Earl F. Wolfman

Meckel's diverticulum: Should it be excised incidentally at operation?

Meckels diverticulum is the most common congenital abnormality of the small intestine, occurring in about 2 per cent of the population. Complications of a Meckels diverticulum, including hemorrhage, inflammation, bowel obstruction, and neoplasms, occur in 15 to 33 per cent of cases and invariably demand operative treatment. When signs or symptoms arise from a Meckels diverticulum, morbidity and mortality are high. Incidental Meckels diverticulectomy should be performed at any age when the morbidity and mortality of the primary procedure will not be increased substantially.

Intestinal necrosis and perforation in patients receiving immunosuppressive drugs

Immunosuppressive agents are frequently used in transplant recipients for prevention of homograft rejection and in patients with leukemia for treatment of their primary disease. From 1973 to 1975, fifty-nine patients undergoing renal transplantation and forty-one patients with leukemia were treated at the University of California (Davis) Medical Center. Intestinal necrosis and perforation developed in four (7 per cent) of those receiving transplants and in four (10 per cent) of the patients with leukemia. One transplant receipient and all four patients with leukemia had extensive necrosis of both the small and large intestines. Two transplant recipients had isolated sigmoid perforations, and one had splenic flexure colonic perforation. All died from septicemia with septic shock. The etiology of these intestinal complication appears related to immunosuppressive agents, particularly high dosages of steroids. Despite the grave prognosis, early surgical intervention is the only method of dealing with these complications. Early diagnosis as well as properly timed and selected operations are necessary for the successful management of these patients.

Pancreatic pseudocyst: Management in fifty-four patients☆

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Primary adenocarcinoma of the vermiform appendix.

Abstract The surgical management of adenocarcinoma of the appendix is discussed. Seven cases of this entity together with a review of the literature are presented. The incidence, classification, pathophysiology of the symptom complex, treatment, and results are reviewed. To obtain the best prognosis, we recommend that right hemicolectomy be performed for invasive adenocarcinoma of the appendix, either at the initial operation or subsequently.

Linear abdominal trauma.

Three cases of blunt abdominal trauma are presented to exemplify the mechanism of trauma and the problems of diagnosis associated with any linear blow to the abdomen. The mechanisms of visceral injury are reviewed, and special attention is directed to the abdominal wall injury that can be present in these patients. This injury has special implications in directing the operative approach and repair. An unusual aortic occlusion is described which is peculiar to this type of injury.

Technetium-99m pyridoxylideneglutamate (P.G.) cholescintigraphy.

Technetium-99m P.G. cholescintigraphy was performed in 27 human volunteers and 81 patients referred for hepatobiliary tract disease. The gallbladder, biliary system, and gastrointestinal tract were well visualized in the normal patients and volunteers. The gallbladder was not visualized in 22 patients with histologically proved cholecystitis with cystic duct obstruction. Nine patients with complet extrahepatic obstruction of the common bile duct were correctly diagnosed. Hepatocellular disease and incomplete obstruction, with and without jaundice, were diagnosed with this technique. Oral cholecystography is superior to this method for the detection of cholelithiasis in nonjaundiced patients.

Hepatobiliary scanning using 99mTc-pyridoxylideneglutamate

Technetium 99m-pyridoxylideneglutamate (99mTc-PG) administered intravenously is excreted by hepatocytes into the bile canaliculi and enters the gallbladder through the cystic duct and consequently, can be used for scanning the hepatobiliary ductal system. A total of 166 patients representing 27 normal subjects, 84 patients referred for investigation for pain in the upper right quadrant of the abdomen and 55 jaundiced patients were evaluated with 99mTc-PG. In normal human volunteers, the agent reached the liver in five minutes, and the common bile duct, gallbladder, and duodenum within 15 minutes. Satisfactory images of the hepatobiliary tract were obtained using small dosages of 99mTc-PG. The gallbladder was not visualized when the cystic duct was occluded. In the presence of acute cholecystitis, cystic duct obstruction, or in chronic cholecystitis where other roentgenographic studies showd a nonfunctioning gallbladder, there was no concentration of 99mTc-PG in the gallbladder. In partial common bile duct obstruction is distended common bile duct was visualized along with delay in transit of radioactivity into the duodenum. Complete common bile duct obstruction was associatedwith no radioactivity in either the biliary or the gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of biliary and gastrointestinal tracts. 99mTc-PG scanning proved capable of differentiating between hepatocellular disease and extrahepatic biliary tract obstruction.

Survival Following Infusion of Pitressin into the Superior Mesenteric Artery to Control Bleeding Esophageal Varices in Cirrhotic Patients

Morbidity and mortality data from patients with bleeding esophagogastric varices treated with portosystemic shunts relate to the clinical status of the patient and to control of hemorrhage both in the immediate postoperative period as well as later. To obtain comparable data following selective infusion of pitressin into the superior mesenteric artery (SMA), records of 23 consecutive patients with cirrhosis, diagnosed by endoscopy as bleeding from varices and treated with SMA pitressin infusions, were reviewed. Twenty-four infusions were performed and hemorrhage was controlled in 12. Fourteen of the 23 patients subsequently underwent portosystemic shunts. Pitressin infusion controlled hemorrhage preoperatively in seven of these, and five survived one year or longer. The remaining seven, in whom bleeding was not controlled by pitressin, died postoperatively. One of nine patients not undergoing a portosystemic shunt survived more than eight weeks after pitressin infusion. Vascular complications occurred in seven of 17 who died. These complications and the delay between institution of pitressin and operative therapy to control variceal hemorrhage appears to be a factor in the high mortality rate. Portosystemic shunt remains the best therapy for uncontrolled hemorrhage and to prevent recurrent bleeding from esophageal varices.

Determination of Intestinal Viability

Operations for intestinal ischemia are frequently done by veterinarians. In equine surgery those conditions commonly producing ischemia are intussusception, volvulus, bowel obstructions, and incarcerated hernias. In an attempt to predict intraoperative bowel viability after the restoration of circulation, a variety of adjuvant methods have been investigated. There is little question that of the techniques currently available, sodium fluorescein injected intravenously approaches the ideal in predicting nonviability in humans and in most animal models. Furthermore, it is safe, takes little operating time, is inexpensive, and is ubiquitously available; in addition, the only special equipment needed is a long-wave ultraviolet lamp. Reliance on this method would seldom result in nonviable bowel being left in situ. Furthermore, the use of fluorescein would minimize the unnecessary resection of viable intestine and, thereby, minimize the postoperative nutritional problems that may occur, especially in equines. The report of Sullins et al questions the accuracy of the fluorescein technique in predicting viability and nonviability in horses and also raises the question as to whether the prediction of viability, after the restoration of intestinal blood flow, also predicts normal intestinal function. Further investigations will be needed to confirm or refute these observations.

Clinical evaluation of 99mTc-pyridoxylideneglutamate for hepatobiliary scanning.

Clinical evaluation of hepatobiliary scanning using 99mTc-PG was done in twenty normal volunteers and eighty-three patients with liver and biliary tract disease. Satisfactory images of the biliary tract were obtained using small dosages of this agent. In normal humans, the agent reached the liver in 5 minutes, and the common bile duct, gallbladder, and duodenum in 10 to 20 minutes. The gallbladder was not visualized when the cystic duct was obstructed in patients with acute and chronic cholecystitis. In patients with partial common bile duct obstruction, a distended duct was visualized and there was delay in transit of radioactivity into the duodenum. With complete common bile duct obstruction, no radioactivity was seen in the biliary or gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of the biliary and gastrointestinal tracts. There were no toxic or other untoward effects in any patients.