Gerald W. Peskin

Spectrum of cholangitis

Of 402 patients admitted with biliary disease over the last three years, cholangitis has been diagnosed in 36. This represents an 8.8 per cent overal incidence and a 33.8 per cent incidence among patients who have undergone operation or manipulation involving the common duct. Based on this experience, a program of prophylaxis and treatment of cholangitis has been devised with special emphasis on the management of elderly patients in the initial postoperative period.

Cardiac injuries : analysis of an unselected series of 251 cases

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

Alterations of in vitro fluid and electrolyte absorption by gastrointestinal hormones

Abstract 1. 1. A study was carried out to determine the influence of gastrin, secretin, and cholecystokinin on in vitro small intestinal absorption of fluid and electrolytes. 2. 2. Employing everted gut sacs, it was noted that these hormones inhibited the net transfer of sodium, chloride, and fluid across the small intestine of the hamster. 3. 3. Furthermore, by measuring the bidirectional fluxes of sodium (Na22) across the small intestine, it was demonstrated that the diminution in the net transfer of this ion resulted from a decrease in the mucosal to serosal component. 4. 4. Tissue uptake of sodium (Na22) from the serosal and mucosal side of gut segments revealed inhibition of mucosal but not serosal uptake, with maintenance of normal intracellular sodium values. 5. 5. Thus, it is thought that the primary action of these polypeptides is at the mucosal membrane of the absorbing intestinal epithelial cell. 6. 6. These results are discussed in relation to the clinical problem of the variants of the Zollinger-Ellison syndrome.

Operative mortality in general surgery

The operative mortality in over 7,000 consecutive cases at a Veterans Administration Medical Center is defined. The mortality in elective procedures is low by most standards and is usually associated with a malignant disease. Older patients appear to have an increased operative mortality. Sepsis is the major factor in death after elective and emergency procedures. Age is a critical factor associated with mortality in this population. Preexisting disease (pulmonary, cardiac, hepatic, and malignant) plays a role in determining outcome. Despite these factors it is possible to achieve excellent operative mortality results in a hospital with a commitment to resident training. An aggressive diagnostic and therapeutic approach is considered reasonable to support these patients with multisystem disease. This often includes the extensive use of expensive resources such as preoperative hospitalization with nutritional support and prolonged stays in the surgical intensive care unit postoperatively.

A new provocative test for the diagnosis of the carcinoid syndrome

Abstract A new provocative test for the carcinoid syndrome is described and its use in a series of patients with various endocrinopathies detailed. Although the series of patients is small, it is hoped that additional trials will confirm these results and allow the utilization of calcium infusion as an early and specific diagnostic aid for carcinoid and related tumors.

Treatment of Hemorrhagic Gastritis with 15(R)-15 Methyl Prostaglandin E2: Report of a Case

A 19-yr-old male developed severe hemorrhagic gastritis following three abdominal operations. Treatment with intravenous cimetidine and hourly antacids to maintain his gastric pH above 5 failed to affect gastrointestinal bleeding. Also, peripheral venous vasopressin, propantheline bromide, and glucagon were without effect. Total gastrectomy was considered to control his bleeding. However, since a number of prostaglandin analogs prevent gastric lesions produced by many noxious agents (e.g., aspirin, alcohol, strong acid or alkali, etc.) in animals and humans, the patient was treated with 50 micrograms of 15(R)-15 methyl prostaglandin E2 intragastrically every 6 h for 10 days. To epimerize the 15(R) form to the more active 15(S) form, 50-100 ml of 50-mN HCl was placed into the patients stomach immediately before each dose. Bleeding ceased within 24 h of the onset of 15(R)-15 methyl prostaglandin E2 therapy and did not recur. The prompt response to 15(R)-15 methyl prostaglandin E2 in combination with hourly antacids in this patient with persistent and severe hemorrhagic gastritis suggests a therapeutic effect and the need for a prospective double-blind clinical trial.

Expanding indications for early parathyroidectomy in the elderly female.

In a study of fifty consecutive patients with hyperparathyroidism we have noted: (1) Automated laboratory studies have increased the incidence of diagnosed hyperparathyroidism, especially in the elderly. (2) Bone abnormalities and mental changes are the most frequent symptoms in this older population. (3) Natural history studies have produced some delay in surgical treatment, accentuating mental aberrations and bone-associated deficits. Especially in the elderly, the benefits in personality change, feeling of well-being, and lessened bone deterioration warrant early operation.

Maechanism of diarrhea of villous adenomas

Abstract 1. 1. A study was carried out to determine the influence of villous adenoma extracts on in vitro colonic absorption of fluid and electrolytes. 2. 2. Employing everted gut sacs, it was noted that villous tumor inhibited the net transfer of sodium, potassium, chloride, and fluid across the colon wall of the rat. 3. 3. Furthermore, by measuring the bidirectional flux of sodium (Na 22 ) across the colonic wall, it was demonstrated that the diminution of net transfer of this ion resulted from an increase in the serosal to mucosal component. 4. 4. These results are discussed in relation to the hydroelectrolytic depletion syndrome associated with some villous adenomas in man.

Diagnosis of occult Zollinger‐Ellison tumors by gastrin radioimmunoassay

The Zollinger‐Ellison syndrome can be best diagnosed by the measurement of elevated concentrations of peripheral venous gastrin. Using the gastrin radioimmunoassay, ulcerogenic tumors were diagnosed preoperatively in 4 patients. In three of these patients, no tumor could be found at laparotomy. In each, a tiny lesion was found in the submucosa of the duodenum, one at subsequent laparotomy, one in the duodenal stump resected for suspicion of retained antrum, and the third at autopsy. In the fourth patient, the duodenum was opened and a tiny duodenal islet cell adenoma resected. In the second and fourth patients, resection of the adenomas appears to have cured the patients without total gastrectomy; they are asymptomatic and have markedly lowered gastrin levels postoperatively. A plan for the management of duodenal islet cell tumors is presented which suggests that total gastrectomy might possibly be avoided if the surgeon is confident that the tumor is confined to the duodenum; this should be verified by following the course of the concentrations of peripheral venous gastrin.

Physiologic Implications of Medullary Carcinoma of the Thyroid Gland

Calcitonin, serotonin, prostaglandins, and an ACTHlike substance may all be secreted by medullary thyroid carcinomas and may account for many of the symptoms and lesions associated with these tumors. There is evidence that they are part of a systemic disorder of neuroectodermal tissue.