Robert N. McClelland

Biliary pancreatitis: Clinical presentation and surgical management

The presentation, surgical management, and clinical outcome in 153 patients with biliary pancreatitis has been reviewed. Only 37 percent of our patients demonstrated any of Ransons 11 prognostic signs of severe pancreatitis, and only 3 percent had 3 or more signs. Fourteen patients underwent emergency operation within 48 hours of admission, 108 underwent briefly delayed operation during the same hospitalization, and 31 were discharged and scheduled for elective cholecystectomy 6 weeks after admission. The biliary pancreatitis grew worse in 7 of 114 patients during initial medical management and required emergency operation, and 81 percent underwent elective surgery within 10 days of admission. When patients were discharged before cholecystectomy, the recurrence rate of acute biliary pancreatitis that required emergency readmission was unacceptably high (61 percent). There was no statistical difference in total number of hospital days, number of intensive care unit days, or mortality between the three groups. Our study suggests that emergency operation with decompression of the ampulla of Vater is unnecessary in patients with biliary pancreatitis, and that briefly delayed operation during the same hospitalization can be performed safely after resolution of acute pancreatitis.

Treatment of Zollinger-Ellison syndrome with exploratory laparotomy, proximal gastric vagotomy, and H2-receptor antagonists

Twenty-two patients with Zollinger-Ellison syndrome were managed by a combined medical and surgical approach. Patients were treated initially with cimetidine or ranitidine. A laparotomy was performed to remove easily resectable tumors and to carry out a proximal gastric vagotomy. Tumors were found in 9 patients (41%) and all visible tumors were removed from 6 of the 9 patients. Fasting serum gastrin concentrations and serum gastrin responses to intravenous secretin were normal 6 wk after surgery in each of the patients from whom all visible tumors were resected and are normal in 4 patients, 6 wk to 5 yr after surgery. Acid secretion was reduced after vagotomy in each patient, even when tumors were not found or completely resected. Thus, vagotomy decreased the acid secretory response to endogenous hypergastrinemia. In addition, vagotomy augmented the inhibitory effect of H2-receptor antagonists on acid secretion. Follow-up has ranged from 6 wk to 6 yr (median, 2 yr). Dosages of cimetidine or ranitidine have been reduced, compared with preoperative amounts, in all but 1 patient. Two patients are taking no antisecretory drugs. Only 3 patients have had occasional symptoms of ulcer disease. Complications such as bleeding, perforation, or obstruction have not occurred in any patient. Endoscopy was performed in all patients to estimate the point prevalence of active ulcers and an ulcer was found in 1 patient. Based on these results, it is our opinion that this combined medical and surgical approach is an effective treatment for patients with Zollinger-Ellison syndrome.

Effect of Selective Proximal Vagotomy on Food-Stimulated Gastric Acid Secretion and Gastrin Release in Patients With Duodenal Ulcer

We studied effects of selective proximal vagotomy on food-stimulated acid secretion and gastrin release in 7 duodenal ulcer patients. Food-stimulated acid secretion was evaluated by sham feeding patients and by infusing food directly into their stomachs. Vagotomy reduced sham feeding-stimulated acid secretion from 28.2 +/- 4.6 to 1.2 +/- 0.7 meq/hr (95% reduction) whereas infused food-stimulated secretion was decreased from 36.1 +/- 4.6 to 17.9 +/- 5.5 meq/hr (50% reduction). In contrast to the reductions in acid secretion, the gastrin response to infused food doubled after surgery. Although selective proximal vagotomy reduced the rate of acid secretion in response to infused food and also reduced by 64% the peak secretory capacity (peak acid output to pentagastrin), fractional secretion (i.e., the secretion rate in response to infused food expressed as a percentage of the peak secretory capacity) increased significantly after vagotomy from 63 +/- 7% to 91 +/- 11%. This increased fractional secretion in response to infused food was probably a result of exaggerated gastrin release after vagotomy.

Gastric secretory and splanchnic blood flow studies in man after severe trauma and hemorrhagic shock

Abstract A group of thirty-three patients with severe multiple trauma and hemorrhagic shock and a group of nineteen normal control subjects were studied in a special trauma research unit to determine the effect of severe acute stress on multiple aspects of human gastric secretion and splanchnic blood flow in relation to stress ulceration. Simultaneous studies of gastric acid, pepsin, nondialyzable solids, fucose, sialic acid, and total splanchnic blood flow were carried out on both patients and control subjects. These studies were performed during basal conditions over a period of two hours and also for two hours after subcutaneous injection of Histalog. On the basis of these studies, it was concluded that excessive acid or pepsin secretion or deficient quantitative or qualitative gastric mucus production was probably not a significant etiologic factor in the production of gastroduodenal stress ulceration. The splanchnic blood flow studies and the presence of blood in gastric juice samples after Histalog injection in approximately 35 per cent of the severely injured patients supported previous opinions that ischemic damage to the superficial gastric mucosa may induce stress ulceration.

