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This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.

In North America and Europe small bowel volvulus is a sporadic form of mechanical intestinal obstruction. Diagnostic problems may occur. The clinical presentation is that of an acute abdomen. The cause of symptoms may be due to narrowing of the bowel itself, or strangulation of the blood supply, or both. The types (primary and secondary) and incidence of small bowel volvulus are age-related and demonstrate astonishing geographical differences. Goals for treatment of small bowel volvulus should include physician awareness and accurate work-up of this uncommon diagnosis.

This report is an analysis of 252 popliteal artery aneurysms (PAA) in 167 patients treated surgically at the University Hospital in Zurich during a 27 year period from 1965 to 1991. The predominance of male patients (95 percent) was consistent with that of other reports. PAA were bilateral in 51 percent of the patients and were associated with aneurysms at other sites in 38 percent. Atherosclerosis was by far the most common cause (98 percent). PAA were symptomatic in 75 percent of the patients, the predominant findings being ischemia from emboli, thrombosis or rupture. Primary amputation was required in 23 extremities. Surgical reconstruction with bypass was performed for 229 PAA. A secondary amputation was necessary in 18 limbs. The risk of complications from popliteal aneurysms, and the good results from surgical treatment suggest that a revascularization procedure in the asymptomatic stage should be recommended unless specific contraindications exist. We conclude that surgical treatment should be performed in symptomatic and asymptomatic PAA larger than 2 centimeters in diameter. Long term results of surgical reconstruction are improved if an autogenous saphenous vein is used and if reconstruction is performed before the occurrence of complications. Polytetrafluoroethylene prostheses should be used when an autologous saphenous vein is not available. The use of Dacron (polyester fiber) grafts is no longer indicated.

Esophageal replacement remains a challenge. Colon and jejunum provide alternative conduits to replace the lower esophagus when stomach is not suitable. Between 1971 and 1991, 41 patients underwent short-segment interposition of the esophagus with jejunum or colon. Indications were failed antireflux procedures (n = 21), nondilatable stricture (n = 9), achalasia (n = 2), moniliasis (n = 2), Barrett's esophagus with carcinoma in situ (n = 2), hemorrhagic esophagitis after esophagogastrectomy (n = 1), motility disorder (n = 1), instrumental perforation (n = 1), carcinoma (n = 1), and leiomyosarcoma (n = 1). Thirty-one patients (75.6%) had prior surgical procedures. Interposition with colon was performed in 22 patients and with jejunum in 19. Major complications occurred in 45% after colon interposition (10/22) and hospital mortality was 4.5% (1/22). Major complications after jejunal interposition occurred in 31% (6/19) and hospital mortality was 10.5% (2/19). A contained anastomotic leak occurred in 1 patient, perforation of a colon segment in 1, and jejunal graft necrosis in a third. Late functional results in 34 patients with a mean follow-up of 87 months were excellent or good in 26, fair in 5, and poor in 1. Colon interposition failed to improve symptoms in 2 patients with gastrointestinal motility disorders. Six patients underwent manometry and barium food provocation study. Two colon segments and 3 jejunal interpositions were hypoperistaltic or aperistaltic according to manometry. There was 1 case of aperistaltic jejunum with a distended afferent loop. When stomach is not available, successful palliation of swallowing can be accomplished with either jejunum or colon. Surgeons involved in the management of esophageal disease should be familiar with the technical details of both procedures.

Objective: A retrospective study of 41 patients with histologically confirmed diagnosis of appendix carcinoid tumors was undertaken by reviewing the surgical records at Massachusetts General Hospital., Methods: There were 8 male and 33 female patients (mean age 32 years). Twenty-two patients (54%) presented with signs and symptoms suggestive of acute appendicitis. In 19 patients (46%) the lesions were discovered incidentally. The tumors were located in 32 patients at the tip, in 6 patients in the middle third, and in 3 patients at the base of the appendix. The tumor was less than 1 cm in diameter in 32 patients, between 1 and 2 cm in 7 patients, and was bigger than 2 cm in 2 patients. In 29 patients, the depth of tumor penetration was confined to the submucosa or to the muscle layers of the appendix, and in 8 patients the serosa was involved. In 4 patients, evidence of tumor extension into the meso-appendicular fat was present, including one patient with a tumor bigger than 2 cm and local lymph-node metastases. Forty patients underwent appendectomy alone. One patient with a tumor size bigger than 2 cm in diameter with positive lymph nodes in the mesoappendix underwent secondary right hemicolectomy. Complete follow-up was achieved in 35 patients, and all patients remained free of tumor recurrence., Conclusions: The authors conclude that appendiceal carcinoids are rare and most often are asymptomatic. Tumors of less than 1 cm are adequately managed by appendectomy alone. The appropriate treatment for tumors of 1 to 2 cm continues to be controversial. Right hemicolectomy is recommended for all tumors larger than 2 cm, whereas preference for an aggressive approach should be given in young patients.

