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Gastric outlet obstruction (GOO) secondary to peptic ulcer disease requiring therapeutic intervention remains a common problem. The incidence of Helicobacter pylori infection in this cohort has not been well defined. Pneumatic dilatation (PD) has been proposed as first-line therapy before surgical intervention. If H pylori infection in patients with GOO is infrequent, PD may not offer permanent control without the need for longterm antacid therapy.The purpose of this study was to examine the incidence of H pylori infection and surgical outcomes in patients undergoing resection for GOO. The records of all patients having resection (vagotomy and antrectomy) for benign disease from 1993 to 1998 for GOO at the University of Tennessee affiliated hospitals were reviewed retrospectively. Smoking history, NSAID use, weight loss, previous ulcer treatment, previous treatment for H pylori, and previous attempts at PD were among the factors examined. H pylori infection was documented by Steiner stain from either preoperative biopsy or, in most patients, final surgical specimens. Surgical complications and patient satisfaction were ascertained from inpatient records, postoperative clinical notes, and, where possible, followup telephone surveys.Twenty-four patients underwent surgical resection during the study period. There were 16 men and 8 women, with a mean age of 61 years (range 40 to 87 years). Weight loss was documented in 58% and averaged 27 lb. Five of 24 patients had previous attempts at PD, 3 of whom were H pylori negative. All five had further weight loss after these failed attempts. Of the 24 patients reviewed, only 8 (33%) were H pylori positive. There were no procedure-related deaths. Longterm clinical followup was possible in 16 of 24 patients, and all but one demonstrated dramatic clinical improvement by Visick score.We conclude the following: 1) In this cohort, H pylori infection was present in a minority; 2) previous attempts at PD were unsuccessful, which may be related to the H pylori-negative status of the patients; 3) mortality related to the operation was zero; and 4) patient satisfaction was positive by the Visick scale. Patients with H pylori-negative GOO resulting from peptic ulcer disease should be strongly considered for an early, definitive, acid-reducing surgical procedure.

Recurrence of surgically treated parathyroid cancer occurs in 30% to 65% of patients and has a poor prognosis; only 1 of 29 cases remained normocalcemic more than 2 years later. No medical attempts to prevent recurrence have been reported. A 24-year-old pregnant woman whose mother died of parathyroid cancer underwent apparently successful surgery for parathyroid cancer. Serum Ca and parathyroid hormone (PTH) returned to normal levels but 3 months after surgery, although normocalcemic, the serum PTH level was elevated. The administration of vitamin D 200,000 U/month or calcitriol 0.5 microgram daily and 1 g of Ca supplementation daily, resulted in the normalization of PTH during 81 months of follow-up. On three occasions, when vitamin D or calcitriol were omitted, serum intact, C-terminal, or mid-molecule PTH levels rose. Ionized and total serum Ca, creatinine, calcitriol and calcidiol levels were normal, and multiple ultrasounds of the neck remained negative after surgery. This observation suggests that serum PTH could be an early marker for the detection of recurrence in parathyroid cancer with normal serum Ca, and that suppression of PTH secretion by vitamin D or calcitriol could avert or delay the progression of recurrence. Additional trials with calcitriol in operated normocalcemic parathyroid cancer with an elevated serum PTH level is recommended.

Twelve patients were operated upon using this technique. Early results show that hyperinsulinemia has abated in these patients and that the need for postoperative bicarbonate replacement, admissions for dehydration or hematuria resulting from pancreatic exocrine drainage into the bladder are also eliminated (9). This new technique of portal pancreatic transplantation is suitable for patients undergoing combined pancreatic and renal transplantation in whom rejection of the pancreas can be monitored through the function of the renal allograft. The procedure is technically feasible and safe. However, large trials are needed to document the full benefits and continued safety of this new procedure.

Since November 1990, 50 laparoscopic herniorrhaphies have been done in 47 patients (three patients with bilateral repairs), including 31 indirect and 19 direct inguinal hernias, three of which were recurrent. The 47 patients included 42 men and five women. Small indirect hernias were treated by plugging the hernia orifice with a tightly rolled polypropylene mesh plug. Large indirect, all direct, and combined hernias were treated by creating a peritoneal flap and stapling a polypropylene mesh screen preperitoneally over the defect. The mesh was stapled to Cooper's ligament, iliopubic tract, and transversus abdominous arch. Forty-five patients were discharged on the day of surgery and the other two within 24 h. The average return to full activity has been two days. The only intraoperative complication was an easily controlled trocar site bleeder. Postoperatively one minor trocar site infection occurred. One persistent and one recurrent hernia were among the group, both large indirect hernias done early in our experience (by the plug technique) before stapling instruments were available. The technique of laparoscopic herniorrhaphy is in its infancy and still evolving as our understanding of anatomy and technology improves. Even if long-term follow-up shows an acceptable recurrence rate and less patient disability, surgeons must weigh the wisdom of converting a procedure from local to general anesthesia and an inexpensive procedure into a more expensive procedure.

