Alexander A. Deutsch

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.

Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment.

The etiology of hemorrhoids has been explained in the past based on anatomic principles, but this study examines the relationship of resting anal pressures to hemorrhoid etiology in 38 patients with hemorrhoids and 29 controls with no perianal symptoms. Three months after treatment by elastic band ligation, anal pressures were again measured in the hemorrhoid group. Anal pressures were significantly higher in the hemorrhoid group before treatment (102±26.33 mmHg) as compared with the controls (76.75±19.56 mmHg) (P<.001). Three months following elastic band ligation there was a small drop in anal pressure (100±26.84 mmHg) but it remained significantly higher than the control group. There was also a significant correlation between symptoms and level of anal pressures. The results indicate that persons with hemorrhoids have higher anal pressures than controls. Elastic band ligation relieves the symptoms but should not affect the anal sphincter pressure. The fact that the anal pressures remained high after treatment could imply that higher pressures are an etiologic component in the formation of hemorrhoids.

Small bowel obstruction: a review of 264 cases and suggestions for management.

Two hundred and sixty-four cases of acute small bowel obstruction were retrospectively reviewed for the purpose of defining factors which could point to the presence of strangulated bowel. History, physical signs and investigations, including body temperature, X-rays, white blood count, and serum amylase, were not significantly different in the simple and strangulated groups. Although an elevated urinary white blood count and a palpable mass were more common in the strangulated group, they were not sufficiently reliable for early diagnosis of strangulation. In reviewing the literature, it is clear that all hernias with obstruction must undergo emergency surgery. Cases with intra-abdominal complete intestinal obstruction should also undergo emergency surgery. A more conservative attitude can only be taken when there is incomplete obstruction.

Differential Effects of Sodium Butyrate and Dimethylsulfoxide on Gamma-Glutamyl Transpeptidase and Alkaline Phosphatase Activities in MCF-7 Breast Cancer Cells

Sodium butyrate and dimethylsulfoxide (DMSO), two known chemical inducers of cell differentiation, were examined on MCF-7 breast cancer cells. Both agents reduce the proliferative capacity of MCF-7 cells, as reflected by inhibition of colony formation in semisolid agar. Sodium butyrate is shown to enhance markedly the activity of two plasma membrane-bound enzymes, alkaline phosphatase and gamma-glutamyl transpeptidase. DMSO does not enhance the activity of these enzymes, but rather induces a small decrease in gamma-glutamyl transpeptidase activity. The present results show that although both agents inhibit cell proliferation, they have a distinct effect on phenotypic expression.

Biochemical tissue markers of human colorectal carcinoma

The potential therapeutic effects of differentiating agents on leukemic and solid tumor cells are being evaluated worldwide. These effects can be followed by morphologic as well as biochemical parameters. The enzymatic profile of four enzymes and the level of carcinoembryonic antigen were studied in 24 human colorectal carcinoma specimens and their adjacent uninvolved mucosa. The enzymes studied were thymidine kinase and 6-phosphogluconate dehydrogenase as markers of proliferation, and alkaline phosphatase and γ-glutamyl transpeptidase as markers of differentiation. A consistent finding was a marker increase in the activities of thymidine kinase and 6-phosphogluconate dehydrogenase in the tumor cells as compared with the adjacent normal mucosa. The activity of γ-glutamyl transpeptidase was not significantly different between tumor and uninvolved colon tissue. Alkaline phosphatase activity was markedly reduced in the tumor specimens. A relationship between the degree of differentiation and the degree of penetration and CEA expression was demonstrated in the tumor specimens as well as in their surrounding uninvolved mucosa.

Septum of the gallbladder, clinical implications and treatment.

We report four patients with a congenital gallbladder septum whose symptoms resembled those of cholelithiasis, in one case giving rise to acute cholecystitis. Cholecystectomy relieved symptoms in all cases and examination of the operative specimen confirmed the clinical diagnosis and X-ray findings. Ultrasonography made a positive diagnosis in the last two cases and no stones were found in any of the cases described. Cholecystectomy is advocated in symptomatic patients with this condition, even when gallstones are not present.

Cholecystectomy for Octogenarians

Fifty-eight patients, above the age of 80, underwent surgery for benign gallbladder disease between 1965 and 1984. They are compared to 2,017 patients under this age operated on over the same period. There were equal numbers of men and women. Acute presentations were more frequent and life-threatening. Immediate definitive surgical intervention which included cholecystectomy, fluorocholangiography and common bile duct (CBD) exploration, when indicated, offered an acceptable chance for cure. There was a 13.8% mortality in the acute cases. Infected bile was present in 76% of cases, extensive CBD pathology (widening 62%, stones 43%), and severe concomitant diseases (e.g. cardiac) in 60% of the cases. As a result, CBD explorations (52%) and choledochoenterostomies (26%) were much more frequent. Cholecystostomy is unjustified because definitive procedures in the aged in our series have achieved equal, if not better results, compared to series of cholecystostomies reported by others. The mortality rate in elective cases above 80 years is high (6.9%) and we think that asymptomatic gallbladder stones should not be operated on in this age group.

Cholecystocolonic Fistula: A Complication of Untreated Cholelithiasis

Cholecystocolonic fistula comprises 10–20% of cholecystoenteric fistulae. A case is described to illustrate the methods of diagnosis and possible complications. Surgical treatment consists of cholecys

Biliary Surgery in Diabetic Patients: Statistical Analysis of 189 Patients

Biliary tract disease and diabetes mellitus are considered to be ominously associated with high mortality and morbidity. The present report deals with 1,500 consecutive biliary procedures and compares the data of 189 diabetic patients (DP) with that of 1,311 nondiabetics (NDP). A wide data base was considered in both categories studied, and all data were computer-analyzed. The most significant results were as follows: (1) in the DP Group there was a higher incidence of patients above 60; (2) a larger percentage of DP were operated upon under emergency conditions (35 vs. 23%, p = 0.01; acute cholecystitis, septic cholangitis). (3) There was a higher rate of DP with septic bile (61 vs. 27%, p = 0.001) and a higher incidence of septic complications (usually wound infection) in the diabetic patients; (4) the mortality rate of DP was not significantly higher in elective cases; however, there was a significant difference in mortality in acute cases (3.1 vs. 1.1 %, p = 0.05). The main conclusions are: (1) A very low mortality rate (2.1 %) was achieved in diabetic patients undergoing surgery for acute cholecystitis and cholangitis, and it seems that the policy of early and definitive surgery adopted has contributed to the good results. (2) There is no significant difference between diabetic and nondiabetic patients with regard to elective surgery for cholelithiasis. (3) This study supports the view that cholelithiasis and its complications are very common in diabetic patients above the age of 50. Sonographic screening for gallstones in such populations seems useful. An epidemiological study of biliary complications in diabetics is being conducted at present by the authors.

Acute Acalculous Cholecystitis versus Acute Calculous Cholecystitis: Review 1970-1988

Ultrasonography has led to an increase in the incidence of acute acalculous cholecystitis (AAC). Fifty-three patients with AAC are compared to 521 patients with acute calculous cholecystitis (ACC), bo