Lawrence W. Norton

Morbidity of colostomy closure

An unexpectedly high morbidity (28 per cent) followed colostomy closure in 100 patients. One patient died postoperatively because of sepsis resulting from disruption of the colon anastomosis. Wound infection (10 per cent), intraperitoneal abscess (1 per cent), bowel obstruction (7 per cent), and fecal fistula (4 per cent) were other significant complications. Wound sepsis was greater after primary than after delayed wound closure. Obstruction did not correlate with the use of either an open or closed technic of anastomosis. Three patients required reoperation for complications. Temporary colostomy was constructed for colon injury in 85 per cent of patients. In view of the considerable morbidity of colostomy closure, alternate technics of managing colon trauma should be considered. Such technics include primary closure and exteriorization of repaired colon. When temporary colostomy is unavoidable, closure is best done by open, two layer anastomosis with delayed wound closure. Colostomy should be recognized as an important procedure associated with significant morbidity.

Small bowel neomucosa

Abstract The growth of small bowel mucosa onto enteric segments, denuded of mucosa, and onto prosthetic material was studied under light and electron microscopy. Mongrel dogs were divided into seven experimental groups. In Group I, 10-cm-long mucosally denuded colonic segments were inserted into the jejunum by end-to-end anastomosis. In Group II, similar segments were prepared and immediately cut into serial sections. In Group III, similar segments were prepared as blind colostomies. In Group IV, techniques to remove residual colon epithelium were applied to the colonic segments. In Group V, 85% of the small bowel was resected in addition to performing anastomosis of the denuded colonic segment to the remaining bowel. In Group VI, tubular polytetrafluoroethylene (Gore-Tex) prostheses were placed in continuity in the jejunum. In Group VII, 10-cm mucosally denuded jejunal segments were attached by end-to-end anastomosis in the jejunum. Biopsies were taken of the mucosa in all segments at various intervals. Mucosal regrowth onto denuded colonic segments (Groups I, III, IV, V) was complete by 13 weeks. Nests of residual colonic cells had reepithelized the segments with mucosa compatible in appearance with colonic mucosa. Small bowel epithelium had grown 5 mm across the anastomosis. Attempts at removing residual colonic cells or stimulating additional growth of jejunal mucosa were unsuccessful (Groups IV and V). Mucosal growth onto one Gore-Tex graft extended 5 mm across the anastomosis (Group VI). Jejunal epithelium grew 1 cm onto denuded jejunal segments (Group VII). The primary obstacle to growing small bowel neomucosa is the lack of intrinsic potential for extended lateral growth.

Massive cecal dilation: Pseudoobstruction versus cecal volvulus?☆

Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory.

Cholecystectomy with and without surgical drainage.

Thirty-seven patients who met specific criteria had cholecystectomy without drainage, and thirty-seven matched control patients had cholecystectomy with drainage. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and may be unwise. Such drainage may result in an increased incidence of postoperative morbidity and prolonged hospital stay.

Clinical indications and accuracy of gray scale ultrasonography in the patient with suspected biliary tract disease

One hundred patients with suspected biliary tract disease underwent gray scale cholecystosonography (GSCS) and had diagnostic confirmation by oral cholecystogram (OCG) and/or operation. Ultrasonography demonstrated the gallbladder in 94 of the 100 patients; 2 patients had had previous cholecystectomy and 3 of the 4 remaining patients had documented stones with no confirmation of a nonvisualizing OCG in the other patient. Among the 88 patients with OCG, GSCS findings correlated in 91 per cent (2 per cent false-positive; 7 per cent false-negative). Among the 43 operative patients, GSCS was proven correct in 91 per cent (no false positive; 9 per cent false-negative). Of 12 patients with jaundice GSCS correlated with operative findings in 75 per cent (no false-positive; 25 per cent false-negative). Diagnostic errors occurred in patients with very small biliary calculi, particularly when a single stone was impacted in the cystic duct. Failure to identify the gallbladder with ultrasound signifies probable cholelithiasis in the patient without previous cholecystectomy. On the basis of this experience, we conclude that (1) GSCS is most useful when jaundice or acute illness precludes conventional studies; (2) GSCS provides an inexpensive, quick, accurate means of diagnosing cholelithiasis with a very high specificity (97 per cent) and moderate sensitivity (88 per cent); and (3) GSCS is the optimal diagnostic procedure for evaluating the biliary tract in the acutely ill, jaundiced, vomiting, allergic, and/or pregnant patient.

