Rupture of the liver and right hemidiaphragm presenting as right hemothorax

A young man hit by a car while riding his motorcycle presented with reversible hypotension, a compression fracture of C6, fractures of the left femur and of ribs 9-12 on the right, and right hemothorax. A falsely negative peritoneal lavage delayed laparotomy, which, when done, demonstrated two right diaphragmatic rents with bleeding into the right chest from a severe liver injury. Presentation of this case demonstrates that while peritoneal lavage is an excellent way to exclude intraperitoneal hemorrhage following blunt abdominal trauma, false-negative results may occur in the setting of hemorrhage with diaphragmatic rupture.

Causes of the failed cervical exploration for primary hyperparathyroidism

Over a period of 42 years, 581 patients with presumed hyperparathyroidism underwent an initial cervical exploration. Abnormal parathyroid glands were removed from 495 patients (85.2%). There was a greater probability of operative success in women, patients over 50 years of age, and patients with hypercalcemia, hypertension, or nonspecific abdominal pain. There was no association of operative outcome with some of the "classic" manifestations of hyperparathyroidism--peptic ulcer disease, neuropsychiatric symptoms, pancreatitis, bone disease, or urolithiasis. The probability of surgical success improved with time, increasing from 56 per cent in the 1950s to 97 per cent in the present decade. This improvement appears to be related to greater operative experience, since all four parathyroid glands were more likely to be found with increased experience, and there was a strong correlation between finding four parathyroids and achieving persistent normocalcemia. The most common causes of operative failure were inaccurate calcium assays (the patient was not truly hypercalcemic), an inappropriate diagnosis ("normocalcemic hyperparathyroidism"), and surgical inexperience. These three factors accounted for at least three fourths of all negative explorations. More accurate diagnostic studies, and careful exploration by an experienced surgeon should maximize the probability of a successful operation for primary hyperparathyroidism.

The significance of nuclear diameter in the biologic behavior of thyroid carcinomas: a retrospective study of 127 cases

The relationship between nuclear diameter and biologic behavior was studied in 127 cases of thyroid carcinoma. Using a sonic digitizer coupled to a minicomputer, nuclear diameters of 200 randomly selected cancer cells from each case (hematoxylineosin-stained paraffin sections) projected at X 400 magnification were traced and averaged. A total of 25,400 measurements were made. The nuclear diameters varied from 4.7 to 13.1 micron. By analysis of variance, the nuclear diameters were significantly different (p = 0.0007) among the four types of thyroid cancers, being largest in the undifferentiated cancers (8.7 +/- 0.8 micron) and smallest in the medullary cancers (6.6 +/- 0.1 micron). Nuclear diameter was also significantly correlated with degree of tumor differentiation (p = 0.002), maximal tumor diameter (p = 0.03), mitotic rate (p = 0.002), and 5-year survival (p less than 0.05) for all types of tumors. The correlation between nuclear diameter and disease stage was significant only for undifferentiated cancers (p = 0.04). No significant correlations were seen between nuclear diameter and duration of disease, sex, or age of the patient.

Occult lesions of the breast

The biopsy of 148 clinically occult lesions of the breast found at mammographic examination yielded 21 instances of carcinoma (14.2 per cent). Five malignant lesions were lobular or in situ carcinoma, 16 were infiltrating ductal carcinomas and 11 were minimal carcinoma of the breast. Carcinomas found by mammographic examination were smaller and less likely to be associated with metastases to the axillary nodes than carcinomas of the breast diagnosed by palpation during the same time period. Biopsy of the breast was performed by several methods: 1, quandrantectomy with the patient under general anesthesia (the results of 29 biopsies yielded five instances of carcinoma, 17.2 per cent); 2, generous excision of breast tissue with the patient under general anesthesia and the lesion being localized by geometric co-ordinates based upon the mammograms (the results of 35 excisions yielded four instances of carcinoma, 11.4 per cent), and 3, mammogram-directed needle localization (the results of 84 procedures yielded 12 instances of carcinoma, 14.3 per cent). Because needle-directed biopsy causes less distortion of the breast, we prefer it to other biopsy techniques in the evaluation of occult lesions of the breast.

