George J. Farha

Acute diverticulitis: Comparison of treatment in immunocompromised and nonimmunocompromised patients☆

The clinical course and required treatment of diverticulitis were reviewed in 76 nonimmunocompromised patients and 10 immunocompromised patients. The immunocompromised patients presented with either minimal or no symptoms and findings. Therefore, to make the diagnosis of acute diverticulitis in this group, a high index of suspicion must be maintained. The required treatment varied considerably between the two groups. In 45 nonimmunocompromised patients (76 percent), medical therapy was successful. Medical treatment failed in the other 14 patients (24 percent). However, the compromised group had no patients in whom medical therapy was successful (100 percent failure rate). Thirty-one of the nonimmunocompromised patients (41 percent) required an operation, whereas 100 percent of the immunocompromised patients with acute diverticulitis required an operation. By relating postoperative complications, we were unable to determine the initial operative procedure of choice in the nonimmunocompromised group; however, in the immunocompromised group, colostomy and resection had fewer surgical complications than colostomy and drainage. The immunocompromised patient with acute diverticulitis requires operation. We believe the operation of choice is colostomy and resection of the involved segment.

Transcystic duct operative cholangiography

Abstract Of 500 consecutive cholecystectomy patients, sixty-nine had clinical indications for common bile duct exploration and twenty-nine of these yielded stones for an overall accuracy rate of 42 per cent. Of the 431 remaining patients, thirty-six demonstrated abnormal cholangiograms and in these, twenty-six yielded stones within the common duct, representing an incidence of 6 per cent of unsuspected stones. Of the total series of 500 patients, sixty-one showed cholangiographic indications for common duct exploration and fifty were positive for stones for an overall accuracy of 82 per cent. The overall incidence of common duct stone recovery was 11 per cent. It is concluded that transcystic duct operative cholangiography should be performed routinely during cholecystectomy when feasible.

Is nasogastric intubation necessary in colon operations

Fifty-six patients undergoing elective colonic resection were prospectively randomized into two groups either with or without postoperative nasogastric decompression. The results demonstrated only minimal differences between the two groups. Postoperative abdominal distention was more common in patients without nasogastric tubes, whereas pulmonary complications were more common in patients with nasogastric tubes. Other morbidity and mortality and hospital stay were the same in both groups. We conclude that in elective colon operations, the routine use of postoperative nasogastric decompression is unnecessary and can safely be omitted.

Pseudolymphoma of the breast. I. In a study of 8,654 consecutive tylectomies and mastectomies

Pseudolymphoma is a benign pathological process that morphologically resembles malignant lymphoma. Its occurrence in the mammary tissue has been described but has not been well investigated. We conducted a prospective and retrospective study of 8,654 consecutive mastectomies and tylectomies of the breast and found only 9 cases (0.1%) of primary lymphoreticular lesions. Of these 9, 5 were pseudolymphomas; 3, histiocytic lymphomas; and 1, Hodgkins disease. Clinically, pseudolymphoma of the breast was described as an enlarging mass giving a dull, aching sensation. A history of physical trauma to the affected area could be traced in 3 patients with certainty. The mean patient age of the entire series was 36 years. Grossly, the tumor was a solid, firm nodule without any evidence of fibrocystic disease. Microscopically, it showed a lymphoid infiltrate with a nodular pattern. Three of the 5 cases revealed distinct germinal centers. Atypical lymphoid cells were not observed in any of these cases. After local excision, no patients had recurrence over a period of two to eight years. In view of a history of trauma, accompanying fat necrosis in some cases, IgG gammopathy, it is postulated that pseudolymphoma of the breast, probably akin to pseudolymphoma of the lung, may represent an overwhelming local response to an injury. This lesion, reactive in nature, should be differentiated from a malignant lymphoma so that patients are not subjected to unnecessary mastectomy, radiation, or chemotherapy.

Incidence and associated mortality of retained common bile duct stones

A hundred consecutive patients who underwent cholecystectomy and exploration of the common bile duct were studied. The traditional indications for exploration resulted in a yield of 55 percent positive explorations. There were nine patients with retained stones, three of whom died. The high mortality rate of patients with retained stones stresses the importance of systematic and thorough exploration of the biliary tree during initial operation. Choledochoscopy, when combined with cholangiography, may decrease the incidence of retained stones.

Role of needle localization of nonpalpable breast lesions.

This study of 89 women who underwent 100 consecutive needle localization procedures for nonpalpable breast lesions revealed a 19 percent malignancy rate. These lesions tended to be small and had a 6.2 percent incidence of nodal metastasis. Needle localization also identified 19 additional patients who were at increased risk for invasive breast cancer. The procedure was effective, well tolerated, carried a low morbidity, and resulted in the removal of a minimal amount of breast tissue. It must be emphasized that although mammography and needle localization are useful tools, they are only adjuncts to breast self-examination and clinical observation.

Drainage in elective cholecystectomy

This randomized, prospective study evaluates drainage of the subhepatic space in patients undergoing simple, uncomplicated cholecystectomy. One hundred twenty-two patients were divided into open (Penrose) drainage, closed sump drainage and no drainage groups. Open drainage resulted in increased morbidity and a longer postoperative hospital stay. The best results were in patients without drains. Subhepatic drainage is unnecessary in simple, uncomplicated cholecystectomy.

Abdominal aortic aneurysms. A comparative analysis of surgical treatment of symptomatic and asymptomatic patients.

This retrospective study of 120 patients identified three separate variables that influence operative mortality in patients with abdominal aortic aneurysms. These are age, presence or absence of symptoms, and presence of three preoperative risk factors or more. Based on this study and the fact that any aneurysm may rupture without warning, we conclude that observation of good risk asymptomatic patients until symptoms occur is unjustified. Asymptomatic patients less than seventy years old can undergo abdominal aortic aneurysmectomy with minimal mortality. Carefully selected asymptomatic patients more than seventy years old can also under surgical intervention with acceptable results.

Massive upper gastrointestinal hemorrhage in the elderly.

Sixty-six elderly patients with massive upper gastrointestinal bleeding were retrospectively analyzed. This study supports the concept of vigorous resuscitation, early diagnosis with fiberoptic endoscopy, and prompt surgical intervention in patients with continued bleeding. When this approach was utilized in a community hospital, operative mortality was reduced to 5 per cent.

Carcinoma of the male breast

Abstract Records of ten patients with malignant lesions of the male breast are reported from the Wichita Veterans Administration Center Hospital since 1933 and St. Francis Hospital during the past ten years. Of these patients the majority had carcinoma, including one melanosarcoma and one neurofibrosarcoma. In one man with long-term survival, the diagnosis of carcinoma is questioned since we are unable to find the pathologic material; it is possible the patient had bilateral fibroadenomas. However, he is included in the report because the strength of the primary diagnosis makes frequent follow-up study necessary, and his case falls among the coded records. Orchiectomy was seldom performed and, on occasion, was ineffective. The marked improvement noted in a recent patient has revived interest in this procedure as a palliative measure. Although results are unpredictable, we have recommended the procedure since that time. A plea is made for more frequent reporting of male patients with breast carcinoma so that some type of analysis of survival rate might be statistically significant. We believe that orchiectomy has much to offer in some patients with metastases from carcinoma of the breast.