The prevalence and severity of late effects in normal rat duodenum following intraoperative irradiation.

In humans, a portion of the duodenum is often at risk for radiation-induced complications following intraoperative radiation therapy for pancreatic carcinoma. To determine experimentally the prevalence and severity of late effects in the normal mammalian duodenum, 190 rats received single doses of 0, 15, 20, 25, 30, or 40 Gy orthovoltage X rays to temporarily exteriorized 3 cm circumferential segments of duodenum. The animals were killed 2, 6, 8, or 10 months later. Actuarial survival, change in body weight, and a radiation injury score based on eight histopathologic alterations were used as endpoints. Epithelial atypia, intestinal wall fibrosis, serosal thickening, and vascular sclerosis were the dominant histopathologic alterations at all dose levels throughout the 10-month observation period. The prevalence and severity of histologic radiation injury showed sigmoidal dose-response relationships with the plateaus starting at 20 Gy. Doses of 20 Gy or greater also resulted in a substantial loss of body weight and a high level of early deaths (20-80 days). All endpoints indicate that intraoperative doses of 20 Gy or greater are associated with unacceptable risks of late and irreversible complications.

Role of an emergency helicopter transport service in rural trauma.

The records of 916 trauma victims transported by an emergency helicopter service were reviewed to evaluate its impact on patient outcome. According to strict criteria, the service was classified as essential, helpful, or "not a factor" in the preservation of life and/or limb in each case. The helicopter service was essential in 14.0%, helpful in 12.9%, and "not a factor" in 56.6% of patients. A fourth category included patients who, despite the delivery of maximal emergency medical care, died as a result of their injuries (16.5%). With the available initial information, it was impossible to determine prospectively which patients would benefit from air transport. We believe that the rapid evaluation of potentially serious injuries and the number of patients for whom the service proved beneficial justify its use, particularly in rural areas.

Cystosarcoma phylloides of the breast: a new therapeutic proposal.

An analysis of forty cases of cystosarcoma phylloides of the breast was undertaken to clarify the relationship between histology, surgical treatment and prognosis of this fibroepithelial tumor. Thirty-eight female patients 12 to 85 years of age, treated for this diagnosis over a 17-year period, were studied retrospectively. Histologically malignant lesions were diagnosed in 17 cases: six were treated by local excision, one by subcutaneous mastectomy with prosthetic implant, four by simple mastectomy, three by modified, two by radical mastectomy, and one by biopsy only. Of the 23 histologically benign tumors, 18 were treated by local excision, three had simple mastectomy, and one had subcutaneous mastectomy with prosthetic implant. Three recurrences, observed (7.5%) among patients with benign tumors, were locally excised. Wide local reexcision has controlled the disease to date after average follow-up of 32 months. In the malignant group, metastases developed in four patients (10%). Three of these patients are dead of disease and one is being treated by chemotherapy. Malignant histology seemed to correlate directly to the presence of pain (46.6%), size of the tumor (average 7 cm in diameter), and older age (average 52 years), but there was no correlation with prognosis. Recent reports on the subject advocate wide local excision for small benign lesions and simple mastectomy for larger or malignant ones. Our data indicates that the histologic appearance does not correlate with the clinical behavior of this neoplasm, and the choice of the procedure does not alter the long-term result, provided that the tumor is completely excised. More radical procedures than wide local excision are not justified for cystosarcoma phylloides which behaves more like a soft tissue sarcoma than a breast gland tumor.

Duodenal trauma in the rural setting.

During the past 15 years, 21 patients with duodenal injuries were treated at the University of Iowa Hospitals and Clinics. The major cause of injury (66.6%) was blunt abdominal trauma. Eighteen patients (85.7%) underwent celiotomy. Only one patient (4.7%) had an isolated duodenal injury. In most cases, a careful exploration of the periduodenal area and lesser sac was necessary to diagnose and treat the injury. No one specific procedure was used in these patients. The use of Penrose drains did not prevent abscess formation in three of nine patients. Overall mortality was 23.8 per cent, but most deaths were related to other serious injuries. Only one death (4.7%) was directly related to the duodenal injury. In the rural setting, duodenal injuries are rare, but when they occur they are frequently the result of blunt trauma. These injuries are commonly associated with other obvious problems and may be easily overlooked. Because the preoperative diagnosis is difficult, careful intraoperative examination of the entire duodenum is mandatory.