Inhibition of bacterial adhesion by antibacterial surface pretreatment of vascular prostheses

Polytetrafluoroethylene grafts were pretreated with oxacillin, with the cationic detergent benzalkonium, or with both substances, either at room temperature or at 90 degrees C. Inhibition zones ranging from 6.4 to 15.2 mm formed around all grafts incubated on Staphylococcus aureus-streaked agar plates except control disks and those treated with oxacillin. Treated grafts were exposed in vitro to S. aureus in high concentration, followed by distilled water lavage. The graft surface was then stained with ruthenium red to stain polysaccharides and studied by scanning and transmission electron microscopy. Colonization of the graft surface by adhesive bacteria was demonstrated in all cases, although it was less prevalent on grafts pretreated with benzalkonium bound at 90 degrees C.

Is serum parathormone assay necessary in evaluating primary hyperparathyroidism?

Serum parathormone (PTH) values are believed useful in diagnosing hyperparathyroidism and in evaluating patients before parathyroid operation. From 1975 through 1983, 328 adults patients with persistent hypercalcemia and normal renal function underwent cervical exploration for presumed primary hyperparathyroidism. Preoperative serum PTH values were obtained in 137 patients. Eight had negative explorations (5.8%): serum PTH values were normal in three patients and elevated in five. Serum PTH values were normal or low in 31 of the other 129 patients (false-negative rate = 24%). Of 191 patients for whom neither serum PTH nor nephrogenic cyclic adenosine-3',5'-monophosphate values did not were obtained preoperatively serum PTH values did not reduce the incidence of negative cervical explorations and, when obtained, they were misleading in one fourth of patients who benefitted from parathyroid exploration.

The significance of mitotic rate: a retrospective study of 127 thyroid carcinomas

The association between mitotic rate and biologic behavior was studied in 127 cases of thyroid cancer. Based on the observation of 12,700 high-power fields (HPF), the mitotic rate varied from 0 to 316 (33.3 +/- 4.9) mitoses/100 HPF. Mitotic rate differed among the four types of thyroid cancers and correlated inversely with the differentiation of the tumors, being highest (156.8 +/- 32.9) in the undifferentiated tumors and lowest (17.3 +/- 2.4) in the papillary tumors. By analysis of variance (AOVA), the relations between mitotic rate and the sex or age of the patient, maximal diameter of the tumor, and vascular or capsular invasion were assessed, but significant relations were not found (r2 = 44.2 per cent). Follow-up observation, possible in 74 patients, showed mitotic rate to be significantly related to the survival period (Student's t-test; P values ranging from 0.02 to 0.05). The patients who were alive five and ten years after surgery had had lower mitotic rates than those who had died during the same follow-up period. The correlation of low mitotic rate with a high degree of differentiation and low potential for invasion might, in part, explain the better surgical cure rates for papillary thyroid carcinoma than for other types of thyroid cancers.

Modified Thiersch operation for rectal prolapse. Technique and results

Rectal prolapse is best treated by intra-abdominal or perineal procedures that either resect the redundant rectosigmoid colon or fix the rectum within the pelvis. We have found the Thiersch procedure to be adequate treatment in patients who are high risk or who have only mild to moderate prolapse of the rectum. Over the past 20 years, we have treated 15 patients with a modified Thiersch procedure, using a knitted Dacron vascular graft to encircle the anus. One patient required a second Thiersch procedure after failure of a Ripstein procedure that followed failure of a Thiersch procedure done with wire. A second Thiersch procedure was required in two patients after suture breakage, and in one patient after removal of an infected graft. Two other patients had graft infections necessitating removal of the Dacron graft; one patient had a perianal infection that was treated without removing the graft. Continence was achieved in six of nine patients previously incontinent, and maintained in the six patients who had been continent before operation. Prolapse was corrected in 13 of the 15 patients. Although the Thiersch procedure is not applicable to all patients with rectal prolapse, it can be used successfully when performed properly.

