Arthur J. Donovan

Duodenal “diverticulization” for duodenal and pancreatic injury

Abstract Duodenal “diverticulization” has been achieved in thirty-four cases of combined duodenal and pancreatic or severe duodenal or pancreatic injury. The operation consists of gastric antrectomy with end to side gastrojejunostomy, tube duodenostomy, closure of the duodenal perforation, and drainage. The combined mortality for these thirty-four cases and a previously reported series of sixteen cases is 16 per cent. Regional complications that developed after duodenal diverticulization were generally well tolerated and not lethal. All duodenal and pancreatic fistulas closed spontaneously.

Choledochal cyst in the adult.

ObjectiveThe authors examined the natural history of choledochal cysts in adults treated surgically. BackgroundAn initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer. MethodsA retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer. ResultsFifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months. ConclusionThis experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Bilateral Breast Cancer

A second primary breast cancer in the opposite breast can be either synchronous or metachronous. The majority are metachronous. A woman who has had breast cancer has a fivefold increase in risk for a second breast cancer. Additional risk factors include multifocal cancer, lobular carcinoma in situ, and an original cancer at an early age with long survival. Lobular carcinoma in situ is predominantly a marker for the subsequent development of a second primary breast cancer. The incidence of synchronous bilateral cancer is approximately 1% to 2% and that of metachronous cancer 5% to 6%. The cancer can be invasive or noninvasive. Mammography has increased the number of synchronous cancers found but not the overall incidence. The incidence of invasive cancer detected by random biopsy of the opposite breast is not high enough to justify routine adoption of this procedure. The remaining breast must be followed for the remainder of the patients life by physical examination and annual mammography. The treatment of the secondary primary breast cancer should be that appropriate for the stage of the disease. The prognosis for the woman with a second primary breast cancer is quite favorable and is dependent on the stage of both the first and the second cancer.

Distal pancreatectomy for pancreatic trauma

Abstract Distal pancreatectomy has been performed in sixty patients with pancreatic disruption with pancreatic ductal injury. Included are eight cases in which the injury was located considerably to the right of the superior mesenteric vessels and 13 cm or more of pancreas was resected. Late complications directly attributable to the pancreatic injury and resection were few, with one instance of long-term pancreatic endocrine insufficiency and one pancreatic pseudocyst. Mortality in these cases was 12 per cent and bore a direct relationship to the magnitude of injury to associated organs. Distal pancreatectomy is the treatment of choice for major injury involving the body or tail of the pancreas. It can be a satisfactory treatment for major injury involving the head of the pancreas.

Biliary lithiasis and helminthiasis

The syndrome of Oriental cholangiohepatitis is characterized by helminthiasis, choledocholithiasis often without cholecystolithiasis, biliary duct stricture and hepatic abscess. The common duct stones are usually multiple, black and friable. Fourteen cases have been seen in recent immigrants to the United States. Thirteen patients had choledocholithiasis, and 1 had viable flukes in the ducts. Choledochoenterostomy is usually required because of multiple stones, including intrahepatic stones, or proven or presumed infestation with Clonorchis sinensis. The latter, the Chinese liver fluke, is an infestation for which medical therapy does not exist. Resection, particularly of the lateral segment of the left hepatic lobe, may be required in cases of abscess and stones associated with stricture of the left hepatic duct.

Traumatic perforation of the duodenum

Summary Experience is reported with respect to the management of twenty-nine patients with traumatic perforation of the duodenum. The mortality was 14 per cent. That in twenty patients without pancreatic injury was 5 per cent, and that in nine patients with pancreatic injury 33 per cent. Pancreatitis developed postoperatively in thirteen patients. Serious regional complications, such as duodenal fistulas, secondary hemorrhage, pancreatic fistula, and sepsis, were observed exclusively in patients with associated pancreatic trauma. Primary closure was satisfactory as therapy in patients without pancreatic injury. Closure plus vagotomy, antrectomy, duodenostomy, and gastrojejunostomy is suggested in patients with combined duodenal and pancreatic injury, or severe duodenal injury. This procedure provides maximal defunctionalization of the duodenum and pancreas and, embodying the Roux-en-Y principle, results in diverticulization of the duodenum. Pancreaticoduodenectomy should be reserved for patients with the most extreme degree of trauma to the duodenal pancreatic area.

