Staged orchiorrhaphy. Therapeutic procedure in cryptorchic testicle with a short spermatic cord.

In 62 planned staged orchiorrhaphies for a "short" spermatic cord, satisfactory location of the testicle following the second operation was achieved in 90% of cases. The testicle was atrophic and had to be excised in only 3.2%. After a follow-up period of two to ten years, the testicle remained satisfactorily located in 77% of cases; adequate size and configuration of the testicle (compared to the contralateral side) was found in 64.5%. In 17%, a partial or complete atrophy developed. No correlation was found between the initial size of the testicle and the late results. It is advocated, therefore, that excision be avoided unless definite atrophy exists. Planned staged orchiorrhaphy is recommended for testicles in high locations that are difficult to bring down. The late preschool period (5 to 6 years) is suggested as the optimal age for the first attempt at orchiorrhaphy and the second stage two years later, if required.

Seminoma of intra-abdominal testis in sixty-seven-year-old man.

A sixty-seven-year-old man found to have a seminoma of an undescended intra-abdominal testis is believed to be the oldest reported patient with this presentation. This case emphasizes the importance of careful palpation of the testis as part of the routine physical examination at any age. Testicular tumor or metastases should be included in the differential diagnosis of retroperitoneal mass.

Use of 5-micron filter in administering 'all-in-one' mixtures for total parenteral nutrition.

An assessment was made of the stability of nine total nutrient admixtures (TNA) for total parenteral nutrition (TPN) and of Intralipid 20% filtered through a 5-micron filter. Mixture samples from 3-litre EVA plastic bags were obtained for tests 4 and 24 h after preparation, before and after filtration through a 5-micron filter during a period of 24 h. The filtered mixtures were collected in 3-litre EVA plastic bags and the contents of the filter were also examined. Stability parameters studied were pH, lipid globule size and visual signs of emulsion breakage. Used for assessment of lipid globule size were a light microscope and a Coulter Counter TA II, which measures particles from 1.4 microns to 43.8 microns in diameter. There were no physical signs of instability in any of the mixtures tested while they were being filtered and collected through the 5-micron filter. Examination of mixture samples prior to filtration and of filter contents revealed the presence of large fat globules, precipitates, solid particles and aggregates. Although these were trapped on the surface of the filter there was no slowing of the rate of flow of the mixture. These findings demonstrate the importance of using a 5-micron filter in delivering total nutrient mixtures in order to avoid the hazards posed by the presence of particles larger than 5 microns in size and show that its use does not affect stability.

The timing of relaparotomy and its influence on prognosis. A 10 year survey.

Review of 3,680 abdominal operations performed in our department during a 10 year period revealed that 95 patients (2.6 percent) required relaparotomy because of surgical complications during the same hospitalization. Of these, 37 patients died, a mortality of 38 percent, which is approximately 10-fold that for similar operations in which reintervention was not necessary. The mortality was greater in male patients and was very high (64 percent) in those over the age of 70 years. The most common complication necessitating relaparotomy was peritonitis (0.9 percent of the total series), followed by intestinal obstruction (0.8 percent) and wound disruption (0.7 percent). The frequency of bleeding requiring reoperation was low (0.1 percent). Intestinal operations were associated with the highest incidence of complications (6.2 percent), followed by gastric operations (4 percent). Assessment of the time interval between the development of the surgical complication and reoperation in each case indicated that there had been an unjustifiably long delay in reaching the correct diagnosis, in performing reoperation or both in 26 percent of this series (40 percent of the cases of peritonitis). This delay was usually greater with early than with relatively later complications. However, our findings failed to support a detrimental effect of this delay and even showed a tendency toward better results and a lower mortality when conservative treatment was prolonged before reoperation was performed.

Spontaneous biliary-enteric fistulas; some considerations on the management of gallstones.

During the past ten years a diagnosis of biliary-enteric fistula was made in thirty-five patients. Six were entirely asymptomatic and another seven patients had suffered only mild symptoms for a short period of time. This indicates that the gallbladder can undergo recurrent episodes of inflammation to the point of fistula formation, with little or no clinical signs of symptoms. An aggressive surgical approach is therefore warranted in patients with cholelithiasis, even when silent stones are involved.

Histopathologic high risk factors influencing the prognosis of patients with early breast cancer (T1N0M0).