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism

A retrospective review of patients treated for secondary hyperparathyroidism by total parathyroidectomy with parathyroid autotransplantation (tPTX) and subtotal parathyroidectomy (sPTX) is presented. Ten patients underwent tPTX, and 22 patients underwent sPTX between 1977 and 1982. Hypocalcemia and complications of its treatment were a problem in the tPTX patients. One patient in the tPTX group and no patients in the sPTX group have required reoperation for recurrence. Both procedures were highly successful in relieving symptoms of secondary hyperparathyroidism and in reversing renal osteodystrophy. The authors believe that sPTX is a proven, effective operation and the operative treatment of choice for secondary hyperparathyroidism.

Postmastectomy angiosarcoma

Six cases of postmastectomy angiosarcoma of the upper extremity have been treated at the North Carolina Baptist Hospital/Wake Forest University Medical Center over the past 25 years. Five patients had typical ductal carcinoma; one patient had mammary Paget's disease. Two patients, including the patient with Paget's disease, had bilateral mastectomies. The five patients with ductal carcinoma had received postoperative radiation therapy. The mean interval between mastectomy and the appearance of angiosarcoma was 17.5 years. Significant lymphedema of the upper extremity preceded the appearance of angiosarcoma in all six patients, and it appears important that special care be taken during mastectomy to preserve the integrity of the lymphatic system. The patient treated with interscapulothoracic amputation is alive at 2 years postamputation; the five patients whose angiosarcomas were treated with wide excision or radiotherapy died an average of 4.5 years later. Interscapulothoracic amputation is recommended as the initial treatment of postmastectomy angiosarcoma of the upper extremity.

Suture technique and wound-bursting strength

Despite advances in wound healing, fascial dehiscence continues to be a problem in celiotomy wounds. Experimental and clinical studies on suture material and on patient-related factors in wound disruption are abundant, but little attention has been given to mechanical factors in wound closure, although they may be of greater importance. A midline abdominal wound was made in 120 Harlan Sprague-Dawley rats, and the fascia was closed with Dacron in one of six ways: simple interrupted, interrupted figure-of-eight, and running, each tied loosely in one half of each group and tightly in the other half. One week later, the rats were reanesthetized and wound-bursting strength was measured. In general, the running suture technique resulted in the greatest wound-bursting pressures. A loosely tied figure-of-eight technique was nearly as good as a loosely tied running stitch, but tying figure-of-eight sutures tightly caused a significant decrease in wound-bursting pressure. The simple interrupted technique was unaffected by suture tension but was generally inferior to the running stitch in terms of wound-bursting strength. Histologic studies were performed, but most of the disparity in wound strength among the suture techniques apparently was due solely to mechanical factors. Closing midline abdominal fascial wounds with a running suture may be a superior method of closure in clean, incised wounds.

Abdominal wound closure. A comparison of polydioxanone, polypropylene, and Teflon-coated braided Dacron sutures

A midline abdominal wound was made in 135 Harlan Sprague-Dawley rats, and the fascia was then closed by the continuous suture technique with 4-0 absorbable monofilament polydioxanone sutures (n = 45 rats), 4-0 permanent monofilament polypropylene sutures (n = 45 rats), or 4-0 Teflon-coated braided Dacron sutures (n = 45 rats). At 1-, 2-, and 6-month intervals, wound-bursting pressures were determined in 15 animals from each group. At 1 month and at 6 months, there was no significant difference in wound-bursting strength among the three types of sutures. At 2 months, wounds closed with Teflon-coated braided Dacron were significantly stronger than wounds closed with the other types of sutures. In most of the braided Dacron suture animals, the fascia burst in areas other than the abdominal wound, indicating that the wound was stronger at that time than was the surrounding fascia. There is no advantage to that added strength, and braided Dacron sutures have been shown to cause greater tissue reaction than monofilament sutures. Therefore, except in patients with poor wound healing who are highly susceptible to dehiscence and in whom permanent low-tissue-reaction sutures may be beneficial, the authors recommend a running suture technique using absorbable monofilament suture, such as polydioxanone, for the routine closure of clean abdominal wounds.