Injuries of the duodenum.

The records of 115 patients with a duodenal injury have been reviewed. The majority of the patients (83 percent) were treated with primary repair of the injury. Twelve patients underwent duodenal diverticulization. The mortality rate in all 115 patients was 12 percent, in 105 patients who survived more than 48 hours 4 percent, and in 26 patients with pancreaticoduodenal injury 15 percent. Vascular injury was the major cause of early death. Enteric perforations were present in 75 percent of the patients with sepsis. The majority of patients with associated pancreatic injury had primary repair and did not have pancreaticoduodenal complications. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy and feeding jejunostomy are useful adjuncts. A more complex operation should be reserved for a highly select group of patients with severe duodenal injury.

Spontaneous hepatic hemorrhage associated with pregnancy. Treatment by hepatic arterial interruption.

OBJECTIVE The authors determined the effectiveness of hepatic arterial interruption in treating patients with spontaneous hepatic hemorrhage associated with pregnancy. BACKGROUND DATA This rare syndrome frequently is seen with eclampsia/preeclampsia and is associated with high maternal mortality. The recommended treatment has been the use of local hemostatic measures. METHODS The authors reviewed their experience managing eight patients by hepatic arterial interruption. RESULTS Operative hepatic artery ligation was the initial method of controlling hepatic hemorrhage in three patients. One patient recovered, a hepatic sequestrum developed in one, and one patient died. Three patients survived after hepatic arterial embolization, but a sequestrum developed in one. Two patients died when hepatic arterial interruption was used after failed local hemostatic measures. CONCLUSIONS The authors believe that hepatic arterial interruption is the preferred treatment for spontaneous hepatic hemorrhage associated with pregnancy. If the diagnosis is made at the time of cesarean section delivery, operative hepatic arterial ligation is indicated. If the diagnosis is made postpartum, percutaneous angiographic embolization should be performed.

Gas in the portal vein of adults with necrotizing enteropathy

Summary Gas in the portal vein has been detected radiologically in twelve adults with necrotizing enteropathy which principally involved the small intestine. The necrosis was not always panmural. Portal venous gas is probably either consequent to enteric mucosal necrosis with passage of luminal gas into portal venous radicles or to a physicochemical alteration in portal venous blood, or to both. Evidence was not detected to support endovascular sepsis as a cause of the portal venous gas. In the majority of these patients it is believed that necrotizing enteropathy was consequent to impaired splanchnic blood flow with enteric ischemia. A primary necrotizing enteropathy cannot be excluded in a few of these patients. Demonstrable mesenteric vascular occlusion was not present in any patient. Three patients survived, two with enteric necrosis which was not panmural and one with panmural necrosis. Usually gas in the hepatic portal venous system is indicative of intestinal necrosis and demands prompt operative treatment.

Reticuloendothelial function in patients with cancer

Abstract Reticuloendothelial function has been studied in patients with cancer by determination of the rate of disappearance from the plasma of microaggregates of albumin. Comparison of the rate of disappearance in twenty-two patients with cancer as compared with fourteen patients without known cancer suggests that reticuloendothelial function was impaired in certain patients with cancer. Alterations in reticuloendothelial function were observed in nine patients undergoing palliative therapy, that is, administration of adrenocortical steroids, adrenalectomy, oophorectomy, administration of 5-fluorouracil, and radiation therapy. In these nine patients a favorable therapeutic response occurred in association with an increase in reticuloendothelial function, and an unfavorable response with decrease in reticuloendothelial function. These initial studies suggest that in man, important relationships exist between the reticuloendothelial system and the course of cancer.