H. William Scott

Comparative studies of the clinical effects of truncal and selective gastric vagotomy.

Abstract A prospective randomized clinical study was carried out in 145 patients to compare the effects of truncal and selective gastric vagotomy. Evaluation of results of vagotomy have been at regular follow-up intervals from six to thirty months. Selective gastric vagotomy appears to be significantly superior to truncal vagotomy in achieving complete vagal denervation of the stomach. The clinical benefits of preserving hepatic and celiac vagal innervation were not impressive.

Clinical appraisal of jejunoileal shunt in patients with morbid obesity.

The cause of morbid obesity remains obscure. No specific endocrinopathy has been implicated and although various explanations have been advanced, no uniformly practical medical or psychiatric program of effective treatment has evolved. The basic factor of gluttony with enormous caloric intake, coupled with indolent or absent exercise activity, appears to be the common denominator in most massively obese patients. Although no precise definition for this syndrome is generally accepted, we identify morbid obesity as existing in any person whose weight has reached a level two to three or more times his ideal weight and who has maintained this level of obesity for five years or more despite efforts by himself, family, friends, and physicians to bring about effective and sustained reduction of weight to medically acceptable standards. In the last fifteen years several groups of investigators have attempted to cope with the problem of massive intractable obesity by surgical operation. The basis for a surgical approach to the problem is the dual concept that massive obesity of the “fat man in the circus” variety is a serious disease of life-shortening severity and that long-term dietary control is usually unsatisfactory. The record of accomplishment in medical treatment of such persons by dietary restriction, including rigid inhospital dietary programs of 800 to 0 calories per day for periods up to 300 days, has been marred by the extremely high rate of recurrence of obesity once rigid conditions of dietary control are relinquished.

Craniopharyngiomas in children

Summary 1. Experience with 16 craniopharyngiomas in children observed at The Childrens Hospital and the Peter Bent Brigham Hospital, Boston, during the period of 1933 to 1945, is reported. 2. Two cases are presented in detailed reports. 3. Embryologic, pathologic, physiologic, diagnostic, and therapeutic aspects of craniopharyngiomas in children are discussed. 4. It is suggested that a critical appraisal be made of roentgen therapy as an adjunct to surgery in the management of these tumors.

Clinical and metabolic studies after total gastrectomy with a Hunt-Lawrence jejunal food pouch☆☆☆

Abstract Among twenty-two patients who have undergone total gastrectomy with Hunt-Lawrence jejunal pouch and Roux-en-Y esophagojejunostomy, eight have survived from three to five years without evidence of recurrence of their primary disease. These patients have been carefully evaluated. Their ability to gain and maintain weight, to eat abundantly in comfort, to return to their preoperative work and physical activities, and to be free of dumping, diarrhea, and severe dietary restrictions has been significantly better than in patients with other types of alimentary reconstruction which we have used after total gastrectomy. Five of this group have gained 13, 14, 27, 35, and 44 pounds, respectively, since discharge from the hospital. Details of clinical follow-up and metabolic appraisal are presented.

Hemorrhagic necrosis of pheochromocytoma associated with phentolamine administration.

A case of ruptured pheochromocytoma is presented, the pathophysiology discussed, and the literature reviewed. Evidence is presented that the use of alpha-adrenergic blockade in general, and phentolamine in particular, may predispose to this complication. Twelve cases of massive hemorrhagic necrosis with or without rupture were found in the literature, including the present case. Six had no operation; one survived. Six had immediate operation; 4 survived. An additional case of hemorrhage into a small pheochromocytoma following phentolamine is presented. This tumor was neither ruptured nor massively necrotic, but the case supports the hypothesis that alpha-adrenergic blockade may cause hemorrhage within the pheochromocytoma.

Lymphosarcoma of the Bowel in Childhood

PRIMARY neoplasms of the large or small intestine are extremely rare in childhood as compared with those in adult life. Except for true adenomatous polyps, most intestinal tumors encountered in ear...

