Clarence J. Berne

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.

Hemodynamic and metabolic changes associated with bacterial peritonitis

Abstract Hemodynamic and metabolic studies of ten patients critically ill with diffuse bacterial peritonitis have been presented. The cardiac output and velocity of blood flow were normal. Total peripheral arterial resistance was markedly reduced in patients in whom systolic blood pressure was reduced to 75 mm. Hg or less despite normal cardiac output. Blood lactate levels were greatly elevated in these patients, indicative of a critical reduction in blood flow necessary to sustain normal metabolism of vital tissues. Our data indicate that an abnormal variation in distribution of blood flow is an outstanding circulatory alteration in patients with diffuse bacterial peritonitis. This hemodynamic effect may be explained by arteriovenous shunting in the systemic vascular bed. The site of such shunting is as yet unidentified, but presumably occurs in the area of peritoneal inflammation. Decreases in alveolar oxygen exchange also indicate the coexistence of arteriovenous shunting in the pulmonary circulation. Ventilatory failure and profound alterations in pulmonary function appear to be significant factors in the lethality of diffuse bacterial peritonitis.

Cardiac arrest; problems in its control.

Abstract 1. 1. Anesthetic death usually represents unrecognized and untreated cardiac arrest occurring in a good risk patient. 2. 2. Uncorrected physiologic disturbances in severely ill patients are often similar to those resulting from imperfect anesthesia or unduly traumatic, bloody surgery. 3. 3. Cardiac arrest is more likely to occur in severely ill than relatively well patients. 4. 4. Operating room deaths occurring in severely ill patients often are attributed to the primary disease. All such deaths should be included and analyzed when the incidence of cardiac arrest is reported from any series of surgical operations. 5. 5. In our cases of cardiac arrest the etiologic factors in order of importance were: asphyxia, relative overdose of anesthetic, operative hemorrhage, inadequate preoperative preparation and hypoxia. 6. 6. When the predominant etiologic factor was anesthetic rather than surgical, resuscitative measures were much more effective. 7. 7. Control of the problem of cardiac arrest is basically a problem in education. The joint program of the Los Angeles County Heart Association and the University of Southern California School of Medicine is described. 8. 8. Proficiency in the treatment of cardiac arrest can be attained best by practical experience in the laboratory.

Local recurrence following subtotal gastrectomy for carcinoma

Abstract Necropsy study of twenty-eight patients who survived subtotal gastrectomy for gastric carcinoma disclosed a “recurrence” rate of 78.6 per cent in the gastric stump and 10.7 per cent in the duodenal stump. The usual subtotal gastrectomy frequently fails to accomplish a complete removal of the primary tumor because an inadequate amount of stomach is removed.

Significance of the nonpassage of radiopaque media through the ampulla of vater during operative cholangiography

Summary The nonpassage of radiopaque media through the ampulla of Vater during secondary operative cholangiography was found to occur frequently in the absence of calculi, neoplasm, or stenosis. Trauma-induced sphincteric spasm, usually related to instrumentation, is believed to have been responsible. When nonpassage is associated with other cholangiographic evidence of disease, the common duct should be explored. If nonpassage occurs without x-ray evidence of other disease and if the ampulla has been traumatized, it may be presumed that transient spasm of the ampulla has been incurred and re-exploration of the common duct is not indicated. Primary operative cholangiography gives more precise information regarding the status of the papilla and its sphincter than does secondary operative cholangiography preceded by instrumentation.

EMERGENCY RIGHT HEMICOLECTOMY.

Summary Twenty emergency right hemicolectomies have been performed over a four year period with a mortality of 20 per cent. Thirteen of these resections were performed for obstructing neoplasm of the right colon, three for extensive inflammatory disease of the right colon, and four for irreversible impairment of the vascular supply of the bowel. Concurrently the mortality for elective right hemicolectomy was 16 per cent. A review of this experience reveals that emergency right hemicolectomy was performed without intraperitoneal septic complications, anastomotic obstruction or leak, or other major regional complications. Intensive local and systemic antibiotic therapy was believed to be decisive in this regard. The results reported are encouraging when the indication for resection was extensive inflammatory disease or a circumscribed area of impaired circulation to the wall of the bowel. The decision to proceed with primary resection of obstructing neoplasms of the right colon should be based on consideration of the patients age, associated disease, duration of obstruction, magnitude of the acute illness, and the patients demonstrated satisfactory tolerance of the initial stages of the operation.

Gastrointestinal tract neoplasms with dependent hypoglycemia

Abstract A seventy-four year old man with primary adenocarcinoma of the colon and hepatic metastases was found to have severe hypoglycemia. A recently developed test using glucagon excluded the possibility of hyperinsulinism and deficient hepatic storage of glycogen as mechanisms for hypoglycemia. Pancreatic islet alpha cell granules were markedly decreased. Twelve similar cases of neoplasms of the gastrointestinal tract with dependent hypoglycemia have been found in the literature. Mechanisms proposed to explain this hypoglycemia are numerous and no single mechanism can explain the oncogenic hypoglycemia in all reported cases.

Effect of a T tube on proximal choledochal pressure

Abstract In these laboratory studies a T tube in the canine common bile duct connected to gravity drainage resulted in a decrease in choledochal pressure proximal to the T tube.