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Twenty-four high risk patients underwent limited operation for bleeding (15) or perforated (9) gastric ulcers. Limited operation is defined as local ulcer management (oversewing or excision of bleeding ulcer and suture closure of perforated ulcer) with (8) or without (16) complementary vagotomy and pyloroplasty. Sixteen patients had serious coexistent disease and eight were physiologically unstable because of continued bleeding or peritonitis. Nine patients (38%) died; seven of 15 (47%) died after operation for bleeding and two of nine (22%) after operation for perforation. Only one patient rebled prior to death, and only two patients died of causes directly attributable to the operative procedure. The remaining six patients died as a result of coexistent disease. Limited operation for gastric ulcer is an option for treatment of highly selected, high risk patients requiring urgent operation for bleeding or perforated ulcer. The addition of complementary vagotomy and pyloroplasty appears to make little difference as to the immediate result but may influence late results. Limited operation does not reduce the mortality rate after operation on patients with bleeding or perforated ulcers.

Diverticular disease in patients 40 years of age or younger has been described as rare but virulent. Previous studies, based on age, on diverticular disease are often confusing because of inexact definitions of the disease status. With these criticisms in mind, the authors studied 322 clinical records on patients admitted with a diagnosis of colonic diverticulosis or diverticulitis to the University of New Mexico Hospital and the Lovelace Medical Center. Of these patients, 285 had documented evidence of colonic diverticula with only 6 per cent of these being 40 years of age or younger. The criteria for acute diverticulitis were met by 86 patients, 17 of whom were 40 years of age or younger. The younger group had disproportionately more men, particularly Hispanics. The authors conclude that acute diverticulitis is more common in the young than suggested by previous reports, but the behavior of the disease is not distinctive.

Ostomy closure following the Hartmann procedure is perceived to be associated with higher morbidity and mortality rates than is ostomy closure following divided colostomy, loop colostomy, and divided ileostomy-colostomy so that ostomy closure after Hartmann procedure may be denied to certain patients. To test that perception, the charts of 59 patients undergoing a Hartmann procedure and 43 patients having ostomy closure after divided colostomy, loop colostomy, or divided ileostomy-colostomy were reviewed. Ostomy closure after Hartmann procedure was accomplished in 46 patients. These 46 patients (Group I) were compared with the 43 patients having ostomy closure following divided colostomy, loop colostomy and divided ileostomy-colostomy (Group II). No deaths occurred in either group. The morbidity rate was 30% for Group I and was 19% for Group II. This difference is not significant. Major complications involved wound, lung, small bowel, and colonic anastomoses. Anastomotic stricture rate was 9% for Group I and 5% for Group II. Small bowel and anastomotic complications in both groups occurred only when ostomy closure was performed after a delay of less than 6 months after ostomy construction. Stricture occurred only after end-to-end colocolostomy and coloproctostomy and did not occur after ileocolostomy or ileoproctostomy. All strictures were successfully treated by reoperation. Anastomotic leak and pelvic abscess did not occur in either group. We conclude that ostomy closure after Hartmann procedure may be more difficult and time consuming than is ostomy closure after loop colostomy, divided colostomy, or divided ileostomy-colostomy, but ostomy closure after Hartmann procedure does not have a higher morbidity rate. We advise a delay of 6 months between ostomy construction and ostomy closure and submit that all patients whose general condition permits reoperation may safely undergo ostomy closure.

Reoperative stomal surgery includes the correction of complications and closure of a colostomy. Necrosis, retraction, and stenosis are the most frequently occurring complications and are simply corrected by straightforward techniques. Prolapse of the colostomy and parastomal hernia occur less frequently. Their repair is slightly more complex than that of the previous group of complications. Colostomy closure ranges from simple suture closure of the loop colostomy, through anastomosis of the divided colostomy, to the sometimes difficult gastrointestinal reconstruction after the Hartmann procedure. Death after closure of colostomy is infrequent, but anastomotic complications occur after all types of closure. Leak and sepsis are by far the most frequent anastomotic complications. Stenosis occurs less often. The same degree of care exercised during colectomy and anastomosis is necessary for optimal results after colostomy closure.

