Leon Goldman

Surgical treatment of chronic pancreatitis

We studied the course of 100 consecutive patients who underwent surgery for pain or biliary obstruction from chronic pancreatitis or both between 1958 and 1982. Patients with pancreatic pseudocysts were excluded. Ten patients had pancreatic resection after previous pancreatic surgery had failed to control pain. Ten of 47 patients (21 percent) studied between 1972 and 1981 had bile duct entrapment from chronic pancreatitis and required biliary bypass operations. The results of longitudinal pancreaticojejunostomy were good in 67 percent of the patients, fair in 18 percent of the patients, and poor in 15 percent of the patients. The results of partial pancreatectomy were good in 60 percent of the patients (all with disease limited to the tail), fair in 20 percent of the patients, and poor in 20 percent of the patients. The results of subtotal pancreatectomy were good in 31 percent of the patients, fair in 37 percent of the patients, and poor in 32 percent of the patients. The results of pancreatic resection in patients with previous unsuccessful surgery for pain relief were good in only 10 percent of the patients. Biliary obstruction is present in many patients with chronic pancreatitis and must be treated surgically to prevent the development of biliary cirrhosis. Hemipancreatectomy is useful in patients with disease limited to the tail. The results of subtotal pancreatectomy are discouraging, especially in patients with a previous unsuccessful operation for pain. When the pancreatic duct is dilated, however, longitudinal pancreaticojejunostomy gives long-lasting relief of pain in most patients.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines.

The course of all 113 patients with Crohns disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%.

Significance of post-cholecystectomy subhepatic fluid collections.

A prospective ultrasound study of the right upper quadrant in 105 patients who had undergone cholecystectomy showed the incidence of fluid collection in the gall bladder fossa to be 24% 2 to 4 days after operation. In all but two patients, these fluid collections were of no clinical significance. The relationship between the presence of fluid and several other variables, such as use of drains and surgical techniques, are discussed.

Zollinger-Ellison syndrome: An analysis of twenty-five cases☆☆☆

Abstract Multiple endocrine adenomatosis was identified in 48 per cent of 25 patients with the Zollinger-Ellison syndrome. This figure is twice that in Ellisons series and is probably closer to the true incidence. Eleven patients had hyperparathyroidism, five had adrenal hyperplasia or adenomas, four had pituitary tumors, three had thyroid tumors, one had carcinoid tumors, and two had hyperinsulinism. It should be emphasized that a patient with hyperparathyroidism and peptic ulcer disease is likely to have ulcerogenic pancreatic tumors. All patients with the Zollinger-Ellison syndrome should be investigated for hyperparathyroidism. Diagnosis is often difficult with presently available technics. Positive information in the form of a high basal to maximal acid output ratio, bioassay positive for gastrin, or demonstration of an islet cell tumor is quite reliable. Negative information is less helpful in attempting to exclude the diagnosis. Total gastrectomy has been very successful as treatment for this disease. Since it is curative and is associated with little nutritional morbidity in these patients, total gastrectomy is the only recommended operation except in patients with primary ectopic tumors; these patients are successfully treated by tumor excision.

Recurrent cholangitis after biliary surgery

After a biliary-enteric anastomosis, the development of cholangitis is usually assumed to be due to obstruction of the stoma. Six patients in whom this was not the case are described. Achlorhydria, duodenal diverticula, and foreign bodies are important predisposing factors. When bacterial contamination is severe in an abnormal intrahepatic biliary tree, especially that which follows long-standing intermittent common duct obstruction, symptomatic biliary infection may occur in the absence of extra-hepatic biliary obstruction.

Evaluation of solitary cold thyroid nodules by echography and thermography

Thyroid operations are an effective form of treatment for thyroid nodules and are associated with minimal morbidity and rare mortality. The major indication for thyroidectomy in non-toxic goiter is the suspicion of thyroid malignancy. Despite the excellent therapeutic effectiveness of thyroid operations, the diagnostic accuracy in differentiating benign from malignant thyroid neoplasms without operation is low. Most medical centers report that the incidence of thyroid cancer in patients having thyroid operations varies from between 5 and 35 percent. Obviously, if only 5 percent of patients who have thyroid operations have cancer of the thyroid, too many people are having thyroid operations and if 50 percent are found to have cancer, too few patients with thyroid disease are having operations and many patients are being followed without definitive treatment.

