Carlos Grodsinsky

The spectrum of colonic involvement in pancreatitis.

SummaryColonic involvement as a result of pancreatitis is an uncommon but interesting complication of the disease. Among the significant manifestations we have seen are: 1) adynamic ileus of the transverse colon, 2) fibrosing, stenosing pericolitis localized to the splenic flexure area, and 3) colonic hemorrhage secondary to necrosis and fistula formation.Ordinarily, conservative treatment will suffice, but in complicated cases, individualized surgical treatment becomes necessary.

Volvulus of the colon

We have reviewed the records of 48 patients who had colonic volvulus. Volvulus occurred in the sigmoid colon in 27 (56%) and in the right colon in 19 (40%). Volvulus elsewhere in the colon is rare, requiring unusual anatomic circumstances of a long mesentery and a mobile colon. The clinical history is characterized by a long history of bowel dysfunction followed by an episode of acute intestinal obstruction. The patient is often aged and is plagued by mental disorders and a number of degenerative diseases. Distention of the abdomen is the most significant finding, and tenderness may indicate peritonitis due to ischemic changes in the bowel. Three-positional films of the abdomen are most valuable, showing great distention of the colon and air-fluid levels in the bowel with regularity. Barium-enema studies will more accurately reveal the site and nature of obstruction. The barium-enema examination must be done carefully. It is omitted when peritonitis is present. Operative treatment is necessary for volvulus of the right colon. Non-operative reduction is effective for nonstrangulating volvulus of the sigmoid colon as an emergency procedure. Sigmoidoscopic examination and insertion of a long rubber tube will give dramatic relief to a substantial number of patients. Operative intervention is necessary when conservative measures fail. When gangrene is found at operation, exteriorization resection of the colon may be life-saving. Elective resections are recommended for patients who are in otherwise good health in order to prevent recurrences. The mortality rate in this series of 48 cases was 12.5 per cent. Cecal volvulus was present in each of the six patients who died. Sepsis and cardiopulmonary diseases were common in patients who died.

The morbidity and mortality of colostomy closure.

SummaryRetrospective analysis was done of 304 patients who underwent colostomy closure at Henry Ford Hospital between 1967 and 1977. A mortality of less than 0.3 per cent and a morbidity rate of 14 per cent, with an average hospital stay of 15 days, is hereby reported. Wound infection was the most common complication with an incidence of 9.5 per cent. Late complications during the study period were less than 3 per cent.In our experience, if the intraperitoneal closure technique with resection and anastomosis is used, colostomy closure can be a safe procedure with minimal mortality and morbidity. We believe colostomy closure should be considered as nothing less than a major colonic resection.

Differentiation between benign and malignant disease of the breast using digital subtraction angiography of the breast

The authors have investigated digital subtraction angiography (DSA) for the differential diagnosis of breast lesions detected initially by mammography. Eighteen patients scheduled for biopsy first underwent digital subtraction angiography of the breast (DSAB). Criteria for malignancy included the presence of abnormal vessels and a “blush” in the area of the lesion. A total of 17 lesions are currently available for histopathologic correlation. Although this is a small series, the initial results of DSAB suggest its potential utility for differentiating between benign and malignant lesions.

Megacolon in teen-aged and adult patients

SummaryMegacolon may be classified as primary or aganglionic, secondary or acquired, and functional or psychogenic. In addition, there are other mechanisms, currently poorly understood, that cause megacolon.Diagnostic studies of the patient with megacolon should include a detailed history, physical examination, rectal and sigmoidoscopic examinations, a rectal biopsy, and (for functional megacolon) psychiatric evaluation. Age of onset, encopresis, and dilatation and elongation of the colon with a narrow rectal or rectosigmoid segment are import details to consider in the differential diagnosis. Biopsy of the rectum will prove the presence or absence of ganglion cells. Careful attention should be given to patients with constipation, lest some of them be unnecessarily relegated to lifetimes of avoidable embarrassment and suffering.We have described the cases of four patients with megacolon who had reached their teens or even young adulthood before being treated. The Swenson pull-through procedure produced excellent results in each case.

Pneumatosis intestinalis: a clinical classification.

