Technique to locate the end of an endotracheal tube.

The use of metallic spinal instrumentation in the low-cervical and high-thoracic spine can impede radiographic verification of the position of an endotracheal tube. The method described here may be of value in solving this problem.

Management of abdominal wall clostridial myonecrosis: the role of total gastrointestinal diversion.

We report the successful management of two patients with abdominal wall gas gangrene and emphasize the principles of proximal gastrointestinal diversion and the initial use of 100% fraction of inspired oxygen (FiO2). Each patient lacked an abdominal wall and intractable fistulas developed. Complete diversion of their gastrointestinal tracts at a proximal level facilitated closure of the fistulas and prevented possible peritoneal contamination. One patient's arterial oxygen pressure was maintained in the 200 to 300 range for two days after admission. This level has been shown to be adequate to stop clostridial alpha toxin production.

Characterization of a common antigen of colorectal and mucinous ovarian tumors, COTA.

A new colon cancer antigen is reported. It is designated as COTA, Colon-Ovarian Tumor Antigen, because it is found in mucins produced by both tissues during malignancy. The new antigen was identified by making antibodies against human colon cancer tissue in goats. The antisera were exhaustively absorbed with lyophilized extracts of normal colon, lung, liver, spleen, kidney, plasma, and the well-known colon tumor antigen, carcinoembryonic antigen (CEA). The new antigen was identified by immunodiffusion. Studies of 28 malignant tissue extracts, 10 ovarian adenocarcinoma cyst fluids, 43 normal tissues, and 5 plasma samples revealed that this antigen is found only in colon tumors and mucinous ovarian adenocarcinomas. The antigen was not detected in serous adenocarcinoma of the ovaries, extracts of adenocarcinoma of lung, breast, kidney or stomach nor in the extracts of normal tissues. Other tests show that this antigen is not CEA, Ca 19-9, or CSAp. It is stable to heating at 65 degrees for 5 minutes; it elutes from an ion exchange matrix (DEAE) with 0.3-0.5M NaCl; it migrates to the alpha-2 region on immunoelectrophoresis; and its size, by exclusion chromatography on Sepharose 4B, is 3-15 million daltons. Anti-COTA stains colon cancer tissue sections indicating that COTA is present in goblet-cell mucin.

Massive rectal bleeding of colonic origin: localization of the bleeding site.

Fourteen patients with massive colonic bleeding underwent preoperative evaluation including visceral angiography and/or colonoscopy. Segmental for subtotal colectomy was performed in each case. The freshly excised colonic specimen was opened and washed clean, and the mucosal surface was closely examined by manually compressing the specimen segment by segment in order to detect the minute bleeding site(s), which were then marked with a suture for histologic sectioning. This maneuver was successful in 13 instances. In 11 of these, histologic identification was made; seven were cases of vascular malformations, and four were cases of diverticular bleeding. In 5 of these 11 cases, colonoscopy and/or visceral angiography failed to localize the bleeding sites; four were cases of bleeding of diverticular origin. Of the two patients in whom histologic identification was not made despite suture identification, one underwent a second colonic resection in which bleeding sites were histologically identified; the bleeding was not caused by vascular malformations or diverticula. The method of examining the freshly excised specimen described is useful for accurate histologic identification of the cause of colonic bleeding, particularly for diverticular bleeding. The method is also useful for immediate assessment of adequacy and appropriateness of surgical resection.

A simple method to determine the resolution of operative cholangiograms.

A cholangiographic technique which facilitates visualization of the catheter itself permits the surgeon to measure the resolution of the roentgenographic technique used. When the wall of the catheter is visible, the surgeon can be confident that the resolution of the technique is in the 0.3 mm range. It is unlikely that stones greater than 0.3 mm in diameter will be missed using this technique.

Physiopathology and management of hyperosmolar hyperglycemic nonketotic dehydration.