The problem of bleeding peptic ulcer

Abstract 1. 1. Ina city hospital where patients with peptic ulcer enter only because of some serious complication of ulcer, there is a high incidence of hemorrhage and resultant mortality. In our experience, this is greatest during the arteriosclerotic age. The mortality rises with each hemorrhage. 2. 2. This study suggests that the occurrence of hemorrhage, similar to that of perforation, is rare in patients following prescribed or proper diet-alkali therapy. In the majority of cases, dietary or alcoholic indiscretion precedes the onset of these complications. 3. 3. Although one must treat each patient according to the merits of his individual case, based on the age of the patient, the presence of arteriosclerosis, the location of the ulcer and the past history, the data collected suggest that indications for surgery may be present in each clinical group as follows: 3.1. (a) In the few patients who are following adequate treatment at the time of the onset of the hemorrhage (Group 1), surgical treatment should be considered during the quiescent stage. 3.2. (b) If surgery is performed for the bleeding type of ulcer, direct attack on the ulcer with its removal, in addition to subtotal gastrectomy, is the procedure of choice and is more likely to reduce the incidence of hemorrhage after surgery. The study of Groups II and III suggests that gastrojejunostomy may not protect against the recurrence of or subsequent hemorrhage from a duodenal ulcer. Thirty patients of this series had gross hemorrhage from ulcer after gastroenterostomy. 3.3. (c) Patients with no history of peptic ulcer, or a very short history, who suddenly bleed (Group IV, have the poorest prognosis for life in the entire series. Transfusions are important in the treatment of this particular group. Surgery is not feasible in the acute stage because of the patients poor general condition. After the hemorrhage has ceased, these patients usually do well on medical treatment. 3.4. (d) Sixty-two per cent of the patients with hemorrhage have had the symptoms of ulcer for many years and, in our experience, represent an uncooperative group (Group v). If, during the acute bleeding phase, hemorrhage keeps recurring while the patient is under medical treatment, with transfusions, immediate surgery should be considered. After the occurrence of two hemorrhages, surgery is indicated during a quiescent period because it is very likely that these patients will not follow prescribed therapy over a long period of time, and the hemorrhage will recur. Conservative treatment is indicated in those patients below the age of forty years, without arteriosclerosis. 4. 4. Hemorrhage and perforation occasionally are associated or coincidental; the prognosis is poor.

Treatment of chronic pancreatitis by longitudinal pancreaticojejunostomy

Abstract A series of fifteen patients is presented in whom pancreaticojejunostomy was performed for chronic pancreatitis. Preoperative abdominal pain and pancreatic calcification were the most constant findings. Three modifications of the original Puestows procedure were employed in this series. The most satisfactory technical procedure at present consists of side to side pancreaticojejunostomy with preservation of the spleen and pancreatic tail. The pancreas at operation was invariably indurated, and ductal obstruction and the chain-of-lakes phenomenon were found in thirteen cases. Microscopic examination of pancreatic tissue revealed severe degrees of atrophy and fibrosis. Good results were achieved in thirteen of the fifteen patients, as evidenced by dramatic relief of pain, often despite continued alcoholic excesses. There were no deaths in this series and no postoperative diabetes occurred. Steatorrhea was corrected by the procedure in two patients and appeared postoperatively in another. In the fibrotic, stone-containing pancreas in which ductal obstruction is the basis for persistent pain, pancreaticojejunostomy offers a physiologic means of treatment. It sacrifices little or no glandular tissue, accomplishes drainage of enzyme to the lumen of the gut, relieves obstruction and usually relieves pain.

PRELIMINARY EXPERIENCES WITH TRANSPLANTS OF CULTURED PARATHYROID TISSUE IN HYPOPARATHYROIDISM

Excerpt A number of attempts to transplant parathyroid tissue into patients with hypoparathyroidism have been made in the past. Results have not been consistent, although occasional isolated succes...

Effect of Synthetic Vitamin K Compounds on Prothrombin Concentration in Man

Summary Three synthetic vitamin K compounds were administered to 26 patients with hypoprothrombinemia. Following treatment the prothrombin concentration: (1) was markedly elevated in 11 patients with obstructive jaundice, (2) was not elevated in 8 and only slightly elevated in 3 patients with chronic diseases of the liver; (3) was not elevated in 1 patient, and after an initial delay was elevated in 1 patient with acute diseases of the liver; (4) was moderately elevated in 2 patients, one with non-tropical sprue, and the other with gastro-colic fistula. When considered in terms of the dosages employed, there were no significant qualitative differences in the relative effectiveness of the three compounds. No untoward reactions were observed except that the patients receiving large doses of 4-amino-2-methyl-naphthol-hydrochloride complained of slight burning pain at the site of injection.