George T. Pack

METABOLIC STUDIES IN PATIENTS WITH CANCER OF THE GASTROINTESTINAL TRACT. II. HEPATIC DYSFUNCTION

Excerpt In a previous communication1it was demonstrated that about 85 per cent of patients with cancer of the gastrointestinal tract had abnormally low plasma levels of vitamin A. In the majority o...

Unusual tumors of the stomach.

Cancer of the stomach has been such a frequent neoplastic disease and so important because of its uncertain etiology, nonspecific symptomatology, morbidity, and the technical problems encountered at radical surgical extirpation, that the uncommon benign and malignant stomach tumors of different histogenesis have not received commensurate consideration until more recent years. The gastric mucosa is the portion of the stomach that bears the brunt of all carcinogenic influences, which probably accounts for the preponderance of carcinomas over other gastric tumors. There is cause for rejoicing over the constant and gradual decline in the incidence of gastric cancer in the United States. Certain carcinomas of unusual character will be considered because of problems in recognition and treatment, namely: ( 1 ) carcinoma-in-situ, (2) superficial spreading cancer, (3) adenoacanthoma, (4) linitis plastica, ( 5 ) carcinoma developing after gastroenterostomy (stoma1 cancers), (6) carcinoma in the ectopic or dystopic stomach. According to the author’s experience, the natural history, pathology, and significance of other tumors, benign and malignant, and usually of mesoblastic histogenesis, are related. Some space-occupying lesions within the stomach, which are not tumors but may be diagnostically confused with neoplasms, are cited in the examples of eosinophilic granuloma, aberrant pancreatic rests, and gastric bezoar.

Combined Radiation Therapy and Surgical Treatment of Technically Inoperable Cancer

The possible combination of radiation therapy and surgical treatment has been a hopeful concept of the oncologist. Great advances have been made in the evolution of radiation therapy of cancer during the past twenty-five years. These accomplishments have been: first, the standardization of technics for x-ray and radium therapy; second, accuracy of dosage through better physical equipment, physical measurements, tumor-dose determination, etc.; third, improvement in equipment to employ voltages of various strengths under proper conditions; fourth, the large accumulated body of knowledge concerning the radiosensitivity of almost all cancers, the better knowledge of the natural history of each disease, and in many instances the determination of the lethal dose in terms of radiation units of treatment. Choice Between Radiation Therapy and Surgical Treatment of Cancer Indications for radiation therapy and for the surgical treatment of cancer have become more clearly defined, although for cancers in some locatio...

Metabolic Studies in Patients with Gastrointestinal Cancer. III. The Hepatic Concentrations of Vitamin A.

Conclusions The low plasma levels of vitamin A of patients with cancer of the gastrointestinal tract probably are not due to a decreased capacity of the livers of those patients to store the vitamin.

Resection of the mandible for medullary osteosarcoma

Abstract A case report is given of a medullary osteogenic sarcoma of the mandible, treated by hemiresection of the mandible. This destructive operation may be performed without mutilation or functional impairment.

General technique of operations for gastric carcinoma

Abstract The purpose of gastrectomy for cancer is a wide removal of all carcinomatous tissue within the stomach and juxtagastric lymphatics. The two divisions of the operation (A) extirpation of the cancer and (B) restoration of gastrointestinal continuity should be sharply differentiated. Selection of the technique for anastomosis should as a rule be delayed until the stage of excision has been concluded. No single method for repair proves suitable for all cases. Flexibility of technique is a prime requisite in gastric cancer surgery. The score of optional methods available provide ample means for safe reconstruction of the digestive tract no matter how extensive the carcinomatous invasion. Alignment of the parts without tension, meticulous care in suturing to ensure broad peritoneal approximation, the use of nonabsorbable suture materials for the outer rows of sutures and free use of interrupted stitches, are essentials that cannot be disregarded with impunity. The entire subject of gastrointestinal repair after resections for carcinoma has long been considered complex and difficult; but much of the apparent complexity is pedantic. Relative simplicity is obtained by focusing attention on the six fundamental anatomic points which underlie similarities and differences between all methods. The operations should be anatomically described for postoperative records, whether or not eponymic names are added. Palliative operations for stomach cancer offer little prolongation of life. In a disease so rapidly fatal without excisional surgery a considerable operative mortality may be faced with equanimity. An attempt should be made to remove the cancer in one or two stages wherever there appears to be reasonable hope of success. In competent hands partial gastrectomy for cancer has proved to be “an operation without undue risk but an operation of generous promise.”