Diaphragmatic rupture from blunt trauma

Records of 31 patients who sustained a ruptured diaphragm from blunt trauma form the basis for this report. There were 23 left-sided ruptures, one bilateral rupture, and seven right-sided ruptures. Viscus had herniated into the chest in 30 patients. Right-sided ruptures were associated with greater morbidity and mortality, mostly due to the more serious associated injuries. Chest roentgenograms were abnormal in all 31 patients; bowel could be seen in the chest in 11 patients. Pneumoperitoneum, upper gastrointestinal barium studies, and liver/spleen scans were all diagnostically helpful in selected patients. The correct diagnosis was made preoperatively in 25 of the 31 patients; one-third of all diagnoses were delayed. All exploratory laparotomies for blunt trauma should include careful inspection of the diaphragm, especially in the posterolateral region, and the area close to the esophageal hiatus to detect diaphragmatic rupture and prevent chronic herniations.

Normocalcemic hyperparathyroidism revisited

From 1957 through 1981, 550 cervical explorations for presumed primary hyperparathyroidism were performed in 536 patients at the North Carolina Baptist Hospital. Fifty-one of those patients who did not have persistent hypercalcemia are the basis of this report. Twenty-six patients with hypercalciuria and normal renal function had recurrent passage of calcium-containing renal stones, but never had documented hypercalcemia. Only five patients (19%) had positive findings at exploration: small, hyperplastic glands (n = 3); small adenomas (n = 2). Seventeen of the 23 patients for whom follow-up data were available continued to form and pass renal stones postoperatively, including three of the five patients with "pathologic" glands (follow-up range: 4 months to 21.3 years; mean--7 years, 9 months). Twenty-five patients (also with normal renal function) had chronic calcium nephrolithiasis, hypercalciuria, and isolated or occasional elevations of serum calcium ranging from 10.6 to 10.9 mg/dl. Thirteen of these patients had abnormal parathyroid glands: adenomas (n = 12); hyperplasia (n = 1). All but two of the 13 were cured of their nephrolithiasis, but all ten of the patients with no abnormal glands for whom follow-up data were available continued to pass renal stones (follow-up range--8 months to 18 years; mean--5 years, 7 months). Thus, our experience with treating "normocalcemic" hyperparathyroidism has been disappointing. Although a substantial number of patients with occasional mild hypercalcemia may benefit from cervical exploration, those patients are not, by definition, truly normocalcemic. Metabolic evaluation can separate hypercalciuric recurrent stone formers with autonomous secondary hyperparathyroidism from patients with suppressible secondary hyperparathyroidism, and can thus more accurately identify patients who may benefit from parathyroid exploration.

Perforated marginal ulcer after palliative gastrojejunostomy

We describe a patient in whom biliary bypass and gastrojejunostomy for palliation of carcinoma of the head of the pancreas led to the late development of a marginal ulcer, which perforated and may have hastened the patient's death.

Multiple primary malignant tumors (MPMT): study of 68 autopsy cases (1963-1980)

