Louis T. Palumbo

Anterior versus abdominoperineal resection. Resection for rectal and rectosigmoid carcinoma.

Abstract Anterior resection of the colon for carcinoma involving the middle and upper rectum, rectosigmoid, and sigmoid is the operation of choice (lesions 7 to 9 cm. above the anal verge or at the peritoneal reflection and above). This restores functional colonic continuity without the need for colostomy and provides the patient with an equally good chance for a five year survival rate as compared to a Miles abdominoperineal resection. This sphinctersaving procedure is an adequate operation for cancer providing dissection includes adequate normal colon above and below these lesions with removal of associated tissues that include the regional lymphatics. Our data showed the morbidity rate to be lower and the five year survival rate to be better than those for the Miles operation in comparable lesions in the areas of the colon described herein. Sphincter-saving operative procedures for cancer of the colon, when properly performed, can be as adequate an operation for cancer as the Miles abdominoperineal resection for lesions at the peritoneal reflection and above

Distal Antrectomy With Vagectomy for Duodenal Ulcer: Results in 611 Cases

Distal antrectomy (25% or less) resection of the distal stomach with bilateral vagectomy, Billroth II, antecolic, Polya or Hofmeister gastrojejunostomy, continues to be our operation of choice for chronic duodenal ulcer. This is based upon our experience in 611 operations and as a result of careful complete repeat in-patient followup studies conducted since our original operation which was devised and performed in July 1953. This procedure controls or eliminates the two major gastric acid stimulatory phases responsible in the pathogenesis and chronicity of a duodenal ulcer: neurogenic (cephalic phase) via the vagal gastric pathways, and the humoral (gastrin) phase via antral stimulation. Even though part of the antrum may remain in the gastric remnant in some patients, antral control is maintained because the antrum remains in the gastric acid stream, there is no stasis, and it is vagectomized. The ulcer diathesis is controlled with a minimal disturbance in gastric physiology, in function, and in gastric reservoir capacity; the procedure will almost eliminate all of the undesirable postoperative gastrointestinal sequelae associated with other operations for duodenal ulcer. It insures the least chance for marginal, gastric, or recurrent ulcer formation, and a low morbidity rate.

Appendicitis—Is it on the wane?

Abstract The incidence of acute appendicitis and the total number of appendectomies performed in the adult population admitted to our Medical Center are decreasing. A twelve-year survey, 1947 through 1958, of our surgical records revealed a progressive downward trend in both instances. The incidence of this disease and the operation for it decreased from 15.4 to 6.4 per cent in the twelve-year period. This significant and progressive downward trend in the adult population may be in some way connected with the many favorable aspects of a better national economy. The medical reasons for this favorable change are not presently known.

Scalene node biopsy—Clinical evaluation and application

Abstract Scalene node biopsy is an additional adjunct to the establishment of a diagnosis in many lesions and an important aid in the determination and selection of patients with pulmonary lesions for thoracotomy. The incidence of positive nodes in proved cases of primary pulmonary carcinoma was 19 per cent in our series. In the instances of non-palpable scalene nodes, the incidence was 8.1 per cent. In a group of patients with pulmonary carcinoma who were considered clinically operable, the scalene node biopsy was positive in 10 per cent. This factor may be an important consideration in selection of patients for exploration and resectability. A properly performed scalene node biopsy should become a definite part of the over-all work-up and evaluation of patients with pulmonary lesions, particularly those with primary carcinoma.

CANCER OF THE COLON AND RECTUM; ANALYSIS OF 300 CASES.

Summary A survey of our experience with the surgical treatment of cancer of the colon in 300 patients treated during a fifteen year period ending in 1963 is presented. A curative procedure was performed in 7 per cent of the patients with a postoperative mortality of 3.5 per cent from all causes. A palliative procedure was performed in 23 per cent with a mortality of 4.4 per cent. At the completion of this fifteen year study, 52 per cent of the patients had died as a result of their disease. The longest periods of survival and the greatest number of survivors were among patients with lesions in the sigmoid, rectosigmoid, rectum, or descending colon. Fifty-seven per cent of the lesions occurred in the sigmoid, rectosigmoid, and rectum. In 14 per cent the lesion was located in the cecum. The most common cell type was adenocarcinoma. The average survival time was thirty-one months, with the longest survivals occurring in patients with lesions of the upper part of the rectum. At the end of five years, 25 per cent of the patients were living and free from their disease. The higher the lesion was in the rectum, rectosigmoid, or sigmoid, the longer was the survival period and the higher were the percentages of survivals.

