Thomas J. Whelan

Focal nodular hyperplasia of the liver.

4 case reports are presented. In 2 cases the focal nodular hyperplasia lesions were in children aged 6 and 7 years. In 3 instances an upper abdominal mass had been present. The other tumor was found on arteriographic studies done for other reasons. Photomicrographic reproductions are shown. There were no histories of steroid therapy. All tumors were resected and histologic findings confirmed the diagnoses. 1 patient died at the surgical operation to remove the tumor. Anomalous and increased arterial supply has been associated with the development of focal nodular hyperplasia of the liver. This was demonstrated in 2 of the cases. The lesion may be due to injury secondary to increased pressure in the sinusoids and portal vein branches from chronic exposure to arterial pressure. Focal hepatic injury with ischemia atrophy fibrosis and regenerative hyperplasia are thought to be the sequence of events. The lesions have been shown to be benign with a 5- and 6-year follow-up in 2 of the cases.

Surgical management of cecal diverticulitis

Ninety surgical cases of cecal diverticulitis at the University of Hawaii hospitals were reviewed from 1980 to 1991. Seventy-eight percent of the study group were of Asian descent, with a mean age of 41.7 years. Right lower quadrant pain and tenderness were the only constant findings, occurring in 86 and 87 of the 90 patients, respectively. The most common preoperative diagnosis was acute appendicitis, occurring in 73% of patients. A right colectomy or cecectomy was performed in 49 patients, an appendectomy in 29, and a diverticulectomy in 10. Seventeen complications occurred, only 1 of which was in the appendectomy group. Follow-up of up to 10 years was successful in 27 of 29 appendectomy patients, only 4 of whom had recurrent pain. There were no instances of a missed cecal carcinoma. We concluded that in those patients in whom carcinoma can be ruled out and in whom there is no evidence of abscess formation, appendectomy combined with postoperative antibiotics is a safe and effective method for the treatment of cecal diverticulitis.

Ischemia of the upper extremity due to noncardiac emboli

Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. Embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynauds phenomenon are pointed out.

Primary liver cancer: A review of 205 cases in Hawaii

Primary liver cancer has one of the poorest prognoses of gastrointestinal tract neoplasms. In the continental United States primary hepatic tumors are relatively rare. Hawaii’s Oriental and Hawaiian populations, however, are at particular risk. Waterhouse [I] places the annual age-adjusted incidence per 100,000 males at 17.5,4.5, and 4.4, respectively, for the Hawaiian, Japanese, and Chinese populations in Hawaii. This report constitutes a clinical review of our experience with hepatocellular carcinoma, cholangiocarcinoma, and “mixed” hepatocellularcholangiocarcinoma.

Ischemic colitis after aortic aneurysmectomy

A retrospective analysis was conducted to quantitatively assess eight suspected risk factors for the development of bowel ischemia after abdominal aortic aneurysmectomy. Eighteen patients were studied and compared with 100 randomly selected control subjects who underwent similar operations during the same time period in five Honolulu hospitals, but in whom the complication did not develop. Prolonged cross-clamp time, hypoxemia, ruptured aneurysm, hypotension, and arrhythmia (supraventricular and ventricular) occurred with significantly greater frequency among the patients with ischemia when compared with the control subjects. Age and other preexisting cardiovascular or gastrointestinal diseases did not significantly correlate with risk of postoperative colon ischemia. In addition, the technique of aortic grafting did not significantly influence the risk of development of ischemic colitis, but the number of patients in this study is too small to provide meaningful data on that point.

Carcinoma of the extrahepatic bile ducts: A ten year experience in Hawaii

A ten year review (1966-1975) of extrahepatic bile duct carcinoma in three major Honolulu hospitals is presented. Fifty-seven patients satisfied the criteria for the study. The disease occurs predominantly in the Japanese population. Survival of patients with upper third lesions proximal to the cystic duct is poor, and all patients followed died within seventeen months of hospitalization or operation. In patients undergoing bypass procedures for lower third (intrapancreatic) lesions, palliation averages ten months. The Whipple operation, performed in fourteen selected patients with favorable lesions, affords palliation averaging twenty months, and five patients were long-term survivors, including two with five year cures. However, morbidity and mortality for the Whipple procedure is high. Methods for improving palliation in upper third lesions and lowering morbidity and mortality from pancreatoduodenectomy are proposed.

Melioidosis of the spleen

Abstract A case of multiple abscesses of the spleen, secondary to metastatic propagation from an abscess in the left antecubital fossa secondary to Pseudomonas pseudomallei, is presented. Melioidosis was diagnosed in this patient by rising titers in the serum of complement fixation and hemagglutination tests as well as identification of the organism. It was a rather fortuitous diagnosis in that a review on melioidosis came across our desks at the time our patient was under active treatment. An awareness of this disease is important with large numbers of American servicement committed to combat in an endemic area.