Francis C. Nance

Primary lymphoma of the gastrointestinal tract.

Primary gastrointestinal lymphoma represents approximately 1% of all gastrointestinal neoplasms. Gastric involvement is more common than small or large intestine and carries a better prognosis. Abdominal pain and weight loss may be the only manifestations and may be present for months or years before the diagnosis is made. Perforation and obstruction occur infrequently. Multiple tumors constitute 8% of cases. Although barium studies and endoscopy reveal the lesion in a high percentage of cases, exploratory celiotomy is not infrequently required for diagnosis. Only one-third of lymphomas are confined to the bowel at laparotomy. Histologically one-third are reticulum cell sarcomas and the remainder lymphosarcoma or lymphocytic lymphoma. Five year survival overall was 38%. Curative resections yielded a survival of 60% regardless of site while palliative resections offered only a 17% chance of cure. As expected, survival was inversely proportional to extent of nodal spread. Postoperative radiotherapy is recommended for residual disease.

Diagnosis and management of blunt abdominal trauma.

The records of 437 patients with blunt abdominal trauma admitted to Charity Hospital, New Orleans, from 1967–1973 have been reviewed and computer-analyzed. There was an 80% increase in the incidence of blunt abdominal trauma when compared with the preceding 15-year experience. Forty-three per cent of all the patients presented with no specific complaint or sign of injury. Blunt abdominal injury was usually diagnosed preoperatively using conventional methods including history, physical examination, and routine laboratory tests and x-rays. Abdominal paracentesis via a Potter needle had an 86% accuracy. The incidence and management of specific organ injuries with associated morbidity and mortality have been discussed. Mortality and morbidity continue to be significant in blunt abdominal trauma. Isolated abdominal injuries rarely (5%) resulted in death, even though abdominal injuries accounted for 41% of all deaths. Associated injuries, especially head injury, greatly increased the risk. The insidious nature of blunt abdominal injury is borne out by the fact that more than one-third of the “asymptomatic” patients had an abdominal organ injured. A high index of suspicion and an adequate observation period therefore are mandatory for proper care of patients subjected to blunt trauma.

Crohn's disease-associated carcinoma: a poorly recognized complication of inflammatory bowel disease

We have reviewed eight cases of Crohns disease associated carcinoma (CDAC) of the bowel treated at Saint Barnabas Medical Center since 1977. Five patients had colorectal carcinoma in areas of dysplasia within histologically recognizable Crohns disease. One of the large bowel carcinomas was a diffusely infiltrating signet ring adenocarcinoma (linitis plastica), three were mucinous carcinomas, and one contained both cell types. Survival ranged from 4 to 55 months. Three patients developed ileal carcinomas in areas of dysplasia within histologically recognizable Crohns disease. One of the ileal cancers was a moderately differentiated adenocarcinoma; two were poorly differentiated adenocarcinomas. Survival ranged from 8 to 44 months. The dysplastic changes seen in the bowel adjacent to the tumors in these patients were identical to the characteristic pre-cancerous (dysplastic) changes well described in ulcerative colitis. The histopathologic changes seen in this high-risk group of patients are also similar to those of previously reported CDAC. Those patients with the more diffuse dysplastic changes might have been detected before the development of invasive cancer had they undergone periodic colonoscopic surveillance. One patient in the series with an asymptomatic lesion was, in fact, identified at surveillance colonoscopy. It would appear that Crohns disease patients have a similar risk for carcinoma previously recognized in ulcerative colitis patients and that surveillance protocols should be developed for this group of patients.

Periampullary malignancy in Gardner's syndrome.

Three cases of familial polyposis coli with associated periampullary malignancies are reported and the literature reviewed, which disclosed 16 additional cases. An additional five unreported cases are known to exist. The authors believe that the development of periampullary malignancy in FPC is a definite extracolonic manifestation of the disease and should be considered a variant of Gardners syndrome. It is recommended that all FPC patients with colon polyps undergo routine surveillance of the upper gastrointestinal tract and that all duodenal polyps discovered be surgically removed when feasible.

New techniques of gastrointestinal anastomoses with the EEA stapler.

