Persistent hepatic hydrothorax after peritoneojugular shunt

Hepatic hydrothorax causes serious respiratory morbidity and is difficult to cure. Evacuation of ascites via peritoneojugular shunt should eliminate the source of the pleural fluid. However, this technique is not infallible. Obtaining pleurodesis by chemical or mechanical means may be necessary. Two cases were successfully treated with pleurectomy and tube thoracostomy, respectively.

Remedial operation for alkaline reflux gastritis and associated postgastrectomy syndromes

Alkaline reflux gastritis is being recognized with increasing frequency after operations that ablate the pylorus as a true sphincter. Medical management is generally ineffective for patients with severe reflux gastritis, but Roux-en-Y diversion of bile and of pancreatic and intestinal secretions provides gratifying results. We studied 100 patients who underwent remedial operation. Roux-en-Y gastrojejunostomy or Tanner's vs Roux-19 procedure gave good to excellent results in most of the 73 patients followed up for from one to six years. Reflux gastritis can occur in association with other postgastrectomy disorders. Fifteen patients with reflux gastritis also had severe dumping or postvagotomy diarrhea. Good to excellent results were obtained in most of these patients by Roux-en-Y diversion combined with an antiperistaltic jejunal segment.

Surgical therapy for diffuse granulomatous colitis

Of 16 patients with diffuse granulomatous colitis treated surgically, nine initially had total proctocolectomy and seven had abdominal colectomy with ileorectal anastomosis. There was no mortality in either group, and there was no anastomotic leak from ileorectal anastomosis. Disease recurred in 22% of patients after proctocolectomy and in 57% of patients with ileorectal anastomosis. A review of the literature on the surgical management of Crohn's colitis reveals a recurrence rate of 3% to 46% (average 20%) after proctocolectomy and a recurrence rate of 6.6% to 75% (average 46%) after ileorectal anastomosis. Colectomy with ileorectal anastomosis is the operation of choice for Crohn's colitis where feasible.

Coarctation of the abdominal aorta: pathophysiologic and therapeutic considerations

Coarctation of the aorta is the most frequent cause of hypertension in infants and children. Ninety-eight per cent of coarctations occur in the descending aorta near the ligamentum arteriosus. Five patients are presented with the relatively rare problem of coarctation of the abdominal aorta. The anatomic,pathophysiologic and clinical aspects in these patients cover a range of variants. Clinical and laboratory studies of the genesis of hypertension in coarctation are reviewed in chronologic outline. An experimental model of abdominal coarctation with hypertensive and renin-angiotensin II correlations suggests but does not prove a renal mechanism for the hypertension. The same conclusion must be drawn from study of the clinical cases.

Results of elective duodenal ulcer surgery in women: comparison of truncal vagotomy and antrectomy, gastric selective vagotomy and pyloroplasty, proximal gastric vagotomy

This study provides a retrospective comparative analysis of results in 90 women patients who underwent three different elective operations for intractable duodenal ulcer disease. Group I (30 patients) underwent truncal vagotomy/antrectomy (TV + A); group II (30 patients) gastric selective vagotomy/pyloroplasty (GSV + P); and Group III proximal gastric vagotomy (PGV). There were no operative deaths among the 90 patients. No patient after TV + A has developed a recurrent ulcer. Two recurrent ulcers developed after GSV + P, and one gastric ulcer occurred after PGV. Dumping, diarrhea, and reflux gastritis were lower after PGV than with TV + A and GSV + P. Follow-up studies have been from six months to ten years. The clinical results among the three groups of women patients compare favorably with results obtained in a recent prospective randomized study using the identical operative procedures in three groups of men patients operated upon for intractability. There was no statistically significant difference between women and men after similar operative procedures, but the postgastrectomy sequelae were less after PGV in both women and men patients.

