Alexander J. Walt

Mallory-Weiss syndrome: A study of 224 patients☆

With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.

Pancreas divisum: Is it a normal anatomic variant?

One thousand five hundred twenty-nine pancreatograms were obtained between 1973 and 1985. Complete pancreas divisum was demonstrated in 41 patients, for an incidence of 2.7 percent, and incomplete pancreas divisum in 14 cases, for an incidence of 0.9 percent. No increased incidence of pancreas divisum was found in any of four groups: an incidental group, a group with alcoholic pancreatitis, a group with unexplained upper abdominal pain, and an idiopathic pancreatitis group. The majority of patients (80 percent) were found to have pancreas divisum as an incidental finding or in association with alcoholic pancreatitis. Of 82 patients with idiopathic pancreatitis, only 2 had pancreas divisum. The three patients with pancreas divisum who had sphincteroplasty of the minor papilla were not helped by the procedure. We conclude that pancreas divisum is a normal anatomic variant and is very seldom a cause of pancreatic pain.

Cysts and Benign Tumors of the Liver

The liver is the site of a wide variety of cystic and benign lesions. This article considers selected entities which tend to fall into the purview of the surgeon. Inflammatory lesions and ectasias of the biliary ducts are excluded.

Therapeutic implications of disturbed gastric physiology in patients with stress ulcerations

Abstract The response of the gastric mucosa to “stress” was evaluated in septic and traumatized patients by: (1) serial gastric, small intestinal, and colonic endoscopy and photography throughout the period of illness; (2) biochemical analysis of the concentration and amount of intraluminal gastric mucus in twenty-five control and thirty-five stress patients, and the concentration of intracellular mucus in intraoperative biopsy specimens taken at surgery in two “stress” and two control patients; and (3) microscopic study of selected lesions. Shortly after injury, decreased gastric mucosal blood flow was reflected in focal areas of pallor followed within twenty-four hours by diffuse erosions confined to the corpus. Intraluminal gastric mucus showed little change in concentration throughout the period of illness but increased in amount when stress persisted beyond three days. No difference was present in the intracellular concentrations of mucus in control and stress patients. Premonitory signs of bleeding have included increased secretion of gastric acid mixed with bile and black flecks of blood, accentuation of adynamic ileus, and increased gastric secretory volumes. Forty-four patients in whom vigorous iced saline lavage did not successfully control hemorrhage required operation. Vagotomy and partial gastrectomy were the most successful procedure in preventing postoperative bleeding but did not significantly improve the survival rate. A plan of management and the results achieved are discussed.

THORACIC AORTIC CLAMPING FOR PROPHYLAXIS AGAINST SUDDEN CARDIAC ARREST DURING LAPAROTOMY FOR ACUTE MASSIVE HEMOPERITONEUM

Experimental studies in dogs were performed to develop a model simulating clinical patients with penetrating wounds of the major abdominal vessels who develop sudden cardiac arrest following laparotomy and decompression of an acute massive hemoperitoneum. Hypovolemic dogs with a saline-distended tense abdomen and major arterial bleeding after laparotomy develop a sudden deterioration of cardiac function despite raped blood infusion, thus simulating the clinical problem. However, thoracic aortic occlusion before laparotomy and until control of distal arterial bleeding prevented such a cardiovascular collapse. Increased intra-abdominal pressure it itself was determental to cardiovascular function; its sudden release by laparotomy was associated with an improvement in cardiovascular function. An approach of thoracic aortic control before laparotomy is recommended in patients with acute massive hemoperitoneum who remain hypotensive before laparotomy.

Gunshot Wounds of the Heart

Abstract Of 245 patients with penetrating wounds of the heart who reached the emergency room of Detroit General Hospital (Receiving Branch) alive during a 13 1/2 year period, 27 had gunshot wounds. These wounds are increasing in frequency both relatively and absolutely, so that now almost 50% of the heart wounds seen are caused by gunshots. A program of treatment characterized by immediate respiratory support, blood volume expansion, and thoracotomy with direct control of the cardiac injury resulted in the survival of 20 of the 27 patients. Other factors favorably influencing survival rate were an initial blood pressure of 50 mm. Hg or higher, cardiac tamponade, and injury to only one chamber. All 9 patients with damage to only one chamber and tamponade survived.