Experience with 34 patients with pyogenic liver abscess is reviewed to evaluate the impact of percutaneous drainage and duration of antibiotic therapy on results of treatment. Patients with shock, adult respiratory distress syndrome, disseminated intravascular coagulation, jaundice, severe hypoalbuminemia, and diabetes had a poor prognosis. Percutaneous drainage was used successfully in 4 of 6 patients, but its use did not affect mortality rate or length of hospital stay. Percutaneous drainage may be the procedure of choice for selected patients. Half of our patients received antibiotics for 2 weeks or less with no abscess recurrences in this group. Long-term antibiotics may not be necessary after adequate surgical or percutaneous abscess drainage.

Perianal suppuration (PAS) is a common surgical problem that is frequently treated inadequately. A series of 101 patients with PAS was reviewed. Thirty-six patients had a history of PAS. Fifty patients had drainage of a perianal abscess; six patients developed fistulas in ano and in two recurrent abscess developed (total, 16%). Thirty-six patients had fistulotomy for established anal fistula: three patients (8%) had recurrent fistulas. Fifteen patients had single-stage drainage of abscess and fistulotomy, and none had recurrent or residual PAS. All patients ultimately achieved healing. These results illustrate the fact that satisfactory results in the treatment of PAS can be obtained by surgeons if established principles of treatment are observed.

The purpose of this study has been to provide information on the mortality and morbidity rates for operation on nonbleeding cirrhotic patients and to identify factors that portend a grave prognosis. A review of 102 cirrhotic patients who underwent a variety of major therapeutic operations revealed a mortality rate of 19.6 percent. Mortality rates were significantly increased (p less than 0.05) by emergency operation (45.8 percent), gastrointestinal related operation (27.6 percent), ascites (37.5 percent), a bilirubin concentration greater than 3.5 mg (44.4 percent), a prothrombin time increase greater than 2 seconds (36.1 percent), a partial thromboplastin time increase greater than 2 seconds (50 percent), an alkaline phosphatase concentration greater than 70 units (40.9 percent), an operative blood loss greater than 1,000 ml (33.3 percent), and the presence of one or more postoperative complications (39.6 percent). Mortality rates were not increased after extremity, genitourinary, or gynecologic operations, an albumin concentration less than 3 g, a serum glutamic oxalacetic transaminase concentration greater than 40 units, hepatomegaly, and a history of previous gastrointestinal bleeding. When significant risk factors were added, mortality rates were significantly associated (p less than 0.001): zero to one factors 5.1 percent, two to three factors 19.4 percent, four to five factors 33.3 percent, and more than six factors 66.7 percent. The complication rate was 47.1 percent and included liver failure (42.2 percent), sepsis (18.6 percent), and bleeding (8.8 percent). Thus, in cirrhotic patients a clear need for operation must exist, liver function must be optimized preoperatively, and the most simple and expeditious procedure must be performed to avoid excessive blood loss and postoperative complications.

Pelvic actinomycosis associated with the use of an intrauterine device (IUD) is a recently recognized combination. The usual manifestation of the disease are those of mild pelvic inflammatory disease (PID) in a woman who uses an IUD. The disease is easily recognized on Papanicolaou-stained cervicovaginal smears. Early treatment involves removal of the IUD and administration of penicillin. Rarely, the disease may be serious and may require drainage of intra-abdominal abscesses, hysterectomy with salpingo-oophorectomy, or both. The second known death from pelvic actinomycosis associated with use of an IUD is reported.