Current management of trauma to the colon.

In a review of 72 cases of trauma to the colon we have demonstrated that a 51 per cent primary closure rate can be obtained if the following considerations are used: 1) anatomic location of colon injury, 2) degree of fecal contamination, 3) number of associated organs injured. Considering these factors individually or in combination we were able to perform primary closure in 51 per cent of our patients, without colostomy and without increasing morbidity and mortality. As a result, the number of hospital days and surgical procedures have been reduced.

Male breast carcinoma.

Fifty men with primary breast carcinoma were seen between the years 1938 and 1983 at the University of Iowa Hospitals and Clinics. In most patients, there was a significant delay between the onset of symptoms and seeking medical advice (mean, 21 months; range, 1-156). The vast majority of patients were treated by simple, modified radical, or radical mastectomy. Ten patients underwent incisional or excisional biopsy with or without radiation because of locally advanced disease or distant metastases. Survival was comparable in the groups of patients treated with simple mastectomy (mean, 70 months), modified radical mastectomy (mean, 61 months), and radical mastectomy (mean, 78 months). Local recurrence occurred in 25 per cent of all patients, and this rate was not dependent on the operation performed. The data suggest that modified radical mastectomy is adequate therapy for local control and staging of the disease without reducing survival from that observed after radical mastectomy.

Carcinoid tumors of the gastrointestinal tract.

Carcinoid tumors continue to be of specific clinical interest because of their diverse presentation, hormonal secretion, and malignant potential. One hundred ninety-two patients with carcinoid tumors were treated at the University of Iowa Hospitals and Clinics between 1938 and 1982. The most common location of these tumors was the appendix (30%), followed by the ileum (23%) and rectum (9%). Metastatic disease occurred in 29 per cent of all patients, with colonic and ileal tumors being the most likely to metastasize (40% and 35%, respectively). Surgical excision continues to be the treatment of choice in resectable tumors. Appendectomy alone proved effective in the treatment of appendiceal tumors less than 2 cm in diameter and without lymph node metastases. Local excision was also sufficient for the treatment of rectal tumors less than 2 cm in diameter and without invasion of the muscularis propria. Ileal, colonic, and locally advanced appendiceal and rectal tumors should be treated with radical excision including resection of the regional lymph nodes. The overall 5-year survival rate was 47%. Patients with metastatic disease had a lower survival rate (25%) compared with patients without metastases (64%).

A search for malignant cells in peritoneal fluid from patients with colorectal adenocarcinoma.

Cytologic examination of peritoneal fluid aids in staging ovarian malignancies and in selecting gastric adenocarcinoma patients for intraoperative adjuvant chemotherapy. Tissue culture of peritoneal fluid could be potentially valuable in confirming cell viability and establishing sensitivity to a variety of anti-cancer agents. It also could be a more sensitive diagnostic tool than cytologic examination alone. We obtained peritoneal fluid specimens from 29 patients at the time of celiotomy: 22 had colorectal adenocarcinoma and seven were controls. Cytologic examination on a portion of each specimen produced only one positive result for malignant cells. Tissue culture of the remainder of the specimens grew cells from all but one of the patients with colon cancer; however, their morphology was similar to the fibroblasts and mesothelial cells that grew from the seven controls. We speculate that these negative results stem from the absence or reduced number of tumor cells in the specimens. Without additional refinement of our methods of specimen collection and processing, cytologic examination and tissue culture of peritoneal fluid from patients with colorectal cancer are of minimal value. Nevertheless, we believe that, with the necessary refinements, they may eventually become invaluable in the management of these patients.

Indications for choledochoduodenostomy.