SPK transplantation is associated with excellent rehabilitation and greater improvement in posttransplant functional status than is KTA transplantation. This improvement is not just a function of the magnitude of the improvement experienced by a few patients but was seen in the majority of patients and the majority of our study parameters. Since pancreatic transplantation adds to the morbidity of kidney transplantation for the uremic patient, longitudinal evaluation which demonstrates added benefits from the restoration of euglycemia by pancreas transplantation is important. Such evidence generated by us (14) and others (15, 16) now provides the justification for continuing pancreas transplantation.

The effectiveness of technetium 99m-labeled red blood cell scintigraphy in localizing hemorrhage, directing surgical intervention, and screening patients for arteriography was determined in 103 patients. The radionuclide scan result was compared to the bleeding site determined by arteriography, endoscopy, or surgery. Eighty-five patients had a bleeding site identified; 18 patients did not and were excluded. Thirty-one scans were performed in 29 patients for upper gastrointestinal hemorrhage. Five positive scans incorrectly localized an upper gastrointestinal bleeding site, although two scans localized the site, for a scan sensitivity of 8%. Fifty-nine scans were performed in 56 patients with lower gastrointestinal bleeding. Fifteen scans were positive, three incorrectly localizing the hemorrhage. Seventy-four percent of the patients with lower gastrointestinal hemorrhage documented by arteriography, endoscopy, or surgery had negative scans for bleeding. The radionuclide scan sensitivity for lower gastrointestinal bleeding was 23%. Surgery was required in 18 patients for bleeding, 11 of whom had negative scans for bleeding. In seven surgical patients with positive scans, in no instance did the scan direct the surgical intervention. Eighteen patients underwent scintigraphy and arteriography; nearly one half of the patients with negative scans for bleeding had positive localizing arteriograms, although almost one half of the patients with positive scans for bleeding had negative arteriograms. Scintigraphy failed to localize hemorrhage in 85% of the patients. Technetium 99m-labeled red blood cell scintigraphy did not direct surgical intervention, nor did it adequately screen patients for arteriography.

The Organ Injury Scaling Committee of the AAST recently published a consensus classification of splenic, hepatic, and renal injuries (J Trauma, 29:1664, 1989). The hepatic injury scale (HIS), based on parenchymal laceration and intrahepatic hematoma, includes grades 1 to 6, representing the least to most severe injury. This study classifies liver injuries by findings at celiotomy, correlates operative findings with transfusion requirements and method of management of liver injury, and relates preoperative CT to anatomic findings at laparotomy. Thirty-seven patients with blunt liver injury were evaluated by abdominal CT with and without intravenous contrast and then underwent celiotomy. Increasing operative HIS correlated well with increasing severity of injury as measured by transfusions and operative management. Thirty-one CT grades did not correlate with operative findings (84%). Four patients had intrahepatic hematomas that were not discovered at operation. Twelve lacerations were graded too high by CT and 15 too low. Of these 15, ten CT scores were at least two grades lower than operative findings. Injuries around the falciform ligament occurred in three of the low misclassifications. One patient with intrahepatic hematoma developed hepatic artery pseudoaneurysm. We conclude that the HIS readily characterizes operative findings of hepatic lacerations and that increasing operative grade correlates well with transfusion requirements and operative management. CT can define intrahepatic hematomas, but does not correlate well with hepatic lacerations. Extreme caution is required when using CT alone to define "minimal" liver injury for prospective management of blunt trauma victims.