Effects of early and late ambulation upon the surgical patient

E ARLY ambulation of the surgicai patient is now becoming an accepted poIicy in many surgica1 centers and clinics throughout the country. This method of postoperative management of patients has taken more than fifty years to gain a substantia1 and sound footing in our country. One of the eartiest reports on the subject was by Ries in 1899. l1 The report by Leithauser in 1941 created a great stimulus to the study of this probIem of earIy ambuIation.7 Since that time many favorable reports have appeared in the Iiterature.1-6~*-10 This report is based on the study of the effects of earIy and Iate ambuIation upon 2,955 patients who had major surgery performed at this hospita1 from September, 1946, to September, 1950. During the first two years of this period the poIicy and routine estabIished was to ambulate patients after the sixth postoperative day. After this period practicaIly a11 of the patients were ambuIated before the third postoperative day. AI1 patients ambuIated within the first three postoperative days were cIassified in the early ambuIation group, whereas those ambulated after the third day were placed in the Iate ambuIation group. AmbuIation in this study consisted of arising from bed, standing, walking and sitting either in a chair or on the side of the bed. The majority of patients in the early group were ambuiated during the first twenty-four-hour period. Those in the Iate group were ambulated from the fourth to the fourteenth postoperative day; however, the majority in this group were ambuIated after the seventh day. This sequence of activities with assistance to the patient was carried out two to three times daiIy unti1 the patient was abIe to manage his own activities safeIy. In a11 cases, whether the patient was ambulated early or late, deep breathing and leg exercises were started immediateIy after the patient reacted from his anesthetic. These activities were carried out several times a day for a period of time as required for each individual or specific groups of patients. Those scheduled for thoracic surgery received thorough preoperative instructions in breathing, upper extremity, shoulder girdIe and posture exercises. They were we11 indoctrinated prior to surgery so that their cooperation in carrying out these exercises foIlowing surgery was easily elicited. This organized program of bed and chest exercises and ambuIation was a result of a combined and coordinated program instituted, supervised and conducted by the members of the Department of Physical Medicine in conjunction with the members of the Department of Surgery and its nursing staff. It is only through teamwork with a we11 deveIoped and we11 organized Department of PhysicaI Medicine that such a program as outlined previously can be carried out.

Lumbar sympathectomy for peripheral arteriosclerosis

Abstract The results of lumbar sympathectomy in the treatment of peripheral arteriosclerotic vascular disease of the lower extremities (including diabetics) in two consecutive series of cases are compared. In Group A there were forty-nine males upon whom seventy-two sympathectomies were performed from 1946 to 1951; in Group B there were sixty-six males upon whom 105 sympathectomies were performed from 1952 to 1955. The patients in both groups were in the forty-four to eighty-five year age range with the largest number (90 per cent) in the fifty-one to seventy year age group. Improvement was experienced in about equal numbers in both Groups A and B, being 86 and 82 per cent, respectively. In 61 per cent of patients in Group A and 69 per cent in Group B who required an amputation, it was accomplished below the knees. The performance of this procedure, as evidenced by the over-all favorable results with about the same frequency in both groups in properly selected patients, continues to be an important method of management of selected patients with peripheral arteriosclerosis on our services. The results are most favorable in the group who exhibit associated vasospasm and a vascular bed which has elastic potentialities; these are evident by the results such as diminution or relief of pain, increased walking distance without pain or discomfort, warmth and dryness of the extremity, more rapid healing of ulcers, subsidence of infection or cellulitis and improvement in edema. In addition, when a major amputation becomes necessary, it can most often be accomplished at a lower level with safety. In some, this procedure may obviate amputation or delay it. The patient frequently is rehabilitated more rapidly and the period of hospitalization is reduced.

Effects of early postoperative ambulation.

Results of early postoperative ambulation in 1700 major surgical cases are compared with those of late postoperative ambulation in 1200 similar surgical cases. The beneficial effects of early ambul...

Biliary tract calculi and associated disease.

Extrabiliary calculi may occur in association with cholecystitis, cholelithiasis, or other diseases involving the biliary tree or pancreas. The indications for exploration of the common duct and the criteria for determining the optimum time for discontinuance of drainage are discussed. The complications, mortality rates and types of incision employed are presented. The value of direct or indirect cholangiography is shown.

Hemipelvectomy in treatment of osteogenic sarcoma of the ilium

Abstract Since the first successful operation by Girard fifty-three years ago 132 cases have been reported. A mortality rate of 60 per cent was reported in the first seventy-nine cases. In the past eleven years operative mortality has dropped to 14 per cent. The overall mortality was 36 per cent. This drop in mortality has been due to the development of methods of combating shock and hemorrhage. The present mortality rate can be expected to drop still lower by a better understanding of the anatomy involved, technics developed and the institution of active steps to prevent shock by free use of whole blood and plasma transfusions. Follow-up statistics have been unsatisfactory to date. However, of the forty-five patients who survived the operation and who were followed for five or more years, twenty-one remained clinically well; twenty-four died of their disease. Radical amputation seems to be a definite and distinct advancement in the radical treatment of selected cases of malignant tumors of the lower extremity, buttock, groin, innominate bone or pelvic parietes and by careful consideration of these factors in the future, prognosis of such lesions can be favorably influenced.