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One hundred and thirty splenectomies were performed at the University Hospital in Birmingham for hematologic disorders during a 12 year period. There were seven deaths of which four were related to sepsis in patients with malignant growths which probably impaired immune competence. Splenectomy was found to be uniformly satisfactory for hereditary hemolytic anemia, for hypersplenism complicating rheumatoid arthritis and for the rare instance of primary hypersplenism. Splenectomy was usually salutary in didopathic thrombocytopenic purpura and in antoimmune hemolytic anemia. When done for diagnosis, splenectomy was definitive in about 50 per cent of the instances. Individual patients with thrombotic thrombocyeosinophilia syndrome benefited. Splenectomy for hypoplastic or aplastic anemia in an actual circulation offered only questionable benefit and is rarely necessary for hyperplenism secondary to portal hypertension.

Blunt trauma to renal arteries often receives suboptimal management because of delayed diagnosis, incomplete preoperative evaluation, associated injuries, or unknown functional capacity of the contralateral kidney. We propose a rational treatment plan from an analysis of our three cases and a review of 118 cases. Two thirds of the patients were male, and left-sided injuries predominated over right 42.9% to 30.6%. In 20 cases the insult was bilateral. Associated injuries occurred in 72%, averaging 1.6 injuries per case, of which one half were intra-abdominal. Flank and/or abdominal pain was present in 73% of cases, tenderness in 65%, and gross or microscopic hematuria in 74%. Repairs were attempted on 38 renal arteries. "Successful" repairs were accomplished in 16 arteries, while repairs failed in 22. Subsequent hypertension developed in 32% of successes. Repair should be attempted in stable patients with unilateral injury of less than four hours' duration, bilateral injuries of less than 20 hours' duration, or injuries with nonocclusion on arteriogram.

The experience with 51 patients who underwent major hepatic resections is analyzed. The operations performed were right lobectomy (in 13 patients); partial right lobectomy (in six patients); lateral left segmentectomy (in 15 patients); and medial left segmentectomy (in one patient). Traumatic injuries determined the need for resection in 31 patients; there were nine (29%) operative deaths. The remaining 22 patients left the hospital and returned to active life. Other indications for hepatic resection were: hepatic abscess (in four patients); primary hepatic tumors (in 11 patients - seven benign, 4 hepatomas); and metastatic tumors (in five patients). Three patients (15%) died in the hospital. All patients who underwent operations for hepatic abscess and benign tumors survived and remained well. Two patients with hepatomas died after operation; the other two patients survived a few months. One patient who underwent operation for a metastatic tumor died after operation; four patients survived 16-36 months. These observations suggest that major hepatic resections benefit patients with severe hepatic injuries that devitalize large segments of hepatic parenchyma, some selected patients with multiple recurrent hepatic abscesses, patients with benign hepatic tumors that are an impending threat to their survival, and perhaps to patients with localized metastatic hepatic tumors. Hepatectomy was of limited benefit to patients with hepatomas.

Consistent weight reduction by gastroplasty requires precise construction of an appropriately sized stoma that will not dilate. The technique described constructs such a stoma around a 32 French Hurst dilator with an external ring of Silastic tubing over polypropylene suture.

This study reports the results of a prospectively randomized trial for treatment of carcinoma of the breast comparing standard (Halsted) radical mastectomy to a modified radical mastectomy. Three hundred eleven patients with primary operable carcinoma of the breast were entered in a surgical and adjunctive chemotherapy trial in Alabama between 1975 and 1978. A total of 91 surgeons participated (all Diplomats of the American Board of Surgery and Members of the American College of Surgeons). All operative reports, pathology and therapy were reviewed by referees. Histologically node positive patients were randomized after operation to receive melphalan or C.M.F.(cytoxan, methotrexate, and 5-FU) for 1 year. After a median follow-up of 5.5 years, there was no significant difference in disease-free survival or in overall survival between the two groups. There was a trend toward improved 5-year survival rates in the radical mastectomy group compared to the modified radical mastectomy group (84% vs. 76%, p = 0.14). There was also an increased incidence of local wound recurrence in those patients receiving modified radical mastectomy, but the differences were not statistically significant (p = 0.09). Longer follow-up will be necessary to evaluate these results more fully.

