Emergency abdominal procedures in patients above 70

The tremendous increase of emergency abdominal operations in elderly adults is due to the growing geriatric population, many with abdominal pathology. There also seems to be a greater willingness of the surgeon to operate on these patients. This report deals with 200 consecutive abdominal emergency operations in patients above age 70. During a period of 8 years, 472 operations in this age group were performed; there was a total of 871 emergency operations in all ages. The number of men was higher than women. The commonest cause of surgery in this group was biliary disease, followed by intestinal obstruction. Appendicitis was responsible for only 15% of the geriatric emergencies. The results suggest that early surgery with definitive procedures offers the best chance of success.

Sonographic monitoring to guide the performance of postabortal uterine curettage

This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation (for instance, retroversion) makes curette insertion difficult.

Acquired immunodeficiency syndrome in the United States: an analysis of cases outside high-incidence groups

From 1 June 1981 through 31 January 1984, 201 cases of the acquired immunodeficiency syndrome were reported involving persons who could not be classified into a group identified to be at increased risk for this syndrome. Thirty-five had received transfusions of single-donor blood components in the 5 years preceding diagnosis of the syndrome and 30 were sexual partners of persons belonging to a high-risk group. Information was incomplete for most remaining patients, but because many of these patients were demographically similar to populations recognized to be at increased risk for the syndrome, previously identified risk factors may have been present but not reported for some of them. Additionally, a few persons who met the case definition for the syndrome probably had other reasons for their opportunistic disease and did not have the acquired immunodeficiency syndrome. The slow emergence of the acquired immunodeficiency syndrome in new populations is consistent with transmission mediated through sexual contact or parenteral exposure to blood.

Systemic prophylactic antibiotics in elective biliary surgery

We tested the effectiveness of prophylactic antibiotics in elective cholecystectomy in 105 patients in a single-blind, controlled randomized trial. Fifty-six patients received prophylactic antibiotics and 49 patients entered the control group. Of the patients who received prophylactic antibiotics, 3.6% had wound infections, v24.5% in the control group. The rate of wound infection in patients with positive bile cultures, diabetes, appendectomies, and choledochotomies was 24.4%, v 3.4% in the group who had cholecystectomies only, with negative bile cultures and no diabetes. We concluded that prophylactic antibiotics are effective in patients with high-risk factors such as diabetes mellitus, exploration of the choledochus, and appendectomy, and in patients with positive bile cultures.

Statistical value of various clinical parameters in predicting the presence of choledochal stones

Persistent choledochal stones, as well as negative choledochal explorations, lead to increased morbidity and expense in operations upon the biliary tract. In an attempt to establish more precise criteria for the presence of CBD stones, 1,000 consecutive cholecystectomies were studied and computer analyzed. Precise determination of the choledochal diameter and preoperative bilirubin levels permit a quite accurate estimate of the probable presence of a choledochal stone.

Unexplained immunodeficiency in children. A surveillance report

From Oct 1, 1982, to Oct 1, 1983, the Centers for Disease Control (CDC) received reports of 35 children whose illness met the CDC definition of acquired immune deficiency syndrome (AIDS). All of the children had serious opportunistic infections without a known underlying illness to explain susceptibility to the infections. The 35 children were residents of ten different states; cases clustered in five major metropolitan areas. Three of the children had a parent with AIDS, and one child who had been previously reported had received a blood transfusion from a person in whom AIDS later developed. Most of the children had at least one parent in a population group in which adult AIDS cases have occurred. Many of the children had histories of prodromal symptoms, including pneumonitis, lymphadenopathy, hepatomegaly, and oral thrush. The mean age at onset of illness was 5 months, and the mean age at diagnosis was 12 months. To determine whether opportunistic infection in children without underlying immunodeficiency was truly a new phenomenon, a review of requests to the CDC for the drug pentamidine isethionate was undertaken. This revealed an apparent increase from 1979 to 1983 in Pneumocystis carinii pneumonia in children without known underlying immunodeficiency.

