Biomedical subjects
Publications and source records attributed to A Dinbar.
Adenocarcinoma of the vermiform appendix is rare. It usually produces signs of acute appendicitis and is discovered only on pathological examination. The treatment of choice is right hemicolectomy, usually performed as a secondary operation. 2 cases of appendiceal carcinoma, in a 59-year-old man and in a 70-year-old woman, are described.
Ultrasonic (US) examination is a simple, effective and quick method of investigating the abdominal wall. We evaluated various cystic and solid lesions in 26 patients by US. In 24 the US diagnosis was correct and revealed pathologic conditions of the abdominal wall such as abscesses, cellulitis, metastatic tumors and hematomas. In 2 patients lesions of the abdominal wall were missed. All but 3 patients were treated surgically.
The decision to revascularize an occluded main renal artery is often extremely difficult, especially when aortic and renal occlusive disease co-exist. The main objectives of surgery are preservation of renal parenchyma and possible amelioration of renovascular hypertension, provided the patient's condition permits. In a 52-year-old man with renovascular hypertension and intermittent claudication transfemoral aortography revealed severe atheromatosis of the aorta and iliac arteries. There was total occlusion of the left main renal artery, but the right renal artery was patent. Aorto-femoral bypass was performed using a bifurcated graft. The left kidney was revascularized using an 8-mm straight graft anastomosed end-to-end with the renal artery and the other end was inserted into the distal part of the bifurcated graft, constituting a triple bypass. The postoperative course was uneventful, blood pressure decreased and renal scan showed good left renal function. 6 months later aorto-bifemoral and renal bypass grafts were fully patent.
We retrospectively reviewed 16 patients in whom primary retroperitoneal liposarcoma was diagnosed and treated. These patients were classified according to the first definitive surgical procedure employed: complete excision with or without radiotherapy; partial excision followed by radiotherapy; only biopsy of tumor followed by radiotherapy. Distribution of tumors according to histologic type was: well differentiated myxoid type, 10; poorly differentiated myxoid type, 4; and mixed type, 2. The main factor in determining resectability was extent and fixation of tumor to vital structures. Recurrent retroperitoneal disease developed in four patients all of whom underwent secondary intervention. We concluded from our experience that complete surgical excision is the most effective primary therapeutic approach for patients with primary and recurrent retroperitoneal liposarcoma.
A simple maneuver that avoids soiling of the field during immediate maturation of colostomy performed for large bowel obstruction is presented. This maneuver involves inflating a large Foley catheter in the lumen of the obstructed large bowel just before maturation is performed.
Acute accumulation of chyle in the peritoneal cavity is rare. It is usually idiopathic and the diagnosis is made at laparotomy, when indicated because of signs of acute peritonitis. Drainage is the only treatment required and the prognosis is excellent. A 33 year-old man who was operated on for signs of acute peritonitis is described. There was more than a liter of chyle, but no underlying pathological condition was found. 3 months after discharge, physical and laboratory examinations were normal, with no evidence of chylomicron retention disease.
2 cases of metastasis of malignant melanoma to the small bowel presenting as surgical emergencies due to obstruction, are reported. In both cases there was no other evidence of metastatic spread at the time of surgery. Segmental resection of involved bowel was performed, providing satisfactory palliation. This reinforces the opinion that surgical resection of symptomatic metastases of malignant melanoma to the small bowel is justified, despite the poor prognosis of the disease itself.
A simple technique of definitive management of acute pilonidal abscess is described. The procedure consists of incision with drainage of pus followed by controlled excision of diseased tissue and lateral sinuses, using a loop diathermy. It allows one-stage definitive management of both acute pilonidal abscess and chronic pilonidal sinuses.
Splenic arteriovenous fistula is a rare but curable cause of portal hypertension. This report describes a patient with such a disorder, presenting with bleeding esophageal varices and ascites. It emphasises the importance of performing selective catheterization of the celiac and superior mesenteric artery in all patients with signs of portal hypertension without evidence of chronic liver disease. Etiopathology and management are discussed.
Seven patients diagnosed as having acute appendicitis were operated on and a cecal wall mass due to cecal diverticulitis was found. In two patients the mass could not be separated from the cecal wall and right colectomy was performed. In five patients, in whom the mass could be separated from the cecum, conservative operations (three diverticulectomies and two wedge resections) were performed, thus avoiding needless, more extensive surgery.
