Leslie W. Ottinger

Carcinoid tumors of the appendix.

OBJECTIVE A retrospective study of 41 patients with histologically confirmed diagnosis of appendix carcinoid tumors was undertaken by reviewing the surgical records at Massachusetts General Hospital. METHODS There were 8 male and 33 female patients (mean age 32 years). Twenty-two patients (54%) presented with signs and symptoms suggestive of acute appendicitis. In 19 patients (46%) the lesions were discovered incidentally. The tumors were located in 32 patients at the tip, in 6 patients in the middle third, and in 3 patients at the base of the appendix. The tumor was less than 1 cm in diameter in 32 patients, between 1 and 2 cm in 7 patients, and was bigger than 2 cm in 2 patients. In 29 patients, the depth of tumor penetration was confined to the submucosa or to the muscle layers of the appendix, and in 8 patients the serosa was involved. In 4 patients, evidence of tumor extension into the meso-appendicular fat was present, including one patient with a tumor bigger than 2 cm and local lymph-node metastases. Forty patients underwent appendectomy alone. One patient with a tumor size bigger than 2 cm in diameter with positive lymph nodes in the mesoappendix underwent secondary right hemicolectomy. Complete follow-up was achieved in 35 patients, and all patients remained free of tumor recurrence. CONCLUSIONS The authors conclude that appendiceal carcinoids are rare and most often are asymptomatic. Tumors of less than 1 cm are adequately managed by appendectomy alone. The appropriate treatment for tumors of 1 to 2 cm continues to be controversial. Right hemicolectomy is recommended for all tumors larger than 2 cm, whereas preference for an aggressive approach should be given in young patients.

The surgical management of acute occlusion of the superior mesenteric artery.

A study of 103 cases of acute occlusion of the superior mesenteric artery is presented. The relation of site of occlusion to etiology, extent of infarction, and survival following resection and revascularization is described. Included is an analysis of the technical factors contributing to successful revascularization, the specific complications of revascularization, and the application of elective second look operations and angiographic techniques. The persistent high mortality (85% in this series) can probably be reduced but only by advances in these areas along with progress in the more general aspects of management of elderly patients with multiple system problems and failure.

Acute small bowel volvulus in adults : a sporadic form of strangulating intestinal obstruction

Small bowel volvulus is an uncommon but important cause of small intestinal obstruction. It often results in ischemia or even infarction. Delay in diagnosis and surgical intervention increases morbidity and mortality rates. Based on cause, small bowel volvulus can be divided into primary and secondary type. Goals for treatment of small bowel volvulus should include physician awareness of this uncommon diagnosis, accurate workup, and advanced surgical intervention. The presentation and subsequent management of 35 patients with small bowel volvulus confirmed by laparotomy are reviewed and discussed. The incidence of small bowel volvulus in the adult European and North American is low. The resultant mortality rate, however, makes diagnosis critically important. The cardinal presenting symptom is abdominal pain. There is no single specific diagnostic clinical sign or abnormality in laboratory or radiologic finding. In practice, the diagnosis can only be made by laparotomy. The failure to perform an exploratory laparotomy cannot be justified. Early diagnosis and early surgery are the keys for successful management of strangulation obstruction of the small bowel.

Acute perforation of the colon associated with chronic corticosteroid therapy.

Perforation of the colon occurred in thirteen patients receiving corticosteroids for diseases unrelated to the bowel. Treatment averaged 3.5 years. The paucity of symptoms, signs, and laboratory indexes of visceral perforation led to frequent delays in treatment and to incorrect preoperative diagnoses in all but three patients. The perforations were often unusual in location (cecum, hepatic flexure, and multiple points in the transverse and descending colon) and often resulted from single punched-out ulcers in otherwise normal bowel. In seven patients the lesion could not be distinguished from perforated sigmoid diverticulitis, but in two of these patients the ulcerations were found in adjacent diverticula. The evidence strongly suggests that corticosteroids can be responsible for ulceration and perforation of the colon either by direct injury or by interference with normal mechanisms of bowel repair.

Delayed appendectomy for appendicitis: Causes and consequences

This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.

Acute cholecystitis as a postoperative complication.

The clinical course and management of 40 patients who underwent operation for acute cholecystitis developing as a postoperative complication were reviewed. Of note was the mortality of 47%, the high incidence of gangrene, perforation, empyema, and cholangitis, and the atypical clinical presentation of acute cholecystitis under these conditions. Awareness of this possible complication, knowledge of its clinical features, and early surgical intervention are important facets of successful management.

Hematuria as a sign of aorto-caval fistula.

An aorto-caval fistula is a rare complication of an abdominal aortic ancurysm (AAA). Typical features, including congestive heart failure and a loud abdominal bruit, may be present and allow prompt diagnosis, but not infrequently they are absent or overlooked and the diagnosis not made preoperatively. Four patients with an AAA and an aorto-caval fistula are described, each of whom presented with hematuria. We believe the presence of hematuria in a patient with a symptomatic AAA should suggest the diagnosis of an aorto-caval fistula. A correct preoperative diagnosis may contribute to better planning of the operative procedure, reduced blood loss, and avoidance of possible pulmonary embolization.

Elective hepatic resection

Abstract Thirty-two cases in which either right hepatic lobectomy or left or partial lobectomy have been carried out for both benign and malignant disease are described and categorized. Diagnostic and operative technics are outlined, the important metabolic aberrations after extensive resection noted, and some observations on hepatic regeneration in man included in this report

Improved limb salvage in popliteal artery injuries

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.

Delayed gastric emptying following gastrectomy.

The characteristics of 46 patients unable to take a solid diet Hi thin two weeks of gastric resection and had no other postoperative complications are reviewed. The incidence of delayed gastric emptying was found to be 2½ times greater in patients with vagotomy and hemigastrectomy than in those with subtotal gastrectomy. In addition, postoperative delay was often prolonged in the hemigastrectomy and vagotomy group. Mechanical factors were responsible for delay in only 10% of these patients. Possible explanations for these delays are made and it is suggested that localized starch peritonitis may explain many cases of “functional efferent limb ileus.” Measures to evaluate the source of delay are recommended and suggest conservative management for the majority of patients. Reoperation is reserved for those who require feeding or draining enterostomy tubes and those whose clinical course and evaluation suggest obstruction.