Orville F. Grimes

Traumatic injuries of the diaphragm. Diaphragmatic hernia.

Abstract Trauma to the diaphragm may be direct or indirect, and herniation may be obscured by concomitant injuries and may remain occult for many years. The early physical signs and symptoms are meager before the abdominal organs have penetrated deeply into the thorax. The progress of injury can be divided into three phases: (1) initial, (2) latent, and (3) obstructive. Most traumatic hernias occur on the left side because of the diminished buffering force on the undersurface of the left hemidiaphragm. Roentgenograms are most often misinterpreted as indicating eventration of the diaphragm, gastric dilatation, or lesions in the lower lung fields or pleura. A dilated stomach in the left pleural cavity may simulate a pneumothorax. Diaphragmatic injury should always be considered in conjunction with trauma to the liver, kidneys, and spleen. Intestinal obstruction may occur with few significant abdominal findings, when most of the involved viscera are in the thorax. The thoracic approach to surgery provides excellent exposure. The herniated viscera which may be adherent to the lung or pericardium can be released conveniently, there is easy access to the diaphragmatic rent, and lacerations near the heart and esophagus can be repaired without fear of further injury. Extensions or separate abdominal incisions may be necessary to manage concomitant injuries, especially in the initial phase. Wounds of the diaphragm are not likely to heal spontaneously; often the omentum or other viscera plug the laceration, thereby preventing acute herniation. However, this same mechanism separates the muscle edges, preventing their union. Traumatic ruptures of the diaphragm are twelve times more common on the left side due to the protection afforded by the liver. Diaphragmatic tears are most common in the dome and the posterior half which are the areas of embryonic weakness. When strangulation of bowel occurs in the thorax, approximately 90 per cent of the cases are due to traumatic hernia of the diaphragm, and when strangulation occurs, the mortality varies from 25 to 66 per cent.

Isolated lipodystrophy : a form of mesenteric tumor

Abstract A peculiar tumor-like alteration of the fat of the small bowel mesentery is described. This lesion was found in five adult patients, all with little or no relating symptomatology. In four an abdominal mass was palpable. Diagnosis was established at exploratory laparotomy in three patients, and at postmortem examination in the remaining two. Grossly, the entire small bowel mesentery was thickened and nodular, rubbery firm, opaque and mottled grey to yellowish orange. Microscopically, there was diffuse involvement of fat cells, most prominent about the periphery of the fat lobules. In the early stages individual fat cells appeared smaller than normal; their cytoplasm was opaque, granular and faintly basophilic, and the nucleus was centrally situated. Later, a mild focal lymphocytic infiltration and perilobular condensation of fibrous tissue were apparent. Only rarely and in small focal areas was there development of lipogranulomas. It is suggested that initial proliferation of mesenteric fat induces a perpetuating alteration in fat cell metabolism through either vascular or mechanical embarrassment. The fat cells, particularly those of the relatively more ischemic peripheral portions of the lobules, lose their ability to absorb fat and their lipolytic activity is compromised. These altered cells undergo the structural changes described heretofore; and as the process progresses, they may actually break down, liberating fatty acids and exciting focal inflammation and fibrosis. These mesenteric masses bear certain resemblances to Whipples disease, Weber-Christian disease with systemic involvement, sclerosing lipogranuloma and traumatic or pancreatic fat necrosis. They must also be differentiated from true fat tumors, lymphosarcoma, tuberculosis and other less common conditions. The premortem diagnosis can be made only at operation. Biopsies should be taken not only of the mesentery but also of the bowel and mesenteric lymph nodes. Surgical resection usually is not feasible, as the process tends to surround the major mesenteric vessels. The prognosis apparently is favorable, for the lesion is slowly progressive and probably selflimited. Alteration in bowel function does not ensue, nor is there evidence that the process later involves other tissues.

Closure of bronchopleural fistulas by an omental pedicle flap

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

Nonpenetrating Injuries to the Chest Wall and Esophagus

Trauma limited to the thoracic cage itself may produce profound pathophysiologic alterations which may be fatal if not promptly treated — from fractures of ribs or sternum and injuries to cartilage, to the severely crushed chest. Esophageal rupture as a result of external blunt trauma to the thorax or abdomen is rare and almost always fatal, and the keynote in management is rapid diagnosis.

Management of massive lower gastrointestinal hemorrhage

Abstract Massive bleeding from the lower gastrointestinal tract often presents problems in diagnosis and management. Nine case reports of recent experiences are presented to illustrate many of the problems involved and a systematic approach to the management of this condition is described.

Primary retroperitoneal tumors

Abstract Retroperitoneal tumors may reach sizable proportions before recognizable symptoms are produced. Since an extensive involvement of retroperitoneal tissues usually occurs, the results of any type of treatment for malignant retroperitoneal lesions are not particularly favorable. Benign lesions in the retroperitoneal area usually can be surgically excised without undue difficulty. Nevertheless, such tumors tend to recur, often in a malignant form. The necessity for adequate follow-up examination of such patients cannot be emphasized too strongly. The diagnosis of retroperitoneal tumors is aided by the use of pyelography and air contrast studies. The presence of such lesions also may be demonstrated by the discovery of extrinsic pressure defects in the stomach or intestine on routine and special roentgen studies of the gastrointestinal tract.