Elective preperitoneal or posterior repair for recurrent groin hernias and primary femoral hernias has been shown to be a technically advantageous approach. In addition to the ease of inguinal floor and femoral canal assessment, scar tissue from prior anterior herniorrhaphy can be avoided. The emergency management of the acutely incarcerated or strangulated hernia of the groin using this approach has not been addressed. During a 30-month period, all patients with a diagnosis of acute incarceration of a groin hernia (n = 28) were surgically managed using either the anterior approach (AA) (n = 14) or the preperitoneal approach (PA) (n = 14). Two patients with strangulated intestine in the AA group required an additional midline incision for bowel evaluation and resection. Intestinal evaluation was easily accomplished through the same incision in four patients in the PA group. The preperitoneal approach also allowed proximal control of incarcerated or strangulated viscera, thus avoiding excessive manipulation of gangrenous or necrotic intestine, potential spillage of infected contents into the peritoneal cavity, and entry of bacteria, toxins, potassium, and the metabolic waste products of anaerobic metabolism into the systemic circulation during hernia reduction. There have been no recurrences in either group, and minor complications, such as wound infection and cellulitis, in the two groups are not statistically different.

The management of eleven patients with major venous and associated liver injuries has been summarized. Aggressive resuscitation includes early operative intervention. Repair of venous injury can be effected if hemorrhage is contained and stepwise exposure instituted. The critical steps in management include: 1) thoraco-abdominal exposure; 2) intermittent occlusion of the porta hepatis; 3) total liver mobilization; 4) judicious use of cava-hepatic bypass.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.

A retrospective analysis was undertaken of 113 patients with biopsy-proven neoplasia of the extraperitoneal rectum and anus occurring between 1970 and 1975. Common initial symptoms included bleeding, constipation, and diarrhea; colon obstruction was the initial symptom in only ten cases. Adenocarcinoma occurred in 90 per cent of cases while lesions such as epidermoid cancer, carcinoid, and melanoma were encountered rarely. Operative treatment consisted of abdominoperineal resection (APR) in 60 cases, colostomy alone in 26 cases, anterior resection 13 cases, and electrocoagulation in four cases. Ten patients refused operative therapy. Of patients undergoing APR, 7 per cent died in the perioperative period. Postoperative morbidity included infection, impotence, bladder dysfunction, and perineal complications. The single most important factor contributing to this high morbidity was perineal wound management: 34 patients managed by the open method sustained a 47 per cent complication rate while the 26 patients with closed and adequately drained wounds had only a 15 per cent complication rate.

Patients requiring amputation of the lower extremity for arteriosclerosis are at high risk for the development of venous thrombosis and pulmonary embolism. Inapparent venous thrombosis was discovered in the amputated leg at operation in eight patients. Pulmonary embolism was documented by angiogram or at autopsy in ten patients. The majority of emboli discovered in this study was not suspected by the physician responsible for the care of the patient. The perfusion lung scan in this elderly group of patients had a false-positive rate of 60 per cent, while a normal lung scan was strong evidence against pulmonary embolsim. Although imperfectly randomized, the prophylactic use of low molecular weight dextran in this study did not decrease the incidence of pulmonary embolism. The pulmonary arteriogram proved a safe procedure in the elderly and should be used before therapy is initiated for suspected pulmonary embolism.

During the 40 years from 1945 to 1984, 159 occurrences of sigmoid volvulus in 140 patients were diagnosed and managed. Treatment modalities gradually evolved from primarily operative decompression in the first 20 years to selective, sigmoidoscopic, nonoperative reduction in the most recent 10-year period. Operative reduction was associated with a 10 per cent mortality, while no deaths were associated with nonoperative reduction. A 60 per cent mortality was noted when gangrenous bowel was present. In the most recent 10-year period, 71 per cent of cases were associated with neuropsychiatric diseases, and one third had a previous episode of sigmoid volvulus. The diagnosis was made on the initial plain abdominal radiograph in 60 per cent, and nonoperative sigmoidoscopic reduction attained in 95 per cent. Following nonoperative reduction, elective resection was performed during the same hospitalization with a 5 per cent mortality. Initial management of sigmoid volvulus should consist of nonoperative attempts at reduction with operative reduction reserved for refractory cases or those with ischemic bowel. Elective resection can be safely performed during the same hospitalization.

Hepatic transplantation is often accompanied by a large volume of intraoperative blood loss which may place extraordinary transfusion demands on a community blood bank. In an effort to conserve blood bank resources, intraoperative autotransfusion has recently been used in our adult patients undergoing orthotopic hepatic transplantation. A group of seven patients receiving autotransfusion was studied and compared to another group of five patients who did not receive autotransfusion. In spite of receiving more blood during the transplant procedure, the autotransfusion group required a mean of 7.9 units less banked blood. Post-transplant transfusion requirements and bleeding complications were similar in both groups. Hematocrit and total bilirubin were not adversely affected, while transient elevation of BUN and serum creatinine appeared to be unrelated to the salvage process. This procedure was found to be safe and cost-effective, while conserving blood bank resources.

