Paul F. Nora

Bowel Obstruction in Pregnancy

Intestinal obstruction during pregnancy and in the puerperium is an uncommon complication, although cases are probably underreported. Fortunately, the mortality rate has improved over the decades. Overall, it was greater than 60% in 1900. By the 1930s, maternal mortality had dropped to 21% and fetal mortality decreased to 50%. Modern rates of maternal mortality have shown continued improvement, with Goldthorp reporting an incidence of 12% in 1966. Over the last 30 years the maternal mortality rate has decreased to approximately 6%, as noted in various series published in the English literature. Fetal mortality rates, however, have remained significantly high. They have remained constant at between 20% and 26%. Furthermore, only one third of patients with prenatal bowel obstruction complete term pregnancies after operative resolution of their obstruction. These findings emphasize the importance of remembering that two patients are at risk when intestinal obstruction complicates pregnancy. The delay from presentation to admission and from admission to definitive management continues to be a significant cause of morbidity and mortality. A high index of suspicion is mandated in this patient population, especially in those women presenting with a history of previous abdominal or pelvic surgery. The high incidence of necrotic bowel found in this subset of patients demonstrates the need for aggressive surgical intervention. Only through diligent and urgent intervention can the morbidity and mortality be decreased. The diagnosis and treatment of a pregnant patient suspected of having a bowel obstruction should be no different from those given to a nonpregnant one.

The consequences of current constraints on surgical treatment of appendicitis

In this study, we sought to identify changes in the picture of a selected surgical condition during an interval of time that has brought about radical departures from previously established policies and programs. As a direct consequence, the patients take a more circuitous route to the surgeon. A significant number of patients with acute appendicitis in 1986 (37 percent) and 1987 (29 percent) suffered a prolonged delay in hospitalization or surgical referral compared with patients in 1980. This delay was accompanied by a more advanced stage of disease that ultimately caused a markedly increased morbidity (13 percent in 1986 and 24 percent in 1987, compared with 5 percent in 1980) and subsequent extended length of stay. This deterioration in patient care and failure at cost containment had previously been examined for conditions that can be operated electively. This study documents that the constraints also affect the treatment of patients whose initial condition requires urgent operative treatment. With specific relation to patients with acute appendicitis, surgeons recognize the value of the negative appendectomy. It appears the so-called gatekeepers must find a way to accept a certain negative hospitalization to referral rate. If current constraints will not allow this, the policies and programs behind the constraints should be changed.

Lipoma of the Esophagus

Abstract Benign tumors of the esophagus are discussed. The uncommon incidence of benign esophageal lipomas, particularly those treated surgically, is emphasized. Early diagnosis and treatment of benign esophageal tumors is urged, to avoid the danger of starvation from an obstructing growth interfering with deglutition, and before possible malignant degeneration occurs. Operative removal is described and postulated as the only definitive treatment for these neoplasms. A case is presented of an aged man with a very large benign lipoma of the esophagus which was removed surgically. Problems encountered and technic of operation employed are discussed.