J. Lynwood Herrington

Cefoxitin versus erythromycin, neomycin, and cefazolin in colorectal operations. Importance of the duration of the surgical procedure.

Perioperative parenteral cefoxitin was compared with oral erythromycin, neomycin and parenteral cefazolin in a prospective, double-blind, randomized evaluation of 119 patients undergoing colorectal operations. Patients receiving cefoxitin had a higher wound infection rate than patients receiving erythromycin-neomycin-cefazolin (12.5% v 3.2%, respectively, p = .06). A direct correlation existed between the duration of the operation and the infection rate. Cefoxitin prophylaxis was as effective as erythromycin-neomycin-cefazolin in patients undergoing surgical procedures of 4 hours or less (infection rates of 4.8% and 4.0%, respectively). However, for surgical procedures lasting more than 4 hours, 5 of 14 patients (37.5%) receiving cefoxitin developed a wound infection v 0 of 13 patients receiving erythromycin-neomycin-cefazolin (p < .05). It is speculative as to whether frequent two-gram doses of cefoxitin given during the operation would provide prophylaxis equivalent to erythromycin-neomycin-cefazolin.

Surgical Management of Reflux Gastritis

Reflux gastritis is now recognized with increasing frequency as a complication following operations on the stomach which either remove, alter, or bypass the pyloric phincter mechanism. The entity may occasionally occur as a result of sphincter dysfunction in the patient who has not undergone prior gastric surgery. The diagnosis is made on the basis of symptoms (postprandial pain, bilious vomiting and weight loss), gastroscopic examination with biopsy and persistent hypochlorhydria. Remedial operation for correction of reflux is indicated in the presence of persistent symptoms when conservative measures fail. Only operative procedures which divert duodenal contents from the stomach or gastric remnant are effective. Both the isoperistaltic jejunal segment (Henley loop) and the Roux-en-Y diversion have been effective as remedial operations for reflux gastritis and merit greater awareness by gastroenterologists and surgeons. Our choice is the Roux-en-Y because of its technical simplicity and lower morbidity rate.

Perforated duodenal ulcer managed by proximal gastric vagotomy and suture plication.

Twenty-one patients with acute perforated duodenal ulcer were managed by proximal gastric vagotomy without drainage and simple closure of the perforation reinforced with an omental patch. There was no operative mortality. No recurrent duodenal ulcers have developed. All patients have achieved a good to excellent clinical result from their operation. Dumping, diarrhea, and reflux gastritis have not developed. Followup studies extend to three and one-half years. Proximal gastric vagotomy with simple closure is safe, effective management for the patient with an acute perforated duodenal ulcer. This operation is a satisfactory compromise between simple closure alone which does not protect against recurrent ulcer and definitive ulcer operations which may subject patients who would not have further ulcer symptoms to the unnecessary risk of increased mortality, morbidity, and postgastrectomy disorders.

The surgical treatment of duodenal ulcer by vagotomy and antral resection

Abstract A review has been made of our experience in 1,127 patients who have undergone vagotomy and antrectomy for the complications of duodenal ulcer. The follow-up study has extended from less than one to more than fifteen years. The over-all results have been quite satisfactory with 93 per cent of the patients having had an excellent or good result following operation. The incidence of recurrent ulcer remains very low, only 0.6 per cent. The operative mortality of 2.7 per cent in the series is in keeping with that of other resports. Nutritional difficulties, weight loss, diarrhea and anemia have not been major problems. The operation of complete abdominal vagotomy and excision of the gastric antrum successfully controls the ulcer diathesis; and in our opinion, is the most satisfactory surgical procedure for the treatment of duodenal ulcer.

Primary closure of the common bile duct

Summary Experience with closure of the common duct after exploration for removal of calenli has been reviewed. The postoperative morbidity was less in the 250 patients having primary common duct closure than in a similar group of 250 patients subjected to T tube drainage. The conditions necessary for closure of the common bile duct after surgical exploration have been outlined. The indications for drainage of the common duct are also discussed. In the usual case primary closure of the common duct incision may be safely performed following exploration for calculi, but drainage is preferred in the presence of intensive inflammatory reaction involving the duct system and adjacent structures.

