Biomedical subjects
Publications and source records attributed to E W Martin.
After gastric restrictive procedures in morbidly obese persons, the reported morbidity is 15 per cent, and mortality is 1 per cent. Pulmonary embolism continues to be the most serious complication. Gastric perforations must be recognized early and treated promptly, as must the common postoperative complications: pneumonia, atelectasis, and wound infection.
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A human pancreatic tumor cell line has been established from the ascites of a patient with histopathologically confirmed adenocarcinoma of the head of the pancreas and maintained for more than 12 months in the laboratory. Epithelioid tumor cell colonies, which resulted from primary tissue cultures of the ascitic cell component, were mechanically isolated by needle micromanipulation. Tumorigenicity was proven in athymic nude mice. Morphologically the pancreatic tumor epithelial cells grew to confluency with moderately tight adhesion to the culture plastic surface and with free-floating cells in the medium. Upon re-establishment of the tumoral xenograft in tissue culture, the epithelial cells retained their original morphology. Histologically the tumor grown in nude mice exhibited prototypic characteristics of the primary adenocarcinoma in the patient, producing abundant mucin and displaying a broad spectrum of glandular differentiation, which ranged from well to poorly differentiated adenocarcinomas with occasionally localized lymphocytic infiltrations. Furthermore, the tumor expressed carcinoembryonic antigen and human pancreas cancer associated antigen. This tumor line, designated AsPC-1, has been cultured for at least 10 passages in vitro and 3 in vivo. It represents a new model for human pancreatic cancer.
During a 5-year period, 21 patients with metastatic cancer receiving chemotherapy for periods ranging from 2 months to 5 years have required emergency abdominal operations. Symptoms in 15 indicated perforated viscus, whereas six developed massive, unremitting hemorrhage. All were operated upon with the sole intent of correcting the life-threatening problem, and every attempt was made to maintain or normalize physiologic parameters postoperatively. Despite this, 51 major complications occurred in 19 patients, and 17 died in the immediate postoperative period, 11 following multiple systems failure. Two died within 1 month of transfer to another hospital nearer home. A single patient lived 5 months at a nursing facility. The only survivor is living in a complete state of remission 9 months after discharge. No distinguishing features that might preoperatively predict which patient might survive emergency operation were found. The monetary cost of returning the sole survivor to society was over $500,000, discounting the emotional expenditure required of patients, families, and hospital staff. The dilemma the surgeon faces in making therapeutic decisions regarding such patients requires careful weighing of realities and the willingness to assume responsibility for the best possible choice in order to free the patient and family from agonizing deliberations.
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The value of the serum level of carcinoembryonic antigen (CEA) as an indicator of recurrent colorectal carcinoma has been accepted, and the use of serial CEA levels to monitor postoperative chemotherapy has been suggested, However, elevated CEA levels may be associated with nonneoplastic conditions, of which the most difficult to evaluate is hepatic disease. The effect of chemotherapy on hepatic function and therefore on CEA level is not clear. We discuss a patient who, after a potentially curative resection for adenocarcinoma, demonstrated a rise in CEA level in the absence of recurrent carcinoma. This rise correlated with administration of intravenous 5-fluorouracil. Liver biopsy demonstrated severe fatty infiltration with no evidence of cirrhosis. The possible liver toxicity of chemotherapeutic drugs must be considered as a factor responsible for the rise in CEA. Simultaneous assessment of hepatic function is essential to the accurate interpretation of CEA levels, especially in patients receiving chemotherapy.
Forty-two patients with the postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). Both the biliary ductal system and pancreatic duct were well visualized in all patients. The ERCP was abnormal in 22 patients (52%). Abnormal findings included choledocholithiasis, papillary stenosis, pancreas divisum, pancreatic carcinoma, sclerosing cholangitis, incomplete cholecystectomy, and chronic pancreatitis. The results of one or more standard liver function tests and/or other noninvasive tests were abnormal in 36 patients; however, none reliably predicted the presence or specific anatomical type of pancreaticobiliary tract disease. Our data indicate that ERCP is essential in the diagnosis and management of the postcholecystectomy syndrome. The high yield of abnormal findings amenable to surgical correction in patients with recurrent biliary tract symptoms following cholecystectomy justifies the use of this procedure in all such patients.
