The world's best-known surgeon.

Henry Norman Bethune was born in Ontario in 1890 and was to become the best-known physician in the world. Bethune, a thoracic surgeon, spent his professional life in Detroit and Montreal, with these periods separated by a year spent as a patient in a tuberculosis sanatorium. This was where his interest in pulmonary disease was stimulated. Pioneer thoracic surgeon, councillor to the American Association for Thoracic Surgery, artist, poet, polemist, conservative-turned-communist, iconoclast, and soldier, Bethune was a highly complex individual. Diverting his energies from surgery to social issues during the depression, Bethune participated in the Spanish Civil War, at which time he designed the world's first mobile blood transfusion unit. Eight months later, Bethune joined Mao Tse-tung's Eight Route Army in China. In 1939 he died of septicemia acquired from a sliver of infected bone while he was operating on a wounded Chinese patient. Bethune's fame today derives principally from the popularization of his accomplishments by Mao, whom he met once and who subsequently decreed that all in China should learn about him. Bethune's posthumous influence played an important role in the reopening of relations between China and the West.

Endoscopic retrograde pancreatography in the surgery of pancreatic pseudocysts.

Endoscopic retrograde pancreatography (ERP) was performed on 83 patients with 99 pancreatic pseudocysts (PCP). ERP was successful in 76 patients; in the other seven PCPs were found at operation. Five characteristic ductal patterns are described and illustrated. The PCPs were situated in the head (51 patients), body (21 patients), tail (20 patients). Thirteen PCPs were less than 2 cm, 50 were between 2 and 5 cm, 29 greater than 5 cm. There were multiple PCPs in 13.2% of patients. ERP was a more accurate diagnostic measure than ultrasonography or upper gastrointestinal roentgenograms, revealing the lesion in 89% of patients. Eight patients with pancreatic ascites had the causative PCP demonstrated prior to operation. Three patients had pancreatic pleural effusions; two with effusions on the right had PCPs of the tail. Five patients had spontaneous connections between a PCP and the stomach (four patients) or duodenum (one patient). Rational surgical planning for the management of PCPs is greatly facilitated by preliminary reconnaisance by ERP.

The surgical implications of estrophile protein estimations in carcinoma of the breast.

Assays of estrophile protein (ER) in 161 patients with no previous additive or ablative hormonal therapy have been analyzed; 47.2 percent were ER positive; 52.8 percent ER negative. A total of 37.5 percent of premenopausal and 50.8 percent of postmenopausal patients had ER-positive tumors. The effects of additive and ablaive hormonal therapy were observed in 75 patients; 63.5 percent of the ER-positive group and 8.6 percent of the ER-negative group responded, but the incidence in the ER-negative group is thought to be spuriously high. The level of the ER content in the ER-positive group did not influence the degree of response. The ER-negative group had a shorter life span after discovery of the tumor and was more likely to develop dominant visceral metastases. Of 15 patients followed with sequential ER assays after hormonal therapy (additive and/or ablative), 14 demonstrated substantial falls in ER levels but these did not correlate with the clinical response. Tumor assayed in nine patients after irradiation of the lesion contained no demonstrable ER. ER assays of breast cancer tissue proved to be a useful but imperfect tool in predicting clinical progress following hormonal maneuvers but some readings may be spuriously low due to imperfect techniques of measurement, prior exogenous hormonal administration or hormonal ablation, and previous irradiation of the tumor.

A correlation between clinical pancreatitis and isoenzyme patterns of amylase.

Fifty-seven patients admitted with the clinical diagnosis of acute pancreatitis had isoamylase analysis on their sera to determine the source of their hyperamylasemia. Our objective was to correlate the isoamylase pattern with our clinical observations. Thirty-nine of 57 patients (68%) had pancreatic hyperamylasemia as expected, but 18 of 57 patients (32%) had normal levels of pancreatic amylase. The hyperamylasemia in the latter group was due either to nonpancreatic hyperamylasemia (16 of 57) of macroamylasemia (2 of 57). Consequently, hyperamylasemia associated with abdominal pain, nausea, and vomiting led to the incorrect diagnosis of acute pancreatitis in 32% of the patients. The measurement of isoamylase profiles can be done rapidly and inexpensively. Knowledge that hyperamylasemia is nonpancreatic in origin may have an important influence on treatment, hospitalization, and the extent of laboratory and radiologic investigation.

