John Boey

A prospective study of operative risk factors in perforated duodenal ulcers.

Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.

Pelvic exenteration for locally advanced colorectal carcinoma.

Pelvic exenteration provided worthwhile palliation and achieved a cumulative five-year survival rate of 38.8% in 49 patients who had carcinoma of the lower colon or rectum infiltrating adjoining pelvic viscera. Survival and the disease-free period were not significantly different after total or posterior exenteration. The stage of disease was the major determinant of outcome: five-year survival rates averaged 51.8% and 28.8% for Stages II and III, respectively. Hospital mortality (26.9%) after total exenteration was chiefly due to technical mishaps, and the inclusion of many high-risk but symptomatic elderly patients. Complete clearance of locally advanced colorectal cancer by pelvic exenteration is indicated in fit patients, especially those with Stage II disease.

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial.

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.

Bleeding duodenal ulcer. A prospective evaluation of risk factors for rebleeding and death.

There were 12 hospital deaths in 433 patients (2.8%, 1.6% at 30 days) presenting with bleeding duodenal ulcer. Excluding patients who underwent immediate operation or early elective surgery, where ulcer size was measured at initial endoscopy rebleeding was evident in 40/288 patients (13.9%) and was associated with an increased mortality (0.4% v 12.5%) (p less than 0.0001). Rebleeding rates for ulcers less than or equal to 1 cm and greater than 1 cm were respectively 28/239 (11.7%) and 12/49 (24.5%) (p less than 0.02). Rebleeding occurred in 13/186 patients (7.0%) in whom endoscopic stigmata of recent haemorrhage were absent and in 27/102 (26.5%) with such stigmata (p less than 0.0001). The mortality rate for patients without stigmata was 3/186 (1.6%) whilst mortality figures for patients with ulcers less than or equal to 1 cm and greater than 1 cm in size were respectively 0/77 and 3/25 (12.0%) when stigmata were identified. Ulcers greater than 1 cm were more frequent in the greater than 60 year age group, more likely to have stigmata and carried an increased risk of rebleeding and mortality.

Proximal gastric vagotomy. The preferred operation for perforations in acute duodenal ulcer.

Simple closure, the conventional operation for perforated acute duodenal ulcers, is associated with symptomatic relapse in a large proportion of patients. In order to assess the role of immediate definitive surgery, 78 fit patients with perforated acute ulcers were prospectively randomized to undergo either closure alone or proximal gastric vagotomy with closure (PGV). Patients taking potentially ulcerogenic drugs or who had severe stress were excluded from the study. Both groups were comparable with respect to age, sex, general medical health, duration of perforation, length of ulcer history, and presence of duodenal scarring. There was no hospital mortality. Minor complications occurred in 7.3% after closure and 10.8% after PGV. At 3 years follow-up, the cumulative recurrence rates were 36.6% and 10.6% after closure and PGV, respectively (p = 0.001). Eighty-five per cent of recurrences after closure were symptomatic, and half of them required re-operation. Duodenal scarring itself did not appear to influence the outcome after closure. PGV was not associated with dumping, diarrhea or other unwanted side effects. Although less than that in chronic ulcers, there is a substantial risk of symptomatic relapse after closure of perforated acute duodenal ulcers. With judicious patient selection, PGV effectively reduces this risk without incurring disabling side effects associated with other ulcer operations.

Bacteria and septic complications in patients with perforated duodenal ulcers

To evaluate the clinical significance of bacterial contamination in perforated duodenal ulcers, we prospectively studied septic complications in 184 consecutive patients. All patients received parenteral antibiotics (over 90 percent preoperatively) for at least 7 days. Thirteen infections developed in eight patients (4.3 percent). Peritoneal cultures, performed in 143 unselected patients, were positive in 33.6 percent of cases. Bacterial growth occurred more often and in heavier amounts in patients who underwent exploration late (after 48 hours) and those who had gross peritoneal soilage. Candida and gram-negative organisms predominated, but there was no correlation with pathogens that produced abscesses or wound infections. Old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when explorations was performed within 2 days of perforation. We treated perforated ulcers as clean-contaminated cases, and recommend that three doses of prophylactic antibiotics be begun preoperatively in all patients.

Angiosarcoma of the thyroid: an immunohistochemical and ultrastructural study of a case in a Chinese patient

A case of angiosarcoma (malignant hemangioendothelioma) developing in a chronic goitrous thyroid gland of an elderly Chinese woman is described. Histologically it showed the same classical appearance of angiosarcoma occurring in the skin and soft tissue. The endothelial origin of this tumor was confirmed by demonstrating Factor VIII‐related antigen in the neoplastic cells with the immunoperoxidase technique and Weibel‐Palade bodies by electron microscopic study. Because of its extreme rarity outside the European Alpine regions, many authorities are reluctant to accept it as a distinct entity and merely consider it as a variant of an undifferentiated carcinoma. Our report not only provides additional evidence that angiosarcoma of the thyroid gland is a specific condition of endothelial origin but also documents the first case among Chinese. Cancer 57:2381–2388, 1986.

Gastric Acid Secretion and Its Predictive Value after Vagotomy for Perforated Duodenal Ulcer

In a prospective randomized clinical trial, gastric acid secretion was compared in patients after simple closure, proximal gastric vagotomy with closure, or truncal vagotomy with pyloroplasty performed for perforated duodenal ulcer. The basal and pentagastrin- and insulin-stimulated acid outputs were similar after either proximal gastric or truncal vagotomy; they were also comparable with the postoperative acid values after corresponding procedures performed electively for chronic duodenal ulcer. Conversely, the basal and maximum acid outputs after simple closure of perforation were no different from the preoperative acid outputs of a group of duodenal ulcer patients matched for age and sex. The efficacy of acid reduction by emergency proximal gastric and truncal vagotomy was shown by the respective ulcer recurrence rate of 3% (1/34) and 6% (2/32) compared with 43% (15/35) after simple closure (p less than 0.01). Acid secretory data and serum gastrin levels did not predict ulcer relapse in patients after simple closure of perforation.

Mesenteric hammock for retaining the small intestine after radical pelvic surgery

The small bowel often partakes in complications seen after major colorectal and other pelvic operations. Trapped loops of small intestine with the pelvic basin may produce benign adhesive obstruction and are also exposed to recurrent malignancy. These problems may be compounded by the effects of radiotherapy. To reduce some of these complications, many methods have been devised to reconstruct the pelvic floor and thereby retain the small intestine within the abdominal cavity. Autogenous material such as omentum and peritoneal flaps have been employed as a substitute for the excised peritoneal pelvic lining. However, these methods may not be feasible in some reoperated patients, especially if prior irradiation has induced extensive peritoneal fibrosis, or if the omentum is absent or attenuated. We describe a technique in which the small-bowel mesentery is used as a hammock across the pelvic brim in order to support the small intestine out of the pelvic cavity. It has been used successfully in patients with complications after abdominoperineal resection for carcinoma of the rectum: one enterovaginal fistula associated with radiation injury and cancer, and three enteroperineal fistulas.