Roger D. Williams

Foreign body perforation of the intestinal tract

Abstract Six cases of foreign body perforation of the intestinal tract have been presented and the literature has been briefly reviewed. Although foreign body perforation is relatively rare, it should be considered in atypical cases of peritonitis, intra-abdominal abscess or intestinal obstruction. The use of dentures, which prevent pain on mastication of bones or toothpicks, probably plays a major role in the ingestion of sharp foreign bodies in adults. Chronic partial intestinal obstruction preceded the acute perforation in two-thirds of our cases and may be responsible in part for the perforation from ingested foreign bodies which might otherwise have passed uneventfully.

Digestive function after radical pancreaticoduodenectomy

Abstract Forty-nine patients have had pancreaticoduodenectomy performed for periampullary carcinoma at the University of Texas Medical Branch Hospitals. Ten of these patients are currently alive. Six patients surviving from twenty to eighty-four months were studied to determine the degree of residual pancreatic function. Half of the patients were unable to regain their weight or resume their previous occupations. All the patients had an increased number of stools per day (three to twelve) and were receiving a small amount of pancreatic enzyme supplementation. Five of the six patients had abnormal amounts of fecal fat and three of them had an elevated fecal nitrogen excretion. A diabetic glucose tolerance curve was found in all six patients, but no treatment other than diet was required. Serum albumin, total exchangeable albumin, and albumin halflife was decreased in all patients. Liver biopsy revealed changes of fatty infiltration in three of four patients. Subjective and objective improvement was obtained by instituting adequate doses of oral pancreatic enzymes. In nine dogs elevated fecal fats and nitrogens as well as diabetic glucose tolerance curves were found after resection and implantation of the distal pancreas. At sacrifice, pancreatic atrophy was found secondary to stricture of the pancreatic duct at the site of implantation. Obstruction of the pancreatic duct followed by resection and implantation of a pancreatic remnant did not influence the subsequent results. It is concluded that implantation of the stump of residual pancreas into the bowel leads to stricture of the pancreatic duct, parenchymal atrophy, and functional insufficiency. The loss of digestive enzymes may prevent the full rehabilitation of the patients. Pancreatic enzyme supplementation in adequate dosage is useful in overcoming this deficit.

Diagnostic and prognostic factors in abdominal trauma.

Abstract This review of 200 patients with abdominal trauma stresses only the more important diagnostic and prognostic factors. Non-penetrating injuries present the greatest diagnostic challenge. Repeated careful evaluation of the abdomen in patients with multiple injuries is of the greatest diagnostic importance. Abdominal pain and the finding of intraperitoneal blood or fluid by needle paracentesis have been of more help than the white blood count or roentgenogram. X-ray studies have been of help in only a third of these patients. Elevation of the white blood count was seen more often with rupture of the spleen than with other injuries. A white blood cell count over 20,000 per cu. mm. has also been found with fractures and injuries to the chest and head even when the abdomen was not injured. In the individual patient this finding has therefore been of little help. Multiple abdominal injuries and severe injury outside the abdomen are of diagnostic and prognostic significance. One out of five of these patients had two or more intra-abdominal organs injured. Forty per cent had other serious injuries outside the abdomen. These masking injuries of the head, chest and extremities were treated before the abdominal injuries in thirty-eight per cent of these patients. The mortality in these 200 patients was 13.5 per cent. Severe shock, unconsciousness and a delay in diagnosis and treatment of the abdominal injury were frequent in the patients who died. Multiple injuries or damage to the brain have been as important as the abdominal injuries as the cause of death.

Comparison of anterior and abdominoperineai resections for low pelvic colon and rectal carcinoma

Abstract A comparison is presented of anterior resection and abdominoperineal resection in 182 patients with carcinoma of the rectum 6 to 15 cm. from the anus. Anterior resection was performed in eighty-nine patients and abdominoperineal resection in ninety-three. The extent of lateral pelvic dissection to 3 cm. or more below the lesion was the same for both procedures. Abdominoperineal resection was associated with 53 per cent complications, a 4.3 per cent operative mortality, and a five year survival of 46 per cent. Anterior resection gave 40 per cent complications, a mortality of 2.2 per cent, operative mortality, and a five year survival The technical ease of the side to end colorectal anastomosis has been credited with a low incidence of suture line problems. These results suggest that the rectum need not be sacrificed in all lesions 6 to 15 cm. from the anus. Anterior and abdominoperineal resections are comparable if adequate lateral and inferior dissection can be accomplished when low anastomosis in the pelvis seems feasible.

Multiple polyposis, polyp regression, and carcinoma of the colon

Abstract In four patients with multiple familial polyposis the relationship of stool frequency and rectal length and distention to polyp regression after colectomy has been discussed. Specially prepared enemas from the Chelidonium majus plant caused polyp disappearance, but they recurred. After colectomy the two patients with the shortest rectal segments have shown polyp regression. In all patients the number of bowel movements markedly decreased after colectomy, but this was most marked in the two patients with polyp regression. Rectal distention was noted in the patient with the shortest rectal segment, least number of bowel movements, and greatest polyp disappearance. Although carcinoma may develop in the rectum after total colectomy and ileoproctostomy, none has been noted in the twenty-three patients reported in the literature to show spontaneous polyp regression. The factors which cause polyp regression may well influence the development of cancer in the retained part of the rectum. From this study it appears that the two factors which effect polyp regression are a short rectal stump and distention of the rectum, associated with a decrease in the number of stools.