A retrospective study of 18 adults admitted to Meir General Hospital with pyogenic liver abscess during the years 1982-88 was conducted. Our most useful diagnostic tool was ultrasound, which was accurate in all 15 patients in whom it was performed. Only two patients presented with multiple abscesses. Increased alkaline phosphatase was the most predictive laboratory finding, seen in all but one patient. One person was treated conservatively by antibiotics only. In one patient the abscess drained spontaneously into the right thoracic cavity. Initial surgical drainage was done in nine patients and percutaneous catheter drainage in seven. Only one patient died, of septic shock, yielding a mortality rate of 5.5%. The treatment-related complication rate, observed in almost half of the patients, was high. All patients with such complications required repeated drainage, which was achieved surgically in all cases.
Of 44 patients admitted with head injuries during 1980-84, 316 (72%) arrived fully conscious with normal neurological status and no X-ray evidence of skull fracture. These cases were admitted for observation, but in none was there any untoward development. On analysis of the cases that developed complications and in the light of the literature, we conclude that it is possible to define a group at low risk for developing complications following head injury. These patients could safely be discharged from the emergency room without admission for observation. This group included 176 (40%) of those admitted and fulfilled the following criteria. They arrived fully conscious, there was no recurrent vomiting, neurological examination was normal, there was no X-ray evidence of skull fracture, and they were between 16-70 years of age. However, these cases should only be discharged from the emergency room after a physician gives oral and written instructions to a responsible adult who accompanies the patient. Such a policy would result in considerable saving of resources by reducing admissions for observation of those at low risk for developing complications.
Forty-five patients with obstructing carcinoma of the colon and rectum were compared with 176 patients with nonobstructing tumor diagnosed over a 10-year period. The age and sex distribution did not differ between the two groups. The site of greatest risk for obstruction was the splenic flexure and descending colon (50%); median survival in these patients was one-half that for other sites. In the obstructed group no patient had Dukes' stage A vs. 9.6% in the nonobstructed patients, and 22% of the obstructed patients had Dukes' D vs. 14% of the nonobstructed patients. The 5-year survival in Dukes' A was 82%, while no survivors were found for Dukes' D. The crude 5-year survival rate was 22.4% in the obstructed patients and 49.1% in the nonobstructed patients; in-hospital mortality was 22.4% and 6.8%, respectively, and the adjusted actuarial survival was 39% vs. 64%, respectively. Curative resection was performed in 68% of the obstructed and 83% of the nonobstructed patients. The adjusted actuarial 5-year survival rates for these patients were 53% and 76%, respectively. The criteria for the tumor grade tested in this study, which included differentiation of the tumor cells, size, and the presence of perforation, did not influence the survival. Twenty-one patients underwent primary resection, 15 had stage resection, and 9 had diversion procedures. The in-hospital mortality rates were 35% for primary resection and diversion procedures and 7% for stage resection. The crude 5-year survival was 32% for primary resection, 42% for stage resection (not statistically significant), and 0 for diversion procedures. The poor prognosis for the obstructed patients in our study was mainly related to 1) high in-hospital mortality, 2) the lower rate of curative resection, 3) unequal distribution of the tumor site, and 4) to a small extent, the difference in Dukes' stage.
The intraoperative diagnostic dilemma of pancreatic cancer vs. chronic pancreatitis often remains unresolved. In the literature, diagnosis based on intraoperative pancreatic biopsy is a matter of controversy. Our study comprised 70 patients with a suspected space occupying pancreatic process who were operated on with the primary goal of arriving at a speedy and precise diagnosis, according to which the appropriate surgery for the specific patient would be performed. Frozen section showed that 44 patients had malignancy of the pancreas; in three patients, there was a false-negative result. In four patients, the histological picture was consistent with chronic pancreatitis. In the remaining 19 patients, biopsy was not performed and the diagnosis was made on the basis of intraoperative inspection and palpation of pancreas. On reviewing the patients, we found that the surgical risk involved in biopsy is quite low and that a high price was paid for diagnosis by inspection and palpation alone. The risk vs. benefit aspect of intraoperative pancreatic biopsy is discussed.
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