Aneuploid islet cell tumor with late metastasis.

An unusual case of insulin producing islet cell tumor is reported which recurred after a 16 yr interval. In most instances malignancy of islet cell tumors is impossible to assess morphologically or functionally but depends on the recognition of metastases. Nuclear DNA analysis provides significant prognostic and biological information in a number of solid human tumors. Retrospective computerized nuclear image analysis of the primary tumor in the present case showed an aneuploid DNA profile similar to that seen in the metastasis. It appears that ploidy studies may be useful in predicting malignant potential of islet cell tumors.

Preliminary study of the anatomy of the venous drainage of the intrahepatic and extrahepatic bile ducts and its relevance to the practice of hepatobiliary surgery.

BACKGROUND: Although there have been many studies of the arterial supply of the biliary system, attempts to study the corresponding venous drainage have been few and all have been incomplete. The purpose of the present investigation is to describe the anatomy of the venous drainage of both the intrahepatic and extrahepatic bile ducts and to determine its relevance to hepatobiliary surgery. METHODS: The intrahepatic and extrahepatic venous drainage of the bile ducts was investigated in seven specimens by injecting a solution of 10% gelatin coloured with Alcian blue into the portal vein or the superior mesenteric vein to outline the venous drainage. The specimens were dissected under loop magnification and representative drawings were obtained. RESULTS: The surface of the intrahepatic and extrahepatic bile ducts was covered by a fine venous plexus. On the surface of the supraduodenal common hepatic duct and common bile duct the venous plexus drained laterally into marginal veins, usually two in number and known as the 3 o'clock and 9 o'clock marginal veins. Inferiorly the marginal veins and the venous plexus communicated with the pancreaticoduodenal venous plexus, which in its turn drained into the posterosuperior pancreaticoduodenal vein, a branch of the superior mesenteric vein. Superiorly the marginal veins divided into a number of branches. Some branches followed the left and right hepatic ducts into the liver, communicating with the venous plexus and the adjacent branches of the portal vein. Other branches of variable size entered either segment IV or the caudate lobe or process via the hilar venous plexus. A most important finding was that even after dividing the bile duct and all communicating veins at the upper border of the duodenum, the venous plexus and the marginal veins filled normally to the level of transection. This occurred almost certainly by retrograde filling from above. CONCLUSION: The satisfactory results of end-to-end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end-to-end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop ofjejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long-term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.

The starch granuloma syndrome.

Starch glove powder is not entirely innocuous when introduced into the peritoneal cavity. Foreign body granulomas formed as relation to starch deposited in the peritoneal cavity may closely resemble malignant seedlings and thus mislead the surgeon in his proposed treatment of bowel cancer. In addition, the occurrence of starch granuloma peritonitis may provoke an unnecessary operation in a patient presenting with fever and peritoneal irritation a few weeks after a seemingly uncomplicated laparotomy.

Thomas Peel Dunhill: pioneer thyroid surgeon.

Thomas Peel Dunhill, a name by now almost completely forgotten in his native Australia, was born in 1876 near Kerang in the State of Victoria. Although he qualified as a pharmacist in 1898, Dunhill had already decided to study medicine and graduated in 1903 from the Clinical School of the Melbourne Hospital. He was regarded as an outstanding student. In 1905 Dunhill was invited to join the Senior Medical Staff at St Vincent's Hospital by Mother Berchmans Daly, the then Mother Rectress. In 1906 Dunhill was awarded the MD and in 1907 he performed his first thyroid lobectomy under local anaesthesia for toxic goitre. As early as 1908, Dunhill understood the essentials for successful surgery in thyrotoxicosis--enough thyroid had to be removed to cure the condition. To this end, he advocated a bilateral attack on the thyroid and advocated thyroidectomy in the thyrocardiac patient. He did this before Theodor Kocher, Charles Mayo, William Halsted or George Crile. In 1911 Dunhill visited the USA and England and communicated his results to the thyroid surgeons in both countries (230 cases of exophthalmic goitre operated on with four deaths). The English could not, or would not, believe his results as the mortality of surgery for exophthalmic goitre at St Thomas's Hospital, London in 1910 was 33%. Dunhill served with distinction in the Great War and his abilities favourably impressed George Gask, who was to become the Professor of Surgery at St Bartholomew's Hospital, London. Gask eventually invited Dunhill to join his Unit and Dunhill left St Vincent's Hospital in 1920. Between 1920 and Dunhill's retirement at the age of 60 in 1935, he became the outstanding general surgeon at St Bartholomew's Hospital. Dunhill and Cecil Joll, were regarded as the leading thyroid surgeons in the UK. Knighted in 1933, Dunhill was appointed surgeon to the Royal Household, serving four British monarchs. In addition to his brilliant surgical career, Dunhill maintained a love for the land. He was an expert fly fisherman. Dunhill retired from surgical practice in 1949 and died at the age of 80 in 1957 at his London home. Many eulogies were delivered, especially by Sir James Paterson Ross and Sir Geoffrey Keynes, his former pupils. Dunhill's exploits as a thyroid surgeon in the development of a safe and effective treatment for thyrotoxicosis and in operating on the thyrocardiac enables this modest, courteous and loyal Australian to be included with Theodor Kocher, Charles Mayo, William Halsted and George Crile in the pantheon of pioneer thyroid surgeons.