Small bowel volvulus is an uncommon but important cause of small intestinal obstruction. It often results in ischemia or even infarction. Delay in diagnosis and surgical intervention increases morbidity and mortality rates. Based on cause, small bowel volvulus can be divided into primary and secondary type. Goals for treatment of small bowel volvulus should include physician awareness of this uncommon diagnosis, accurate workup, and advanced surgical intervention. The presentation and subsequent management of 35 patients with small bowel volvulus confirmed by laparotomy are reviewed and discussed. The incidence of small bowel volvulus in the adult European and North American is low. The resultant mortality rate, however, makes diagnosis critically important. The cardinal presenting symptom is abdominal pain. There is no single specific diagnostic clinical sign or abnormality in laboratory or radiologic finding. In practice, the diagnosis can only be made by laparotomy. The failure to perform an exploratory laparotomy cannot be justified. Early diagnosis and early surgery are the keys for successful management of strangulation obstruction of the small bowel.

Thirty-six patients with symptomatic Schatzki rings were treated by rupture of the ring and repair and followed up an average of 6 years. Thirteen (37 percent) had no recurrence of symptoms; 8 (23 percent) had recurrence of mild symtpoms; 14 (40 percent) had recurrence of symptoms as severe as those experienced preoperatively. Failure was associated with recurrence of the ring and hernia in some. In others, stricture with or without recurrence of the hernia was noted. Analysis of the procedures did not suggest a means of improving results.

Stool frequency was studied in 43 patients several years after they had undergone ileorectal anastomosis. Seven (16%) of the patients had high and potentially disabling frequency. The level of anastomosis above the anus, patient age, and length of ileum resected were not shown to be important factors. Resection in patients with neoplastic disease was generally better tolerated than in those with diverticulosis. From this study, it seems that potentially disabling stool frequency will be an inevitable consequence in about one sixth of the patients having the operation.

While splenic vein obstruction is a well-described feature of chronic pancreatitis, analogous occlusion of the superior mesenteric and/or portal veins (SMV-PV) has not been appreciated. We present 14 instances of SMV-PV obstruction in patients with proved chronic pancreatitis without cancer. Portal hypertension was first suspected because of variceal bleeding (4/14) or unexpected varices at laparotomy (10/14). The angiographic appearance mimicked that of pancreatic cancer. The splenic vein was also occluded in eight of the 13 patients who had angiograms. The liver was normal in all 14 cases. The clinical importance of SMV-PV occlusion in chronic pancreatitis lies in (1) its presentation by variceal bleeding, (2) the probable necessity for nonshunting means of control for bleeding varices, (3) the increased difficulty of operations on the pancreas because of portal hypertension, and (4) the possible confusion with pancreatic cancer.

The clinical course and management of 40 patients who underwent operation for acute cholecystitis developing as a postoperative complication were reviewed. Of note was the mortality of 47%, the high incidence of gangrene, perforation, empyema, and cholangitis, and the atypical clinical presentation of acute cholecystitis under these conditions. Awareness of this possible complication, knowledge of its clinical features, and early surgical intervention are important facets of successful management.

The management of surgical patients requiring intensive care is complicated by abnormalities in multiple body systems. An effective method of organizing data collection and treatment is essential. The widely applied "problem-oriented" approach is not entirely satisfactory in the context of surgical intensive care. An alternative method is presented in which management is structured by body systems. The function of each system is analyzed and a plan for each is defined. Data display is arranged by systems rather than problems and is compatible with modern computer technology. A surgical patient under treatment for pancreatitis is presented to illustrate this approach. Experience with 220 patients on a residency teaching service supports the impression that system-structured management is an effective method of managing the course of an acutely ill patient and should be widely applicable to such patients in any general surgical environment.

In seventeen patients who had a proctocolectomy for ulcerative or granulomatous colitis, the levator muscles and perineal tissues were sutured primarily. In all patients the pelvic peritoneum was left open to allow the remaining intestine to fill the pelvic space. In eight patients in whom the pelvic space was not drained, uncomplicated healing occurred in five, but the other three patients developed infected pelvic collections leading to delayed perineal would healing. In the subsequent nine patients in whom the pelvic space was drained, all patients had uncomplicated healing. There has been no instance of perineal hernia or intestinal obstruction during four years' observation. This method of managing the pelvic space and perineal would, based upon obviating all blood or serum collections, has been simple, safe, comfortable, and effective in eliminating the prolonged morbidity of an unhealed perineal would.