Cancer of the bile duct: The occult malignancy☆

Primary malignant lesions of the bile duct system are almost always discovered at a late stage, and largely because of this, the prognosis with this disease is poor. Despite this bleak prognosis, many of these lesions are well differentiated and relatively slow growing. In contrast to periampullary lesions, which may be polypoid or papillary with a relatively good prognosis, bile duct cancers are almost always of the infiltrative type and are often scirrhous. Metastases to lymph nodes occur in the majoirty of patients, about half have liver metastases, direct invasion of the liver occurs frequently, extension into the wall of the bile duct often occurs early, periductal involvement often precludes resection, and perineural invasion frequently extends far beyond the limits of resection. The early periductal spread of these lesions along with the anatomic barriers, that is, the portal vasculature, often prevents wide excision of tumors in the supraduodenal portions of the bile ducts. These lesions are difficult to detect accurately and, because of this, often are nonresectable when definitive diagnosis is established. To detect these tumors more frequently during exploration of the extrahepatic biliary system, especially during cholecystectomy, biopsy specimens of any indurated area should be taken. The discovery of white bile in the common duct is highly suggestive of malignant disease, scrapings of indurated areas may establish the diagnosis, and perhaps the interior of the ductal system should be visualized directly with the optical instruments currently available. However, since most intraductal malignant lesions resemble fibrous strictures, direct visualization may not allow distinction between the two; moreover, biopsy may not establish the diagnosis of malignant disease since often the lesions are extensively fibrotic. Retrograde cholangiography with the duodenoscope probably will be used increasingly in the study of various problems in the bile ducts, including malignant disease. It is unlikely, however, that this method will contribute to the discovery of lesions confined to the mucosa, since carcinoma at this stage seldom produces symptoms and duodenoscopy would rarely be carried out in a patient without significant biliary symptoms.

Achalasia of the esophagus

Summary Achalasia is a neuromuscular disorder of the esophagus associated with the degeneration or absence of the myenteric nerve plexuses. Peristalsis is uncoordinated or absent in the body of the esophagus; this, coupled with failure of the gastroesophageal sphincter to relax, results in dysphagia. The hypersensitive muscular response to methacholine occurs classically in achalasia and allows an early diagnosis to be made, which is when treatment is more effective. The two most commonly used methods of management are forceful bougienage and extramucous esophagocardiomyotomy. Both procedures are most effective in early stages of achalasia. Each procedure has its advocates and each has its rightful role. The patient with a redundant sigmoid-shaped esophagus is best considered for myotomy; dilatation in these circumstances may be hazardous. Patients with associated conditions such as hiatal hernia, epiphrenic diverticula, suspected gastroesophageal malignancy, peptic ulcer disease, and recurrent achalasia after myotomy are best treated surgically. The direct surgical approach has merit not only in treatment of the patients with achalasia intractable to conservative measures but also as an alternative to repeated bougienage. Good to excellent results were obtained in 78 per cent of the patients who underwent cardiomyotomy; various types of bougienage yielded good to excellent results in 45 per cent. When extensive dilatation, redundancy, and kinking of the esophagus have developed, careful, unhurried, and deliberate cardiomyotomy accomplished under direct vision and with absolute control of the length, breadth, and extent of the myotomy is less hazardous. In this series, there was no mortality and the incidence of postoperative esophagitis was low. The number of esophageal perforations (three patients; 5.5 per cent) from forceful bougienage, the total lack of mortality, and the gratifying results have led us in recent years to use cardiomyotomy frequently as the primary treatment for achalasia.

Replacements of the esophagus

Abstract The esophagus may be replaced by various means. The skin tubes fashioned from the anterior thorax which were formerly used to restore continuity after esophageal resection have been superseded by more direct methods. Resection of the esophagus for both malignant and benign disease has become a common-place procedure. The ability to surgically remove many types of esophageal disease is well established. Some uncertainty still exists about the best method of restoring gastrointestinal continuity after esophageal resection. The stomach is admirably suited for use as an esophageal substitute. It is easily mobilized and has attributes which make its use favorable from most aspects. Its shortcomings are minimal even when it is used in the treatment of benign disease. Experience has shown that if the esophageal resection is extensive and the esophagogastrostomy is performed at a high level in the thorax, esophagitis is not a frequent development. The jejunum and colon are often used as esophageal replacements. The jejunum has certain limitations related both to its anatomically short vascular arcades and to certain physiologic and long term observations of patients undergoing these replacement procedures. The use of the colon presents fewer technical difficulties than does the jejunum, and is well suited for total or nearly total replacement of the esophagus. A discussion is presented here which questions the justification of the use of the colon or jejunum in the management of malignant disease of the esophagus. It is suggested instead that the stomach is a more satisfactory esophageal substitute in these instances. In the treatment of benign esophageal stenoses the colon or jejunum should find their greatest use as esophageal replacements.

Surgical treatment of ulcerative colitis

Abstract Chronic ulcerative colitis remains a mysterious disease, the cause of which is as yet unknown. Most patients are adequately managed on a medical program. When the involvement of the colon by the pathologic process is minimal or moderate, the problem is in no way a surgical one. Certainly the disease varies greatly in duration and severity. However, when the disease has so progressed that the bowel wall is ulcerated, fibrosed and stenotic, when there is considerable bleeding, and when polypoid lesions are present in the colon, ulcerative colitis should be considered a surgical problem. The number of patients in our series who received surgical therapy (21.5 per cent) is similar to that reported by others in the literature. Although the number of cases per year which have come to surgery has not increased, it is significant and gratifying to see that the number in good preoperative condition has been significantly greater in the past few years. By this means the mortality associated with the surgical treatment of this disease has markedly diminished. Although an occasional patient may warrant one-stage removal of the colon for chronic ulcerative colitis, it is still our opinion that the staged removal is by far the better procedure. In recent years we have combined ileostomy with partial removal of the colon, usually as far down as the sigmoid, as the initial procedure. Ileostomy as the first stage of the operative procedure was mainly performed in the early years of the series and the mortality incident to it was excessive. Complications have been frequent, as is to be expected in the surgical treatment of such a debilitating and extensive disease process.