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To evaluate the significance of plasma levels of carcinoembryonic antigen (CEA) in patients with ovarian cancer, a chart review of such patients from May 1974 to August 1978 was undertaken, along with a literature survey in order to consolidate the data for analysis. The data indicate the CEA levels are consistently lower in ovarian cancer than in colorectal cancer and that the assay is not of value in the primary diagnosis of ovarian cancer. It may, however, be of prognostic significance in that advanced disease and undifferentiated tumors which carry the worst prognoses demonstrate elevated CEA levels with higher frequency. CEA levels may also be of value in assessing the response to therapy and in detecting recurrent disease. Patients who demonstrated good clinical responses to therapy showed a drop to low plasma CEA levels while patients with poor responses showed no decrease or a rise in CEA levels. Moreover, CEA rose again after a postoperative drop in patients with recurrent disease before they demonstrated clinical evidence of recurrence. The relationship of plasma levels to tissue levels of CEA and to histologic type of ovarian carcinoma remains unclear.
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Acute pancreatitis is classified as idiopathic when an underlying cause cannot be identified through a careful history and appropriate noninvasive tests. Unless a cause can be identified, recurrent attacks cannot be effectively prevented. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 35 patients considered to have idiopathic recurrent acute pancreatitis, and an anatomic abnormality of either the pancreatic or biliary ductal system was demonstrated in 16. Ten underwent appropriate surgical procedures based on the results of ERCP, and 80% had no further episodes of acute pancreatitis. ERCP established the precise nature of potentially correctable anomalies and thereby facilitated precise preoperative planning. The wider use of ERCP in these patients may lessen the number of cases of acute pancreatitis considered to be idiopathic and lead to appropriate surgical therapy.
Clinical observations and data obtained in animal experiments indicate that the gastric partition is most susceptible to the stresses of solid food boluses between the second and sixth postoperative weeks, predisposing the operation to early failure. Tensiometer studies indicate that by the sixth to the eighth postoperative week, the staple line is as strong as uninjured stomach. Liquid diet restriction for eight weeks after gastric partitioning reduces the incidence of early operative failure. Until safe and effective methods of increasing staple line strength are established, all patients having gastric partitioning should be restricted to a liquid diet for eight weeks after operation.
Esophageal transection with the EEA stapler was performed in five patients with bleeding esophageal varices. Bleeding from varices has not recurred in surviving patients during follow-up of up to 27 months. One death occurred during the postoperative period. Esophageal transection with the EEA stapler is an effective means of preventing recurrent variceal hemorrhage. This technique is best suited for patients requiring emergency operation to prevent exsanguination and for those in whom a major shunting procedure is contraindicated because of the severity of hepatic disease or other medical illness.
Intraoperative Doppler ultrasound examination of ischemic intestine was used to determine viability and to establish margins of resection, even when the findings differed from the surgeon's clinical appraisal. Ten of 25 segments in 23 patients were clinically judged nonviable, but because of arterial flow within the segments was detected by Doppler ultrasound, none was resected. The subsequent benign clinical courses of the patients demonstrated the viability of the segments. Two segments were judged clinically viable, but because Doppler signals were absent, both were resected. Histologic examination demonstrated severe ischemic changes in both segments. Nine segments were judged both by clinical criteria and by Doppler ultrasound examination to be nonviable, and all nine were resected. Histologic examination confirmed ischemia or infarction in all. Doppler ultrasound was a more reliable intraoperative predictor of viability of ischemic intestine than clinical assessment alone, and its use averted postoperative complications and unnecessary second-look procedures.
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The accuracy of Doppler ultrasound in predicting the viability of ischemic intestine secondary to venous obstruction was assessed. Twenty loops of ischemic intestine were created in dogs by temporarily obstructing venous return from the bowel. Doppler arterial flow signals within the intestine quickly disappeared following venous occlusion. In ten segments, arterial signals promptly returned following release of venous occlusion. Nine of these ten segments were viable at reoperation 24 hours later. In ten segments, no arterial signals could be detected following release of venous occlusion, and only one segment proved to be viable. Doppler ultrasound findings were far more accurate in distinguishing between viable and nonviable intestine thatn were clinical guides to intestinal viability.