John P. Welch

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries.

BACKGROUND Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation. METHODS Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study populations demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality. RESULTS No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization. CONCLUSION Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Long-term management of diverticulitis in young patients

PURPOSE: This study was designed to determine the natural history of documented diverticulitis that resolves after treatment with intravenous antibiotics and bowel rest in patients under the age of 50. METHODS: Records of 40 patients aged 50 or under who were hospitalized with the diagnosis of acute diverticulitis between 1980 and 1984 were reviewed to obtain data regarding how the diagnosis was made. Patients successfully treated with antibiotics were contacted five to nine years after their attack and surveyedviatelephone questionnaire about symptoms, recurrent attacks, and surgical interventions. RESULTS: A total of 40 patients were included in the study. Ten patients (25 percent) required surgery during initial admission, and 30 patients were discharged with resolution of their symptoms after treatment with intravenous antibiotics and bowel rest. A five-year to nine-year follow-up was obtained on patients treated medically, one-third of whom underwent operation for diverticulitis during this period, and two-thirds of whom did not require surgery during the follow-up period. All operations were elective with single-stage resections. CONCLUSION: Based on our data, we do not recommend surgery in this population after a single episode of diverticulitis that resolves after treatment with antibiotics.

Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection.

Isolated dissection of a peripheral artery is a rare event. Only 11 reports exist in the literature of dissection of the superior mesenteric artery, most of which have been fatal. This is the first documented case of the successful treatment of an acute ischemic event caused by a superior mesenteric artery dissection. In addition, the new technique of right gastroepiploic artery-to-superior mesenteric artery bypass is introduced as a satisfactory method of revascularization.

Carcinoma of the stomach after gastric operation

Seventeen cases of carcinoma of the stomach occurring late after previous gastric operation are presented. In all instances, patients had undergone gastroenterostomy, with or without gastric resection. Most patients had undergone the initial operation for peptic ulcer disease an average of 18 years before presenting with the tumor. Endoscopic biopsy of the gastroenterostomy and gastric cytologic evaluation offered a high degree of sensitivity and specificity in making the diagnosis. These tumors appeared to originate in the gastric mucosa near the stoma. Survival was poor with both curative and palliative therapy. Alkaline bile reflux, achlorhydria and bacterial colonization are discussed as possible causes. Patients who have undergone partial gastric resection are at increased risk for the development of carcinoma of the stomach remnant. We recommend that any patient in whom new upper gastrointestinal symptoms develop more than 10 hears after partial gastrectomy should undergo endoscopy with biopsy of the gastric mucosa adjacent to the anastomosis.

Endoscopic localization of colon cancers

In order to determine the accuracy of endoscopic localization of colon cancers, the endoscopic location was compared to the actual location at the time of operation in 320 patients who underwent resection of intraabdominal colon cancer between 1983 and 1988. The endoscopic location was correct in 86% of the cases. There were 44 endoscopic errors, including seven missed cancers. One-third of all endoscopic errors occurred when the tumor was in the cecum. We conclude that endoscopy is an accurate method of localizing colon cancers. However, with the advent of laparoscopic surgery and the loss of the ability to palpate the colon, the 14% of endoscopic errors take on a greater importance and additional means for localizing tumors should be pursued in selected cases.

Enterolith intestinal obstruction owing to acquired and congenital diverticulosis. Report of two cases and review of the literature.

Diverticulosis of the small bowel, complicated by enterolith formation with ensuing obturation obstruction, was recently documented in two patients. One patient had an enterolith formed within a Meckels diverticulum; the other had an enterolith dislodged from an acquired diverticulum. Both patients presented with signs and symptoms of acute small bowel obstruction. Only 20 such cases of bowel obstruction secondary to jejunal enterolithiasis and five cases secondary to Meckels enterolithiasis have been reported. The mechanism of obstruction may involve local encroachment or enterolith expulsion with distal bowel obstruction, although the latter is much more common. Optimally, enteroliths are broken up and milked into the proximal colon without incising the bowel. Alternatively, the enterolith may be milked proximally to a less edematous portion of bowel and an enterotomy may be performed. At times, the primary diverticulum is resected with the contained enterolith.

Primary malignant tumors of the small bowel. The Hartford Hospital experience, 1969-1983.

The medical records of 51 patients with primary small bowel cancer were reviewed. Twenty patients had carcinoid tumors, 17 had adenocarcinomas, 8 had leiomyosarcomas, and 6 had lymphomas. Presenting complaints were protean in nature and only 33 percent of patients had a correct diagnosis at the time of operation. Curative resection was attempted in 55 percent, but most patients presented late in their illness and only 27 percent had localized tumors. Survival has been poor: at most recent follow-up, 59 percent were dead, 14 percent were alive with disease, and 27 percent were alive and well. Earlier diagnosis may improve survival. Patients at risk for these tumors are usually more than 50 years of age with vague complaints such as weight loss, pain, abdominal fullness, and fatigue. They should undergo complete evaluation centered around exhaustive radiographic studies and liberal use of endoscopy.

Colonic complications of acute pancreatitis and pancreatic abscess

Colonic involvement should be suspected in patients with severe acute pancreatitis, especially in the following clinical settings: plain abdominal radiographs suggesting bowel ischemia, colonic obstruction, acute lower gastrointestinal hemorrhage, gram-negative septicemia, enteric bacteria on Gram stain or culture of peritoneal fluid, and feculent abdominal drainage from a previously drained pancreatic abscess. Intraoperatively, the pancreas should be widely drained and the fecal stream diverted. Colonic hemorrhage and nonviable bowel require immediate resection. Broad-spectrum antibiotic administration and vigorous nutritional support also are required in these critically ill patients. Although proximal diversion and pancreatic diversion alone may suffice, colonic resection may be required later for persistent obstruction or fistulization, but in a more elective setting. Colonic anastomoses should be performed only when pancreatic inflammation and associated sepsis have resolved completely.

The 99mTc-labeled RBC scan. A diagnostic method for lower gastrointestinal bleeding

The experience with 62 99mTc-labeled in vivo scans performed for lower gastrointestinal bleeding is discussed. Thirty-seven scans were deemed positive. The tendency of scans to become positive correlated with observations of active bleeding. Five patients had fulminant hemorrhage, necessitating emergency operation. In this group, scanning accurately located the bleeding sources prior to intervention. Seven other patients having later operations bled less rapidly. The bleeding site was localized accurately by scanning in three of these patients. Two studies were falsely positive and two were negative, whereas angiography was positive in two patients studied. Labeled RBC scanning is a useful technique in the early evaluation of patients with lower gastrointestinal bleeding, obviating the need of arteriography in some cases.

Gastric lymphoma: A clinicopathologic reappraisal☆

Histologic material from 42 cases diagnosed as gastric lymphoma at Hartford Hospital was reviewed, confirming the diagnosis in 37. Three cases of pseudolymphoma were found. The incidence of gastric lymphoma has increased steadily over the past 50 years: 35 percent of cases occurred during the past decade. Most patients with gastric lymphoma are in the seventh or eighth decade of life. Resection offered the best chance for long-term survival, either alone or with radiation therapy. Nodal status was correlated with length of survival of survival; 60 percent of patients with negative nodes survived 5 years or more. Cases were classified according to the Rappaport classification and the Working Formulation of Non-Hodgkins Lymphomas. The formulation was more useful than the Rappaport classification in assessing prognosis in various types of lymphoma and better reflects our current understanding of neoplasms of the lymphoid system.