Experience with the intra-abdominal approach for complicated hernias of the inguinal region.

In this report we describe our experience using the transabdominal approach for the reduction and repair of incarcerated or strangulated hernias of the inguinal or femoral region. This technique allows for the division of the constricting ring under direct vision as atraumatically as possible and permits a simplified Cooper's ligament type of repair with great accuracy, safety and ease. Thus, all risks associated with the conventional techniques are minimized and the chances for success of reconstruction are markedly enhanced. Short and long term results have been excellent in 22 patients with complicated inguinal or femoral hernias, five of them recurrent and five with strangulated bowel, with a mean follow up of 80 months.

Preservation of compromised intestine after ischemic injury.

It is possible to preserve ischemic intestinal segments, which currently are routinely resected, following superior mesenteric artery occlusion by exteriorizing them through the abdominal wall with De Martell clamps and observing them carefully. If the functional demands of an anastomosis are not imposed, the circulation of such segments will often be restored, and they will withstand successful anastomosis a few days later. If circulation fails to improve or deteriorates, prompt resection and possibly reexteriorization can be done without delay. Intestinal absorptive surface, crucial to subsequent survival may thus be saved.

Washing with or without chloramphenicol in the treatment of peritonitis: a prospective, clinical trial.

One hundred one suitable patients with peritonitis of diverse origin were randomized into two groups. In each patient in group 1 (50 patients), the abdomen was washed after the appropriate surgical procedure with normal saline solution, and 2 gm chloramphenicol was introduced before abdominal closure; in each patient in group 2 (51 patients), the abdomen was washed as in group 1, but chloramphenicol was not instilled. All patients were given 1 gm chloramphenicol intramuscularly either preoperatively or intraoperatively and 3 gm daily for 3 days. Chloramphenicol was selected on the basis of its activity against aerobic and anaerobic bacteria and its demonstrated stimulating effect on peritoneal macrophages in vitro. All explorations were done through the midline, and the skin and subcutaneous tissues were closed secondarily 3 to 4 days after operation. No drains were used. The two groups were roughly comparable, but results were significantly better for all parameters studied in patients receiving chloramphenicol locally. Blood dyscrasias were not observed. It is suggested that the combination of washing and local antibiotics is superior to washing alone; in addition to its parenteral administration, chloramphenicol is of considerable value if instilled in the area of peritonitis after washing; and besides its bacteriostatic action, chloramphenicol may have a local stimulating effect on peritoneal defenses and may therefore be the drug of choice for local use in generalized peritonitis.

Hypothesis: increasingly intensive locoregional treatment of breast cancer may promote recurrence.

Evidence is presented compatible with the hypothesis that the inevitable tissue injury to the breast engendered by mastectomy or primary radiotherapy may in itself be a factor facilitating recurrence through a variety of local, regional, and systemic tumor-promoting mechanisms. The potential for tumor enhancement appears to be commensurate with the extent of injury and concerns both local and systemic recurrence. The hypothesis lends itself well to experimental testing. If confirmed, it will point to the importance of minimizing any form of tissue injury in the process of treating primary breast cancer, be it by operation or irradiation and curtailing the extent or intensity of both.

Preoperative chemotherapy: advantages and clinical application in stage III breast cancer.