Perforation of the colon occurred in thirteen patients receiving corticosteroids for diseases unrelated to the bowel. Treatment averaged 3.5 years. The paucity of symptoms, signs, and laboratory indexes of visceral perforation led to frequent delays in treatment and to incorrect preoperative diagnoses in all but three patients. The perforations were often unusual in location (cecum, hepatic flexure, and multiple points in the transverse and descending colon) and often resulted from single punched-out ulcers in otherwise normal bowel. In seven patients the lesion could not be distinguished from perforated sigmoid diverticulitis, but in two of these patients the ulcerations were found in adjacent diverticula. The evidence strongly suggests that corticosteroids can be responsible for ulceration and perforation of the colon either by direct injury or by interference with normal mechanisms of bowel repair.

Mortality in 100 patients undergoing resection of ruptured atherosclerotic aneurysms of the abdominal aorta was 58%. In addition to advanced age and concurrent cardiac disease, lethal factors included preoperative hypotension, cardiac arrest, anuria, and free intra-abdominal rupture. Failure to establish the correct diagnosis until the onset of these four signs contributed to the high mortality.

An aorto-caval fistula is a rare complication of an abdominal aortic aneurysm (AAA). Typical features, including congestive heart failure and a loud abdominal bruit, may be present and allow prompt diagnosis, but not infrequently they are absent or overlooked and the diagnosis not made preoperatively. Four patients with an AAA and an aorto-caval fistula are described, each of whom presented with hematuria. We believe the presence of hematuria in a patient with a symptomatic AAA should suggest the diagnosis of an aorto-caval fistula. A correct preoperative diagnosis may contribute to better planning of the operative procedure, reduced blood loss, and avoidance of possible pulmonary embolization.

We have observed 11 cases in which the use of the ultralightweight knitted Dacron arterial graft made by the United States Catheter and Instrument Co. (USCI) was complicated by Interstitial hemorrhage dilation, or both. Although the incidence and specific cause of failure of this graft are unknown, we have discontinued its use on the basis of this experience.

Transluminal angioplasty for the management of atherosclerosis obliterans has been performed in 160 patients for 100 iliac and 98 femoropopliteal lesions. The procedure was performed percutaneously except in eight patients in whom operative exposure was required. Angioplasty was technically successful in all 100 iliac artery lesions. There was hemodynamic and clinical improvement in 92 lesions. The procedure was technically successful in 84 of the 98 femoropopliteal artery lesions with hemodynamic improvement in 74 and clinical improvement in 78. There were ten complications directly related to the angioplasty and six related to the arteriographic procedure. Cumulative patency rates for the angioplasties were 92% and 75% at three years for iliac and femoropopliteal lesions, respectively. These promising results suggest that transluminal angioplasty has a definite role in the management of atherosclerosis obliterans of iliac and femoropopliteal arteries.

In all common forms of inguinal herniorrhaphy, stitches pass either just superficial to the internal iliac artery and vein or through their sheath. Despite the potential for arterial injury, documented cases seem to exist only in the foreign-language literature. We report four cases of arterial injury following inguinal herniorrhaphy in adults. The artery is placed in jeopardy when the transversalis fascia is incorporated in the stitches used to close the medial aspect of the internal inguinal ring. The depth of penetration of the needle and the proximity of the external iliac artery must be accurately judged. Injury can result from direct puncture of the artery or avulsion of one of its branches. Immediate repair of any arterial injury is paramount, and newly subnormal pulses below the inguinal injury are unacceptable. Exposure must be adequate, and division of the floor of the inguinal canal may be necessary for this purpose. Repair may require a simple hemostatic suture, a patch graft, or an interposition graft.

The characteristics of 46 patients unable to take a solid diet within two weeks of gastric resection and had no other post-operative complications are reviewed. The incidence of delayed gastric emptying was found to be 2 1/2 times greater in patients with vagotomy and hemigastrectomy than in those with subtotal gastrectomy. In addition, postoperative delay was often prolonged in the hemigastrectomy and vagotomy group. Mechanical factors were responsible for delay in only 10% of these patients. Possible explanations for these delays are made and it is suggested that localized starch peritonitis may explain many cases of "functional efferent limb ileus." Measures to evaluate the source of delay are recommended and suggest conservative management for the majority of patients. Reoperation is reserved for those who require feeding or draining enterostomy tubes and those whose clinical course and evaluation suggest obstruction.