The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy.

BACKGROUND: Cholecystectomy remains the only satisfactory treatment for symptomatic gall bladder stones. Unfortunately, in some cases the operation is complicated by vasculobiliary injury. The present study was undertaken to investigate the blood supply of the normal biliary system, to simulate vasculobiliary injuries described after cholecystectomy, and to determine the possible effects of the vascular injury on biliary reconstruction. METHODS: The blood supply of the biliary system in nine normal livers was investigated by injection of the coeliac axis and superior mesenteric arteries with coloured gelatin. The specimens were dissected under magnification and drawings prepared. Injection dissection studies were also carried out in eight specimens in which various vasculobiliary injuries encountered after cholecystectomy were simulated. RESULTS: The bile ducts possess an arterial plexus on their surface which is supplied from below by ascending marginal vessels derived from the postero-superior pancreaticoduodenal artery. These marginal vessels end above in the right hepatic artery or its branches. The right and left hepatic ductal systems are supplied by the right and left hepatic arteries and their sectoral or segmental branches. The right and left hepatic arteries communicate freely via the hilar plate arterial plexus. This collateral system allows the blood supply to the right hepatic duct to be maintained after ligation of the right hepatic artery and interruption of the common hepatic duct or excision of the confluence. CONCLUSION: A knowledge of the blood supply of the normal biliary system and the collateral hilar plate arterial plexus forms the anatomical foundation for successful reconstructive surgery, not only in vasculobiliary injuries following cholecystectomy, but also for a wide range of hepatobiliary procedures.

Acute mesenteric ischaemia.

The experience of acute mesenteric ischaemia at St Vincent's Hospital, Melbourne, has been reviewed over 17 years. The mortality remains appallingly high. This applies particularly to those patients who had thrombosis of the superior mesenteric artery, amongst whom the mortality in this series was 97%. The mortality was slightly less in the group suffering from embolic occlusion of the superior mesenteric artery (66%), and in those suffering from thrombosis of the superior mesenteric vein (60%). A mortality of 66% was also found in patients suffering from non-occlusive gut ischaemia. Delay in diagnosis accounted for this high mortality. Early diagnosis is all-important, and this depends on the performance of mesenteric angiography in any patient suspected of having mesenteric ischaemia. Appropriate surgery may then be carried out in the occlusive group and supportive treatment, including intraarterial papaverine infusion, given to those with non-occlusive ischaemia. There is a pressing need for simple non-invasive tests to segregate those patients suffering from acute mesenteric ischaemia from those whose acute abdomen is due to some other cause.

Potential life-threatening variations of drug concentrations in intravenous infusion systems: potassium chloride, insulin, and heparin.