Thirteen of fourteen dogs developed marked increases in hepatic hemosiderin (postshunt siderosis) after construction of portacaval shunt, whereas only three of 12 dogs developed such siderosis after construction of a portacaval shunt and end-to-side gastrojejunostomy with duodenal exclusion. Splenic hemosiderin was increased markedly in dogs with portacaval shunt but increased minimally in dogs with portacaval shunt and gastrojejunostomy. Rib marrow fat increased slightly in dogs with portacaval shunt and decreased slightly in dogs with portacaval shunt and gastrojejunostomy. Thus continued iron absorption appears to account for the development of postshunt siderosis and the addition of gastrojejunostomy ameliorates postshunt siderosis by diminishing iron absorption.

Twenty-nine patients suspected of having appendicitis while pregnant had appendectomies, and 20 patients had appendicitis. Right lower quadrant pain and tenderness of less than 24 hours duration with nausea and vomiting, a fever of 38 C or less, and a leukocyte count of more than 15,000 were the more common findings in patients with appendicitis. Right lower quadrant pain and tenderness of more than 24 hours' duration, fever of more than 38 C, and a leukocyte count of less than 15,000 were more common findings in patients with idiopathic right lower quadrant pain or such pain associated with urinary tract infection. Neither fetal nor maternal death or complication occurred. The use of antibiotics and progestational agents appeared to be a matter of choice and did not appear to influence fetal or maternal outcome. These data support the concept that peritonitis rather than appendectomy is the cause of fetal and maternal death and complication in pregnant women suspected of having appendicitis and further argue for early appendectomy in such patients.

In a review of 512 patients having elective cholecystectomies without choledochotomy, patients having drainage of the gallbladder bed were found to have longer postoperative hospital stays, higher incidences of fever postoperatively and both wound infections and postoperative complications than those patients not having such drainage. The use of antibiotics perioperatively and gallbladder bed closure did not alter these outcomes. We conclude that the routine use of drainage and prophylactic antibiotics in elective cholecystectomy not only is unnecessary but also may be harmful.

Three type I diabetic patients nonresponsive to subcutaneous insulin were implanted with a subcutaneous peritoneal access device. In these patients, multiple subcutaneous injections had been unable to prevent recurrent hospital admissions for diabetic ketoacidosis. The patients were responsive to intravenous insulin but had limited accessible peripheral veins. Complications of thrombosis and/or septicemia from permanent central venous catheters prevented the long-term use of this route. The peritoneal access device was implanted subcutaneously adjacent to the umbilicus with its insulin delivery catheter terminating in the peritoneal space. Transcutaneous injection of insulin into the subcutaneous access port resulted in the same quantity of insulin entering the peritoneal space. Using a mixture of regular and protamine zinc insulin in a ration of 1:1 resulted in acute increases in plasma free insulin concentration with meals and a declining background level postprandially. All peritoneal access devices have been functioning well for at least 2 mo and in one of the implanted diabetic subjects, it has been in continuous use for 5 mo with no evidence of peritonitis or resistance to peritoneal insulin. These results suggest that a subcutaneous peritoneal access device may provide an alterative insulin delivery route for patients who are nonresponsive to subcutaneous insulin injections.

The natural killer (NK) activity of peripheral blood mononuclear cells from 25 patients with squamous cell carcinoma of the lung, malignant melanoma, or epitheloid cancers of the gastrointestinal tract was measured by the lysis of 51Cr-labeled K562 target cells. NK activities of many patients with lung cancer or malignant melanoma were decreased relative to normal controls. This abnormality was significantly correlated with advancing stage of disease and the percentage of monocytes in the cell suspensions. Addition of indomethacin or removal of monocytes did not restore depressed NK function to normal levels. Abnormalities of NK function did not appear to be secondary to the presence of mononuclear suppressor cells. The response to interferon was also impaired in patients with advanced disease. The number of effector:target conjugates was normal even in patients with depressed NK function; however, the number of active lytic effectors was decreased. These results imply that the cells which bind tumor targets are present in patients with advanced cancers, but these cells are either immature or functionally inactive.

