Charles W. Mayo

A further evaluation of the one-stage low-anterior resection

SummaryFollow up data have been presented on 424 patients with carcinoma of the rectum or rectosigmoid, or both, who underwent one-stage low-anterior resection.A total of 27 patients died in the immediate postoperative period, giving a hospital mortality of 6.4 per cent.Hospitalization of the remaining 397 patients averaged 19.4 days, and if 128 patients with postoperative complications are excluded, hospitalization of the remaining 269 patients averaged 14.3 days.The most frequent postoperative complication was fecal fistula (13.1%).The sphincteric function was satisfactory eventually in 93.7 per cent of the cases.When the hospital deaths and palliative procedures were excluded, the five-year survival rate was 61.4 per cent, and the ten-year survival rate was 49.7 per cent. Five-year survival rates with and without nodal involvement are presented, and 15-year survivals (statistically insignificant) are discussed.The three-year intraluminal recurrence rate was 9.7 per cent, and the total local recurrence rate during the same period was 14.2 per cent.

Submucous lipomas of the small intestine.

S YMPTOMATIC lipomas of the small bowel are unusua1. The report of such cases serves to focus attention on the pIace of benign tumors in the differential diagnosis of intestina1 obstruction (particuIarIy by intussusception), unexplained meIena and epigastric distress. I, The rarity of benign tumors of the smaI1 bowe1 is attested by severa studies. King7 in rgr7 couId find reports of onIy 119 cases of histoIogicaIIy proved benign tumors in the Iiterature, twenty-nine of which were cases of Iipoma. WiIIis in rg2o’g cuIIed only nineteen such benign tumors from 7,492 necropsies at Boston City HospitaI and Massachusetts Genera1 HospitaI, an incidence.of I per 394 individuaIs. Kirshbaums of thezCook:County HospitaI c in Chicago found tweIve benign tumors in 5,754 necropsies from 1929 to 1934, an incidence of I per 480 persons. HaIf of his were Iipomas. In 1931 Comfort2 reported twenty-four cases of submucous Iipoma of the gastro-intestina1 tract that were encountered in the course of 3,924 necropsies performed at the Mayo Clinic. Raiford14 at Johns Hopkins HospitaI in BaItimore found fifty benign tumors, or I per 930, but to his I 1,500 necropsies he added 45,000 surgical specimens; seven of the fifty tumors were Iipomas. The incidence of subcIinica1 Iipoma of the smaI1 intestine found in the study which we report on subsequent pages was I per 325 necropsies. Ewing4 said that congenita1 predisposition of the tissue is an essentia1 factor in the orrgin of most Iipomas. He stated that the comparative isoIation of the blood suppIy of the IobuIes that reappear in Iipomas suggests that the anomaIy which predisposes to the Iesion is connected with the distribution of blood vessels in the fatty tissues. Kiilliker and ToIdt’O stated, according to Ewing, that fat Iobules have a certain independence in deveIopment which constitutes them a sort of primitive organ. No pecuIiarity in the chemica1 composition of the fat of Iipomas, no deficiency of Iipase and no grounds for the assumption that the fat of these tumors is beyond the reach of the fatmobiIizing factors of the body were found by WeIIs.l* However, since many Iipomas continue to grow whiIe the body is emaciating and not a few remain unaffected during the Ioss of body fat in tuberculosis (MadeIung12) or gastritis (Kuster”), one must assume that IocaI conditions, possibly the character of the circuIation, may prevent absorption of the Iipoma. The reIative freedom of the small intestine from stasis of fecal content, except in the termina1 portion of the ileum where the fecal materia1 accumuIates before passing into the cecum, is considered to be of significance by Raiford since the tumors in his series occurred most frequentIy in the termina1 part of the iIeum. Stasis is Iikewise found in the stomach and large intestine and these sites are aIso especiaIIy susceptibIe to invasion by a tumor. Stasis is known to be conducive to irritation; and if one accepts the irritation theory of the cause of cancer, stasis must, Raiford has said, be accepted as a contributing factor. He has further pointed out that since the small intestine deveIops chiefly during the Iatter four months of feta1 life, it is pIausibIe to assume that there is far less opportunity for arrested deveIopment and the mispIacement of embryonic tissue to occur in the small intestine than in the remainder of the gastrointestina1 tract. It is striking that Mayo and Griess’3 for a period ending December 3 I, r 947, found aImost three times as many surgicaIIy significant submucous Iipomas of the Iarge intestine

Gallstone obstruction of the small intestine.