Proximal gastric vagotomy without drainage

Proximal gastric vagotomy without drainage is widely accepted in Great Britain and Europe but in the United States has been done mainly in university centers. The operation denervates the acid-secreting parietal cell mass of the stomach, preserving vagal innervation to the gastric antrum and extragastric abdominal viscera. The procedure is safe and is associated with few underisrable side effects. Long-term studies are needed to determine the rate of recurrence of duodenal ulcer in patients treated surgically in this way.

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.

Current management of carcinoma of the anus and perianus

Malignant lesions of the anus and perianus account for 2.4% of malignant cancers of the colon, rectum, and anus. Based on our experience with 56 patients as well as a review of the recent literature, the following recommendations are made: Bowen's disease, Paget's extramammary disease, basal cell, and perianal epidermoid carcinomas arise in the perianus, rarely metastasize, and may be managed by wide local excision. Cloacogenic transitional cell (basaloid squamous carcinoma) and the more common epidermoid anal canal tumors require abdominoperineal resection with wide perineal excision. Therapeutic groin dissection is indicated if the inguinal nodes are or become the site of metastases, but prophylactic groin dissection is not indicated. The five-year survival for epidermoid carcinoma of anus treated by abdominoperineal resection ranges from 40 to 58%. Improvement in survival rate will require early recognition by the patient and early diagnosis and treatment by the physician. Delay in diagnosis occurs because cancer is not considered frequently enough as a possible cause for the patient's symptoms.

Perforated duodenal ulcer managed by proximal gastric vagotomy and suture plication

Twenty-one patients with acute perforated duodenal ulcer were managed by proximal gastric vagotomy without drainage and simple closure of the perforation reinforced with an omental patch. There was no operative mortality. No recurrent duodenal ulcers have developed. All patients have achieved a good to excellent clinical result from their operation. Dumping, diarrhea, and reflux gastritis have not developed. Follow-up studies extend to three and one-half years. Proximal gastric vagotomy with simple closure is safe, effective management for the patient with an acute perforated duodenal ulcer. This operation is a satisfactory compromise between simple closure alone which does not protect against recurrent ulcer and definitive ulcer operations which may subject patients who would not have further ulcer symptoms to the unnecessary risk of increased mortality, morbidity, and postgastrectomy disorders.

Transabdominal proctopexy (Ripstein procedure) for massive rectal prolapse

Transabdominal proctopexy (Ripstein procedure) for correction of massive rectal prolapse has greatly simplified the complicated problem of managing procidentia. The operation secures the rectum into the hollow of the sacrum by a Teflon sling. This restores and maintains the normal posterior curve of the rectum and prevents intussusception with subsequent prolapse. There has been no recurrence of rectal prolapse and no mortality in 36 patients, half of whom have been followed from five to ten years. Posterior proctopexy is a simple, safe and effective operation to repair massive rectal prolapse.

A prospective study to determine the efficacy of antibiotics in acute pancreatitis

This study is a double "blind" prospective evaluation of the efficacy of antibiotics (Ampicillin) in the treatment of acute alcohol-induced and idiopathic pancreatitis. Fifty-eight patients with acute pancreatitis were randomly divided into antibiotic and non-antibiotic treatment groups. The two groups were comparable clinically at the onset of the study and other than for antibiotics received identical therapy. The patients without antibiotics had a clinical course equal or slightly more favorable than the antibiotic treatment group in all parameters examined. These data indicate that prophylactic use of Ampicillin is not indicated in patients with routine acute alcohol-induced or idiopathic pancreatitis. The role of prophylactic antibiotics in patients with pancreatitis related to biliary calculi and those with more severe varieties of acute hemorrhagic or necrotizing pancreatitis remains to be more clearly defined.

Adenocarcinoma of the colon and rectum in young adults

A retrospective analysis was made in 47 young adults (20 to 40 years of age) with adenocarcinoma of the colon and rectum. Rectal bleeding was the most frequent presenting symptom. Tumor grade had no correlation with survivial. Smaller tumors were associated with better prognosis. Depth of invasion was a most important prognostic factor. There was no operative mortality. The five-year survival rate in these young adults compares favourably with the overall survival statistics for colorectal carcinoma.