The investigation of concentrations of active agents in common carrier media for intravenous infusion revealed that potassium chloride tends to form a pool when it is added without mixing to carrier media in glass or polyvinyl chloride (PVC) containers which are already suspended in their functional position with ports pointing downwards. Heparin behaves in a similar fashion when added without mixing to carrier media in PVC containers. Such uneven distribution may expose a patient to potentially dangerous, possibly lethal, concentrations of a drug even when a relatively small amount of it is used. Insulin floats to the top of a Haemaccel container if its contents are not adequately mixed after addition of insulin. The resultant irregularity of insulin dosage may make the management of diabetic ketoacidosis more difficult. It is recommended that the instructions for the adequate mixing of contents should appear on all containers of carrier media for intravenous infusions.

Retroperitoneal perforation of a peptic ulcer situated in the second part of the duodenum.

Retroperitoneal perforation of a peptic ulcer of the second part of the duodenum is an extremely uncommon complication producing both diagnostic and management difficulties. The tenth recorded case of this condition--the first managed successfully by the technique of primary closure and 'duodenal diverticulization'--is reported.

Localization of a phaeochromocytoma situated in the pelvis by radionuclide scanning.

Accurate localization of an extra-adrenal (pelvic) phaeochromocytoma was achieved by radionuclide scanning using 99 Tcm-Sn-DTPA. This facilitated the planning of the surgical approach and the subsequent removal of the tumour.

Problems in the diagnosis and management of acute pancreatitis.

Despite the lack of precise knowledge as to its exact mechanism of causation, acute pancreatitis continues to engage the clinician's attention. The world medical literature is replete with publications on the subject and the numerous Australian studies attest to the continuing clinical interest (Hennessy, 1965; Bennett and Jepson, 1966; Kune, 1968; Barraclough and Coupland, 1972; Battersby and Chapuis, 1977 and Reid and Kune, 1978). The majority of these reviews concentrate on the supposed aetiology and clinical features of acute pancreatitis and cover well trodden ground. It is the purpose of this paper to review the problems in the diagnosis and management of acute pancreatitis in the light of present knowledge and to relate these to 494 patients with acute pancreatitis admitted to St Vincent's Hospital, Melbourne, during the period 1968 to 1979. The diagnosis of acute pancreatitis in these 494 cases was made at operation, autopsy or by the demonstration of an elevation in the serum amylase above 1200 International units (I.U.) per litre in patients with compatible symptoms and signs.

The anatomical basis for segment III cholangiojejunostomy with analysis of 13 cases.

BACKGROUND: The majority of patients who require palliation for jaundice and pruritus resulting from malignant hilar obstruction are treated by stenting. Stenting is usually achieved from below after performing an endoscopic retrograde cholangiopancreatography. In some cases the rendezvous technique is employed, negotiating the passage through a malignant stricture from above and stenting from below. A minority of cases, such as those who had a previous polyagastrectomy and those in whom attempts at stenting have failed, are considered to be suitable for a Segment III cholangiojejunostomy. We have investigated the anatomical basis for Segment III duct bypass and have critically analysed the results in 13 patients. Ten patients were treated by Segment III duct bypass alone, and three patients had a Segment III duct bypass combined with stenting of the right liver. METHODS: The anatomy of the biliary tree was investigated by dissection of 54 normal livers removed at autopsy. Clinical details of the 13 patients who had Section III cholangiojejunostomy were obtained from hospital records and by contacting treating practitioners. RESULTS: In 64.8% of the anatomical dissections, the findings were favourable for a Section III cholangiojejunostomy. In these specimens the Segment III duct bypass would have drained Segments II, III and IV. In 35.2% of the specimens the anatomical disposition was potentially unfavourable, mainly due to the Segment II or IV ducts joining close to the confluence and therefore liable to obstruction by the tumour. In nine of the 54 specimens the true left hepatic duct was less than 6 mm in length, making it unsuitable for a bypass procedure to drain the left hemi liver. Of the 10 patients who were subjected to a palliative Section III cholangiojejunostomy only, there was one postoperative death. Of the nine patients who survived, six obtained excellent palliation of jaundice and pruritus. CONCLUSIONS: In carefully selected cases, Section III cholangiojejunostomy achieves excellent palliation in patients with unresectable hilar malignancies that have been unable to be stented pre-operatively or who have unresectable tumours at the time of laparotomy.

Aorto-Caval Fistula: Successful Management of Two Cases.

