Willis P. Maier

Preoperative nuclear scans in patients with melanoma

One hundred forty‐one liver scans, 137 brain scans, and 112 bone scans were performed in 192 patients with clinical Stage 1 melanoma. One liver scan was interpreted as abnormal; liver biopsy of that patient showed no metastasis. There were 11 suggestive liver scans; three of the patients with suggestive liver scans had negative liver biopsies. The remaining eight patients were followed from 4 to 6 years and none of those patients developed clinical evidence of hepatic metastases. All of the brain scans were normal. Five patients had suggestive bone scans and none of those patients had manifested symptoms of osseous metastases with a follow‐up of 2 to 4.5 years. This study demonstrates that the use of preoperative liver, brain and bone scan in the evaluation of patients with clinical Stage 1 melanoma is virtually unproductive.

Extrahepatic biliary ductal injury in closed trauma

Abstract The fourth case of hepatic duct injury due to closed abdominal trauma is reported. Diagnostic features concerning biliary ductal injury as well as pathophysiology of these injuries are discussed. The important clinical difference between the effects of infected and sterile bile in the peritoneal cavity are emphasized. Treatment is briefly mentioned. A tabulation of the recorded cases of biliary ductal injury since Lee and Wherrys review is included.

Periareolar abscess in the nonlactating breast

Periareolar abscesses in nonlactating women are usually accompanied by a sinus tract that communicates with the nipple. This abnormal tract represents the source of the initial invasive infection and, if left unattended, may be the nidus for recurrence. The medical records of 32 patients with periareolar abscess treated at Temple University Hospital from January 1970 through January 1980 were reviewed. Follow-up data were obtained recently for 21 patients, including 1 patient with bilateral disease. Several patients also had an inverted nipple. Nineteen patients denied recurrence after our initial treatment and two required a secondary procedure for cure. Only one patient was dissatisfied with the postoperative appearance of the surgical site. None required partial or simple mastectomy for cure, as reported elsewhere. Excision of the sinus tract and, when present, correction of the inverted nipple as herein described are necessary to prevent reinfection. Simple abscess excision or incision and drainage is usually inadequate therapy.

Antireflux surgery for symptomatic gastroesophageal reflux: mechanism of action.

To determine the effects of Nissen fundoplication upon the symptoms of reflux and the diagnostic tests employed to evaluate reflux and to examine the relationship between gastroesophageal reflux and lower esophageal sphincter pressure before and after fundoplication, 10 patients with symptomatic reflux were studied before and after operation. Clinical evaluation, barium esophagography, endoscopy with mucosal biopsy, esophageal manometry, acid-perfusion and acid-reflux testing, and gastroesophageal scintiscanning were performed on each patient before and after surgery. Following fundoplication, marked symptomatic, radiographic, endoscopic, and histologic improvement was observed. Serial acid-reflux tests at increasing gastroesophageal pressure gradients returned to normal after surgery. Lower-esophageal-sphincter (LES) pressure increased from 8.2±1.3 to 12.0±1.5 mm Hg (P<0.01). In addition, surgery resulted in a significant decrease in the gastroesophageal reflux index from 17.4±2.4 to 2.7±1.1% (P<0.001). Surprisingly, the pre- and postoperative resting LES pressures did not correlate significantly with corresponding gastroesophageal reflux indices for individual patients. We conclude that increased LES pressure alone does not explain adequately the functional and clinical improvement which follows fundoplication.

Gastroesophageal scintigraphy to assess the severity of gastroesophageal reflux disease.

Thirty-six (36) patients with symptomatic gastroesophageal reflux were studied. Symptoms of heartburn, regurgitation and dysphagia were scored as to their severity and compared to quantitative tests of gastroesophageal reflux. Patients were studied with the acid reflux test, fiberoptic endoscopy, esophageal mucosal biopsy with a pinch forceps, esophageal manometry and radioisotopic gastroesophageal scintigraphy. Symptoms were scored according to an arbitrary grading system as mild, moderate, or severe. There were significant correlations between symptoms scores and both the degree of endoscopic esophagitis and the gastroesophageal reflux indices as measured by the radioisotopic scintiscan, but not with the degree of histologic esophagitis or lower esophageal sphincter pressure. Review of the findings suggests the following profile for patients who might require antireflux surgery: severe symptoms, presence of endoscopic esophagitis; resting lower esophageal sphincter pressure below 10 mmHg; and gastroesophageal reflux index above 10%.

Long-term follow-up of patients with Grave's disease treated by subtotal thyroidectomy

This long-term follow-up study of 83 patients with Graves disease who were treated by subtotal thyroidectomy reemphasizes the fact that postoperative hypothyroidism occurs primarily in the first postoperative year (27 percent of the study patients). In addition, there was no evidence of progressive increase in the incidence of hypothyroidism in subsequent years. Patients treated with radioactive iodine have a reported incidence of hypothyroidism of 70 percent 10 years postoperatively [4]. The 6 percent incidence of recurrent hyperthyroidism is much less than a reported incidence of 90 percent in patients treated with long-term antithyroid drugs [7]. Subtotal thyroidectomy continues to be an excellent method of treatment for patients with Graves disease and compared favorably with both radioactive iodine and long-term antithyroid drugs.

Diverticulitis of the cecum with chronic penetration and massive hemorrhage.

Abstract Two cases of cecal diverticula with granuloma formation that presented with massive hemorrhage are reported. This specific combination has been recorded infrequently in the literature. With granuloma formation carcinoma cannot be excluded and right hemicolectomy should be performed. In the presence of pain and a mass in the right lower quadrant, with or without hemorrhage, cecal diverticular disease must be considered. Although cecal diverticular hemorrhage is rare, this condition may be present in any person presenting with colonic hemorrhage. “Blind” left colonic resection for diverticular hemorrhage is to be condemned because of this possibility.

Breast biopsy vacucylinder

Summary There is a need for a simple, reliable means for obtaining biopsy specimens of the human breast that are more ample than those obtainable with needle technics. Such tissue specimens are needed for improved diagnosis of cancerous and precancerous lesions as well as for other studies requiring adequate amounts of tissue. We have designed, constructed, and preliminarily tested an instrument for such purposes. The instrument has repeatedly secured tissue specimens 3 or 4 mm in diameter and several centimeters in length from the breast immediately prior to mastectomy. It consists of a cylinder 3 or 4 mm in diameter with a disposable razor-sharp cutting tip and an adapter at the opposite end to which a vacuum tube is applied. Experience with more than twelve cases to date has been without complication.