The four common types of small bowel malignancies have different clinical presentations, routes of metastatic spread, and prognoses, and may require selective treatment. A review of our experience over a 16-year period revealed 45 cases: 16 adenocarcinomas, 13 carcinoids, nine leiomyosarcomas, five lymphomas, and two fibrosarcomas. Adenocarcinomas tend to occur in the upper part of the small intestine, cause obstruction and occult blood loss, and metastasize to the regional nodes and liver. Carcinoids generally begin in the distal portion of the small bowel, may form rather large metastatic masses and cause obstruction from a metastatic mass or intussusception, and are often multiple. Leiomyosarcomas develop in any part of the bowel, may present a primary mass, gross hemorrhage, or perforation, and have blood-borne metastases. Lymphomas tend to occur in the distal part of the small bowel, with pain or mass formation, and spread via the lymphatics. Critical analysis of the clinical presentation and findings should allow preoperative recognition of the specific pathologic type.

Aspiration of acid gastric juice poses a potential threat during operations. Many anesthesiologists use a variety of agents aimed at decreasing gastric volume and/or acidity. The effect of three agents on gastric volume, pH, and flora, and the effect of cefazolin on gastric flora in morbidly obese patients were studied. Cefazolin did not sterilize the gastric lumen. Almost one-half of patients not treated with an H2 blocker had a pH below 2.5 and a gastric volume of 20 ml or more. Five had both a low pH and significant volume and, thus, the potential for lethal aspiration. Two doses of cimetidine, 300 mgm orally, or of ranitidine, 150 orally, the evening before and the morning of operation decreased gastric volume and raised pH reliably to a level that should be protective from fatal aspiration. However, gastric cultures after these drugs were positive 86% of the time with a larger variety of organisms than in the untreated stomachs. Metoclopramide failed to decrease gastric volume or raise pH. Transoperative cefazolin was used in all patients. Clinical infection was not a problem.

Bilateral catamenial pneumothorax occurred in a 32-year-old parous woman. The 41 previously reported cases of catamenial pneumothorax occurred on the right side. This patient was treated with left-sided pleurodesis and, subsequently, with hysterectomy and bilateral salpingo-oophorectomy. The pathologic mechanism of this peculiar syndrome has been attributed to reflux of air via the genitalia and fenestrations in the diaphragm, menstrual shedding of endometrial cells growing in the visceral pleura, or, possibly, aveolar tissue damage secondary to vascular and bronchiolar spasm resulting from dinoprost tromethamine released from menstrual debris. Treatment needs to be tailored to fit the individual patient's specific pelvic and intrathoracic pathology and procreative desires.

Blunt chest trauma occurs in up to 50 per cent of all fatal motor vehicle accidents and is the primary cause of death in 12-25 per cent; yet only 15 per cent of patients with chest trauma arriving alive to the emergency department require early thoracotomy. Pulmonary artery disruption from blunt trauma is extremely rare. Two patients both women, older and obese with multiple rib fractures and little pulmonary parenchymal damage are reported. Neither had injury to the aorta, heart or intra-abdominal organs. One patient survived after lateral repair of the left main pulmonary artery and the other exsanguinated from a laceration of the right main pulmonary artery. Intrapericardial exposure of the proximal pulmonary arteries may be necessary for control of hemorrhage. Trauma surgeons should be familiar with this technique. Indications for immediate thoracotomy should include: massive hemothorax (greater than 1000 ml), continued bleeding greater than 300 ml in the first hour, bleeding greater than 200 ml/hr for 5 hours, or increasing hemothorax in spite of tube thoracostomy. Close adherence to these guidelines would have allowed both patients to be explored earlier.

"Physician extenders" of various types have been produced in the past few years. The University of Alabama in Birmingham has trained surgeon's assistants over the past 9 years, graduating 53 individuals after a 2-year course of didactic, laboratory, and clinical instruction. The graduates have performed satisfactorily, working with surgeons in the community setting and as part of highly specialized teams in large medical centers. One third work in general surgery, one third in cardiovascular thoracic surgery, and one third in other special areas. The authors conclude that these individuals will play an increasing role in allowing surgical therapy to be delivered in an efficient and effective manner.

Colon exteriorization procedures were done in two patients who also were, or became, psychotic. Each patient pulled on the exteriorized loop, causing severe bowel injury. In known or potential psychotics some other form of colonic injury management--other than exteriorization--should be utilized, or extreme caution should be taken to prevent inadvertent self-injury by the patient.