Gastrojejunostomy: is it helpful for patients with pancreatic cancer?

A retrospective review of palliative outcome of gastrojejunostomy in patients with pancreatic cancer was conducted. Eighty-one patients were analyzed in two groups depending on duodenal patency. Forty-five patients (group I) had no evidence of duodenal obstruction. Thirty-six patients (group II) had evidence of impingement on the duodenum by the pancreatic cancer. A third subset of patients was also studied for outcome. These 21 patients (five group I and 16 group II) had nausea and vomiting as major symptoms and were judged to have the most to gain from gastrojejunostomy. Patients were categorized by outcome. Poor outcome was defined as either death during the hospitalization for gastrojejunostomy or death within 30 days of operation even if the patient left the hospital. Risk for poor outcome depended on group. In group I, 18 of 45 patients (40%) had a poor outcome compared with 25 of 36 (70%) patients in group II (p less than 0.001). Nineteen of the 21 (90%) patients with nausea and vomiting had a poor outcome. It is an unfortunate paradox that the more patients need gastrojejunostomy for pancreatic cancer, the less likely they are to have a favorable outcome. Gastric outlet obstruction in pancreatic cancer appears to be a terminal event. A prospective study is needed to see if any true palliation of vomiting can be affected in these patients.

Pancreatic ascites: recognition and management.

In a patient with chronic ascites, an abnormally raised ascitic fluid amylase concentration and a protein content above 2.5 gm/100 ml is diagnostic of pancreatic ascites. Thirty-one episodes in 26 patients treated between 1958 and 1975 have been analyzed. Twenty patients (65%) experienced abdominal pain and ten (32%) had concomitant pleural effusions roentgenographically. Although a leaking pancreatic pseudocyst was the cause of ascites in at least 21 episodes (70%), an abdominal mass could only be palpated in two of 26 patients. Roentgenographic series of the upper part of the gastrointestinal tract failed to demonstrate pancreatic pseudocyst in 7 of 21 episodes (33%). Endoscopic retrograde pancreatography is invaluable in delineating the pancreatic ductal system and, in conjunction with intraoperative pancreatography, makes a vital contribution to rational surgical therapy. Medical treatment or external drainage during 18 episodes resulted in death in four (22%) and recurrences of ascites or pancreatic pseudocyst in nine (64%). Since routine pancreatography followed by pancreatic resection or internal drainage has been instituted, mortality and recurrence have been reduced to zero.

The continuing dilemma of lobular carcinoma in situ.

We reviewed the courses of 250 consecutive women with lobular carcinoma in situ of the breast entered into the Surveillance, Epidemiology, and End Results program of the Michigan Cancer Foundation, Detroit, Mich, between 1973 and 1986. No patient had known invasive cancer at the time of initial entry. The average follow-up was 93.1 months; 212 patients had mastectomy for the initial lesion and 65 patients had less than mastectomy, of whom one developed a new lesion in the ipsilateral breast. Thirty-seven patients (14.8%) were later found to have lesions in the contralateral breast, 25 within the first year. Thirteen of the 38 lesions (5.2% of the total series) were invasive, and 11 were primarily ductal. Seventeen patients died, two of breast cancer, two of unknown causes, and 13 of non-breast-related causes. The maximum mortality from breast cancer is 1.6% to this point. The frequency of mastectomy fell from 78.1% in the years 1973 through 1983 to 52% in 1984 through 1986, reflecting a change in surgical philosophy. Although no guarantees can be given to any individual patient, the great majority of patients with LCIS unassociated with a proved invasive cancer can be safely treated with less than mastectomy.

Pancreatic pseudocysts communicating with the stomach: demonstration by endoscopic retrograde pancreatography.

The use of endoscopic retrograde pancreatography (ERP) provides important information in the management of pancreatic pseudocysts unavailable by other methods. When the pseudocysts communicate with a hollow viscus, the surgeon is better able to deal with the problem if aware of this fact prior to operative intervention. A pancreatic pseudocyst communicating with the stomach was demonstrated by ERP in each of four patients. One of these patients had pancreatic ascites and the other had left-sided pleural effusion, and both were treated successfully by distal pancreatectomy. The other two patients responded to nonoperative treatment. This report emphasizes the potential diagonstic value of ERP in determining the presence and the fate of pseudocysts.

