Leonard Rosoff

Early postoperative small bowel obstruction.

The hospital records of 41 patients with a diagnosis of early postoperative small bowel obstruction were reviewed in an attempt to identify criteria which could be used to separate those patients who would require an operation to resolve their obstruction, from those who would resolve with nonoperative therapy. The usual symptoms, signs and roentgenologic changes seen with mechanical bowel obstruction were not useful discriminants in making such a determination. All patients were initially treated nonoperatively with intestinal intubation, antibiotics and parenteral fluids. Thirty patients resolved without an operation and 11 required an operation. There was one death in the latter group, an overall mortality of 2.4%. Initial nonoperative therapy is warranted in such patients.

Injuries of the spleen.

Pathology, Clinical manifestations, and diagnostic aids such as abdominal paracentesis, angiography, and radionuclide studies, and important features of emergency splenectomy.

Hemodynamic and metabolic changes associated with bacterial peritonitis

Abstract Hemodynamic and metabolic studies of ten patients critically ill with diffuse bacterial peritonitis have been presented. The cardiac output and velocity of blood flow were normal. Total peripheral arterial resistance was markedly reduced in patients in whom systolic blood pressure was reduced to 75 mm. Hg or less despite normal cardiac output. Blood lactate levels were greatly elevated in these patients, indicative of a critical reduction in blood flow necessary to sustain normal metabolism of vital tissues. Our data indicate that an abnormal variation in distribution of blood flow is an outstanding circulatory alteration in patients with diffuse bacterial peritonitis. This hemodynamic effect may be explained by arteriovenous shunting in the systemic vascular bed. The site of such shunting is as yet unidentified, but presumably occurs in the area of peritoneal inflammation. Decreases in alveolar oxygen exchange also indicate the coexistence of arteriovenous shunting in the pulmonary circulation. Ventilatory failure and profound alterations in pulmonary function appear to be significant factors in the lethality of diffuse bacterial peritonitis.

Mechanism and treatment of shock associated with acute pancreatitis

Summary The mechanism of circulatory shock complicating acute pancreatitis is a critical reduction in plasma volume. Serial hemodynamic and metabolic studies were performed on five patients in shock associated with acute pancreatitis. The mean arterial blood pressure and cardiac output were reduced and peripheral arterial resistance was increased. Mean circulation time was markedly prolonged, reflecting decreased velocity of blood flow. Coma, oliguria, hyperamylasemia, and metabolic acidosis were consistent features. Since the state of shock associated with pancreatitis is due to a volume deficit with marked arterial vasoconstriction, volume replacement alone with avoidance of vasoconstricting agents is indicated. Prompt plasma volume replacement favors reversal of the hemodynamic and metabolic deficits of this type of shock. Hypotension and coma, the two notable clinical features, were reversed after the infusion of large volumes of colloid and crystalloid solutions.

Operative Treatment of Acute Cholecystitis

Deterioration of the patient with acute cholecystitis as an indication for emergency operation is associated with a high mortality. Earlier operation in such patients may effectively reduce this mortality and the complications consequent to progressive acute obstructive cholecystitis.

Acute emphysematous cholecystitis: An analysis of ten cases

Summary Ten cases of acute emphysematous cholecystitis are reported. Three patients were treated nonoperatively and seven patients were operated upon. There was one death which occurred postoperatively but was not related to emphysematous cholecystitis per se. More frequent use of abdominal roentgenograms will aid in the early recognition of this entity. The roentgenographic criteria of emphysematous cholecystitis consist of the presence of gas in the lumen of the gallbladder or in the wall or pericholecystic tissues or combinations of these. The initiating factor in the development of emphysematous cholecystitis appears to be obstruction of the cystic duct. Bacteria are of secondary importance. Evidence is presented to support the position that patients with this condition should be treated in the same manner as patients with other forms of acute cholecystitis. Intensive antibiotic therapy should be started as soon as the diagnosis is made and continued until clinical manifestations of the disease have subsided. Surgical treatment is based on the persistence or progression of clinical findings during the course of treatment. Patients doing well during the period of preparation may be treated nonoperatively. This may be also considered for patients with severe coexisting disease.

Triiodothyronine-secreting (toxic) adenoma of the thyroid gland. Light and electron microscopic characteristics

A patient with thyrotoxicosis due to a triiodothyronine (T3)‐secreting autonomous adenoma is described. The histomorphology of the neoplasm was similar to other neoplasms previously reported. Ultrastructural features of the adenoma are compatible with a very actively secreting follicular cell and are best compared with the ultrastructure of a diffuse toxic goiter. Distinctive features that separate toxic adenomas from various thyroid carcinomas and normal thyroid parenchyma are discussed.

Biochemical tests for hepatobiliary disease.

Among many uses, liver “function” tests are important to the surgeon in the differential diagnosis of preoperative and postoperative jaundice and for the detection of lesions within the liver, portal system, or biliary tract for which operative procedures are helpful.

Total parathyroidectomy in the treatment of renal osteodystrophy.

A total parathyroidectomy was performed upon a 17-year-old boy with severe renal osteodystrophy and metastatic calcification which had failed to resolve during 4 months of intermittent hemodialysis. The extraosseous manifestations (pruritis, anorexia, depressed affect) of parathyroid hyperactivity disappeared within 2 to 3 weeks following parathyroidectomy. By the fifth postoperative month, the metastatic calcification had disappeared, osteitis fibrosa was no longer present radiologically, and the bony architecture had become normal except for residual deformities. Parathyroidectomy is recommended during the course of chronic renal disease when clinical or osseous evidence of unremitting parathyroid hyperactivity is evident.