SummaryReview of our experience with pneumatosis intestinalis has allowed identification of three major clinical groups of patients. In each of these groups, the etiology of pneumatosis intestinalis usually can be identified, and it frequently has an ominous prognosis. Treatment should be directed to the underlying condition when possible, and hence must be individualized. Those patients who would be categorized as Group I can simply be kept under observation. Patients in Group II might obtain relief from breathing increased concentrations of oxygen. For patients in Group III vigorous therapeutic measures generally are necessary to ensure survival. The increasing use of mechanically controlled ventilation and positive end-expiratory pressure may be contributing to the incidence of pneumatosis intestinalis. The ileus sometimes observed in these patients may accompany or precede the development of intramural air, a condition identifiable on roentgenographic examination. Awareness of the possible presence of intramural air may help in identifying patients who may not need operation. But even when roentgenographic examination has confirmed the presence of intramural air, abdominal exploration still may be necessary to rule out a diagnosis of perforated viscus. We hope that these concepts and our emphasis upon individualization of treatment may improve the prognoment patients who have pneumatosis intestinalis.

The spectrum of radiation enteritis: surgical considerations

Radiation therapy, often used to treat gynecologic and urologic pelvic malignancies, has varying, adverse effects on the bowel. Radiation enteritis may occur from one month to 20 years after irradiation, and disabling symptoms may require surgery in 10 to 20 per cent of patients. From our experience with 20 patients who required surgery for radiation enteritis and who were followed for up to 20 years, we were able to identify three clinical groups. Patients in the first group need only medical treatment for their symptoms and observation, whereas patients in the second group may present with acute, debilitating, life-threatening symptoms that may require emergency surgery. Patients in the third group have a long-standing history of intermittent bowel obstruction and/or enteric fistulas that are best treated with adequate nutritional support followed by timely surgical intervention.

The management of colonic and rectal injuries

SummaryOne hundred fifty cases of patients treated at the Henry Ford Hospital with traumatic injuries of the colon and rectum are reviewed. Five of 119 patients treated with exteriorization died, two of them from multiple visceral injuries, shortly after operation. The mortality rate for the primary-closure group of 24 patients was 8.3 per cent. In this group, 11 patients had postoperative complications. Thirty-nine of the 119 patients in Group II had 62 complications. Infection was the predominant problem in both groups of patients. We still believe that exteriorization of the injured colon remains the safest method of managing these patients.

Postoperative Pulmonary Complications in the Geriatric Age Group

ABSTRACT: Postoperative pulmonary complications are a serious danger to any patient who undergoes surgery. The increase in geriatric surgery has brought into focus certain marginal factors that can spell the difference between success and failure. In a series of 300 elderly patients who underwent major surgery at the Henry Ford Hospital, there were 34 in whom clinical and radiologic evidence of atelectasis developed. In 19 others, x‐ray examination of the chest showed various infiltrates suggesting pneumonitis, and sputum cultures grew coliform bacteria. Despite appropriate treatment, 5 patients died from postoperative pulmonary complications. Illustrative cases of hypoventilation, atelectasis, pneumonia and pneumothorax are presented. Recommendations are made for the care of the elderly undergoing major surgery, including the preoperative identification of chronic lung disease, determination of the respiratory reserve, preoperative exercises in deep breathing and coughing for use after operation, adequate oxygenation during the surgical procedure, close supervision of postoperative respiratory ventilation for the first seventy‐two hours, selective use of mechanical respiratory assistance, and emphasis on early ambulation.

Complications of Peptic Ulcer Disease in Geriatric Patients

ABSTRACT: Many patients with the complications of peptic ulcer disease are in the geriatric age group. This is partly the result of the overall increase in this segment of the population in recent years, and partly the result of delay in the referral of younger patients with intractable forms of the disease. Hemorrhage is the most common life‐threatening manifestation of peptic ulcer in the geriatric patient. Prompt evaluation by esophagogastroscopy and barium x‐ray examination is of paramount importance in proper management. Perforation of peptic ulcer is less common in the elderly. When diagnosed, it requires immediate surgical treatment. Pyloric obstruction should be suspected in a patient with chronic nutritional depletion, superimposed acute dehydration, electrolyte imbalance and even shock. Nasogastric decompression of the dilated stomach and re‐establishment of fluid and electrolyte balances should be attended to before carrying out definitive surgical treatment.