A retrospective study of 78 women with early breast cancer was undertaken with the aim of detecting histopathologic risk factors that would influence the prognosis of these patients. Histologic tumor type, nuclear grade of tumor, tumor margin, and lymphoid infiltration near the tumor as well as blood vessel invasion and lymphatic tumor emboli were evaluated. The overall 10 year survival rate was 79.2 percent. In correlating the aforementioned criteria against survival rate, it was found that the patients without any of the histopathologic risk factors had a 100 percent rate, whereas those with one risk factor had a 79 percent rate and those with two or more risk factors a 66 percent rate. Nuclear grade and lymphoid infiltration were found to have the highest significance in regard to recurrence and the mortality rate. The findings of this study suggest that in patients classified as having T1N0M0 disease without any of the histopathologic risk factors, operation is the only treatment indicated. Patients with one or more positive risk factors should receive adequate adjuvant therapy in order to increase their survival rate.

Lymphocyte subpopulation before and after operation in patients with benign vs malignant breast disease.

Multiple parameters of immune function were measured serially before and one and five weeks following operation in 14 patients with fibrocystic disease of the breast (Group A) and in 20 patients with stage 1-2 infiltrating duct carcinoma (Group B). These parameters included the following: WBC, total number and percentage of lymphocytes, numbers of B cells, T cells, T-active, T-helper and T-suppressor cells and the ratio between the latter as well as spontaneous suppressor or helper activity and the graft-versus-host reaction. Prior to operation no statistically significant difference was found between the two groups except for the number of T-helper cells, which was higher in Group B (p less than 0.05), and the spontaneous suppressor activity, which was higher in Group B (p less than 0.05). The finding of such a high percentage (80%) of negative graft-versus-host reactions five weeks after operation together with the high suppressor activity may indicate the presence of tumor micrometastases. The burden of surgery and general anesthesia was stronger in Group B, with a pronounced difference found between the groups (p = 0.0005), but the interaction between the influence of time (surgery and anesthesia) and the groups was not as great (p = 0.4864) and was found to be different for each group.

Free perforation of small intestine in adults.

In a 14-year period 15 cases of free perforation of the small bowel in adults were treated in our department. In two patients perforation was caused by a foreign body and in six by each of the following: duplication of the small bowel, Hodgkin's lymphoma, vasculitis and steroid treatment, intussusception, adhesions, diverticulum. All patients presented with the signs of diffuse peritonitis. One patient died before surgery. Of the 14 patients operated upon, 10 underwent resection and primary anastomosis and four suturing of the perforation. In six cases the etiology remains unknown even after surgical intervention and pathological examination. The mortality rate of the 14 operated patients was 7.1%. 78.5% of the patients were operated on within 24 hours of onset of symptoms, and early surgery is considered to be the most important factor in the low mortality rate achieved in this series.

Catheter obstruction: analysis of filter content of total nutrient admixture.

Catheter blockage in patients receiving long-term parenteral nutrition with fat-containing total nutrient admixture (TNA) is a relatively common complication. A study was carried out to characterize the material which is filtered out of the TNA and is a potential cause of catheter blockage. A total of 45 bags containing the same TNA solution were stored for 7 days at 4 degrees C. The stability of the solution in all the bags was then confirmed by light microscope and Coulter Counter, to determine the particle-size distribution, following which the solution was filtered through a 5-microns filter. Chemical analysis was then made to determine the amount of solid particles, fat and precipitates of Mg, Zn, Ca, Na, and K in the filter contents. Each bag was found to contain 7326 +/- 2681 solid particles as plasticizers and the main component of the filter contents was fat (99.4%) whereas electrolytes as precipitates constituted less than 0.5%. The amount of fat and electrolytes lost on the filter from the solution was negligible. Our analysis of the material trapped on the filter, which may block the catheter during long-term therapy, suggests the importance of filtration and of finding a means for dissolving the fat, the main component of the filter material.

Wandering spleen with torsion of pedicle in a child presenting as an intermittently-appearing abdominal mass.

Wandering spleen with torsion of the splenic pedicle is a rare condition with vague clinical manifestations. If this diagnosis is under condiseration, it can be established by angiography or by splenic scan.

Primary hyperparathyroidism in children.