Two cases of aorto-caval fistula resulting from spontaneous rupture of an aortic aneurysm into the inferior vena cava are described. Although both patients showed the classical signs of a pulsatile abdominal mass with a palpable thrill and a continuous murmur, and the site of the communication was the same in both cases, only the first showed obvious signs of a massive arteriovenous fistula, with a collapsing pulse and severe oliguria promptly cured by correction of the fistula. The second patient illustrates the ability of one elderly patient to survive a series of disasters in aneurysm surgery, namely frank rupture of the aneurysm, high output renal failure, caval thrombosis and intraperitoneal suppuration.

The Zollinger-Ellison syndrome: a review of the St Vincent's Hospital, Melbourne experience.

Eight cases of the Zollinger-Ellison syndrome were diagnosed at St Vincent's Hospital in the period 1966-84. Although a rare tumour, its true incidence is almost certainly greater than the number of cases represented in this series. The Zollinger-Ellison syndrome should be suspected in all cases of recurrent peptic ulceration, in cases of peptic oesophagitis not responding to medical treatment, in some cases of diarrhoea and in those cases of peptic ulceration associated with hypercalcaemia. Rarely the gastrinoma may first present as a mass in the head of the pancreas causing obstructive jaundice. Diagnosis has been made easier by estimation of fasting serum gastrins and the use of the secretin test. Localization is difficult. The treatment of the condition remains contentious. In those cases shown to be harbouring a so-called solitary gastrinoma, laparotomy should be performed with a view to resection. If the gastrinoma cannot be localized then it is reasonable to use H2 blocking agents to control hypersecretion. The presence of hypercalcaemia due to hyperparathyroidism must be controlled by parathyroidectomy. Total gastrectomy is reserved for those few cases who for one reason or another are not controlled by adequate H2 blocking therapy. In the presence of malignant gastrinoma with metastatic disease, hypersecretion is controlled by the use of H2 blocking agents. In this group cytotoxic chemotherapy may be used in an attempt to control the mass effects of the tumour.

Herpetic whitlow.

Three cases of herpetic whitlow are reported. This occupational hazard of medical and paramedical personnel caused by finger infection by ther herpes simplex virus is often confused with bacterial (pyogenic) infection of the pulp of the finger or thumb. Unnecessary surgical drainage may then be carried out, with prolongation of morbidity. Wider recognition of this entity should enable a correct clinical diagnosis to be made in every case. The treatment is conservative as the condition is self-limiting. Topical application of idoxuridine appears to be beneficial.

Rupture of the bowel due to road trauma: the emergence of the "seat belt syndrome".

Seat belts have proved to be life saving for drivers and passengers involved in motor-car collisions. The number of severe head, face and trunk injuries has been significantly reduced. However, the wearing of belts has been responsible for an increased incidence of bowel rupture, in itself a potentially lethal injury if not diagnosed and treated early. There is still much to be done in improving seat belt design.

Traumatic retroperitoneal rupture of the duodenum.

A report of six cases of retroperitoneal rupture of the duodenum is presented. A high index of suspicion is necessary to enable early diagnosis to be made and appropriate treatment carried out. Early treatment will prevent the extremely rare, but at present uniformly fatal complication of gas gangrene. Plain X-ray and Gastrografin studies may help to elucidate the situation in particular cases, but are no substitute for repeated careful abdominal examination. It is suggested that large doses of penicillin be employed where possible in the management of these cases, in addition to such antibiotic therapy as may be expected to be effective against the usual Gram-negative bowel flora.

The tensor fasciae latae myocutaneous flap closure of major chest and abdominal wall defects.

BACKGROUND: The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit's experience in pedicled and free TFL flaps. METHODS: The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. RESULTS: The defect was satisfactorily repaired in all cases without subsequent herniation. The closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. CONCLUSIONS: We conclude that the TFL flap is the method of choice for repairs of major truncal defects.

Instrumental removal of retained stones after choledochotomy.

Despite the widespread use of operative cholangiography and choledoschoscopy, stones are still left behind after exploration of the common bile duct. Reoperation is associated with a significant morbidity and mortality. The use of a steerable catheter-basket technique has enabled stones to be removed from the biliary tract in the vast majority of cases without significant complications and has practically eliminated the need for further surgery.