Robert B. Sawyer

Repair of peristomal colostomy hernias

Peristomal herniation represents the second most common late complication of abdominal wall enterostomy. Early herniation results from the creation of too large of a fascial defect. Late herniation is caused by a gradual enlargement of the fascial defect because of a poor selection of the colostomy site or an intrinsic weakness of the fascia due to the patients age or general condition. Once peristomal herniation occurs, operative repair should be considered in an otherwise healthy person. Previous reports advocate primary repair of the herniation. In the present series of nine patients, three patients developed recurrence of the hernia six to eight months after primary repair. Six patients had colostomy hernia repairs that involved moving the site of the original stoma. All of these repairs remain intact at an average of two years, nine months (range, four months to six years). We therefore believe that the solution to the problem of recurrent colostomy herniation lies in the transposition of the site of the original colostomy.

Volvulus of the colon

Abstract A group of fifty-three patients with volvulus of the colon is reported. There were thirty-five adults and eighteen children. This fairly rare cause of intestinal obstruction was more devastating in the latter, accounting for a mortality rate of 44.4 per cent, compared with 5.7 per cent in the adults. The incidence of this lesion is reviewed and the embryology, pathologic process, diagnosis and treatment are discussed.

Infectious emphysema of the gastrointestinal tract in the adult

Summary The finding of gas in the viseera outside the lumen of the gastrointestinal tract is rare but is potentially so dangerous that early diagnosis and aggressive treatment are mandatory. Five illustrative cases of pneumatosis of varying causes are presented, with details of their management.

Hypernatremia with pharmacologic doses of steroids.

Abstract Three cases of hypernatremia were encountered in patients given pharmacologic doses of hydrocortisone in the course of treatment of septic shock. All three patients failed to respond to the usual dilutional therapy for this hyperosmotic state, but serum sodium was reduced in the third patient after treatment with methylprednisolone and spironolactone. We postulate that the high doses of hydrocortisone inhibit pituitary release of antidiuretic hormone, which usually results when the sodium is retained. Logically, the most important factor in the management of patients with septic shock is elimination of the infection; however, when this cannot be done and it is necessary to maintain patients on prolonged steroid therapy, spironolactone seems indicated to reduce any hypernatremia that develops.

OCCULT CARCINOMA OF THE BREAST

Abstract Three cases of occult carcinoma of the breast are presented. Each case represents a different approach to this problem. In general it is best to biopsy all seemingly abnormal lumps palpable in the axilla, even though statistics suggest that the majority of these will be of nonspecific or benign pathologic origin. We do not believe that a frozen section followed by homolateral radical mastectomy is the proper approach if the lymph nodes are adenocarcinomatous. Instead, the patient should be given further careful examination for a possible primary lesion. This should include x-ray studies as the primary carcinoma may originate in aberrant axillary breast tissue, in an axillary sweat gland or in the respiratory or gastrointestinal tracts. If no primary site is found, the treatment of choice is homolateral radical mastectomy, except in patients who could not tolerate extended surgery or who show evidence of bone metastasis. There will be cases in which a primary site may never be found.

Fatal primary cancer of the lung in a teen‐age smoker

Fatal primary carcinoma of the lung in a 16‐year‐old boy who smoked cigarettes is described. The disease progressed rapidly even after a lobectomy, without evidence of lymphatic involvement, was performed. A plea is made for even broader education of physicians and laymen in the potential harmful effects of cigarette smoking.

Choriocarcinoma in the male patient presenting as gastrointestinal hemorrhage

Abstract A case of fatal choriocarcinoma in the man is described, and the symptomatology and pathology of this rare condition are discussed.

General Surgeons in the World of Gatekeepers

Iam extremely honored to be speaking before my friends about some issues that are of critical interest to each of us, issues that we must tackle both individually and together if the role of the general surgeon in today’s society is to retain its significance. Since our meeting in Tucson last year, a great change has taken place in this country’s medical profession. Twelve months ago, doctors in the United States were carefully preparing themselves for the interface with government and the proposed health care reform. But that reform never happened. Since President Clinton’s so-called managed competition disappeared, it has been replaced with unbelievable speed by the appearance of new managed-care entities all over the country. Sometimes we are probably tempted to think that the difficulties our profession faces today are unique, the result of a government that has changed. But history tells us otherwise. The government has long been involved in our work, and only in the more recent generations has that relationship become more adversarial. Thirty-six years ago, in 1958, my father, Ken Sawyer, stood before this very organization and delivered his presidential address.’ The fact that he did that is another reason why I’m honored to be here before you all today. But more important, the core of his message was not all that different from what you will hear from me over the next few minutes. The title of his 1958 address was “Eternal Vigilance,” and it centered on the need to be organized and work together in the face of governmental changes affecting our calling as surgeons. For him, it was the threat of socialized medicine. For us, it is the threat of managed competition and managed care. Before I get into those topics and where we should consider taking ourselves in the future in light of them, however, I think it is appropriate to touch on a couple of historical footnotes about the Southwestern Surgical Congress, and its important role in organized medicine in this country. Nearly half a century ago, in 1948, three surgeons-Dr. B.T. Beasley of Atlanta, Dr. R.L. Saunders of Memphis, and Dr. Walter Stuck from here in San Antoni-attended the meeting of the Southeastern Surgical Congress in Hollywood, Florida. There, they acknowledged that the Southwest was

The pathogenesis of diverticulosis coli

SummaryThe pathogenesis of colonic diverticulosis still is not well understood. It is believed that it is a combination of the degenerative process of aging, associated with spasm and increased intraluminal pressure. There is strong evidence to support the view that a muscle abnormality with shortening and hypertrophy precedes diverticulosis. An associated increase in the frequency and magnitude of spontaneous contractions causes an increase in internal pressure on the colon wall. Ultimately, this results in herniation and pouch formation. Once the diverticulum has herniated through the wall permanently, the continued increased pressure forces fecal contents into the pouch. This also causes vascular engorgement, necrosis of the mucosa, and bacterial penetration.The actual inflammation of diverticulitis results from perforation, rather than stagnation of fecal material. The shortening of the bowel, with spasm and thickening of the circular muscle, results in diverticular disease, and the common “spastic colon” may well be a precursor of diverticulosis coli.

Proliferative cysts of the pancreas.

Abstract Four cases of cystadenoma and one case of cystadenocarcinoma of the pancreas are described. Diagnosis of such pancreatic neoplasms is rare prior to exploratory surgery, although recent advances in x-ray technics, especially angiography, should improve preoperative diagnosis. An aggressive surgical approach is necessary in the treatment of papillary cystadenomas since they are potentially malignant lesions, and early removal of cystadenocarcinomas may allow surgical cure.