Serum amylase and its isoenzymes: A clarification of their implications in trauma

Previous reports on the use of the serum amylase level to assess pancreatic injury in patients with blunt abdominal trauma have been disappointing. The availability of methods to measure the serum isoamylases (P & NP) might be expected to improve the accuracy with which the serum amylase level is used. Sixty-one patients treated for a variety of blunt trauma injuries were studied. All categories of injury were included. Isoamylase levels were determined from admission sera and were compared to injuries found at laparotomy. Three patients had major pancreatic injury but only two of these patients showed a rise in the pancreatic isoamylase. Sixteen additional patients had a rise in the pancreatic isoamylase without evidence of pancreatic injury. Eight of these patients had no component of abdominal injury whatsoever. Two patients with isolated head injury had substantial elevations of pancreatic isoamylase. The regulation of serum amylase is multifactorial and variable. The measurement of serum isoamylase levels does not offer great improvement over the serum amylase in evaluating patients with blunt abdominal trauma.

The morbidity and cost of the temporary colostomy.

THE DECISION tO divert the fecal stream is influenced by many factors. Ideally, a t empora ry colostomy should: 1) help to preserve life; 2) reduce morbidity; 3) cause no complication; 4) be closed as soon as poss ib le ; 5) be c losed w i t h o u t c o m p l i c a t i o n . Whenever we fail in any of these five areas, a price is paid in human suffer ing and in expendi tures by the public. In 1973, Pelok and Nigro 1I published a prospective study of complications related to construct ion of a t empora ry colostomy in the patient with colonic injury. T h e following year, Kirkpatrick 9 published a prospective randomized study o f the alternatives in management o f injury to the colon, with emphasis on pr imary closure and exteriorizat ion of the injured segment. We have examined the clinical courses o f patients in whom tempora ry divert ing colostomies were established. Our objectives were threefold: 1) to de te rmine the combined morbidity associated with construct ion and closure o f a colostomy; 2) to d e t e r m i n e the economic cost to the patient and society, expressed as a funct ion of the dura t ion of hospitalization for construction and closure, the interval f rom construct ion to closure, and the time spent in the opera t ing room for closure; 3) to identify the means by which we may reduce the morbidi ty associated with a t empora ry colostomy and its cost to the individual patient.

Calculi complicating a renal transplant

Four months after a cadaver kidney transplant, kidney stones were found in the renal allograft. Three major predisposing causes of nephrolithiasis were found in the patient, including hyperparathyroidism, renal tubular acidosis, and urinary tract infection. Hypercalcemia was corrected by parathyroidectomy. During the subsequent three years there was no enlargement of the renal stones and adequate kidney function was maintained. Renal tubular acidosis was not severe and seemed to be related to chronic rejection. Urinary tract infection was readily corrected with antibiotics and did not recur after the immediate post-transplant period. Surgical therapy for nephrolithiasis involving a kidney allograft was defferred since urinary flow was not obstructed. This course of management is recommended for use in patients with calculi complicating renal transplantation.

Penetrating Wounds of the Neck: Principles and Some Controversies

Some of the principles, pitfalls, and controversies in the management of penetrating wounds of the neck have been reviewed. All three policies to exploration of the neck advocated by different authors have merit and can be considered optimal under certain circumstances. Since delayed surgical treatment of major vascular and esophageal injuries results in higher morbidity and mortality, exploratory operations are appropriate when such injuries are suspected, even though preoperative studies are inconclusive. A systematic approach to the management of penetrating wounds of the base of the neck has been outlined. The role of a shount to maintain adequate cerebral blood flow during repair of carotid artery injuries has been discussed. In patients who have severe preoperative neurologic deficit and no blood flow in the injured carotid artery at operation, ligation of the artery rather than repair of injury appears to be indicated.