The management of lower gastrointestinal bleeding has evolved from a number of technological advances allowing precise diagnosis and localization of the bleeding site. This study of 40 angiographically demonstrated lower gastrointestinal bleeding lesions reinforces much of the data indicating the diagnostic and therapeutic trends. Twenty-four patients had bleeding diverticula with angiographic demonstration in 11 patients. Seven cases of vascular ectasia were identified, and nine patients had a variety of significant bleeding sites other than the two main sites that were listed. Pitressin was useful for control of bleeding in six of seven diverticular patients but was less useful in the vascular ectasia group in which only one patient was actively bleeding. Total abdominal colectomy and segmental resection were successful in control of hematochezia in 24 of 25 operative cases. Sixteen patients did not require surgical treatment.

Four cases of gunshot wounds to the suprarenal abdominal aorta are described. All required prosthetic graft replacement including one or more visceral arterial branches. Two patients survived. Factors important in survival were rapid transportation permitting early resuscitation and retroperitoneal tamponade which delayed exsanguination and permitted stabilization with systematic management. The major problem in management of gunshot wounds of the suprarenal abdominal aorta is limitation of visceral ischemia, particularly hepatic and renal. Special adjuncts such as local renal hypothermia, as used in these cases, or bypass techniques are necessary and should be available before exploration of a periaortic hematoma due to gunshot wound in this area.

Retrospective review of eight years' experience with the Mallory-Weiss syndrome emphatically supports the need for accurate, early localization of the site of upper gastrointestinal hemorrhage. Pertinent aspects of the history and physical and laboratory evaluation of this group of patients were analyzed to determine the relative merits of each in diagnosis and treatment. Angiography was helpful as a diagnostic aid in a small group of patients. Endoscopy, the cornerstone of diagnosis, is essential in the choice of the management program. Data from this study support the following conclusions: (1) patients not bleeding at the time of endoscopy rarely require surgical intervention; and (2) patients bleeding at the time of endoscopy vary as to their need for operative treatment and deserve a trial of preliminary medical therapy.

Four patients with chronic portal vein occlusion (or near occlusion) who required major hepatic resection or transplantation are described. In each case, portal vein patency was restored, and objective evidence of long-term patency is presented in three patients. These patients demonstrate the feasibility of restoring and indefinitely maintaining portal venous flow coincident to major hepatic surgery.

Twenty consecutive patients receiving 21 hepatic transplants were treated with cyclosporine and low-dose corticosteroids. Survival was 80 per cent at 30 days, 75 per cent at 6 months, and 65% in the 6-17 months follow-up period. Compared with earlier series, this improved survival using cyclosporine results from fewer infectious and sound healing complications. Reliance on hepatic biopsy to confirm the diagnosis of rejection may also reduce the corticosteroid exposure and help diminish the complications of excessive immunosuppression.

Serial liver biopsy and close clinical monitoring in 55 consecutive hepatic allografts have disclosed a syndrome of cholestatic jaundice that simulates rejection. This syndrome is associated with distinct histologic findings and resolves spontaneously without modification of immunosuppressive management. The cause of the cholestasis is probably related to subcellular organelle damage produced by cold ischemia, and its importance stems from the confusion it creates with regard to rejection diagnosis. Recognition of this syndrome can result in decreased immunosuppression in hepatic allograft recipients, a secondary decrease in infectious complications, and improvement in the survival rate.

One hundred radial-cephalic fistulas were surgically created for hemodialysis between April 1970 and September 1973. A side-to-end anastomosis was constructed in 86 per cent of cases. Overall patency interval was 13 months. Factors responsible for shunt failure are outlined. Blood vessel quality and surgical technique are the most important factors in achieving a low failure rate. Use of the fistula for early hemodialysis has not been associated with complications and is advocated.

The surgical experience with hyperparathyroidism at this institutition of 32 cases since January 1969, has been presented. The age range, sex ratio, associated disease and location of adenomas follows previously reported patterns. Analysis of various preoperative laboratory data confirm that no single test consistently can establish the diagnosis of hyperparathyroidism. At exploration, all glands should be identified and all adenomas removed. Subtotal parathyroidectomy consisting of excision of 3 3/4 glands should be performed for hyperplasia.