PHARMACOLOGICAL PROTECTION AGAINST SWINE STRESS ULCER

Cholestyramine, methysergide, and methylprednisolone were evaluated in a swine hemorrhagic shock model as they protect against stress ulceration. Twelve control piglets developed gastric ulcers within 48 hr of shock. The early intragastric administration of cholestyramine prevented ulceration in 8 of 9 animals (89%) providing additional evidence that swine stress ulceration depends upon bile reflux into the stomach. When cholestyramine administration was delayed for 1 hr, only 2 of 5 swine were protected which suggested that bile damage to mucosa occurs rapidly. Prefeeding with methysergide, a serotonin antagonist, protected 2 of 4 piglets. Giving methysergide intravenously during shock afforded no protection to 4 other animals. Methylprednisolone given in high doses intravenously to 5 piglets early in shock prevented ulceration uniformly. Delay in administration by 1 hr in 5 other animals resulted in ulceration. The mechanism of methylprednisolone protection was not studied, but results are consistent with the hypothesis that steroids stabilize lysosomal membranes. On the basis of results in the swine model, cholestyramine and methylprednisolone might be considered for clinical trial as pharmacological prophylaxis against stress ulceration. Their success would appear to depend on very early administration after the stressful event. The clinical usefulness of methysergide cannot be predicted on the basis of these experiments.

Gastric mucosal blood flow measurement

1. 1. Pertechnetate clearance (CTc) by the stomach before and after betazole stimulation was compared to regional measurements of gastric blood flow utilizing nuclide (Chromium-51 and Cerium-141) labeled microspheres in five piglets. 2. 2. Pertechnetate clearance closely correlated (correlation coefficient 0.926) with mucosal blood flow in the gastric corpus measured by the microsphere technique. Betazole increased blood flow in the corpus region by 100% but did not alter this relationship. Except in one experiment, microsphere blood flow valves in the antrum and fundus were unchanged by betazole and did not significantly correlate with pertechnetate clearance. 3. 3. Pertechnetate clearance appears to be a reliable method of determining gastric mucosal blood flow in experimental animals and may be considered as a noninvasive method for measuring such flow in humans.

Community experience with small bowel bypass for morbid obesity

A comparison of small bowel bypass performed at university centers and by private practitioners in a large metropolitan area demonstrates definite stmilarities in terms of patient selection, mortality and morbidity, and weight loss results. The only aspect of small bowel bypass in the private sector that could be criticized would be the adequacy of follow-up. An operation with as many known and probably other unknown long-term complications as jejunoileal bypass necessitates prolonged careful patient follow-up. We belive the person most qualified to provide such follow-up is the surgeon who performed by bypass procedure.

Colorectal Cancer: Current Concepts in Diagnosis and Treatment

This book is a delight for the clinician treating patients with colon cancer. It is concise yet thorough. It is remarkably up to date for a textbook. The format is clear, and the illustrations are clean. Subject matter includes a wide range of diagnostic and treatment concerns plus a reasonable degree of research data. This is primarily a book for the surgeon who manages his patient through the full course of treatment of colorectal cancer. A number of chapters are outstanding. Surgical treatment of colon cancer is discussed by the editors themselves. Their writing style is fresh and direct with a sense of precise organization. They correctly focus on technique as the key to surgical treatment but include reviews of screening, colonoscopy, and adjuvant therapies as well. The classic determinants of what colon is resected for what disease are restated in exact anatomic terms. Results of operation are expressed in

1984 Year Book of Digestive Diseases

The 1984 Year Book of Digestive Diseases , edited by a gastroenterologist, Norton J. Greenberger, MD, and a surgeon, Frank G. Moody, MD, is a compendium of more than 300 summaries of articles that appeared in 51 journals published in 1983. In making their selection of important work, the editors reviewed approximately 10,000 articles dealing with gastrointestinal tract disorders related to internal medicine, surgery, pediatrics, diagnostic radiology, nuclear medicine, pathology, clinical pharmacology, and basic science. The book is organized by organ systems of the gastrointestinal tract and liver. After each summary, one of the editors comments on the significance or methodology of the study. The last few pages include capsule comments (abstracts) of an additional 18 articles and visual vignettes, which are reproductions of instructive illustrations from a half dozen articles. This book is useful to the surgeon who needs to scan a vast literature for key contributions to gastroenterology and