Summaries of two patients who were not operated upon because they seemed to have only minor upper abdominal stab wounds are presented. Both patients later developed symptomatic diaphragmatic hernias for which operation was required. These patients illustrate a shortcoming of the selective method of management of upper abdominal stab wounds and suggest that diagnostic paracentesis and peritoneal lavage should be employed regularly in patients who do not have a clear indication for laparotomy.

A remotely controlled, programmable insulin delivery system was implanted in a diabetic man and the feasibility of the technique was examined. Specific problems included (1) development of an appropriate surgical approach, (2) identification of methods to assess the integrity of the insulin delivery system following implantation, and (3) assessment of plasma glucose and free-insulin profiles obtained with the implanted system. The insulin pump was implanted submuscularly through a midline abdominal incision. The insulin reservoir was placed subcutaneously to allow percutaneous refilling. The insulin delivery catheter terminated in the peritoneal space. No postoperative wound infection occurred and rapid healing of the surgical site ensued. In vivo assessment of the system included (1) dye contrast roentgenography, (2) vasopressin stimulation, and (3) reservoir volume monitoring. Short-acting insulin was then placed in the implanted reservoir and delivered by the system for one month. Mean plasma glucose concentration declined to normal levels, as did glycosylated hemoglobin. Plasma insulin profiles were normalized with appropriate insulin peaks with each meal. We conclude that implantation of a remotely programmable insulin pump is feasible in type I diabetic man. Additional studies are necessary to define which patients will benefit from this type of insulin delivery system.

The use of tube PMCF as salvage for a failed colon bypass of the esophagus has not been described previously. The present report describes the technique and successful use of a tubed PMCF as a solution to the problem of a failed cervical anastomosis after colon bypass of a long distal esophageal stricture.

Eight of 17 patients with necrotizing pancreatitis (47 percent) developed 12 intestinal fistulas. Pancreatitis occurred most often secondary to alcohol abuse, and fistula complicated controlled open drainage of the lesser sac more often than sump or Penrose drainage of the lesser sac. Fistulas appeared more often in patients with two or more drainage operations than in those with a single drainage procedure. Most duodenal fistulas closed with nonoperative therapy, whereas jejunal and colonic fistulas required operative closure. Operative techniques included both simple suture closure and resection with anastomosis. Five patients (29 percent) died. Thus, although frequent debridement and controlled open drainage may reduce the mortality rate of necrotizing pancreatitis, it appears to increase the likelihood of intestinal fistulas, which may require operative treatment.

The incidence of primary breast cancer is known to be increased in patients with previous endometrial or ovarian cancer, but the behavior of the breast cancer and the ultimate outlook for such patients is unknown. To provide data concerning these two questions, a group of 123 patients treated for breast cancer alone (Group I) served as a control for comparison with ten patients who had endometrial cancer (Group II) and six patients who had ovarian cancer (Group III) prior to diagnosis of breast cancer. The interval between the diagnosis of endometrial cancer and breast cancer averaged 4.6 yr, and between ovarian cancer and breast cancer, 5.4 yr. Age at diagnosis of breast cancer in Groups I, II, and III was 56, 66 (P = 0.05) and 56 yr, respectively. The incidence of patients with stage I, II, and III breast cancer was similar in Groups I, II, and III as was tumor size and number of metastatic nodes in each stage in each of the three groups. Average duration of follow-up after diagnosis of breast cancer was 3, 3.1, and 2.8 yr in Groups I, II, and III, respectively, with 70%, 60%, and 33% of patients living and free of either breast cancer, endometrial cancer, or ovarian cancer. Two of four deaths in Group II were due to endometrial cancer, and all four deaths in Group III were due to ovarian cancer. The remaining two deaths or recurrences in Group II were due to breast cancer. We conclude that 1) the behavior of breast cancer is similar in patients with or without previous endometrial or ovarian cancer; 2) breast cancer develops at an older age in patients with previous endometrial cancer than in patients with or without previous ovarian cancer and 3) death or recurrent cancer in patients with breast cancer and previous ovarian cancer is due to ovarian cancer, whereas, death or recurrent cancer in patients with breast cancer and previous endometrial cancer is due equally to breast cancer and endometrial cancer.