Review of 8428 autopsies (1870 for known cancer) showed that 68 patients had had multiple primary malignant tumors (MPMT). Those 68 cases represented 0.8 per cent of all autopsies done, 3.6 per cent of all cancer autopsies. Diagnosis of MPMT was made only at autopsy in 24 cases (35.3 per cent). Thirty-six patients were male, 32 female. Their average age was 64 +/- 2.3 years. Cancers were "synchronous" (diagnosed within a six-month period) in 15 patients, "metachronous" (diagnosed at greater than six-month intervals) in 49, and "combined" in four. Metastatic foci were seen in 53 patients. Fifty-nine patients had two primary malignant tumors (PMTs); seven had three PMTs; one had four PMTs; and one had five PMTs, for a total of 148 tumors. Over half (53.1 per cent) of the second PMTs occurred within five years of the first PMTs. First PMTs were most common in the hematopoietic system and the cervix; second PMTs were most common in the lungs and the hematopoietic system. Second PMTs were less well differentiated than index PMTs. Forty-four deaths had not been directly tumor-related. Nineteen patients with metachronous MPMT lived more than ten years. Of 23 patients with one pulmonary PMT, 22 died within two years. Concomitant findings of pulmonary artery embolism, gallstone(s), thyroid or prostatic hyperplasia, and benign tumor were common in these patients. It is hoped that accumulation of data from this and other series of MPMT will provide insight into the clinicopathologic characteristics, the causes, and the interrelationships of these lesions that constitute primarily a disease of the elderly.

Oxyphil cell adenoma and hyperparathyroidism

Although the oxyphil cells of the human parathyroid generally are not thought to be involved in the secretion of parathyroid hormone, there have been numerous reports in the literature describing functional oxyphil cell adenomas. We reviewed 453 consecutive parathyroid explorations in 446 patients over a 13-year period and identified 15 patients whose hyperparathyroidism had been caused by adenomas composed almost exclusively of oxyphil cells. All patients were relieved of their hypercalcemia postoperatively, and there have been no recurreness during a mean follow-up of 40 months (100% follow-up). Three patients have died, all without evidence of recurrent hyperparathyroidism at the time of death. Immunoperoxidase and ultrastructural studies confirm that oxyphil cells from these adenomas contain parathyroid hormone and suggest that they are capable of secretory activity. A review of the literature showed that functional oxyphil adenomas occur more frequently than is usually appreciated, although they are an uncommon cause of primary hyperparathyroidism.

Malignant fibrous histiocytoma of the mediastinum and lung: a report of three cases

One case of primary malignant fibrous histiocytoma of the lung and two cases of that tumor in the mediastinum are reported. Primary malignant fibrous histiocytoma is rare in those areas, appearing more commonly in deep fascia and skeletal muscles of the extremities and torso and in the retroperitoneum. Most of the tumors contain both fibroblast-like and histiocyte-like cells; some contain pleomorphic giant cells and inflammatory cells. They are often confused with other sarcomas, and their true biologic potential is not clearly defined. Radiation appears to be a very useful adjunct to surgical therapy and was used in the cases reported here.

Clinical spectrum of blunt tracheobronchial disruption illustrated by seven cases

Tracheobronchial disruption resulting from blunt trauma is unusual, but when it does occur it can have serious immediate and delayed consequences. A high index of suspicion for this injury and an awareness of the variety of clinical, radiographic, and bronchoscopic presentations are the key elements in diagnosis. Our experience with seven patients with blunt tracheobronchial trauma seen from 1972 through 1980 is reviewed. Emphasis is placed on the importance of early diagnosis to avoid the complications associated with delayed repair.

Multiple primary carcinomas of the colon and associated extracolonic primary malignant tumors

A review of 308 cases of colorectal carcinoma showed 12 cases (3.9%) of colorectal multiple primary malignant tumors and 14 cases (4.5%) of colorectal primary malignant tumor associated with extracolonic primary malignant tumor. A total of 60 tumors was involved: 14 each in the sigmoid and transverse colon; eight in the cecum; six in the rectum; one each in the ascending and descending colons; three each in the bladder and prostate; two each in the breast, cervix, and lung; and one each in the skin, nasopharynx, kidney, and endometrium. Three of the four patients with multifocal cancer were found to have in situ cancer, and 12.7% of concomitant adenomas had malignant changes. Seven patients had regional lymph node metastases. Of the six patients with rectocolonic multiple tumors who had adequate follow-up data, survival in three ranged from 19.5 to 60 months; three were alive and well 15 to 51 months after resection. Survival of patients with primary rectocolonic and extracolonic tumors was similar. From these data and the pathologic study of the resected specimens, we recommend for any patient with cancer of the rectocolon that the entire colon be searched for multiple primary malignant tumors, that extracolonic tumors be considered second primary tumors unless proved to be metastases, and that follow-up be long and include frequent rectocolonic examinations for a second primary tumor.