Cholecystectomy in patients with cirrhosis. A surgical challenge.

Cholecystectomy or cholecystostomy was performed in 49 patients with cirrhosis with a mortality of 10.2%. Massive intraoperative blood loss was found in 16.3% and major wound problems (dehiscence, abscess) in 12.2%. Intraoperative blood loss, amount of blood transfused, and mortality were correlated with the Child classification of hepatic reserve. Mortality was 23.5% for Child C patients vs 0% for Child A patients. Excessive blood loss from a hypervascular biliary bed and resulting liver failure and sepsis were the usual causes of death. Elective surgical intervention for Child A and B patients with symptomatic cholelithiasis is warranted. In Child C patients, however, every attempt should be made to increase the class to a Child B.

Electrocoagulation of bleeding in the upper part of the gastrointestinal tract: a preliminary experimental clinical report.

Electrocoagulation of gastric or esophageal bleeding sites was evaluated in dogs using a flexible suction coagulator electrode passed through the endoscope using an electrocautery unit (Cameron-Miller model 80-7910). Acute and chronic coagulation studies in 25 dogs showed that electrocoagulation of both the esophageal and gastric mucosa was safe at an electrocautery unit setting of 5 for three to five seconds. This level of coagulation was successful in stopping bleeding created from actively bleeding esophageal and gastric mucosal defects by taking multiple large biopsy specimens. Based on these data, six patients with active bleeding gastric lesions have undergone mucosal coagulation. This successfully stopped the bleeding initially in all six patients; two patients rebled and required operative intervention within 48 hours. Further clinical evaluation is being implemented to determine its clinical role in the treatment of bleeding in the upper part of the gastrointestinal tract.

The impact of technology on the management of pancreatic pseudocyst. Fifth annual Samuel Jason Mixter Lecture.

The records of 299 patients with 357 admissions for pancreatic pseudocysts seen between 1960 and 1989 were studied; 233 patients underwent operation. The natural history of pancreatic pseudocysts has been clarified by newer technology, such as ultrasonography, computer tomography, amylase isoenzyme measurements, and endoscopic retrograde cholangiopancreatography. All have influenced diagnosis, nonoperative management, and surgical operation. Differences between pancreatic pseudocysts associated with acute pancreatitis in contrast with chronic pancreatitis, and the complications of obstruction, hemorrhage, rupture, pancreatic ascites, infection, and jaundice can now be more rationally treated. Pancreatic pseudocysts and pancreatic ductal changes are now revealed earlier, especially by endoscopic retrograde cholangiopancreatography. Paradoxically, this information has encouraged nonoperative conservative therapy and also larger operations, eg, resection and adjunctive pancreaticojejunostomy. Partial resection of the pancreas together with the pancreatic pseudocysts was performed in 58 (25%) of the 233 patients. Recent technology permits cautious exploration of selective pancreatic pseudocyst drainage percutaneously or transgastroduodenally avoiding laparotomy.

Aged amylase: a valuable test for detecting and tracking pancreatic pseudocysts.

Amylase-rich fluid that incubates ("ages") within a pancreatic pseudocyst undergoes a change that can be detected by isoenzyme analysis of amylase from the serum. This aging is a result of deamination of the asparagine and glutamine residues on the amylase molecule. Eighteen of 20 patients with surgically proved pseudocysts had greater than 15% aged (deaminated) amylase in their serum. Levels of aged amylase returned to normal following treatment of their pseudocysts. Twenty of 23 patients with acute pancreatitis had levels of aged amylase below 15% (P less than .05). A criterion of 15% aged amylase resulted in 87% specificity, and 91% sensitivity for the diagnosis of pseudocysts. Because this test is noninvasive and easy to perform, it should become the ideal screen for patients at risk of development of pseudocysts, Endoscopic retrograde pancreatography, ultrasonography, and abdominal computed tomographic scanning should be reserved for confirmation of the diagnosis when the result of isoenzyme analysis is positive.

Duplication of the duodenum extending into liver.

A large intrahepatic duodenal duplication connected to the duodenum by two openings is described. No similar cases of intrahepatic cysts have been found in the literature. The patient, a forty-four year old woman, had recurrent and numerous bouts of right upper quadrant pain over many years before the intrahepatic portion of the cyst was drained by a Roux-en-Y anastomosis after the connections with the duodenum had been excised.

