An historical perspective.
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Comprehensive Health Care↗
Biomedical subjects
E W Martin
Publications and source records attributed to E W Martin.
Mass lesion of the breast after augmentation mammoplasty.
Examination of the breast after augmentation mammoplasty may be relatively easy, but the evaluation of a mass lesion presents particular possibilities and problems. Closed compression capsulotomy occasionally results in rupture of the gel prosthesis, and when silicone contacts the surrounding breast tissue, a firm granuloma can result. A patient after augmentation mammoplasty had a mass lesion of the breast following trauma. At operation, the gel prosthesis was found to have ruptured and resulted in a silicone granuloma. A history of closed compression capsulotomy or trauma is important in the preoperative evaluation of such patients, and both the surgeon and the patient should be prepared to procede with replacement of the implant at the time of biopsy.
Accidents, Home↗
Chronic and recurrent appendicitis.
Acute appendicitis is a well known clinical entity, but many physicians are unwilling to accept appendicitis as a chronic or recurrent illness. Of 225 patients undergoing appendectomy, sixteen (7 per cent) had findings suggestive of chronic, recurrent, or subacute appendicitis. Four patients had chronic abdominal pain and histologic findings of chronic inflammation. Nine patients had previous episodes similar to that which resulted in appendectomy. All had acute suppurative appendicitis pathologically. Three patients had only one episode of abdominal pain, but had pathologic evidence of subacute inflammation. Because this study was retrospective, we suspect that the true incidence of recurrent appendicitis is significantly greater, as reported by others. Indications for operation must be strict, for unless there are specific signs and symptoms of appendiceal disease, appendectomy will often be of no benefit.
Abdomen↗
A retrospective and prospective study of serial CEA determinations in the early detection of recurrent colon cancer.
The results of the present study emphasize the importance of minimizing the time delay between a significant elevation in CEA and a second-look operation. Equally important are the frequency of serial determinations, a thorough understanding of the limitations of the assay, and careful evaluation of the clinical condition of the patient.
Carcinoembryonic Antigen↗
Detection of deep venous thrombosis by impedance plethysmography.
Ninety-eight limbs in sixty-seven patients supected of having lower extremity deep venous thrombosis were evaluated by physical examination, venous impedance plethysmography (IPG), and venography. Diagnosis based on physical signs commonly associated with deep venous thrombosis was false-positive in 43 to 66 per cent and false-negative in 26 to 73 per cent when compared with evidence obtained by venography. The overall accuracy of IPG was 94 per cent, with false-positive results occurring in 10 per cent and false-negative results in 4 per cent. IPG is sufficiently accurate to be considered a reliable screening test for lower extremity deep venous thrombosis.
Adolescent↗
Surgical decision-making in the treatment of pancreatic pseudocysts. Internal versus external drainage.
One hundred patients with documented pancreatic pseudocysts who underwent surgical drainage are reported on. Accurate assessment of the size and location of the pseudocyst using ultrasonography, endoscopic retrograde cholangiopancreatography, angiography, and upper gastrointestinal roentgenography is essential. After diagnosis, the next 4 to 7 weeks is a critical period, after which surgical intervention becomes mandatory if the cyst has not resolved. This period between diagnosis and operation is hazardous and demands close clinical follow-up. When oepration is required, the preferred procedure continues to be internal drainage because it is associated with less morbidity and a lower mortality. However, external drainage appears to be a suitable second choice. Fewer than 10 per cent of the patients in this series who underwent external drainage developed fistulas, and the overall rate of late morbidity was acceptable.
Abscess↗
Use of Doppler ultrasound in intestinal surgery.
Doppler ultrasonography was used intraoperatively in 117 patients undergoing intestinal anastomosis or enterostomy to determine the adequacy of blood supply at the margins of resection. Doppler findings were compared with clinical assessment of intestinal blood flow by the operating surgeon. In 92 per cent of cases, Doppler signals and clinical observation coincided. However, in five of six cases in which Doppler signals were absent at one margin, the surgeon resected additional intestine, selecting margins within 1 cm of the nearest arterial Doppler signal. All five patients had uneventful healing. In the one case in which the surgeon chose to rely onthe appearance of the bowel despite the absence of Doppler arterial signals, ischemic necrosis of the proximal segment and anastomotic disruption occurred. The technique of Doppler ultrasonography is readily learned, and the instrument is available in most hospitals. Intraoperative use of Doppler ultrasonography can help identify intestine lacking a blood supply adequate to assure viability before changes in the appearance of the bowel alert the surgeon to the problem.
