G. B. Ong

A prospective study of operative risk factors in perforated duodenal ulcers.

Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.

Pelvic exenteration for locally advanced colorectal carcinoma.

Pelvic exenteration provided worthwhile palliation and achieved a cumulative five-year survival rate of 38.8% in 49 patients who had carcinoma of the lower colon or rectum infiltrating adjoining pelvic viscera. Survival and the disease-free period were not significantly different after total or posterior exenteration. The stage of disease was the major determinant of outcome: five-year survival rates averaged 51.8% and 28.8% for Stages II and III, respectively. Hospital mortality (26.9%) after total exenteration was chiefly due to technical mishaps, and the inclusion of many high-risk but symptomatic elderly patients. Complete clearance of locally advanced colorectal cancer by pelvic exenteration is indicated in fit patients, especially those with Stage II disease.

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial.

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.

Gastrocystoplasty in Dogs

While performing a colocystoplasty for cancer of the urinary bladder, we found that the stomach was low-lying and that the pylorus could reach the pelvis with ease. It then occurred to us that the pyloric portion of the stomach could be used to replace the urinary bladder, after which the duodenum could be anastomosed to the divided urethra. As we were not certain whether this operation would he feasible, we studied it in dogs. Technically it was difficult, but after losing some dogs we managed to succeed in performing the operation and grafted a pyloric portion of the stomach to the urethra of the dogs. A study was made on both the function of this new bladder and the gastric secretion. After two years we were quite satisfied that the gastric pouch would serve as a urinary bladder and that there was no hyperchlorcaemic acidosis in these dogs.

Carcinoma of Large Bowel in the Young

The incidence of large-bowel carcinoma in young people seems to be increasing. Twenty-one cases occurring between the ages of 13 and 25 are reviewed. Most cases were found to be in an advanced state of the disease. High grade malignant growths were found to be twice as common in the young as in adults. The mode of presentation is no different from that in adults and a plea is made for improving results of treatment by earlier diagnosis, which can be established by an increased awareness of the disease in children and young adults.

Bacteria and septic complications in patients with perforated duodenal ulcers

To evaluate the clinical significance of bacterial contamination in perforated duodenal ulcers, we prospectively studied septic complications in 184 consecutive patients. All patients received parenteral antibiotics (over 90 percent preoperatively) for at least 7 days. Thirteen infections developed in eight patients (4.3 percent). Peritoneal cultures, performed in 143 unselected patients, were positive in 33.6 percent of cases. Bacterial growth occurred more often and in heavier amounts in patients who underwent exploration late (after 48 hours) and those who had gross peritoneal soilage. Candida and gram-negative organisms predominated, but there was no correlation with pathogens that produced abscesses or wound infections. Old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when explorations was performed within 2 days of perforation. We treated perforated ulcers as clean-contaminated cases, and recommend that three doses of prophylactic antibiotics be begun preoperatively in all patients.

Tracheostome construction during laryngectomy —a method to prevent stenosis

A new technique for construction of the tracheostome at the time of total laryngectomy is described. It involves making an X‐shaped incision on the lower skin flap and four slits on the divided trachea. The result is a serrated suture line at the tracheocutaneous junction. The incidence of stenosis in 116 patients who did not have this method of construction was 31%. Sex difference and previous irradiation was not found to be related to the occurrence of stenosis. Of 25 patients who had the new method of tracheostome construction, only one patient had to wear a tube until she died at 7 months. The rest, followed up for at least 9 months, did not have stenosis. It is concluded that this new method of tracheostome construction will reduce the incidence of stenosis.

Subglandular Urethral Fistula Following Circumcision: Repair by the Advancement Method

AbstractA post-circumcision urethral fistula is reported and a 1-staged repair is described.

Pyloric function five to eleven years after Ramstedt's pyloromyotomy

Pyloric function after Ramstedts pyloromyotomy was assessed in seven patients aged five to eleven years and compared to that in sixteen normal children. Gastric emptying (T 1/2) of liquid, as measured by the double sampling test, was faster in patients than in normal children. Duodenal reflux was calculated from the sodium content in gastric aspirates. At rest, it was greater in patients than in normal children. In the poststimulatory state, there was no difference. Gastric acid secretion was similar in both groups. Rapid gastric emptying might explain the high incidence of peptic ulcer reported in several series of long-term follow-up patients. Increased duodenal reflux at rest might account for a similar increased incidence in gastritis and dyspepsia.

Gastric carcinoma developing in chronic gastric ulcer in the rat treated with N-methyl-N1-nitro-N-nitrosoguanidine

The purpose of this experiment was to determine if chronic gastric ulcer in the rat is prediposed to tumor formation when exposed to a known gastric carcinogen. N-methyl-N1-nitro-N-nitrosoguanidine (NG). Rats were subjected to a standard ulcer-producing operation. Treatment with oral NG (as drinking water) was continued for at least 40 weeks. Appropriate control groups underwent sham operation and/or were fed with tap water. The experiment terminated at 52 weeks. The results showed that significantly more tumors were found at the edge of a chronic ulcer or at the site of previous mucosal injury in the rats which had the ulcer-producing operation and fed with NG than controls (P < 0.005). However, the number of tumors per rat stomach was the same when the rats were treated with NG whether an ulcer-producing operation or a sham operation was carried out. Furthermore, 1852 rats in the group with ulcer-producing operation and NG had chronic ulcers without tumors. It is concluded that, in the rat, the presence of a chronic gastric ulcer is more likely to localize the development of a tumor to the ulcer or to the site of previous injury, but does not increase the overall incidence of gastric tumors.