In summmary, at University Hospital of Jacksonville, we have performed 36 side-to-side choledochoduodenostomies over the past five years. We have repeatedly demonstrated that choledochoduodenostomy is the procedure of choice for obstructing or partially obstructing lesions of the distal or mid common bile duct, and our extensions of the original indications have not affected the morbidity or mortality as previously reported.

Malignant melanoma in childhood and adolescence.

A retrospective chart review of 25 patients under the age of 20 years with malignant melanoma, diagnosed between the years 1938 and 1984 at the University of Iowa Hospitals and Clinics, was conducted. Nine of the patients were under the age of 14 years, and 18 patients were females. There appeared to be a frequent delay in diagnosis of the primary lesion, occasionally incorrect initial diagnosis, and under-treatment in these young patients. Primary treatment varied from limited excision of the lesion to wide excision and regional lymph node dissection. Females appeared to have a better prognosis than males, and wide local excision with or without regional lymph node dissection was associated with the most favorable outcome. Overall 10-year survival in this group of patients was 56 per cent, a rate that compares well to the overall survival in adult patients with malignant melanoma.

Specimen xeroradiography after needle localization and biopsy of noncalcified, nonpalpable breast lesions.

Xeroradiography was used to detect and aid in needle localization of 63 nonpalpable breast lesions over an 8-year period. In 28 patients (44%), no microcalcifications were present in the lesion biopsied. Xeroradiographs of these noncalcified lesions after their submersion in water carried a clean and close resemblance to their in vivo appearance and aided the pathologist in localizing the abnormality within the biopsy specimen. This simple method improved the accuracy of the needle-guided biopsy while allowing excision of minimal breast tissue. A total of 17 (27%) lesions revealed malignancy. At the time of mastectomy, all carcinomas were at an early stage with no nodal involvement. No recurrence has been detected to date with a mean follow-up period of 24 months. This procedure requires close cooperation between the surgeon, radiologist, and pathologist.

Evaluation of an emergency air transport service as a component of a rural EMS system.

The authors reviewed the records of 569 patients transported by an emergency helicopter service to evaluate its impact on the outcome of patients with multisystemic injuries. A Total Trauma Score for each patient was computed. A number of other factors were also considered, including the nature of the injury, number of systems injured, origin and duration of flight, resuscitative maneuvers, number of blood transfusions given and the timing of operations required to treat the injury. The service was then rated utilizing strict specific guidelines as either essential, helpful or not a factor, in the preservation of life and/or limb in each case. A fourth group was comprised of patients who expired as a result of their injuries. The air transport service was essential to 16.5% and helpful to 10.9% of patients. In spite of rapid evaluation and maximal intervention, 102 (17.9%) of the patients died. The group for which air transport was judged "not a factor" (54.7%) consisted of patients whose injuries would not have proven fatal had their transportation to the tertiary care center been delayed. Retrospective analysis of the data available to the tertiary care center at the time of the decision to transfer the patients by air revealed that it was not possible to differentiate those patients who did not benefit from the service from those for whom the service was judged essential or helpful. Even though 17.9% of the helicopter transported patients died at some time during their period of hospitalization, they did receive the benefit of prompt sophisticated evaluation and management of their injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive hemoperitoneum secondary to spontaneous rupture of hepatic metastases: report of two cases and review of the literature.

Two cases of massive hemoperitoneum secondary to spontaneous rupture of hepatic metastases are presented. This devastating complication of hepatic malignant disease is difficult to diagnose preoperatively. However, the diagnosis should be considered in patients with known malignant disease who present with unexplained blood loss, shock, or signs consistent with an acute surgical abdomen. The presence of fever and leukocytosis with these signs and symptoms may also be part of the clinical picture. Treatment by hepatic resection is never curative. Review of the literature indicates that local control of the bleeding site by suture ligature, packing with topical hemostatic agents, or hepatic artery ligation offers the best chances of obtaining hemorrhage control and some degree of palliation in these desperately ill patients.