James T. Adams

Adenocarcinoma of the small intestine

Sixty-five patients with adenocarcinoma of the small intestine were encountered over a 31 year period. The duodenum was the most common location, with a decreasing frequency distally. Associated malignancies were present in a fourth of the patients. Presenting signs and symptoms were vague and related to either obstruction or bleeding. Barium contrast examination and endoscopy for duodenal tumors were the primary diagnostic modalities. Curative treatment was wide resection of bowel and mesentery for jejunal and ileal tumors and pancreaticoduodenectomy for duodenal tumors. Favorable prognosticators included jejunal location, absence of nodal metastases, and a well-differentiated grade. Stage for stage, the prognosis of patients with adenocarcinoma of the small intestine parallels that of patients with adenocarcinoma of the colon. With greater awareness of this tumor, it is possible that earlier detection will lead to improved overall survival.

Management of cholelithiasis in patients with abdominal aortic aneurysm.

Gallstones were detected in 42 of 865 patients with abdominal aortic aneurysm (4.9%). Eighteen patients underwent concomitant aneurysm resection and cholecystectomy. Eleven patients had aneurysmectomy without cholecystectomy. Thirteen patients underwent cholecystectomy alone. There were no significant increases in operative mortality, duration of operation, or length of hospital stay when cholecystectomy was added to aneurysm resection. However, there was one instance of prosthetic infection which occurred in a patient who did not have his graft retroperitonealized prior to cholecysteptomy, and who also underwent gastrostomy and drainage of the liver bed. There have been no graft complications in the remaining 17 consecutive patients who had their graft retroperitonealized prior to cholecystectomy. Nine of 11 patients who underwent aneurysmectomy without cholecystectomy experienced an episode of acute cholecystitis during a mean follow-up period of 2.9 years. Two of these episodes occurred in the immediate postoperative period and one patient died of biliary sepsis. On the basis of these findings, concomitant aneurysmectomy and cholecystectomy is advised in those patients with cholelithiasis undergoing aortic aneurysm resection providing no contraindications exist.

Steroid effect on the release of the lysosomal enzyme acid phosphatase in shock.

The effect of corticosteroids on cellular resistance in shock was studied by serial measurement of the serum concentration of the lysosomal enzyme acid phosphatase in untreated and steroid dogs subjected to hemorrhagic, endotoxin and cardiogenic shock. In each shock category, elevation in serum acid phosphatase was significantly less in steroid treated dogs as compared to untreated animals at corresponding time intervals. This difference was most apparent in endotoxin shock, next in hemorrhagic shock and least in cardiogenic shock. Steroid treatment also reduced the serum lactate increment in hemorrhagic and cardiogenic shock and delayed or reduced the onset and severity of the occurring acidosis, an apparent reflection of the ability of steroids to promote increased tissue perfusion. In addition, steroid treatment increased or prolonged survival in all three shock groups. By showing that glucocorticoids affect a reduction in the release of the lysosomal enzyme acid phosphatase during shock, the study offers direct evidence that steroids enhance cellular resistance to shock stress in the dog. Whether this salutary effect is due solely to the ability of steroids to stabilize cellular membranes or is in part secondary to promoting improved tissue hemodynamics could not be established. The interpretation and clinical application of these results must take into account the possibility of a species specific response.

Effect of sphincteroplasty on gallbladder function and bile composition.

The effect of sphincteroplasty on bile concentration and composition and on gallbladder function was investigated in the dog. Gallbladder and hepatic bile samples were analyzed for cholesterol, phospholipid (lecithin), bile salt concentration and individual bile salt content. Motor function was studied by cholecystokinin-cholecystography with changes in gallbladder volume computed from the radiographs. All bile samples were cultured and at the conclusion of the experiments, the gallbladders were histologically examined. Sphincteroplasty did not alter biliary cholesterol concentration but the concentration of lecithin and bile salts decreased in gallbladder bile and increased in hepatic bile (p <.001). These changes depict a trend toward greater lithogenicity for gallbladder bile and lesser lithogenicity for hepatic bile. Postoperative analysis of individual bile salts in gallbladder bile showed an increase in mono-hydroxy and dihydroxy bile salts and a decrease in trihydroxy bile salts (p <.001). This tendency has been shown to be conducive to gallstone formation. The concentrating ability of the gallbladder was partially eliminated by sphincteroplasty but gallbladder filling and motor response to stimulation by cholecystokinin was not affected. All gallbladders demonstrated histologic changes of chronic inflammation and all developed a significant bacterial flora following sphincteroplasty. It is concluded that cholecystectomy should always be performed following transduodenal sphincteroplasty not because of any resultant abnormality of motor function, as has previously been held, but because of the resultant abnormality of gallbladder pathophysiology.

