A.Gerson Greenburg

Influence of age on mortality of colon surgery

The geriatric population continues to grow and surgical decision making is often confused by the effect of aging. This study is part of an ongoing effort to determine surgical risk in the elderly population and to identify the significant factors affecting outcomes which could be used to plan surgical procedures. Records of 163 patients over 70 years of age with elective or emergency surgery (133 patients and 30 patients, respectively) were reviewed. There were 17 deaths. All deaths in a cohort of patients under 70 were examined as well. Ninety-five variables were explored to seek differences between groups. The patients who died, independent of age, were similar. Patients over 70 years of age who died differed from the survivors in many ways, both physiologically and in terms of disease state. Survivors were younger; did not have congestive heart failure; had better hepatic, renal, and pulmonary function; less extensive involvement if malignant disease was present; and fewer postoperative complications. If these factors were removed and only apparently normal physiologic characteristics considered, there were no differences in mortality between the patients over 70 years of age and younger patients. Age was less of a factor than physiologic status.

Spectrum of cholangitis

Of 402 patients admitted with biliary disease over the last three years, cholangitis has been diagnosed in 36. This represents an 8.8 per cent overal incidence and a 33.8 per cent incidence among patients who have undergone operation or manipulation involving the common duct. Based on this experience, a program of prophylaxis and treatment of cholangitis has been devised with special emphasis on the management of elderly patients in the initial postoperative period.

Operative mortality in general surgery

The operative mortality in over 7,000 consecutive cases at a Veterans Administration Medical Center is defined. The mortality in elective procedures is low by most standards and is usually associated with a malignant disease. Older patients appear to have an increased operative mortality. Sepsis is the major factor in death after elective and emergency procedures. Age is a critical factor associated with mortality in this population. Preexisting disease (pulmonary, cardiac, hepatic, and malignant) plays a role in determining outcome. Despite these factors it is possible to achieve excellent operative mortality results in a hospital with a commitment to resident training. An aggressive diagnostic and therapeutic approach is considered reasonable to support these patients with multisystem disease. This often includes the extensive use of expensive resources such as preoperative hospitalization with nutritional support and prolonged stays in the surgical intensive care unit postoperatively.

Revisiting the recurrent groin hernia

The anatomic defects of recurrent groin hernia in 413 patients treated consecutively using the preperitoneal approach have been cataloged and the results of the repair evaluated. No specific predicting factors could be identified for most of the patients. Defects are highly variable and not at all predictable. Pure direct defects predominated (58 percent), tended to be at the tubercle (41.9 percent), and were relatively small (less than 4 cm in 77 percent of the patients). Recurrence was associated with a number of previous repairs but the rate was only 4.3 percent for the series with 11 of 18 patients having at least three repairs. The recurrence rate for first rerepair using this approach was 1.6 percent (4 of 248 patients) within 5 years for 80 percent of the patients followed. The preperitoneal approach is a useful, safe, and effective technique for the treatment of recurrent groin hernia and should be widely implemented.

Expanding indications for early parathyroidectomy in the elderly female.

In a study of fifty consecutive patients with hyperparathyroidism we have noted: (1) Automated laboratory studies have increased the incidence of diagnosed hyperparathyroidism, especially in the elderly. (2) Bone abnormalities and mental changes are the most frequent symptoms in this older population. (3) Natural history studies have produced some delay in surgical treatment, accentuating mental aberrations and bone-associated deficits. Especially in the elderly, the benefits in personality change, feeling of well-being, and lessened bone deterioration warrant early operation.

The practicality of the Congo Red test, or is your vagotomy complete?

The use of Congo Red testing for adequacy of vagotomy in a variety of clinical situations is described. Its intraoperative use is presented for the first time, thus allowing the surgeon immediate documentation of the completeness of his vagotomy and hopefully averting incomplete vagotomy, the single most common cause of ulcer recurrence after vagotomy-pyloroplasty.

The Congo red test to determine completeness of vagotomy: Clinical application

Over the past 5 years, we have evaluated the Congo red test for vagal competence as to its reliability under varied clinical conditions both intraoperatively and postoperatively. Our technique has been useful and accurate in approximately 200 patients. Insuring completeness of vagotomy during the operation has been of use in 42 patients uncovering an unsuspected incomplete vagotomy in 4. In a series of 31 patients with recurrent ulcer symptoms, the documentation of the cause as well as the presence of the ulcer is possible with one simple maneuver--endoscopy. Furthermore, the test has been utilized postoperatively in over 100 patients to determine the longevity of a negative test as well as the clinical sequelae of apositive study. With a trend to more selective vagal section and a continuing significant incidence of recurrent ulceration, we are convinced that the congo red test is an important adjunct to the surgical care of ulcer patients.

A study of fundoplication disruption and deformity.

Three distinct forms of postoperative breakdown after Nissen fundoplication have been discussed. Disruption and recurrent reflux is most common, with slipping occurring infrequently. For the first time, three patients developing a proximal gastric pouch deformity causing partial obstruction of the fundus without recurrent herniation are reported on. Two patients required remedial surgery.

Computer Assisted Diagnosis and Computer Consultation in Neurology: Preliminary Testing of Diagnostic Accuracy for the Neurologist System

The Neurologist system is a computer program for consultation in clinical neurology which employs human-like reasoning in diagnosis, covers a broad diagnostic domain, has the capacity to explain strategies and conclusions and is readily expandable. Neurologist employs the strategy of first localizing a neurologic disease, then uses these data as well as mode of disease onset, rapidly to focus on a limited number of diagnostic possibilities which are then sequentially investigated. This paper presents the results of the preliminary assessment of Neurologists diagnostic accuracy. For a set of 30 test cases, the systems leading diagnosis was correct in 77%, and separation of correct and incorrect diagnostic hypotheses was excellent. Further evaluations of the system are in progress.

Fluorocarbon emulsions as blood replacement fluid: Influence on the omental microcirculation

Abstract The results of this microvascular in vivo study indicate that, at the present, the tested fluorocarbon emulsions cannot be considered as a blood substitute for clinical applications because these solutions caused the deterioration of microhemodynamic function and caused damage to both endothelial wall and blood cells. This could only be demonstrated by methods currently used for microcirculatory research since the macrohemodynamic parameters measured were not indicative of severe side effects during the experiments. Our findings indicate that the major effect of fluorocarbon emulsions on the microcirculation is due to pharmacological action which causes arteriolar constriction, vessel wall damage, and blood cell aggregation. These effects do not appear to be a consequence of the elevated oncotic pressure. Similarly, particle size associated with a 15% emulsion could not be demonstrated to be the primary cause for the observed microhemodynamic changes. We conclude that emulsions with comparatively higher concentrations of fluorocarbon could only be utilized if their pharmacological activity on the microcirculation can be controlled.