Pharyngeal pseudodiverticulum in an adult

Posterior perforation of the cervical portion of the esophagus may present deceptive clinical and roentgenographic pictures. In the neonate, the clinical picture resembles that of esophageal atresia; in the adult, the roentgenographic appearance may resemble Zenker diverticulum. In either instance, treatment should be no different from that employed for more commonplace esophageal perforations, namely, prompt, aggressive surgical intervention.

Surgical treatment of popliteal artery injuries

Twenty-seven patients with injury to the popliteal artery and associated structures were operated on during the past 15 years. There was no operative or hospital deaths. The limb salvage rate was 56%; the amputation rate was 44%. Those patients with penetrating injuries were found to have a much better salvage rate (85%) than those with blunt trauma (29%). Preoperative arteriography and immediate repair of the popliteal artery by either end-to-end anastomosis or a vein graft is advocated for these patients. Popliteal vein injuries should be repaired when possible by lateral suture or end-to-end anastomosis. Fasciotomy is advocated on a selected basis.

Management of pancreatic ascites

Two patients with persistent pancreatic ascites are presented. Both were managed successfully by internal drainage. A trial of nonoperative treatment with nasogastric intubation and intravenous hyperalimentation is advocated for patients with pancreatic ascites. Patients who fail to improve usually have a pancreatic duct disruption and should have internal drainage operation and/or distal pancreatic resection.

Evaluation of three methods for managing penetrating colon injuries

Although primary intraperitoneal repair of selected penetrating colon injuries is a feasible method of treatment, injudicious use of this method, especially in wounds of the right colon, led to increased morbidity, in the group of 90 patients studied. Colostomy may be avoided in selected patients by using primary repair with exteriorization of the injured segment. The technique described is a reliable compromise which protects the patient from the danger of intraperitoneal suture line disruption and possibly avoids the inconvenience and morbidity of formal colostomy. Since exteriorized primary repair has been a safe, effective method of managing gunshot wounds of the colon in selected patients, we advocate its increased use.

Conservative surgical treatment of reflux esophagitis and esophageal stricture

During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intra-operative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.

Acute perforated duodenal ulcer. An evaluation of surgical management

The surgical management of acute perforated duodenal ulcer has been evaluated in 360 patients. Simple closure was done in 254 patients, with a mortality of 6.7%, a morbidity of 21%, and an average hospital stay of 11.9 days. In 106 patients (29%) who underwent definitive operation for treatment of duodenal ulcer disease at time of perforation, the mortality was 2.8%, the morbidity was 15%, and the average hospital stay was nine days. Follow-up studies of simple closure in patients with no previous ulcer symptoms showed that 72% of the patients remained asymptomatic; in patients with previous ulcer symptoms, only 23% were asymptomatic. Definitive operation for acute perforation is indicated in good-risk patients who have a history of ulcers. Parietal cell vagotomy and simple closure was used in four patients with excellent early results.

Esophageal perforation: an increasing challenge

Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.

Surgical management of reflux gastritis

Reflux gastritis is now recognized with increasing frequency as a complication following operations on the stomach which either remove, alter, or bypass the pyloric phincter mechanism. The entity may occasionally occur as a result of sphincter dysfunction in the patient who has not undergone prior gastric surgery. The diagnosis is made on the basis of symptoms (postprandial pain, bilious vomiting and weight loss), gastroscopic examination with biopsy and persistent hypochlorhydria. Remedial operation for correction of reflux is indicated in the presence of persistent symptoms when conservative measures fail. Only operative procedures which divert duodenal contents from the stomach or gastric remnant are effective. Both the isoperistaltic jejunal segment (Henley loop) and the Roux-en-Y diversion have been effective as remedial operations for reflux gastritis and merit greater awareness by gastroenterologists and surgeons. Our choice is the Roux-en-Y because of its technical simplicity and lower morbidity rate.