We present here a series of seven children with primary hyperparathyroidism caused by parathyroid adenoma. Chief cells were the primary element in six patients and water-clear cells in one patient. A brief review of the literature on primary hyperparathyroidism in children is included. Emphasis is placed on the clinical characteristics of this rare disease in children.

Partial splenectomy in Gaucher's disease.

In 11 children with hypersplenism due to Gaucher's disease, partial splenectomy was planned with the aim to prevent the development of postsplenectomy sepsis and also to slow the advance of the disease in the rest of the reticuloendothelial system by permitting continuing accumulation of the beta-glucocerebroside in the remaining splenic tissue. In seven children, partial splenectomy was performed successfully, the weight of the splenic tissue removed ranging from 400 to 3,680 g. The postoperative course was uneventful and the average duration of hospitalization was 12 days. In subsequent follow-up, isotope scanning demonstrated continuing growth of the splenic remnant and there were no episodes of postsplenectomy sepsis nor evidence of increased accumulation of beta-glucocerebroside in the liver or bones. These children showed a marked improvement in the growth curve and dramatic improvement in the hematologic picture. Of the four remaining children, in two, partial splenectomy was followed by complete removal of the remaining spleen due to necrosis, whereas in two, total splenectomy was performed since the huge spleens were extensively infarcted. Our experience suggests that partial splenectomy is the treatment of choice in the management of young patients with hypersplenism due to Gaucher's disease.

Intramural hematoma of duodenum following endoscopic intestinal biopsy.

We present the fourth case to be reported in the literature of intramural hematoma of the duodenum following endoscopic small bowel biopsy. It is the first reported to have been diagnosed by ultrasonography and confirmed by contrast roentgenograms. Conservative treatment was effective in achieving satisfactory resolution of the obstruction within seven days, as evidenced by barium meal examination. The mechanism of trauma, in light of the other cases reported in the literature, is discussed.

External biliary-pancreatic fistulas.

Twenty-seven patients treated for pancreatic and/or biliary-cutaneous fistulas have been reviewed. Four patients died mainly because of cardiopulmonary and septic complications. Spontaneous sealing of the fistula occurred in 81% of the conservatively treated cases (48% of all cases). All the LO fistulas but only 68% of the HO fistulas treated conservatively sealed spontaneously. Eleven patients were treated surgically. There were three deaths and three failures (reappearance of fistula). All the patients who died had been operated on within three months after the appearance of HO fistulas. There was no mortality among the patients with LO fistulas or among patients operated on at a later stage. We have reached the following conclusions: 1. There is a significant difference in prognosis between low output and high output fistulas. 2. In LO fistulas, there is no need for a surgical intervention aimed to close the fistula unless it persists for at least one year. 3. In HO fistulas, if a corrective operation is necessary, it should be withheld for at least three months whenever possible. 4. Roux-en-Y fistulojejunostomy is considered to be the procedure of choice. 5. Infection and premature colsure of the external part of the fistulous tract should be avoided by insertion of drains and repeated surgical drainage, where necessary. 6. High caloric feeding, elemental diet and intravenous hyperalimentation are very important factors that enhance recovery in the surgically and conservatively treated patients.

The postoperative appearance of the liver on scanning following omentopexy of the hydatid cyst.

Six patients were operated on for hydatid disease of the liver by the omentopexy method. On repeated scans of the liver performed respectively one and four years after the operation, it was seen that the scanning defect at the site of the cyst still remained, without being replaced by normal liver tissues. The patients recovered fully and had no complaints.

Upper gastrointestinal bleeding from uncommon causes in patients with concomitant peptic ulcer: a clinical, diagnostic and therapeutic pitfall.

In the majority of cases, massivm a peptic ulcer arises from the ulcer. On rare occasions, the bleeding emanates from other sites in the gastrointestinal tract. Four patients, all of whom had suffered from peptic ulceration for lengthy periods, and who were referred to hospital with severe bleeding from sources other than peptic ulcer, are presented. This group of patients poses particular diagnostic and therapeutic problems, which are discussed. The need for performing emergency gastroscopy and/or selective angiography, in an attempt to localize the source of bleeding preoperatively, is stressed. In doing so, one is taking into consideration the many difficulties sometimes encountered during operation in locating a bleeding point in a bowel filled with blood clots. In those patients in whom the source of the hemorrhage cannot be ascertained, early surgical intervention is advised, because the bleeding may possibly be coming from a tumor of the small bowel.