Splenectomy for hematologic disorders.

In 1887, Sir Spencer Wells [1] operated on a patient with the preoperative diagnosis of a uterine fibroid, but instead he noted a “wandering spleen”, which he removed. The patient later proved to have hereditary spherocytosis; thus, the first surgical cure of a hematologic disorder was inadvertent and became manifest postoperatively when the patient’s anemia and chronic jaundice disappeared. Micheli is generally given credit for introducing the concept of splenectomy for hemolytic anemia in an article published in 1911 [2]. As a medical student in Prague, Kaznelson proposed to Schloffer, a professor of surgery, that splenectomy for idiopathic thrombocytopenic purpura be performed in a 36-year-old woman. The case and the successful elevation of the platelet count to above normal levels was reported 4 weeks after the procedure in 1916 [3].

Vascularity of gastrointestinal staple lines demonstrated with silicone rubber injection.

Gastrointestinal stapling devices were applied across canine small intestine, and then the blood supply of the stapled segments was immediately filled with silicone rubber. After tissue clearing and microdissection, the outstanding vascularity of the staple lines was clearly demonstrated. The B configuration of the closed staple allows blood vessels of substantial size to pass through it. This might make staple technique especially advantageous whenever vascularity is critical.

Acute acalculous cholecystitis complicating abdominal aortic aneurysm resection

Acute acalculous cholecystitis developed in six patients recovering from repair of an abdominal aortic aneurysm. All patients were men with significant concurrent medical illnesses, and three patients had undergone operation for a ruptured aneurysm. Symptoms appeared at a mean of 3 weeks postoperatively and consisted of right upper quadrant pain, fever, leukocytosis, and slight elevation of liver function test results. Treatment consisted of cholecystostomy (three patients) or cholecystectomy (three patients), with an overall mortality rate of 50%. When cholecystitis is suspected after aortic aneurysm repair, early confirmation of the diagnosis should be obtained with ultrasound or a technetium hepatobiliary scan and cholecystostomy or cholecystectomy undertaken if the patient does not rapidly improve with medical management.

An Evaluation of the Nissen Fundoplication

The characteristic radiological findings which follow a Nissen fundoplication are reviewed. The esophagus may be narrowed but is intrinsically normal. A pseudotumor at the medial aspect of the fundus is generally present. The history and radiographic findings can normally differentiate this defect from neoplasm or a nonoperated hiatal hernia. Postoperative clinical evaluation has shown this procedure to be very valuable in the amelioration of symptoms.

Diagnostic laparotomy for fever or abdominal pain of unknown origin

Diagnostic laparotomy performed on twenty-four patients with FUO and twenty-seven patients with obscure abdominal pain resulted in a positive yield of 87 and 82 per cent, respectively. No deaths occurred in either group and the complication rate was minimal. These findings indicate that it is appropriate to include laparotomy in the armamentarium for diagnosis of the cause of FUO and abdominal pain.

The barium enema as treatment for massive diverticular bleeding.

I Will be confining my remarks to the treatment of massive diverticular bleeding, and I assure Mr. Heald that the modality that I will be mentioning is available, even in England. .About 15 per cent of patients with diverticular disease of the colon will bleed from this source. In the great majority of instances, the bleeding is slight, or even occult, and associated with diverticulitis. While significant acute bleeding is unusual in this condition, nevertheless, diverticular disease of the colon is now recognized as the most common cause of massive bleeding from the large intestine. Fortunately, in most of these patients with massive bleeding, the bleeding will stop spontaneously with no more than bed rest and transfusions, if needed, but, in some patients, the bleeding will continue and, in these patients, operative intervention becomes a consideration. However, diverticular disease of the colon is a condition of the adult, and a notable feature of those patients who bleed massively is that they are elderly, and thus we have a selected, fragile group of people, often with associated cardiovascular, ptflmonary and renal disease, who do not tolerate emergency operations of any appreciable magnitude. When we consider the high operative mortality rates that have been reported, avera~ng about 20 to 25 per cent, then