Ruptured anastomotic pseudoaneurysms after prosthetic vascular graft bypass procedures

Pseudoaneurysms of prosthetic vascular grafts are a well-recognized phenomenon. In the past year we treated four patients with ruptured pseudoaneurysms, each of whom originally underwent surgery after March 1981. The main etiological factors were infection and mismatching between the physical characteristics of the prosthetic graft and the host artery. Once this diagnosis is suspected, pseudoaneurysms should be treated as an emergency. They should be resected, a new extraanatomical bypass constructed, and the wound left open.

Duodenal diverticula occurring in a family--chance or inheritance?

The incidence, aetiology and possible inheritance of duodenal diverticula remain controversial. These aspects are discussed through the presentation of a family, in which duodenal diverticula occurred in a man and his two sons. To the best of our knowledge, this is the first such family documented in the medical literature. This familial occurrence may be attributed solely to the high incidence of duodenal diverticula in the general population (set by various authors at up to 14.2%), and, therefore, of no hereditary significance at all. We believe a screening study of the families of individuals with proven duodenal diverticula is most desirable, for it could shed light upon the controversial questions of incidence, aetiology, and inheritance patterns of duodenal diverticula.

The treatment of primary hyperparathyroidism during pregnancy

Data on the management of primary hyperparathyroidism during pregnancy are sparse and relatively few parathyroidectomies have been performed during pregnancy. Provided the diagnosis can be established with reasonable certainty, removal of a parathyroid adenoma should be undertaken during the second or at the beginning of the third trimester. Parathyroidectomy in the hands of a surgeon familiar with this operation carries few risks. The complication rate of untreated cases may reach 80 per cent and include spontaneous abortion, fetal death and neonatal tetany. We present two cases of pregnant women who underwent successful parathyroidectomy during the course of gestation.

Selective antibiotic prophylaxis in biliary surgery

Wound infections and septic complications are among the most frequent complications of biliary surgery. Such complications frequently occur in patients with infected bile. The presence of infected bile is predictable and can be expected in patients defined as high-risk patients. Short-term perioperative antibiotic prophylaxis was shown to be effective on an unselective basis by several authors. In this study of 231 consecutive biliary procedures, antibiotic prophylaxis was used on a selective basis in high-risk patients only. The high-risk patients were 55% of the entire group. Perioperative prophylaxis was given for 24 hours using four gentamicin injections starting two hours prior to anesthesia. Selective prophylaxis was shown to be highly effective reducing the wound infection rate to 3.5% in this group, compared to 12.5% in a similar group without prophylaxis. The selective use of prophylaxis was shown to be highly cost-effective as compared to the group without prophylaxis as well as reported groups of unselective prophylaxis in biliary surgery.

Hemipelvectomy for liposarcoma: an unusual case and course

A patient with liposarcoma of the upper thigh and pelvis treated by hemipelvectomy is described. Preoperative treatment with radiotherapy and chemotherapy induced regression and necrosis of the growth. The treatment of this tumour is discussed as well as the possibility that the pre-operative therapy converted an inoperable tumour into an operable one.

Site-specific, simultaneous presentation of colonic carcinoma in identical twins

The development of identically sited carcinoma of the colon in identical twins is described. A simultaneous presentation occurred. The case is discussed in the context of the cancer family syndrome.

One-stage subtotal colectomy with anastomosis for obstructing carcinoma of the left colon

Fourteen cases of severe obstructing carcinoma of the left colon were treated by emergency subtotal colectomy and ileorectal or ileosigmoid anastomoses. There was one death after two months and a further two septic postoperative complications. Follow-up stretched from two to 39 months (an average 13.7 months). One patient died of a myocardial infarction after 11 months and another of liver metastases after 21 months. Two patients were lost to follow-up at 12 and 25 months, and nine patients remain alive and well, free of disease. The last nine cases were consecutive, and two additional patients with obstruction had only colostomy performed due to their poor conditions. A staged approach to treatment reduces long-term survival as well as inducing a high cumulative mortality and morbidity rate. Colostomy also reduces the quality of life for the elderly patient. Results of this form of treatment are surprisingly good, and it is advocated as the treatment of choice for the vast majority of patients.