Prospective, randomized, controlled trial of ticarcillin and cephalothin as prophylactic antibiotics for gastrointestinal operations

The effectiveness of ticarcillin (one 6 g dose at the start of the operation) and cephalothin (three 2 g doses given at 4 hour intervals from the start of the operation) as prophylactic antibiotics in operations on the colon, stomach, small bowel or obstructed biliary tract was determined in a prospective, randomized, blind study of 190 patients. Data from the 152 patients forming the definitive study revealed a significant reduction in the rate of wound and peritoneal infections with the use of ticarcillin (3.4 percent) and cephalothin (5.3 percent) over that with the use of a placebo (27.8 percent). Cultures showed no evidence of antibiotic resistance in the contaminant organisms of patients who later developed infections. Both antibiotic regimens offered excellent protection against infection after gastrointestinal operations; neither produced untoward side effects. The very short duration of treatment, particularly with ticarcillin, conferred the additional benefits of low cost, simplicity of drug administration, and negligible risk of the emergence of resistant bacterial strains.

Morbidity and mortality rates in major blunt trauma to the upper chest

It is widely believed that fractures of the first rib are associated with more severe injuries than fractures of other ribs. To confirm or refute that belief, we conducted a retrospective review of 168 patients with major blunt trauma resulting in fractures of the upper ribs treated at the North Carolina Baptist Hospital. A comparison of morbidity and mortality rates in relation to highest rib fractured showed essentially no correlation. We concluded that all patients with deceleration or crushing injuries involving upper-rib fractures must be suspected of having significant multiple organ system trauma and evaluated accordingly.

Malignant lymphoma of the thyroid gland with plasma cell differentiation (plasmacytoma)

An unusual case of malignant lymphoma of the thyroid is reported. The predominant appearance of the neoplasm was that of a large cell ("histiocytic") lymphoma, but a discrete portion of the tumor showed features typical of plasmacytoma. Electron microscopy revealed a wide spectrum of cell types, ranging from very immature lymphoid cells to relatively well-developed plasma cells. The findings support the concept that the neoplastic process represents an immunoblastic sarcoma composed of proliferating transformed B lymphocytes (immunoblasts) and their progeny (plasma cells) rather than two distinct lymphoid neoplasms occurring simultaneously.

Paraganglioma of the thyroid gland

A case of a paraganglioma located within the thyroid gland is reported, and the light- and electron-microscopic features are described. Review of the literature reveals only one other case of intrathyroidal paraganglioma, which was associated with bilateral carotid body tumors. Regarding the present case, no similar tumors have been noted elsewhere. The findings support the view that the thyroid gland should be included among the unusual sites at which primary paragangliomas may occur.

Staging laparotomy in Hodgkin's disease

Staging laparotomy (multiple liver and lymph node biopsies and splenectomy) was performed at the North Carolina Baptist Hospital in 123 patients with Hodgkin's disease. There were no deaths. Wound, pulmonary, intra-abdominal or urinary tract complications developed in 17 patients. Of those complications, one case each of pelvic abscess, subphrenic abscess, small bowel obstruction, staphylococcal peritonitis and subphrenic hematoma required a major intra-abdominal operation. The patients were classified on the basis of histopathology; nodular sclerosis--40, mixed cellularity--44, lymphocyte predominant--24, lymphocyte depleted--13, and undetermined--2. The pathological stage following laparotomy was unchanged from the clinical stage in 62%, reduced in 15%, and advanced in 23%. Subsequent therapy, therefore, was altered in 38% of the patients. Lymphangiography, done in 108 patients, showed lymph node involvement in 46 patients and no involvement in 62 patients. Of those lymphangiographic findings, 79% were confirmed histopathologically, 19% were falsely positive, and 1.8% were falsely negative. There were positive findings of Hodgkin's disease in the spleen in 42% of patients. The staging laparotomy continues to be a valuable tool in the staging and treatment of Hodgkin's disease.