Rare presentation of actinomycosis as an abdominal mass: report of a case.

PURPOSE: The purpose of this article was to report an unusual presentation of abdominal actinomycosis masquerading as a tumor. METHODS: The patient was a 54-year-old male who presented with vague abdominal discomfort and a palpable left lower quadrant mass defined on CT scan. Multiple intraoperative core biopsies were nondiagnostic, and he underwenten bloc resection of the mass and adjacent organs for a presumed tumor. RESULTS: Examination of tissue from deep within the excised specimen revealed sulfur granules diagnostic for actinomycosis. CONCLUSION: Abdominal actinomycosis is an extremely rare infection that can mimic multiple disease processes and requires accurate diagnosis for successful therapy. This novel presentation and a review of the literature are reported.

Reduction in the morbidity and mortality of major hepatic resection. Experience with 52 patients.

The general surgeon can be expected to encounter patients who require major hepatic resection with increasing frequency. Successful resection of large neoplasms requires meticulous attention to surgical technique. Use of the Lin hepatic compression clamp significantly reduces morbidity and mortality, operative time, and blood loss, and should be employed whenever possible during hepatectomy. In addition, an extended subcostal incision with use of the table-attached Hepco Upper Hand retractor offers superb exposure and avoids the morbidity associated with thoracoabdominal incisions.

Use of distal splenorenal shunt in children referred for liver transplant evaluation

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 +/- 4 years, and the average weight was 39 +/- 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Childs class A, and three were Childs class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 +/- 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 +/- 20 months after shunt surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

A 25-year experience with hemicorporectomy for terminal pelvic osteomyelitis.

Background: Hemicorporectomy involves amputation of the pelvis and lower extremities by disarticulation through the lumbar spine with concomitant transection of the aorta, inferior vena cava, and spinal cord. In addition, conduits are constructed for diversion of both the urinary and fecal streams. Of 57 cases reported in the literature, limited experience exists with hemicorporectomy for terminal pelvic osteomyelitis, with only 11 cases described. Furthermore, there is little information available regarding perioperative mortality and long-term survival. This article describes the largest reported series of hemicorporectomies performed for terminal pelvic osteomyelitis. Methods: A retrospective review of the medical records for nine patients who underwent hemicorporectomy at the authors’ institution was conducted followed by interviews with all surviving patients. Results: At follow-up, four patients were alive and five patients were dead. For all patients, the average survival after hemicorporectomy was 11.0 years (range, 1.7 to 22.0 years). There was no perioperative mortality within 30 days of surgery. None of the surviving patients suffered from recurrent decubitus ulcers. Conclusions: Including this clinical series, a total of 66 hemicorporectomies have now been reported in the literature. Twenty cases were performed for terminal pelvic osteomyelitis with no mortality within 30 days of surgery, and 53.3 percent of patients were alive and well at long-term follow-up. Given the low perioperative mortality along with the ability of patients to achieve long-term survival following this operation, hemicorporectomy should be offered to appropriate patients suffering from terminal pelvic osteomyelitis.

Hemicorporectomy: back to front

Hemicorporectomy involves amputation of the pelvis and lower extremities by disarticulation through the lumbar spine with concomitant transection of the aorta, inferior vena cava, and spinal cord, as well as creation of conduits for diversion of the urinary and fecal streams. A review of the literature reveals that the surgical technique has been relatively unchanged since 1960. The standard anterior to posterior approach is associated with significant blood loss and morbidity, likely contributing to lengthy hospital stay. Herein, we describe our back-to-front approach to hemicorporectomy, involving early division of the vertebral structures and spinal cord, pre-empting engorgement of Batsons plexus, thus minimizing blood loss. In addition, this approach greatly improves exposure of the pelvic vessels, allowing for a technically less challenging and safer procedure.

Parietal cell vagotomy in a surgical training program

Parietal cell vagotomy was performed in 48 patients at the Parkland Memorial Hospital and the Dallas Veterans Administration Hospital between April 1977 and January 1981. The maximum follow-up time was 50 months and the average was 28 months. Seventy-five percent of the patients were followed for more than 1 year. There were no operative deaths. Four patients (8.3 percent) had persistent postoperative side effects including two documented ulcer recurrences (4.2 percent). Acid secretion studies were reviewed to characterize the longterm effect of parietal cell vagotomy. These studies demonstrated marked postoperative reductions in gastric acid secretion. The results of this study suggest that with the simplified technique described in this paper, parietal cell vagotomy can be performed with minimal mortality and morbidity by surgical residents under direct staff supervision.