Jack Hoffmann

Appendix mass: Conservative management without interval appendectomy

Forty-nine patients had conservative treatment of an appendix mass without interval appendectomy. Five were lost to follow-up within 6 months, and 44 patients were followed for between 6 months and 22 years. In nine patients (20 percent) recurrent appendicitis developed, and six (14 percent) suffered chronic pain not thought to be due to appendicitis. Of the recurrences, 66 percent occurred within 2 years of the initial attack. Barium examination of the cecum was successful in diagnosing two of three additional patients in whom a right iliac fossa mass was not due to appendicitis. The morbidity and expense of routine interval appendectomy was thus eliminated in 80 percent of the patients.

A prospective, controlled study of prophylactic drainage after colonic anastomoses

A prospective randomized, controlled trial was designed to study the influence of accorrugated latex drain on anastomotic integrity, wound infection, and respiratory complications after elective colonic resections above the pelvic peritoneum. Sixty patients entered the trial; 28 were drained and 32 undrained. Three patients in the undrained group died soon after surgery of causes unrelated to their colon anastomoses. There were no other differences in the incidence of postoperative complications in the two groups. When an anastomosis leaked, neither feces nor pus emerged via the drain. It is concluded that while the drains did not increase the incidence of postoperative complications, neither did they accomplish the purpose for which they were inserted. If, in addition, the economic cost of drainage is considered, it would seem that there is no advantage in inserting prophylactic drains after colonic anastomoses and their routine use needs to be reconsidered.

Prospective controlled vagotomy trial for duodenal ulcer. Results after 11-15 years.

A prospective, randomized, controlled trial was conducted to compare truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV) and parietal cell vagotomy (PCV) as elective treatment for duodenal ulcer. Between 11 and 15 years after operation, 248 patients were available for study of the recurrent ulceration rate by a life table method, and 197 patients could be studied with regard to postvagotomy symptoms. The recurrent ulcer rates were 28.5% for TV, 37.4% for SV, and 39.3% for PCV. These differences were not statistically significant. The incidence of severe postvagotomy symptoms was as follows: dyspepsia, 18.4% for TV, 20.5% for SV, 8.6% for PCV; dumping, 5.9% for TV, 19.6% for SV, 2.2% for PCV; diarrhea, 9.8% for TV, 11.8% for SV, 4.4% for PCV. The incidence of severe dumping was significantly less frequent among the PCV patients than the SV group. The differences did not reach statistical significance in any of the other groups. There was no significant difference in the Visick gradings among the three groups either before or after treatment of the failures. About two thirds of the patients in each group were finally satisfied with their operation, often after second operations or prolonged medical treatment. It is concluded that none of the three forms of vagotomy can be recommended as the standard operative treatment of duodenal ulceration.

Tube cecostomy and staged resection for obstructing carcinoma of the left colon.

Over a 17-year period, all patients presenting with acute obstruction of the left colon due to carcinoma were treated by emergency tube cecostomy. There were 57 patients aged between 35 and 93 years. After the decompressive procedure, eight died, 34 had complications, and eight were left with permanent cecostomies. Forty-one underwent secondary procedures of which 35 had resections. Seven patients died postoperatively and 15 had complications. Of the 34 survivors, in 23 the cecostomy closed spontaneously, and 11 had operative cecostomy closure. Of the latter, four died postoperatively, and nine had complications. Thus, 30 survived the entire treatment program. Reasons for the high morbidity and mortality are discussed. Comparison is made with other forms of treatment in the literature. A treatment program is suggested, using tube cecostomy for poor-risk patients and primary resection without anastomosis for patients in better condition.

Peritoneal lavage in the diagnosis of acute peritonitis

The study was aimed at determining the value of peritoneal lavage as an aid in the diagnosis of acute peritonitis when the diagnosis could not be made by ordinary clinical criteria. Thirty patients were studied prospectively. Twenty-five of the patients were suspected of having peritonitis but doubt existed because of an unreliable history or equivocal or confusing abdominal signs. Five remaining patients were comatose and an intraabdominal source of sepsis needed to be excluded. The technique of lavage and criteria for diagnosis have been presented herein. There were 10 true-positive results, no false-positive results, 19 true-negative results, and one false-negative result (positive predictive value 100 percent, confidence level 95 percent). There were no complications due to the test. Peritoneal lavage is a useful method of diagnosing or excluding peritonitis in patients with confusing abdominal signs. Negative results of laparotomy or prolonged observation may thus be obviated in such patients.

Parietal cell vagotomy as an emergency procedure for bleeding peptic ulcer.

Twenty-three selected patients presenting with massive bleeding from peptic ulcers underwent emergency parietal cell vagotomy (PCV). Nineteen patients had a duodenal ulcer, two a prepyloric ulcer, and one a gastric ulcer. The patients were studied retrospectively with regard to postoperative mortality and morbidity, early rebleeding, and recurrent ulceration. Two patients (9%) died after operation, one of rebleeding. No others suffered rebleeding. One further patient had major respiratory complications and 14 others developed minor complications. The remaining 21 patients were followed for between 2 and 72 months. Two patients (10%) developed recurrent ulcers. The authors conclude that parietal cell vagotomy may be used as an emergency operation for bleeding peptic ulcer in selected cases with an acceptably low mortality, rebleeding rate, and incidence of recurrent ulceration.

Parietal cell vagotomy. A 23-year study.

ObjectiveThe authors studied the long-term ulcer recurrence rate after elective parietal cell vagotomy (PCV) for duodenal, pyloric, or prepyloric ulcers. Summary Background DataRecurrent ulceration rates of around 10% are reported after PCV. Recurrence rates are, however, proportional to the duration of follow-up. Series presenting long-term follow-up are sparse in the literature. MethodsFrom 1969 to 1979, 350 patients underwent elective PCV. Three hundred forty-seven accessible patients were observed prospectively at intervals of 1 to 5 years to detect recurrent ulcers. The median duration of follow-up was 140.2 months (range 1 month-22.75 years). ResultsSeventy-six of the 347 patients (21.9%) developed recurrent ulcers. Calculation of the integrated ulcer recurrence rate indicates a constant monthly recurrence risk of 0.16%. Recurrences occurred as late as 17 3/4 years after operation. Eighty per cent of the recurrences occurred after 10 years of follow-up. ConclusionThe results confirm that the rate of recurrent ulceration after PCV is proportional to the duration of follow-up.

Conservative treatment of abdominal stab wounds with omental protrusion

Two cases of abdominal stab wounds with omental protrusion treated conservatively are presented. Omental protrusion in a patient without signs of shock or peritoneal irritation is not an absolute indication for explorative laparotomy.

Metastasis of cecal carcinoma via a preexisting colovesical fistula

A case is reported in which cells from a cecal carcinoma appear to have passed through a preexisting colovesical fistula to grow in the submucosal layers of the urinary bladder.