De Petz clamp in surgical treatment of gastric cancer

Summary The de Petz sewing clamp furnishes a rapid hemostatic suture, which is of great service in selected cases of gastric resection for carcinoma.

HEMOSTASIS IN MAJOR EXTIRPATIVE SURGERY FOR CANCER

The avoidance of hemorrhage in major extirpative surgery for cancer is most important for the successful conduct of the case. The operative and postoperative course of the patient in whom hemorrhage has been avoided is much smoother and healing is much more rapid. The cause of hemorrhage may exist in the preoperative state, or may be the result of changes owing to blood loss occurring during operation and the efforts a t replacement of blood and fluid. In the preoperative state, hemorrhagic diatheses, liver damage with prolonged prothrombin time, pancytopoenia in the lymphomas and in patients undergoing radiation therapy and chemotherapy, and jaundice can be anticipated and corrected by careful preoperative study and treatment. Changes caused by blood loss occurring during operation, such as changes in blood coagulation in shock, interdonor incompatibilities, age of blood in massive transfusion, hypotension with subsequent blood loss when blood pressure has been restored, and fibrinolysis can be prevented in many patients by planned operations in which preliminary ligation of the blood supply to the tissues or organs to be extirpated is performed. Some major operations, such as radical mastectomy, radical groin dissection, and prostatectomy do not lend themselves to planned ligation, but one must depend on meticulous local control of bleeding by clamp and ligature, packing, etc. Preliminary ligations are possible in many operations such as pelvic exenteration and radical hysterectomy with node dissection in which the internal iliac arteries are ligated prior to the dissection, interscapulothoracic amputation in which the subclavian vessels are ligated at the initial step in the. operation, rectal resection with ligation of the inferior mesenteric artery, right hemicolectomy with ligation of the iliocolic vessels, thyroid lobectomy with ligation of the inferior and superior thyroid arteries, splenectomy with preliminary ligation of the splenic vessels, gastrectomy with ligation of the right and left gastric arteries a t their origin, pulmonary resections, and other major amputations, such as hip joint disarticulations and hemipelvectomy, and controlled hepatic lobectomy. We have reported over 100 hemipelvectomies in which the average blood loss was only 1,000 cc. because we practiced the technique of preliminary ligation of the common iliac artery and its branches. Some of these patients lost less than 500 cc. of blood, as determined by weight. Most of these pa-

Metabolic Studies in Patients with Cancer of the Gastro-Intestinal Tract. XX. Lipotropic Properties of Protein.∗

Conclusions 1. Patients with gastrointestinal cancer fed protein-rich diets pre operatively do not have fatty infiltration of the liver at laparotomy. 2. Patients with gastro-intestinal cancer who ingested 75 g of amino acid mixture during the 10 hours before operation were found at laparotomy to have concentrations of fat as abnormally high as those of fasted patients.

Metabolic Studies in Patients with Cancer of Gastro-intestinal Tract. XV. Lipotropic Properties of Inositol.∗

Recent studies from this hospital have demonstrated that the livers of patients with gastro-intestinal cancer almost uniformly are infiltrated with fat. 1 In contrast to this finding, normal fat contents were found in the livers of 11 patients with carcinoma of the gastro-intestinal tract who each received 8 g of lipocaic† during the night prior to laparotomy. The average hepatic fat concentration of this latter group was only 0.46 that of the control untreated patients. 2 Lipocaic, however, is a crude mixture which contains significantly large amounts of choline and inositol,† both of which are lipotropic alone. 3 , 4 In experimental animals, the lipotropic effects of lipocaic apparently are not due to its choline alone, 5 and this observation has been confirmed here for human subjects. 2 On the other hand, when about 4 times the amount of inositol present in the 8 g of lipocaic was administered to a group of 8 patients with gastro-intestinal cancer, with but one exception the concentrations of fat in their livers were found to be within normal limits. The average lipid value was 0.42 that of the control group. Because it seemed probable then that the inositol alone might account for the physiologic effects of the lipocaic, another group of 10 patients with carcinoma of the gastrointestinal tract was given during the last 10 preoperative hours only that amount of inositol (280 mg) contained in the effective dose of lipocaic. The clinical and chemical methods used have been described in a preceding communication of this series. 1 The results obtained from the ingestion of the smaller amounts of inositol indicate that in the patients studied, the lipotropic properties of the lipocaic could be accounted for by its content of inositol alone (Tables I and II). Of the values of hepatic lipid, only one was significantly elevated, and the average of the group was only 0.50 that of the control group.