Between 7935 and 1951, at the Mayo Clinic, 9 patients with gallstone obstruction of the small intestine have been treated surgically without a death. The case of 1 of these patients, a man 80 years of age, is presented in detail. The interesting roentgenologic findings in such cases are discussed and details of the surgical treatment are considered.

Unilateral and bilateral hernia

T HIS study was undertaken primarily for the purpose of determining whether there was any increased risk to the patient in the performance of bilateral over uniIatera1 inguinal herniotomy. It resolved into an analysis of the postoperative complications and an attempt to ascertain the etiologic factors concerned. It was felt that information might be obtained which would aid in determining the value of thyroid extract as a prophylactic agent against embolism. The total number of cases studied was 1066, comprising a consecutive series of 522 bilateral and 544 unilateral herniotomies. Of the total number of patients, only 71, or 6.6 per cent, were females. Although various types of surgical procedures are employed in the treatment of inguinaI hernias they are sufficiently standardized to give a reasonable basis for comparison, and it can be said that there is approximately twice as much surgical trauma, and the duration of operation and anesthesia is approximately twice as long in bilateral herniotomy as in unilateral herniotomy. Right inguinal hernia occurs more frequently than left inguinal hernia, but there is no significant difference between the two in the risk of operative treatment, as far as comphcations are concerned. An interesting point was noted that, regardless of the side on which operation had been performed, phIebitis occurred much more frequently in the left Ieg. We shaI1 first concern ourseIves with those compIications that couId be of FeIIow in Surgery, The Mayo Foundation

A review of important contributions of surgery for cancer of the gastrointestinal tract

SummaryAlthough many of the surgical procedures and methods used today in the treatment of cancer of the gastrointestinal tract are not new, they are being used with far better results than were previously obtained because of the introduction of chemotherapeutics and antibiotics late in the 1930s. Safe blood transfusions, better anesthesia, and understanding of fluid and electrolyte balance have also been major contributing factors to surgical progress.Various important procedures and contributions can still be made in the surgeons everlasting struggle with inflammatory and malignant disease of the intestinal tract.

That hazardous eminence, the colostomy spur

Abstract Serious and sometimes fatal complications may follow crushing of a colostomy spur. These complications may manifest themselves shortly after the application of the enterotome, at any time while it is in position, or not until a variable time after it has come off. The occurrence of complications can be kept at a minimum by care in formation of the spur at the time of the original operation, by care in the application of the crushing device, and by proper management of the patient during convalescence. The clamp should be protected from traumatizing influences while it is in place and the activity of the patient should be limited. Confinement to bed is unnecessary but reasonably close surveillance is essential. Hasty tightening or premature removal of the enterotome is to be avoided. The surgeon should bear in mind the complications which may occur whenever unusual reactions follow the application of clamps or whenever he finds himself regarding the procedure as trivial or performing it thoughtlessly or hastily.

Gallstone obstruction of the sigmoid colon.

About 3 per cent of all cases of acute small-bowel obstruction are caused by gallstones. However, gallstone obstruction of the colon is quite rare. If such colonic obstruction does occur, it is usually in the sigmoid colon.It has been reported that gallstones which cause intestinal obstruction usually are 2.5 cm. in diameter or larger and reach the intestine through internal biliary fistulas. The authors report a case of gallstone obstruction of a normal sigmoid colon in which the gallstone entered the colon through a cholecystocolonic fistula.

Great Names in American Medical History

This is one of a series of biographic sketches of outstanding physicians of the past from each of the 50 states. The subjects have been selected by the medical society of each state or its designated committee.

The diagnosis and treatment of ileitis.

Regional enteritis is a chronic nonspecific granulomatous inflammation primarily of the terminal part of the ileum. The cause is unknown. Medical treatment consisting of measures of a supportive nature should be tried first. If this fails after adequate trial, then surgical treatment must be considered in a high percentage of cases.