Results of a review of the clinical course of five patients in whom hyperosmotic hyperglycemic nonketotic dehydration developed suggests that a treatment regimen of a high dosage of insulin and free water administration may not be effective. Analysis of the physiopathology of the syndrome points to sodium and water deficits as the principal cause of symptoms. A rapid lowering of the blood glucose level may be detrimental, since this leads to an osmotic gradient between the central nervous system and the intravascular space. Treatment should be directed at the rapid replacement of sodium and water with minimal administration of insulin. This treatment plan allows restoration of membrane potentials by an adequate supply of sodium and maintains osmotic equilibrium by providing diffusable sodium to compensate for the osmotic gradient associated with a gradual lowering of the blood glucose level.

Bacterial endocarditis in the critically ill surgical patient.

The association of endocarditis with persistent intraperitoneal sepsis and right-sided heat catheterization (Swan-Ganz catheter and central venous catheter) was found in four (27%) of 15 patients with endocarditis identified at the University of Kentucky Medical Center, Lexington, during a 14-year period. These four patients had (1) intra-abdominal abscesses as a persistent source of sepsis, (2) documented septicemia, (3) long-term use of right sided heart catheters, and (4) prolonged hospitalization with a fatal outcome. In each case, endocarditis with persistent septicemia was considered a major factor contributing to a fatal outcome. Identification of a new cardiac murmur associated with septicemia was the most reliable means of diagnosis in these patients. The best form of treatment seems to be prevention by (1) eliminating septic foci, (2) using central catheters for specific indications for as short a period as possible, and (3) promptly discontinuing use of the catheter when septicemia is suspected.

Colonic tumorigenesis in rats with 1,2-dimethylhydrazine.

Subcutaneous injections of the carcinogen dimethylhydrazine in inbred Fischer 344 male rats induced squamous-cell carcinomas in the ear canal, adenocarcinomas in the small bowel and duodenum, and adenomas and adenocarcinomas in the large bowel. The incidences of the tumors induced in the large bowel and ear canal were dose-related. As for tumors of the large bowel, the average size of adenomas was less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa. The average size of early adenocarcinomas was greater than that of adenomas but less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa.

Technical complications of ileostomy.

A review of 45 patients with ileostomy revealed a complication rate of 24%. A higher incidence of complications was seen in those patients who were obese (80%), who had chronic ulcerative colitis (45%), or who had an emergency ileostomy because of a surgical complication (50%). Strict attention to technic should prevent the majority of these complications.

What can experimental colorectal cancer tell us about colorectal cancer in man?

From a survey of the etiology of colorectal cancer, consideration of the basic pathologic characteristics of ulcerative colitis and familial polyposis of the colon suggests that they might be sister diseases. Similarities in the primary and secondary target organs and in fecal steroid metabolism might be more than coincidental. Thus, it would seem reasonable to pay particular attention to several groups of patients who are receiving therapy or have had operations that alter bile acid and/or cholesterol metabolism: 1) patients who have had jejunoileal bypass procedures for morbid obesity or hypercholesterolemia, 2) patients taking cholestyramine and/or other anti-hyperlipidemic agents, 3) patients receiving chenodeoxycholic therapy to dissolve gallstones, 4) patients taking the birth control pill, and 5) young patients who have had a cholecystectomy. Proponents of such therapy and physicians treating patients who develop colonic cancer or polypoid disease after having had such therapy are encouraged to provide accurate reports.

Diagnosis of acute abdominal injuries in patients with spinal shock: value of diagnostic peritoneal lavage.

Loss of sensory, motor, and reflex function during spinal shock obscures the usual signs of significant blunt abdominal trauma. In a retrospective study of ten acutely quadriplegic patients, initial physical findings, vital signs, and hematocrit determinations were not found to be helpful in detecting intra-abdominal injury. Diagnostic peritoneal lavage was an accurate indicator of the presence or absence of significant intraperitoneal hemorrhage in all ten cases in this series.

Diagnostic exploratory celiotomy: an outdated concept in blunt abdominal trauma.

Diagnostic exploratory celiotomy as the primary procedure in the trauma patient is rarely indicated since the validation of peritoneal lavage as a diagnostic technic. The accuracy of diagnostic peritoneal lavage is clearly superior to that of initial or repetitive clinical evaluation of trauma patients, and its cost is miniscule compared with unnecessary diagnostic celiotomy.