A new instrument for accomplishing inverted stapled anastomoses in the gastrointestinal tract is described. Side-to-side, end-to-side and end-to-end anastomoses can he performed. Techniques developed for utilization of the instrument in virtually all gastrointestinal anastomoses are described. In most instances a proximal or distal enterotomy is required. Experience with 57 anastomoses in 42 patients is reported. One leak occurred; no other complications not recognized intraoperatively were observed. Anastomoses completed included gastroduodenostomy, gastrojejunostomy, cholecystoje-junostomy, colocolostomy and ileocolostomy. Hazards and complications associated with the use of the instrument are described. It should be used only after the surgeon has acquired the skills to operate the instrument properly. The instrument saves time, creates better anastomoses than can be obtained by hand sewing and is extremely versatile. It may permit safer anastomoses in adverse conditions, such as in obstruction and peritonitis. The instrument opens new horizons in gastrointestinal surgery.

Changing patterns in the management of pancreatic pseudocysts.

The records of patients treated from 1938 through June, 1974, for pancreatic cysts have been reviewed. There was 205 cysts including 168 pseudocysts, 21 neoplastic, 13 retention, and 3 congenital pseudocysts. An analysis of two eras has been made: cysts treated prior to 1962 (56 patients) and cysts treated after 1962 (98 patients). In the earlier era 66.4% of patients were treated by external drainage and 34% by excision or internal drainage. By marked contrast in the more recent era only 27% were treated by external drainage and 73% by excision or internal drainage. The recurrence rate fell from 27% in the earlier era to 6% in the modern era. Improved morbidity was evidenced by a reduction from 32.2% to 15.3% in additional procedures required. Individualization in the treatment of pseudocyts with adherence to establish criteria for procedure selection with increased reliance on excision or internal drainage, as well as early diagnosis and timely intervention have improved the results of surgical therapy in this disease.

Role of Urea in the Hyperammonemia of Germ-Free Eck Fistula Dogs

Hyperammonemia and symptomatic hepatic encephalopathy occur in germ-free (GF) animals after creation of an Eck fistula. The role of urea as a possible substrate for ammonia production in germ-free Eck fistula dogs was assessed in this experiment. End to side portacaval shunts were performed in GF and conventional dogs. After recovery, 40 g of urea in 200 ml of water were given by orogastric tube, and blood ammonia levels measured 3 and 6 hr postingestion, both in GF and conventional Eck fistula dogs. Conventional dogs had massive increases in blood ammonia averaging 483% after urea ingestion. GF dogs had only a minimal change averaging -6.35%. Hydrolysis of urea plays no role in the hyperammonemia of GF Eck fistula dogs, in striking contrast to conventional dogs and probably patients. The experiment provides indirect evidence that there are no endogenous ureases present in the gastrointestinal tract of the dog.

Carcinoma arising in a choledochal cyst.

SummarySix cases of carcinoma arising in a choledochal cyst have been found in the literature. We have reported an additional case and have reviewed the worlds literature. The mean age of onset was 41 years of age. The classic triad of jaundice, pain and mass in the right upper quadrant has been found in only 1 patient. Choledochal cyst has never been diagnosed preoperatively, although biliary tract disease was suspected in 5 patients. At surgery, the anatomy often has been distorted and a second operation has been necessary to clarify it. The average survival time after diagnosis has been 9 months.

Absolute barrier isolation and antibiotics in the treatment of experimental burn wound sepsis

Abstract 1. 1. A model for studying the effect of absolute barrier isolation on mortality from burn wound sepsis is described. 2. 2. Systemic polymyxin alone did not increase survival in this model. 3. 3. Topical mafenide with or without systemic polymyxin markedly improved survival from experimental burn wound sepsis. 4. 4. The mortality of animals treated with systemic and oral polymyxin, topical mafenide, and absolute barrier (germfree) isolation was the same as the mortality of similarly treated animals without isolation. 5. 5. In this model, absolute barrier isolation was of no value in the treatment of experimentally contaminated burn wounds.

Congenital duodenal web in an adult

Summary1. A case of a congenital duodenal web in an adult is reported.2. Sixty cases of this entity have now been described.3. Symptoms are often vague and nonspecific. X-ray diagnosis may be difficult.4. Treatment in most cases should consist of excision or incision of the web.