The sequential pneumatic compression device in surgery for lymphedema of the limbs

A modified technique for operations for lymphedema of the limbs is presented and illustrated in three cases. The technique consists of using the Lympha-Press, a new sequential pneumatic compression apparatus, which was used before operation for reduction of lymphedema, facilitating the surgical procedure, during operation to enlarge the lymphatic vessels, making creation of the lymphatico-venous anastomosis easier, and after operation to avoid early occlusion of the anastomosis, serous accumulation, pain, wound infection and ugly scars.

Surgical treatment of primary hyperparathyroidism in the elderly patient

The treatment of 11 elderly patients with primary hyperparathyroidism is described. All the patients underwent exploration of the neck and removal of a parathyroid adenoma, and the operation was well tolerated. After surgery, serum Ca concentrations returned to normal. The commonest symptoms in these elderly patients before operation included extreme fatigue, muscle weakness, mental disturbances, personality changes, severe depression, psychosomatic retardation and mild-to-severe dementia; all improved dramatically.

Laparoscopy in the prevention of unnecessary appendicectomies: a prospective study

More than one-third of all appendicectomies are unnecessary. A study was directed towards reducing the misdiagnosis of appendicitis, thus preventing needless operations. Thirty-six women in the fertile age group and with a diagnosis of appendicitis were subjected to laparoscopy before surgery. All women had undergone a gynaecological examination to rule out disease of the female genitalia. As a result of the laparoscopy, surgery was cancelled in one-third of the cases, which were found to have acute gynaecological disease not requiring surgery.

Haemorrhoids: a doctor's dilemma

The different forms of treatment for haemorrhoids are described. These include conservative therapy, elastic band ligation, sclerotherapy, cryosurgery, anal dilatation, lateral sphincterotomy and formal surgery. Controlled trials comparing these methods of treatment indicate that surgery should be rarely performed. Of the remaining methods available, elastic band ligation or anal dilatation are recommended.

A new sequential pneumatic device for the prevention of deep vein thrombosis

A new sequential pneumatic instrument for the prevention of deep vein thrombosis (DVT), the Lympha Press, was investigated in neurosurgical patients. In the control group, 50% of patients developed DVT and in the treated group only 4.3% were affected. These results demonstrate the highly beneficial effect of this method of preventing DVT during and after surgery, especially when the use of other preventive methods is precluded.

'Malignant' macroscopic appearance of an inflammatory testicular lesion--a reminder for surgeons

Inflammatory changes in the tunica vaginalis testis may assume a misleading appearance which is highly suggestive of malignancy. Obviously, histological examination is crucial for establishing the corrent diagnosis. This phenomenon has been described in texts dealing specifically with testicular pathology, but is not emphasized in standard text books of urology, surgery or pathology. An illustrative case serves as the basis for discussing this entity, for the purpose of familiarizing it to surgeons, urologists and pathologists who are yet unaware of it.

Computed tomographic diagnosis of abdominal aortic aneurysm

Diagnosis of abdominal aortic aneurysms has been facilitated by the use of computed tomography (CT). This is illustrated by four cases, presented here, two of which were diagnosed by angiography and CT, and two having been operated upon on the basis of CT diagnosis alone. We feel that CT can replace angiographic studies by supplying the surgeon with all the pre-operative details needed. CT is more accurate than angiography, since the latter may underestimate the true diameter of aneurysms, or can even give false-negative results. With CT it is possible to detect signs of rupture or pre-rupture states of aneurysms that have not been suspected on angiographic or clinical grounds.