Controversial aspects of diagnosis and management of blunt abdominal trauma

Abstract Controversial factors from the literature in the diagnosis and management of blunt abdominal trauma have been discussed in relation to experiences with 278 patients during the past sixteen years. There should be little controversy over the need for a team approach in the management of these patients. The frequency of multiple intra-abdominal injuries requires broad experience with all abdominal surgery or close cooperation between general surgeon and urologist. A transperitoneal approach through a midline incision seems preferable to more limited procedures. The frequency of extraabdominal injury further encourages close consultation with the orthopedist, thoracic surgeon, and neurosurgeon. Special diagnostic procedures do not replace repeated clinical evaluation in diagnostic accuracy. Realization that roentgenograms are of very limited value except in injuries of the genitourinary tract may decrease controversy regarding their routine use. The value of the white blood cell count as an aid to diagnosis of visceral injury is lessened in the light of the frequent leukocytosis which occurs with injuries to the extremities and head in the absence of abdominal injury. Needle paracentesis is of value only when performed carefully and when negative aspirations are not considered of diagnostic significance. Controversies regarding the management of injuries to specific organs have been discussed. Pancreatic fistulas continue to occur after external drainage procedures; further evaluation of internal drainage with the initial operation is encouraged. Liver resection should present no controversy if it is performed when necessary to accomplish adequate debridement. Double catheter drainage after repair of injury to the bladder seems less important than assurance that the drainage tube remains open. Much of the controversy regarding management of abdominal injuries may arise from combining statistically those patients with blunt and open injuries or failure to appreciate the importance of multiple injury.

Nomenclature and genetic relationships of apples and pears from Terceira Island

Heritage apple (Malus domestica Borkh. hybrids) and pear (Pyrus communis L. hybrid) trees grow in villages throughout Terceira Island, Azores, Portugal. Some of these pears have different names but similar morphology. The objective of this study was to determine synonymy, homology, and phylogeny of apples and pears from Terceira and to examine potential relationships of the island pears with standard apples and pears of Portuguese or American descent. Nine apple microsatellite markers were used to determine genetic relationships. Distance- and parsimony-based cluster analysis grouped these genotypes into separate apple and pear clades. The Terceira apples were divided into two clades: the maçā and the reineta-reinette. Among the 17 heritage apple genotypes, seven unique accessions were identified and four groups of synonyms, or possibly clones, were detected including: ‘Reineta Agosto’ and ‘Reineta Verde’ from Altares; ‘Reineta Castanha’ and ‘Reineta Verde Miuda’; ‘Maçā Pêra,’ ‘Maçā Calhau’, ‘Pêro Branco’ from Salga and from Terra-Chā and ‘Maçā Marmelo’; and the five genotypes ‘Maçā Sao Joao’, ‘Malápio Rosa’, ‘Maçā Gaspar’, ‘Maçā Branca’ and ‘Maçā Pato’. In addition, two homonyms were detected. ‘Pêro Vermelho’ from Terra Chā was a separate genotype from a tree from Doze Ribeiras of the same name, but Pêro Branco from Terra Chā appears to be a clone that can be distinguished by an additional allele at CH1F07a from a tree with that name from Salga. One pair of apple clones, ‘Reineta Agosto’ and ‘Reineta Verde’ from Altares appear to be derived from an unreduced gamete of ‘Golden Delicious.’ Another apple genotype ‘Maçā Acida’ could be a sibling of the ‘Maçā Pêra’ clonal group. Other tested standard apples from the US genebank were unrelated to Terceira genotypes. Of the seven heritage pears, five unique genotypes and one pair of synonyms were detected. ‘Pêra Papo Pintassilgo’ from Raminho and ‘Pêra Vermelha’ from the nursery of Serviço de Desenvolvimento Agario da Terceira (SDAT) were synonyms. ‘Passans du Portugal’ was related to ‘Pêra Cabaca’ but other standard pears from the US genebank were unrelated to Terceira genotypes. Future studies will include additional apple and pear cultivars from other Islands of the Azores and continental Portugal, and wild Asian species to further explore genetic relationships.

Problems in the diagnosis and treatment of abdominal aortic aneurysms

Abstract Experience with surgery for abdominal aortic aneurysms in a growing community of transients and retirees suggests that the diagnosis of aneurysm is being delayed and that surgery is recommended late. Pain or a pulsating mass was found in all patients when seen in surgical consultation, yet the diagnosis was first made by roentgenogram in 38 per cent of the patients with nonruptured aneurysms. The significance of pain and the need to examine carefully the abdomen of elderly patients are emphasized. Late diagnosis or concern over the risks of surgery caused a delay of over four months in the surgical treatment of one third the patients. The 39 per cent incidence of rupture could have been decreased by earlier diagnosis and recommendation for surgery. Pulmonary and cardiac complications remain a problem in these elderly patients. Mortality has been lowered to 7.4 per cent for elective surgery and 34 per cent for emergency surgery for ruptured aneurysm by paying closer attention to complications and by shortening the surgical procedure.

Experimental evaluation of a Teflon tendon prosthesis

Abstract A specially prepared Teflon “graft” has been used to replace tendons in twenty-two dogs. The results have been compared with seven autogenous grafts after periods of observation up to ten months. The extensor digitalis longus or anterior tibialis tendons were used since they are long, have sufficient strength, and function under an extensor retinaculum. The Teflon prostheses functioned better than the autogenous grafts. A mesothelium-like sheath formed around most Teflon grafts and allowed relatively free motion. Although solid attachment of Teflon grafts to recipient tendon ends has been difficult to accomplish, these results suggest that Teflon may have limited possibilities as a tendon substitute.

Selective hepatic venography in primary liver cell carcinoma

With apparent inoperable hepatic cell carcinoma, knowledge of adequate venous outflow from tumor-free liver tissue permits extensive resection with long survival.