Gastritis and gastric blood flow in hyperdynamic septic pigs.

The present study was designed to determine the gastric hemodynamics in a septic model that causes both a hyperdynamic state and acute erosive gastritis. Sepsis was established in twelve pigs by the intramuscular shank injection of Pastuerella multocida (42 X 10(8) colonies) in triptose phosphate broth; four pigs received sterile broth injections (shams) and eight received sterile saline injections (controls). After 18 hours, cardiac output was measured by both the cardiogreen dilution technic and the radioactive microsphere dilution technic; cardiac output was then compared to total and regional gastric blood flow measured by the raioactive microsphere entrapment technic. Acute erosive gastritis developed in septic pigs in the fundus and body of the stomach; the antrum was spared. Cardiac output was significantly increased in septic pigs compared with sham and control pigs. Total gastric blood flow and regional blood flow to the fundus, body, and antrum were also increased in direct proportion to the increase in cardiac output. These data suggest that acute erosive gastritis is primarily due to an end-organ cellular insult from sepsis and is not primarily due to a decrease or redistribution in gastric blood flow.

Mallory-Weiss syndrome. A study of 224 patients.

With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.

Pancreas divisum: is it a normal anatomic variant?

One thousand five hundred twenty-nine pancreatograms were obtained between 1973 and 1985. Complete pancreas divisum was demonstrated in 41 patients, for an incidence of 2.7 percent, and incomplete pancreas divisum in 14 cases, for an incidence of 0.9 percent. No increased incidence of pancreas divisum was found in any of four groups: an incidental group, a group with alcoholic pancreatitis, a group with unexplained upper abdominal pain, and an idiopathic pancreatitis group. The majority of patients (80 percent) were found to have pancreas divisum as an incidental finding or in association with alcoholic pancreatitis. Of 82 patients with idiopathic pancreatitis, only 2 had pancreas divisum. The three patients with pancreas divisum who had sphincteroplasty of the minor papilla were not helped by the procedure. We conclude that pancreas divisum is a normal anatomic variant and is very seldom a cause of pancreatic pain.

Calculi complicating a renal transplant.

Four months after a cadaver kidney transplant, kidney stones were found in the renal allograft. Three major predisposing causes of nephrolithiasis were found in the patient, including hyperparathyroidism, renal tubular acidosis, and urinary tract infection. Hypercalcemia was corrected by parathyroidectomy. During the subsequent three years there was no enlargement of the renal stones and adequate kidney function was maintained. Renal tubular acidosis was not severe and seemed to be related to chronic rejection. Urinary tract infection was readily corrected with antibiotics and did not recur after the immediate post-transplant period. Surgical therapy for nephrolithiasis involving a kidney allograft was defferred since urinary flow was not obstructed. This course of management is recommended for use in patients with calculi complicating renal transplantation.

The training and role of the surgeon in the intensive care unit.

The central question for surgeons is whether the patient in the surgical intensive care unit (SICU) is better served by a surgeon or a nonsurgeon as the responsible physician and as administrator of the SICU. This article explores the challenge of the SICU and the need for solutions, reviews the qualifications of the consultant in surgical critical care, and provides a job description of the director of an SICU.

Penetrating wounds of the neck: principles and some controversies.

Some of the principles, pitfalls, and controversies in the management of penetrating wounds of the neck have been reviewed. All three policies to exploration of the neck advocated by different authors have merit and can be considered optimal under certain circumstances. Since delayed surgical treatment of major vascular and esophageal injuries results in higher morbidity and mortality, exploratory operations are appropriate when such injuries are suspected, even though preoperative studies are inconclusive. A systematic approach to the management of penetrating wounds of the base of the neck has been outlined. The role of a shount to maintain adequate cerebral blood flow during repair of carotid artery injuries has been discussed. In patients who have severe preoperative neurologic deficit and no blood flow in the injured carotid artery at operation, ligation of the artery rather than repair of injury appears to be indicated.

Emergency treatment of wounds of the colon.

Colonic wounds vary greatly in their severity and the number of concomitantly injured organs. Relatively few colonic wounds are single; these can usually be treated by primary repair. The approach to colonic wounds generally must be selective and take into account the degree of associated shock,contamination, and surrounding tissue damage. Judicious application of the wide variety of technical approaches available today has increased the incidence of primary repair to over 50% and has reduced mortality to 10% to 15%.