Total Duodenal Diversion for Treatment of Reflux Esophagitis Uncontrolled by Repeated Antireflux Procedures

The operations of Nissen, Hill, and Belsey are adequate in controlling esophaegeal reflux in the majority of patients. In a small percentage however, objective and subjective evidence of esophagitis persists in spite of repeated operations to restore lower esophageal sphincter competency. These failures are then usually treated by operative procedures of great magnitude involving organ interposition. Repeated antireflux operations directed to the gastroesophageal area may in some instances result in impairment of blood supply with an increased risk of both esophageal and gastric fistulae. In the past many observers have felt that reflux esophagitis resulted solely from the effects of acid-pepsin secretions bathing the distal esophagus. Recently experimental and clinical data have indicated the importance of duodenal contents in the etiology and perpetuation of reflux esophagitis. During a recent two year period, 6 patients with persistent reflux esophagitis uncontrolled by repeated antireflux procedures have been seen on our service. These 6 patients, underwent 12 unsuccessful antireflux operations elsewhere. Three of the 6 patients had also been subjected to vagotomy-antrectomy for a coexisting duodenal ulcer. A marked lowering of gastric acidity took place but esophageal reflux and esophagitis persisted. These three patients were treated on our service by takedown of the Billroth I anastomosis, closure of the duodenal stump and diversion of the duodenal contents into a Roux-en-Y limb. Three other patients who had undergone unsuccessful antireflux procedures alone were subjected to antral resection, Roux-en-Y diversion and transthoracic vagotomy.This simplified approach to the treatment of persistent esophageal reflux uncontrolled by repeated antireflux procedures has given satisfactory results. The operation should be considered when technical considerations preclude further surgical attempts to perform another effective antireflux operation. Total duodenal diversion should, however, not be considered as the primary operation for the patient suffering from reflux esophagitis. However, in circumstances discussed above this indirect approach appears preferable to major resectional procedures.

STENOSIS OF THE GASTRIC ANTRUM AND PROXIMAL DUODENUM RESULTING FROM THE INGESTION OF A CORROSIVE AGENT.

Abstract A case of cicatrizing gastric antral stenosis extending into the proximal duodenum has been presented. The surgical problem posed by this patient has been discussed.

Remedial operations for postgastrectomy syndromes

Summary The various postgastrectomy syndromes have been described. A carefully taken history and appropriate diagnostic studies usually will result in defining with reasonable accuracy the specific syndrome from which the patient is suffering. Attempts have been made to emphasize the importance of selecting the proper remedial operation that might best correct the patients symptomatology. The history of the development of various remedial operations has been briefly discussed and the experience of several authorities has been cited. A small experience with remedial operations performed by the author has been discussed in detail. Careful case selection and a lengthy trial of conservatism are stressed as important requirements before advising remedial operation. In properly selected cases, remedial operation has much to offer these otherwise hopeless gastric cripples.

METASTATIC MALIGNANT MELANOMA OF THE GALLBLADDER MASQUERADING AS CHOLELITHIASIS.

Summary Metastatic malignant melanoma involving the gastrointestinal tract apparently occurs not infrequently. Three cases of gastrointestinal involvement have been observed in one institution during a recent two year period. One of the three cases proved to have metastatic malignant melanoma involving the mucosa of the gallbladder which was thought on preoperative cholecystogram to represent nonopaque gallstones.

Definitive surgical treatment in duodenal ulcer disease

Summary A brief review of the historical background of modern surgical treatment in duodenal ulcer disease is presented. Consonant with better understanding of etiology, there has emerged the concept in recent years that gastric vagotomy is of fundamental importance in operative treatment and that the complementary procedure of choice lies between antral resection and “physiologic antrectomy” as produced by pyloroplasty. Our experience in the use of truncal vagotomy with antral resection in 1,750 patients with a recurrence rate of 0.7% is summarized and compared with that of Weinberg and others in their use of vagotomy with pyloroplasty. Results of a controlled clinical study in which truncal vagotomy and selective gastric vagotomy were randomized in our hospitals in 145 patients have indicated clearly the superiority of the selective technic in effecting complete gastric vagotomy. The combination of selective gastric vagotomy with antral resection and Billroth I gastroduodenostomy in our opinion comprises the most nearly optimal features currently known in elective operations for duodenal ulcer in good-risk patients. Truncal vagotomy with pyloroplasty is a second choice “compromise” procedure which should be reserved for the poor-risk patient in whom immediate salvage of life and not long-range control of ulcer disease is the primary concern.