Colon↗
Use of Doppler ultrasound in intraoperative localization of intestinal arteriovenous malformation.
Precise localization of an intestinal arteriovenous malformation is essential for the complete resection of the lesion. Identification at operation can be difficult, and intraoperative angiography is not without complications. Blood flow within the small vessels of the bowel wall can be easily detected by Doppler ultrasonography, and arterial flow can be distinguished from venous flow. Intraoperative use of the Doppler ultrasound technique localized an AVM in the small intestine. Distinctive flow signals were present over the intestinal AVM which allowed it to be easily differentiated from adjacent normal intestine. Confirmation was secured by measuring the PO2 of blood aspirated from the vein draining the involved segment and comparing it to the PO2 from a vein draining an adjacent segment.
Arteriovenous Malformations↗
Gastric partitioning for morbid obesity.
The complication rate in jejunoileal bypass for morbid obesity is unacceptably high. Gastric bypass is technically difficult. In our series, 115 patients have undergone gastric partitioning for morbid obesity. The operation consists of stapling across the stomach below the gastroesophageal junction, leaving a gastric food reservoir of 50--60 cc. A 1 cm opening is left in the central portion of the staple line, allowing slow emptying into the distal stomach. The result is a reduced eating capacity and frequency which produce loss in weight. Three-quarters of the patients are women, and the age range is 17--62 years. Preoperative weights averaged 147 kg. Mean operative time was 48 minutes, and postoperative stay was 6.2 days. All patients were extensively evaluated preoperatively with upper GI series, cholecystogram, a number of blood chemistry tests, and endocrinologic and psychiatric consultations. All patients underwent a preoperative Minnesota Multiphasic Personality Inventory test. Cholecystectomy for cholelithiasis was performed on 18% of the patients at the time of operation. Of the seven patients operated on more than one year ago, five have lost an average of 31.6% of their preoperative weight. Of the 12 operated on less than one year but more than six months ago, eight have lost an average of 21% of their initial weight. The early failure rate of 33% has been reduced to 15% at present. One death occurred from pulmonary embolus 10 days following discharge, giving a mortality rate of .08%. The complication rate is 10%, comprising two pulmonary emboli, two psychoses, one wound dehiscence, one wound hernia, and ten wound infections, six of which were minor. There have been no complications of ulcer disease, reflux esophagitis, liver disease, renal disease, or metabolic disorders. Gastric partitioning is a safe, fast effective alternative for the surgical treatment of morbid obesity.
Adolescent↗
Reasonable surgical treatment for tumors of the liver associated with the use of oral contraceptives.
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Adenoma↗
Assessment of anastomotic blood supply by Doppler ultrasound in operations upon the colon.
Doppler ultrasound was used to determine whether or not colonic anastomoses have sufficient blood supply for healing to occur. Experimental anastomoses placed at, or 1 centimeter from, the last audible arterial signal healed; those placed 2 or 3 centimeters distally had a high incidence of disruption. Results were statistically significant by chi-square analysis, p less than 0.05. Clinical parameters of intestinal viability would not have predicted anastomotic failure.
Animals↗
Correction of hypersplenism following distal splenorenal shunt.
The effect of splenorenal shunt on hypersplenism was assessed in 47 patients with splenomegaly, 26 of whom had significant thrombocytopenia or leukopenia. Of 16 patients with thrombocytopenia, platelet count returned to normal in 15 (94%) following operation, an improvement which was statistically highly significant (P less than 0.001). Of 16 patients with leukopenia, leukocyte count returned to normal in 11 (69%), also a highly significant improvement (P less than 0.001). Dramatic relief of hypersplenism occurs in the majority of patients following splenorenal shunt. Thrombocytopenia is more consistently corrected than is leukopenia. The etiology of liver disease appeared not to be a factor, but leukopenia was corrected more consistently in alcoholic than in nonalcoholic patients, while there was no difference in the postoperative response of thrombocytopenia to the operation. Long-term follow-up in 26 patients demonstrated sustained improvement in 57% of patients with preoperative leukopenia and 78% of patients with thrombocytopenia. Since significant improvement in leukopenia and thrombocytopenia will occur following the distal splenorenal shunt, hypersplenism is not a contraindication to this procedure.
Female↗
Direct carcinoembryonic antigen assay in diagnosis and prognosis.
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Carcinoembryonic Antigen↗
Intraoperative localization of intestinal arteriovenous malformation.