Fifty-seven patients with carcinoma of the pancreas underwent gastrojejunostomy (GJ) alone or in conjunction with biliary bypass. The mortality rate for GJ alone was 18%; for the combined biliary and duodenal bypass operation it was 5%. Fifteen patients (26%) had delayed gastric emptying (DGE) postoperatively for periods extending from nine to 31 days (average, 16 days); five patients (33%) died. Eight (57%) of 14 patients with preoperative duodenal obstruction and five (42%) of 12 patients with retrocolic GJ experienced DGE postoperatively. Stomal diameter in the patients with DGE averaged 6.5 cm, and 8.4 cm was the average in those without DGE. We conclude that DGE is a frequent and serious problem after GJ for patients with unresectable pancreatic cancer.

The entry of third party payors into the field of health care has brought about increasing awareness of cost-effectiveness. Since breast biopsy is among the most commonly performed operations and open to criticism, the purpose of this report is to provide data relative to cost-effectiveness of breast biopsies at the University of New Mexico and to compare such data with 1) cost-effectiveness of mammographic screening for breast cancer, and 2) cost-effectiveness of judicious use of mammography in patients with breast complaints. From 1972 through 1978, 1064 patients were seen because of complaints relative to the breasts and 516 breast biopsies were done. Seventy patients were found to have cancer (14% of the breast biopsies). Using the October 1978 through March 1979 cost schedules for hospital and professional fees, the average cost of a breast biopsy was $1,216.00 for general anesthesia, $751.00 for assisted local anesthesia, and $520.00 for local anesthesia. The major differences lay in 1) anesthesia and operating room average charges of $618.00 for general anesthesia, $451.00 for assisted local anesthesia, and $260.00 for local anesthesia; 2) room charge of $174.00 for general anesthesia; and 3) laboratory and x-ray charges of $256.00 for general anesthesia, $120.00 for assisted local anesthesia, and $91.00 for local anesthesia. In 1978 64% of breast biopsies were done under local anesthesia as opposed to 1972 when 22% were done under local anesthesia. For the 516 breast biopsies, 47% were done under local anesthesia, 4% under assisted local anesthesia and 49% under general anesthesia. The calculated overall cost of the 516 breast biopsies was $448,794.00 or $6411.00 per cancer. Comparing our data to those of Lewis at our 1978-79 cost schedules and assuming our anesthetic mix in his patients, his cost per cancer identified was $3973.00 in patients with breast complaints. His cost figure is considerably lower than ours because of a higher yield of cancer (41%). Making the same assumptions for cost and anesthetic mix, the cost per biopsy proved cancer diagnosed in mammographic screening for breast cancer is $11,175.00 (Feig), and $24,482 (Lewis). Thus, 1) use of local anesthesia rather than general anesthesia reduces cost of breast biopsies by $694.00 per breast biopsy, 2) greater precision in selection of patients for breast biopsies is mandatory to reduce cost of diagnosis of cancer, 3) present state of the surgical art is more cost-effective than is screening for breast cancer.

A series of 169 patients having biopsies of palpable lymph nodes was critically reviewed to increase the diagnostic yield. The overall yield was 70.4%. The yield in patients suspected of having neoplasms was 80.6%, in patients in whom differential diagnosis involved neoplasm and infection, 60%, and in patients suspected of having infection or disease with lymphadenopathy as a prominent part of the picture, 27.2%. High yields were found in patients with palpable cervical nodes (76.4%), female patients (74%), and patients older than 40 years (85.5%). Supraclavicular nodes produced the highest yield in any group (90%). Axillary and inguinal nodes produced yields of 62.5% and 38.5%, respectively. The size of lymph nodes was not related to yield, and only eight of 79 (10.9%) nodes produced growth on culture.