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.

The recent wide availability of sonography and computed body tomography has added a new dimension to the diagnosis of abdominal masses. Recently in six patients exploratory laparotomy failed to reveal a mass demonstrated by preoperative cross-sectional imaging and subsequently confirmed in the postoperative period by reexamination with or without percutaneous needling. Three of the six patients had previous pancreatic inflammatory disease which may have limited the surgical evaluation of the retroperitoneum. Prior to the advent of cross-sectional imaging, there were few available direct means for discovering errors in intraabdominal surgical diagnosis. While exploratory laparotomy is obviously crucial for confirmation of abdominal masses, radiologists should be reminded that it is not infallible.

A study of 103 cases of acute occlusion of the superior mesenteric artery is presented. The relation of site of occlusion to etiology, extent of infarction, and survival following resection and revascularization is described. Included is an analysis of the technical factors contributing to successful revascularization, the specific complications of revascularization, and the application of elective second look operations and angiographic techniques. The persistant high mortality (85% in this series) can probably be reduced but only by advances in these areas along with progress in the more general aspects of management of elderly patients with multiple system problems and failure.

Twenty-four patients with acute sigmoid diverticulitis and associated pelvic fluid collections seen on computed tomographic scans underwent percutaneous catheter drainage as an adjunct to surgical therapy. Fourteen of the 24 underwent a single-stage surgical procedure within 10 days of drainage. Five patients required two-stage surgical procedures because localized inflammatory changes precluded a primary resection despite the absence of a residual abscess at surgery. Two of the three remaining patients initially had no surgery, but they had recrudescences of their symptoms that required surgical drainage within 8 months. One patient in whom surgical resection was deferred remained asymptomatic 10 months after percutaneous drainage. A retrospective review of 87 patients undergoing surgery for diverticulitis suggested that the percentage of two-stage surgical procedures has decreased in the last 5-10 years, but there remains a substantial number of patients who might benefit from percutaneous catheter drainage of diverticular abscess of the sigmoid colon.

A case of obstruction of the distal portion of the small intestine by a concretion that had originated within a jejunal diverticulum is presented. Obstruction was relieved by removal of the calculus through an enterotomy. The patient's recovery was uncomplicated.

This report describes 140 cases in which Linton splenorenal shunts were performed for the management of the complications of portal hypertension by a large number of surgeons in a single hospital. There was a history of variceal bleeding in 130. Using the Childs designation to reflect hepatic functional reserve, the overall operative mortality was 12% (3 for A; 6 for B; 26 for C). Five-year survival was 41% (57 for A; 35 for B; 26 for C). Subsequent variceal bleeding was noted in 10% of survivors; hepatic encephalopathy in 19%; and terminal liver failure in 18%. Classification and results are reported in a form that should facilitate comparison with other methods of management.

Thirty-four patients with intermittent lower gastrointestinal bleeding were diagnosed angiographically as having angiodysplasia of the cecum and right colon. Repeated barium and endoscopic examinations were negative. Right colectomy was performed on 17 patients, who were followed postoperatively for up to 7 years. Of these, four patients rebled, two of whom had angiographic evidence of related lesions involving other parts of the colon and terminal ileum. Silicone rubber injection and tissue-clearing techniques on the specimens have facilitated the pathologic identification of these lesions. Histologically, they are dilated submucosal veins and arteries associated with areas of overlying mucosal thinning and occasional ulcerations. Although the pathogenesis of the lesion is unknown, we think they are acquired rather than congenital and result from chronic submucosal arteriovenous shunting secondary to mucosal ischemia. Of the 34 patients, 17 had a history of cardiac disease.

A review of 24,000 consecutive autopsies during a 23-year period from 1952 through 1975 at the Massachusetts General Hospital revealed 473 patients died with surgically intact arteriosclerotic abdominal aortic aneurysms (AAA). Contrary to previous studies, the incidence of rupture of AAA between 4 and 7 cm in our experience is similar and significant (25%). The location of rupture and duration of symptoms were recorded. Of the multiple-risk factors considered, only size seemed to bear on the likelihood of AAA rupture. Of 52 patients followed 3 months to 10 years before death with known AAA, the majority died of the ruptured AAA. In a surgical environment with an expected mortality of less than 2%, even small aortic aneurysms should be resected.