Intestinal arteriovenous malformation (AVM) is an uncommon cause of gastrointestinal hemorrhage and is difficult to diagnose. Selective visceral angiography is essential to make the diagnosis and to localize the lesion. We treated two patients in whom AVMs of the small intestine were located by means of arteriography and intraoperative selective mesenteric venous pressure and PO2 measurements. The local venous return from an intestinal AVM is characterized by elevated venous pressure and PO2 levels compared with the venous drainage of adjacent normal intestine.
Aged↗
Significance of asymptomatic carotid bruits.
To assess the significance of the asymptomatic carotid bruit, the subsequent occurrence of symptomatic cerebrovascular insufficiency and stroke in 256 patients who had undergone operation for atherosclerosis arterial occlusive disease of the lower extremities was documented during a period of two to seven years postoperatively. At the time of operation, none had had a stroke or exhibited symptoms of cerebrovascular insufficiency, but 60 of the 256 patients had audible carotid bruits. A statistically significant difference was demonstrated: 21 (35%( of the 60 patients with carotid bruits exhibited manifestations of cerebrovascular insufficiency, in contrast to 30 (16%) of the 196 patients without bruits. It seems that detection of an asymptomatic carotid bruit is not an innocent finding, but rather predicts a higher incidence of cerebrovascular complications than that expected on the basis of generalized atherosclerosis alone.
Adult↗
The use of serial CEA determinations to predict recurrence of colon cancer and when to do a second-look operation.
The concept of second-look surgery was introduced by Wangensteen 25 years ago, and 17% of patients were reported to be converted to a cancer-free state. Instead of an arbitrary time interval for reoperation, serial CEA values were used as the indicator of colon cancer recurrence and second-look operation. Twenty-two retrospective and 18 prospective patients were evaluable. There was no operative mortality. The CEA Nomogram was used to determine whether the CEA change was significant. All patient-samples were analyzed in duplicate, stored, and compared with the most recent sample; therefore, each patient served as his own control. The prospective results emphasize the importance of minimizing the time delay between a significant change in CEA values and reoperation. Equally important are the frequency of serial determinations (every one or two months), a thorough understanding of the limitations of the CEA radioimmunoassay, and the clinical condition of the patient.
Carcinoembryonic Antigen↗
Mannitol and glucose: effects on gastric acid secretion and endogenous gastric inhibitory polypeptide (GIP).
Serum gastric inhibitory polypeptide was measured in dogs prepared with Heidenhain pouches and Mann-Bollman fistulae following the intraduodenal (ID) infusion of isotonic saline, 20% glucose, or 20% mannitol. Following ID 20% glucose, serum GIP concentrations rose significantly (P less than 0.05) between 30 and 120 min and there was a significant inhibition (P less than 0.05) of acid secretion in the Heidenhain pouches between 15 and 75 min. A good correlation (r = 0.925) was found between the rise in serum GIP and the inhibition of acid secretion. Although neither ID isotonic saline nor 20% mannitol stimulated GIP release, the latter produced a significant (P less than 0.05) inhibition of acid secretion between 60 and 105 min. We conclude: (1) the inhibitory effect of acid secretion following ID glucose is mediated in part by the release of endogenous GIP; (2) glucose and mannitol probably inhibit gastric acid secretion by different mechanisms.
Animals↗
Abdominal aortic surgery in the presence of a horseshoe kidney.
Prior experience with the rare combination of horseshoe kidney and significant atherosclerotic vascular disease suggests difficulty in intraoperative management, often requiring division of the renal isthmus or sacrifice of some renal tissue. Seven patients have been managed successfully over the past ten years at The Ohio State University Hospital. There were six men and one woman, ranging in age from 39 to 66 years. Of the five patients with abdominal aortic aneurysm, four had a pulsatile abdominal mass, three had abdominal pain, and one had back pain. The other two patients had progressively symptomatic aortoiliac disease. All seven patients had hypertension, easily controlled by medication. Critical diagnostic procedures are preoperative intravenous pyelogram (IVP) and abdominal aortic arteriogram. The IVP detected the previously unsuspected diagnosis in 100% of the cases. The arteriogram accurately located the aneurysm in relation to the renal vascular supply, and disclosed aberrant blood supply in three of four patients with aberrant vessels. All seven horseshoe kidneys were fused at the lower pole. The operative approach involves meticulous dissection of the aberrant blood supply to the kidneys, and mobilization of the isthmus for adequate retrorenal aortic exposure. In six of the seven patients, the grafts were placed posterior to the isthmus. There were no deaths, and there were no complications related to the presence of the horseshoe kidney. In three of the seven patients, hypertension improved. Patients with horseshoe kidney and aortic disease may be safely operated upon without damage to the kidney. IVP and selective angiography are essential to provide preoperative information.
Adult↗