Even though mammographic techniques have improved and small tumors of 0.5 cm in diameter can be detected, decreased breast cancer mortality has not yet resulted. Because small tumors may cause systemic spread, in many patients breast cancer at the time of diagnosis is a systemic disease which is incurable. A reduction in breast cancer mortality seems possible by prophylactic bilateral mastectomy in women at extraordinary high risk of breast cancer. These are patients with (a) breast cancer in mother and sister, (b) breast cancer in mother or sister and a combination of various risk factors (early menarche - late menopause, nulliparity, late first pregnancy), (c) noninvasive malignant breast disease (carcinoma in situ), (d) therapy-resistant fibrocystic disease with intolerable pain and/or extreme anxiety (carcinophobia, and (e) benign breast neoplasia with malignant potentials (cellular atypia = precancerosis). Also, in breast cancer patients without regional and systemic spread and who are at high risk for developing cancer in the other breast, prophylactic contralateral mastectomy may be indicated. These are patients with (a) unilateral invasive breast cancer in the premenopause and a family history (mother or sister) of breast cancer, (b) unilateral invasive lobular carcinoma or tubular (ductal) carcinoma, and (c) unilateral invasive breast cancer and precancerous lesions in the other breast.

We have reported our experience with 347 consecutive colon anastomoses in 321 patients seen over an 8 year period. The overall anastomotic failure, mortality, and complication rates were 1.4, 2, and 10 percent, respectively, for the entire series. The complication and death rates were significantly higher in patients whose anastomoses were completed as part of an emergency procedure. Even though various one- and two-layer inverting techniques, suture materials, and staples were used, we could not identify any one method as being clearly superior in preventing anastomotic complications, although the results do suggest that some caution may be appropriate before mechanical stapling devices are universally applied. The results support that adherence to accepted surgical principles of reducing the solid content and fecal flora of the colon prior to operation, insuring an excellent blood supply to both bowel ends, even approximation of the bowel ends with inverting sutures which include the submucosal layer of the bowel, absence of tension, meticulous hemostasis, and avoidance of anastomosis in the presence of peritonitis are the primary means of avoiding dehiscence of colon anastomoses.

During a ten year period, 69 patients underwent 100 operations for more than 147 intra-abdominal abscesses. The over-all mortality was 24.6 per cent and the redrainage rate, 30.4 per cent. Most often, abscesses were located in the subphrenic space and followed elective gastrointestinal surgical procedures. Most patients harbored two or more different organisms. Mortalities were low in patients less than 20 years of age having a single abscess, a short duration of fever prior to drainage and after operations on the colon and secondary operations on the appendix. Mortalities were high in patients more than 40 years of age having multiple abscesses; a prolonged duration of fever prior to drainage; multiple drainage procedures, and abscesses after gastroduodenal, hepatobiliary and pancreatic procedures. The mortality and redrainage rate were lower in patients given appropriate perioperative prophylactic antibiotics than inappropriate perioperative prophylactic antibiotics at the antecedent operations. The mortality and the redrainage rate were not related to duration of administration of appropriate prophylactic antibiotics or the number of different isolates. The choice of incision for drainage should be based upon clinical findings rather than a matter of personal preference. Prompt defervescence was a sign of successful drainage. In the present study, the prime importance of prompt drainage and the secondary role of antibiotics in the treatment of intra-abdominal abscess are confirmed.

An RBE for acute skin reaction to peak pions, for a specific fractionation scheme, has been established at 1.40-1.44. The time of development of acute skin reactions varied in 2 patients with 30 metastatic skin nodules treated with doses varying from 1,175 to 1,951 peak pions and 2,350 to 3,901 rads of 100 kVp x rays. The reactions reached their peak approximately one week apart at all dose levels with both forms of radiation. No untoward effects have been seen in epidermis or subcutaneous tissues as late as 169 days after the start of treatment. All nodules disappeared and have not returned 169 days after treatment. There is a strong suggestion that the response of thick tumors is sensitive to the proportion of high LET radiation deposited at various levels in the tumor.