Evaluation of canine intestinal submucosa as a vascular substitute.

Abstract The jejunal submucosa, whether used as a fresh autograft or preserved homograft, was uniformly successful in the thoracic vena cava of the dog. Preserved submucosal homografts initially functioned well in the thoracic aorta up to six months, then aneurysm developed. Fresh autografts implanted into the thoracic aorta have performed less well. The abdominal vena cava grafts of submucosa all failed early.

CHANGES IN BODY COMPOSITION AFTER JEJUNOILEAL BYPASS IN MORBIDLY OBESE PATIENTS.

Four years ago we began a study of the responses of patients with morbid obesity to the intestinal bypass operation described by Payne and DeWind [I]. In that procedure the proximal jejunum is divided 14 inches from the ligament of Treitz and anastomosed to the side of the terminal ileum 4 inches from the ileocecal valve. Although six of eleven patients treated by the Payne procedure had satisfactory weight reduction and good physical rehabilitation, five patients so treated have failed to lose adequate amounts of weight [2]. Radiologic study of possible causes of failure in these five patients has shown dilatation and elongation of proximal jejunum and terminal ileum with reflux of orally ingested barium into the bypassed ileum for distances of 3 to 5 feet. These changes appear to have thwarted the aim of the Payne procedure. During the last sixteen months, an additional fourteen massively obese patients have been submitted to a new type of intestinal bypass [3]. The principle involved in the new procedure is to divide the jejunum a few inches distal to Treitz’s ligament and to divide the ileum a few inches proximal to the ileocecal valve; proximal jejunum is anastomosed end to end to the distal ileum. The end of the distal jejunum is closed and drainage of the bypassed small intestine accom-

The Management of Gastric Ulcers: A Current Review

In the past 10 years, 163 patients with documented gastric ulcers were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. One hundred thirty-five were initially managed medically. Medical therapy was successful in 58 patients (43%) in this group. Twenty-eight (17%) patients required surgical treatment initially. An additional 77 patients (57%) became candidates for surgical management when their medical management failed. Of this group, 40 now have been surgically treated and 37 still have symptoms while on medical treatment. Three patients being treated for benign ulcers, two for as long as six years each, were found to have carcinoma of the stomach diagnosed by subsequent endoscopy and biopsy in one and by laparotomy with gastrectomy to include the ulcer in two. We consider subtotal gastrectomy or surgical resection of the antrum, including the ulcer site, to be the preferred surgical treatment for gastric ulcers, and this was done in 50 cases. Vagotomy was done in addition to the antrectomy in 31 of these, and in addition to the subtotal resection in 11. Two patients who had vagotomy and resection subsequently developed a marginal ulcer. One of these who had a subtotal resection and vagotomy healed with medical treatment. The one who had a vagotomy and antrectomy required a second vagotomy for a missed vagus nerve. Gastrointestinal endoscopy in the past 10 years has improved to the point that very few malignant ulcers are missed by endoscopic biopsy. Large ulcers, those that perforate or continue to bleed, and those that fail to heal on medical treatment for a maximum of 2 to 3 months should be submitted to an antrectomy that includes the ulcer. Vagotomy should be added in selected cases.

Single stage proctocolectomy for severe ulcerative colitis: Comparison with less extensive surgical procedures

Abstract Fifty patients with severe ulcerative colitis were submitted to major colonic resections during a fifteen year period. Thirty-six patients had single stage ileostomy and proctocolectomy with one early death (operative mortality 2.8 per cent). Fourteen patients had multiple stage procedures: usually ileostomy, abdominal colectomy with rectum left in place as the first stage. There were two early deaths in this group (operative mortality 14 per cent) and two later deaths. Second stage abdominoperineal resection of rectum because of recurrent ulcerative colitis has been necessary in seven of ten survivors of this group. This retrospective study validates the continued advocacy of single stage proctocolectomy in both elective and emergency management of patients with severe ulcerative colitis. An impressive degree of rehabilitation has been obtained in every patient after successful proctocolectomy.