Dan W. Elliott

Prospective controlled study of gastrointestinal stapled anastomoses

A controlled prospective study was carried out in a university-affiliated community hospital to evaluate the use of gastrointestinal staples compared with conventional sutures for anastomotic construction. The study included 100 randomized cases (50 sutured and 50 stapled) requiring anastomoses. Consecutive patients were accepted into the study, and no patients were excluded. There was no significant difference between the two groups in operating room time or the duration of postoperative hospitalization, nasogastric intubation or intravenous intubation. The complication rate was similar and comparable to previously published results. On three occasions, it was necessary during operation to convert from the use of staples to sutures when immediate disruption was noted at a gastroduodenal anastomosis.

Reassessment of primary resection of the perforated segment for severe colonic diverticulitis

Primary resection with colostomy has been widely adopted during the past decade for the treatment of patients with severe complications of diverticulitis. Because of this, a retrospective review was performed of all patients undergoing surgery for colonic diverticular disease during the two time periods 1974 to 1978 (n = 196) and 1982 to 1986 (n = 230). Forty-three patients had abscess or peritonitis from 1974 to 1978, whereas 52 had these complications from 1982 to 1986. Colostomy and drainage alone were used for 31 of 43 patients (72%) from 1974 to 1978, while primary resection with colostomy was used for 39 of 52 patients (75%) from 1982 to 1986 (p less than or equal to 0.5). Despite this shift in treatment method, mortality increased from 14% in 1974 to 1978 to 19% in 1982 to 1986 (p = NS). Patients with peritonitis had identical mortalities (22%) during both intervals. Patients with abscess experienced an increase in mortality from 8% in 1974 to 1978 to 15% in 1982 to 1986 (p = NS). The widespread use of primary resection for patients with severe complications of diverticulitis appears not to have altered mortality for those with diffuse peritonitis and may have worsened the outcome for those with abscess.

Effect of lost pancreatic juice on gastric acid and peptic ulcer

Abstract Gastric acid levels tend to rise if pancreatic enzymes become insufficient for normal digestion of fat. This may occur after extensive pancreatic resections and in occasional patients with chronic pancreatitis. The loss of jejunal enterogastrone appears responsible. Experimental evidence is reviewed and a program for management suggested.

Prevention of ulcer after pancreatic surgery

Abstract Extensive pancreatic resections for cancer are complicated by gastrojejunal ulceration and hemorrhage in a significant number of survivors. Experimental evidence indicates that an increase in production of gastric acid accounts for these ulcers, rather than a loss of alkaline pancreatic secretions. Hypersecretion of acid is induced by an operative procedure which preserves the pancreatic islets while preventing adequate enzymes from reaching the upper part of the small bowel. This hypersecretion is sharply reduced by gastric antrectomy. The experiments reported herein show that oral pancreatic enzymes can lower or prevent hyperacidity if they are begun immediately after operation, before hyperacidity becomes established. Enzymes also seem more effective after pyloroplasty or antrectomy. These observations support the essential role of pancreatic enzymatic digestion in regulating gastric acidity. In patients undergoing pancreatoduodenectomy, three steps seem important: (1) removal of the gastric antrum, (2) anastomosis of the pancreatic tail to the jejunum, and (3) administration of oral enzymes in the early postoperative period. Clinical experience with thirty-one patients is described, in which two hospital deaths ( 6 1 2 per cent) and no anastomotic ulcers occurred.

Primary mesenteric infarction

Abstract Primary mesenteric infarction has occurred in eighteen patients in ten years, or about twice a year at a 600 bed community hospital. Usually it has been misdiagnosed and appropriate treatment was delayed. The typical patient is in the age range in which arteriosclerosis appears and has complaints suggestive of intestinal obstruction or gastroenteritis. Abdominal roentgenograms were interpreted as showing intestinal obstruction in three-fourths of these patients. Most of the patients showed clinical and chemical evidence of dehydration. Serum amylase level is often elevated. With more vigorous preoperative intravenous fluid administration and early operation, the prognosis in these patients might be significantly improved.

Effect of antrectomy on gastric acid hypersecretion induced by isolation of the proximal small bowel.

Abstract Significant gastric acid hypersecretion from Heidenhain pouches follows conversion of the upper half of the small bowel below the pancreatic ducts into a defunctionalized Thiry fistula, or excision of this segment. Since comparable hypersecretion is produced by both procedures, this hyperacidity is probably due to the removal of a gastric acid inhibitor normally released by this segment of the bowel. Antrectomy with Billroth I type reconstruction radically reduces this acid hypersecretion well below base line controls, suggesting that the normal intestinal inhibition of acid is directed against antial gastrin. If the antrectomy is performed first, and the Thiry fistula formed later, the fistula induces a modest increase in acid, and subsequent excision of the fistula lowers acid levels to those expected after antrectomy alone. This reaction after antrectomy suggests that significant lengths of defunctionalized bowel also have the potential of releasing an acid-stimulating hormone.

Gastric analysis in the absence of demonstrable gastric pathology

Abstract This study represents a retrospective evaluation of eighty patients with upper gastrointestinal complaints who had negative results on x-ray evaluation. All of these patients had gastric analysis and fifty-nine patients had hyperacidity by our criteria. The mean follow-up period was fifty-five months. After this relatively short follow-up time, the data already indicate that: 1. 1. Eventual morbidity due to peptic ulcer disease increases as maximal free acid concentration increases. 2. 2. Eventual significant morbidity can be expected in 61 per cent of the patients with hyperacidity. 3. 3. Major morbidity can be expected in 20 per cent of the patients with hyperacidity. 4. 4. Surgical intervention will be required in 17 per cent of the patients with hyperacidity. It appears that gastric analysis is of predictive value in symptomatic patients in whom normal findings are seen on x-ray study, and it should consequently be a part of the evaluation of every patient with upper gastrointestinal complaints.

Portal Hypertension, vol 14 in Major Problems in Clinical Surgery series

This is a convenient small volume of 283 pages that looks like the preceding 13 monographs in this series. The editor of this volume, Charles Child III, MD, also wrote most of the first monograph in this series, The Liver and Portal Hypertension . The instant success of that volume did much to establish the widely used Child criteria for evaluating operative risk. Now, a decade later, the reader might expect a revised second edition. Instead, this volume brings together the latest thinking of 17 eminent authorities. There are 11 chapters, each with a principal author who has made a different and notable contribution to the surgery of bleeding esophageal varices. Dr. Child has asked each author to write his current opinion of the subject. As a result, there is some inevitable duplication. Several authors discuss the pathogenesis of portal hypertension on the basis of their own investigations. Where such talented