Carcinoma of the parathyroid

We report on eight cases of parathyroid carcinoma seen at the Bowman Gray School of Medicine, Winston-Salem, NC, since 1969. Diagnosis of a parathyroid disorder was made on the basis of elevated serum calcium levels and associated disorders such as renal calculi, peptic ulcer disease, pancreatitis, and demineralization of bone. Six of the involved glands were on the left side. In seven patients, the disease was localized to the gland or adjacent structures; one patient had cervical lymph node invasion. Except for the last patient, in whom radical neck dissection and wide excision was done, local excision with adequate margins was the only procedure done. The patient with metastases died of his disease four years later. One patient died of myocardial infarction two years later, but had been normocalcemic in the interval between operation and death, and one patient is hypercalcemic and has had two local recurrences within a 3 1/2 year period. The other five patients are alive and well. The routine use of automated serum level determinations of all hospitalized patients has led to early detection of this malignancy, while it is still a stage I lesion in many instances. On the basis of this material, we conclude that radical neck dissection can no longer be advocated as a routine measure in the treatment of parathyroid carcinoma.

A randomized prospective evaluation of orally administered antibiotics in operations on the colon

In this randomized, prospective study of 91 patients undergoing operations on the colon, we found that neomycin, neomycin-phthalylsulfathiazole and neomycin-erythromycin base all provided adequate intestinal antisepsis. Wound infection rates for all groups were also similar and close to the national average for operations on the colon. A detailed analysis of the wound infections in our series revealed that 60 per cent of these infections were from organisms different from those found on the colonic mucosa. This evidence indicates the possible advantage of parenteral antibiotic therapy to achieve adequate tissue levels of antibiotics not presently possible with orally administered agents.

Agenesis of the gallbladder--an inherited defect?

Agenesis of the gallbladder is a rare anomaly believed to be an organogenetic failure. This is the third instance of familial agenesis of the gallbladder reported in the literature. The diagnosis of agenesis of the gallbladder can only be made during exploratory celiotomy and must be confirmed by an intraoperative needle cholecystogram. This congenital anomaly should be suspected when oral cholecystography shows a nonvisualizing gallbladder in relatives of any patient with proven agenesis of the gallbladder.

Ruptured abdominal aortic aneurysms: review of 33 cases treated surgically and discussion of prognostic indicators

Over an eight-year peroid at NCBH, 33 patients were operated for ruptured abdominal aortic aneurysm. Factors associated with an increased mortality included preoperative blood urea nitrogen levels of more than 20 mg per cent, severe preoperative hypotension, duration of symptoms of less than 24 hours, free peritoneal rupture and blood transfusions of greater than 19 units. Preoperative hypotension was the most selective preoperative prognostic parameter. From a review of this and other reported series, it was concluded that reduced mortality from ruptured abdominal aortic aneurysm can best be achieved by prompt diagnosis followed by surgical treatment before cardiovascular collapse can occur.

Diagnosis and management of occult gastrointestinal bleeding: visualization of the small bowel lumen by fiberoptic colonoscope

In 95 per cent of patients, the source of gastrointestinal bleeding can be determined by the usual roentgenographic and endoscopic methods. In the remaining five per cent of patients, the source of bleeding is obscure and special diagnostic procedures will be necessary. Among the special procedures that have been reported are the fluorescein string test, stepwise aspiration of intestinal contents, detection of radioactive red blood cells by stepwise aspiration, Geiger counter or scanning, and selective visceral angiography. An additional procedure, reported here, combines exploratory celiotomy with total endoscopic examination of the bowel.

Etiologic factors and consequences of splenic vein obstruction

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Central venous pressure monitoring: misinterpretation, abuses, indications and a new technic

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