Many lines of evidence support the view that BC is all too often a systemic disease and that micrometastases become enhanced after resection of the primary. Assuming that these two basic considerations do in fact apply, it can be argued that systemic treatment as the initial attack against operable BC has several advantages over the conventional postoperative adjuvant therapy: (a) Systemic treatment before operation may destroy clonogenic cells in the primary tumor which are responsible for the development of metastases; (b) primary tumor shrinkage following systemic therapy may serve as an early, simple, and inexpensive index of the overall chemosensitivity of the tumor; (c) systemic treatment as soon as the diagnosis is made may prevent the development of drug-resistant mutations, which are likely to form spontaneously early in the natural history of the disease; (d) preoperative chemotherapy may suppress the production of tumor-elaborated substances that protect the tumor from immune destruction by the host; (e) the average delay of about 1 month in the treatment of micrometastases in the postoperative adjuvant setting leads to at least a 30% increase of micrometastatic tumor burden, which can be prevented by preoperative treatment; (f) a number of other considerations suggest that the maximal chemosensitivity of each tumor exists at the earliest possible point in time, i.e., at the time of diagnosis; (g) after the initial postchemotherapy immunosuppression immunity recovers, in fact exceeding the pretreatment level, and if surgery is performed during this phase of heightened immunity chemotherapy is utilized as an immunostimulating agent; and finally (h) as more effective systemic agents are discovered, locoregional treatment with surgery and/or radiotherapy may become progressively more limited and it may ultimately be possible to dispense with these modalities. Experimental evidence scattered in the literature over the past three decades attests to the value of preoperative chemotherapy. Likewise, progressively greater numbers of uncontrolled studies have found preoperative chemotherapy most rewarding in miscellaneous sarcomas and in advanced tumors of the head and neck, kidney, and testes, as well as in a variety of other sites, including the breast.(ABSTRACT TRUNCATED AT 400 WORDS)

Systemic therapy as the initial step in the management of operable breast cancer.

Evidence is presented to suggest that treatment of primary breast cancer may be more advantageous if begun initially with chemotherapy, to attack the systemic component of this disease which is ultimately responsible for all deaths. It is also suggested that the current widely practiced reverse policy of surgery followed by adjuvant chemotherapy is probably counterproductive and that the deeply entrenched use of Handley-Halsted tenets largely prevents acceptance of the newer evidence and adoption of change.

Maximal cytoreduction, chemotherapy and contact nonspecific immunotherapy for stage III carcinoma of the ovary.

A combination of therapeutic modalities was studied in 38 consecutive patients with intra-abdominally disseminated carcinoma of the ovary. Resection or destruction by electrocoagulation of all visible tumor was possible in 12 patients. Intra-abdominal chemotherapy and immunotherapy were given postoperatively and were continued systemically for one year. Serious postoperative complications and deaths did not occur. Five patients are well at 12, 22, 26, 34 and 49 months, and two are alive with disease at ten and 22 months. For 18 of the remaining 26 patients in group 2, elimination of all visible tumor was not possible technically, and in eight patients in group 3, an irresectable tumor was found. All of these patients received cyclic chemotherapy as those in group 1 but without immunotherapy. Patients in group 2 had a median survival time of about 16 months, no long term survivors and a mortality of 75 per cent at two years. The patients in group 3 had a median survival period of less than three months and were all dead before the end of the first year. Our results in this group are similar to those recently reported by others for patients with equally advanced disease treated by chemoimmunotherapy. Maximal tumor cytoreduction may be the most important of all the treatments we used, and a prerequisite to successful chemotherapy and immunotherapy. Contact nonspecific immunostimulation in this setting appears to be sound and safe and warrants further study to determine its ultimate contribution to patient survival.

Long term survival after compound hemipelvectomy.

Three patients survived free of disease ten and one-half, ten and almost six years, respectively, following compound hemipelvectomy for a variety of tumors. Each patient had been operated upon previously at least three times, but the tumors were still well localized despite the propensity for local infiltration or growth. In addition to the lower extremity and the ipsilateral pelvic bones, varieties of organs were resected. In one patient with chondrosarcoma of the pelvis, there was a local recurrent mass and, in another with adenocarcinoma of the appendix, a solitary pulmonary metastasis. Both of these lesions were successfully resected, and the patients remained free of disease nine and four and one-half years, respectively, after resection of the recurrent lesions. The third patients had carcinoma of the penis with metastases in both groins; carcinoma of the breast devedeveloped nine and one-half years after hemipelvectomy. The two younger patients were fitted with prostheses, and all three adjusted fairly well physically and psychologically to their disability. Frequently, the huge size of these tumors, the infiltration of many contiguous structures and, possibly, other features known to be associated with a bad prognosis make them appear to be incurable. We suggest that slowly growing tumor which remain localized for a long time can be controlled if adequately excised, possibly because they may be associated with strong systemic immunity. The extremely few such patients who may be encountered in surgical practice ought, therefore, to be recognized as potentially curable and treated accordingly, despite the often formidable risk or technical problems at operation and the resultant postoperative disabilities.