Thirty-eight morbidity obese patients undergoing gastric bypass were divided into two groups. All patients received general endotracheal anesthesia with muscle relaxation and controlled respiration with N2O-O2 mixture. In addition, group I, 17 patients, received balanced anesthesia, while the remaining 21 patients, group II, received thoracic (T-5) epidural analgesia. Postoperative analgesia was achieved with morphine intravenously in group I and with 0.5% bupivacaine epidurally in group II. Circulatory function was measured and calculated using radial artery cannulation and pulmonary artery catheterization with Swan-Ganz thermodilution catheters. A significant decrease in cardiac index (10% and 14% in groups I and II, respectively), in left and right ventricular stroke work (12% to 30%), systolic blood pressure-heart rate product (16% and 28% in groups I and II, respectively), in arterial venous oxygen content difference and oxygen consumption (31% and 39% in groups I and II, respectively) was observed during surgery. A decrease in intrapulmonary shunt from 20% +/- 2.9% before anesthesia to 15% +/- 2.1% intraoperatively was seen in patients given epidural anesthesia. Postoperatively epidural analgesia was associated with a decrease in left ventricular stroke work 12%), systolic pressure-heart rate product (10%), arteriovenous oxygen content differences (17%), and oxygen consumption (20%), compared with values observed when patients experienced pain. Morphine given for relief of postoperative pain was not associated with significant changes in cardiovascular function. Continuous epidural analgesia used postoperatively for relief of pain in morbidity obese patients, following upper abdominal surgery, slightly decreases oxygen requirement and benefits cardiovascular function as reflected by a decrease in left ventricular stroke work.

Thirty-one patients were operated on for benign thyromegaly extending to the thorax in an 11-year period at the University of Alabama in Birmingham. Neck mass (65%), dysphagia (36%), and dyspnea (32%) were the most common symptoms. All patients were euthyroid. Five patients had previous thyroid surgery. A thyroid scan was performed on 24-patients. Fourteen (58%) suggested a thoracic extension while ten (42%) failed to identify a thoracic extension. The indications for resection were increasing symptoms, increasing size despite the use of dessicated thyroid therapy, and to establish a diagnosis. The left thyroid lobe extended into the thorax more frequently (70%) than the right. Most patients had multinodular goiter (94%). Three patients had occult carcinoma (10%) and two patients had Hashimoto's disease. Median sternotomy combined with a collar incision to provide exposure for excision of intrathoracic thyroid extension was used in six patients. There was no operative mortality. There was no increase in operative morbidity and a slight increase in average stay from 5.3 days with a collar incision alone to 6.8 days with the combined incisions. Median sternotomy does not increase morbidity or mortality. Specific indications for more liberal use of sternotomy extension of a collar incision are proposed for the management of substernal and intrathoracic goiters.

Wound complications cause significant morbidity in patients undergoing gastric restrictive procedures. Two randomized, prospective trials were done evaluating suture technique and material. A subcutaneous suction catheter was used for 48 hours in all patients. In Trial I a Polyglactin-910 (Vicryl) suture, #1 in size, was used. Patients were randomized between interrupted Smead-Jones far-far-near-near sutures and running sutures. Because hernia formation appeared excessive in both groups of patients, a second study was done comparing running #1 polydioxanone (PDS) and #1 polypropylene (Prolene) suture. Hernia formation was excessive in this group as well. The authors conclude running and interrupted closures are of equal reliability. Hernia formation was excessive in both groups. The type of suture material used in these studies was inconsequential. A better method of closure is needed in morbidly obese patients to achieve less postoperative hernia formation.

Six patients with symptomatic celiac axis compression syndrome are reported on. Four were treated surgically with arterial reconstruction. None of these four patients was benefited more than temporarily by the corrective surgery. One patient had an abdominal exploration and highly selective vagotomy unrelated to the celiac axis and is symptom-free ten months after surgery. One patient had no surgery and remains symptomatic. Angiographic evaluation in all patients demonstrated that despite high grade stenosis of the celiac axis, there was no radiographically discernible reduction in constrast flow to the celiac axis because of well developed collaterals from the superior mesenteric artery. These results indicate that compression of the celiac axis may be merely an incidental angiographic finding, so this syndrome needs cautious evaluation.

A review of pyogenic liver abscess at the University of Alabama in Birmingham revealed 29 cases, of which 22 were single and seven were multiple. Etiology was cryptogenic in 11, secondary to biliary tract disease in seven, trauma in six, and pyelophlebitis in four, and secondary infection in a primary neoplasm in one. No single set of specific diagnostic criteria could be elucidated, but fever occurred in every patient. Leukocytosis, hypoalbuminemia, and elevated alkaline phosphatase were present in more than 80 per cent of patients. Other clinical findings and routine laboratory abnormalities were less consistently present. In suspect patients, a technetium-99 scan was positive in 18 of 19. Ten patients died, including six of seven with multiple abscesses, seven of seven with positive abscess and blood cultures, and seven of 11 in whom liver abscess was not suspected prior to operation or autopsy. Diagnosis demands a high index of suspicion, in patients in whom suggestive factors are present, and liberal use of the technetium-99 scan. Successful treatment requires exploratory laparotomy, with care of discern any underlying septic focus or the presence of multiple abscesses, and wide drainage of the abscesses, as well as vigorous supportive care and appropriate antibiotics.