Biomedical subjects
Publications and source records attributed to G L Juler.
Actinomycosis of the common bile duct can masquerade as cholecystitis. This is the first report of a case. The bacteriologic and pathologic characteristics are described. This opportunistic saprophytic organism took advantage of 15 years of prednisone therapy for rheumatoid arthritis. The actinomycosis was successfully treated with tetracycline-deoxycycline for 6 weeks.
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Thirty-eight patients underwent either a colon interposition (18 patients) or an esophagogastrostomy (20 patients) for cancer of the distal two-thirds of the esophagus. Both procedures had essentially the same 30-day mortality (22% versus 20%), a similar major complication rate (78% versus 75%), and recurrent dysphagia rate (17% versus 15%). The lowest complication rate was seen in the colon interposition for cure (33%), as compared to esophagogastrostomy for cure (70%). The longest average survival time (14.6 months) was seen after a colon interposition for cure, with 33 per cent of patients alive at two years, compared to 12.4 months average survival and 30 per cent alive at two year seen in the esophagogastrostomy for cure group. There were no five-year survivals. Preoperative radiation appeared to have a beneficial effect regardless of tumor cell type or operative procedure. Surgical management of esophageal cancer appears to be palliative in most instances, regardless of operation performed.
A new prosthetic material, microporous expanded Teflon (PTFE) was compared with Marlex mesh in the experimental animal. Triangular pieces of each material were placed beneath the transversalis fascia in the right and left groins of seven white New Zealand rabbits (mean weight, 8 kg). The animals were sacrificed are two week intervals. PTFE was found to retain its position and shape without local or peritoneal reaction. By contrast, Marlex mesh showed marked inflammatory reaction and scarring with complete distortion of the graft. Microscopically, PTFE was completely invaded by fibroblast at eight weeks, with flat orientation of graft to the fibrous tissue forming a "neofascia". In contrast, Marlex mesh lacked fibroblastic incorporation of the graft with marked scarring and distortion. These findings suggest that PTFE could be a useful fascial buttress in inguinal hernia repair where Marlex mesh is now used.
A sensitive method for localizing the resting place of catheter-injected therapeutic gelatin emboli is described. Surgical gelatin (Gelfoam) is labeled with 99mTc and each embolus observed on the persistence scope of a gamma camera after injection. This technique reduces the chance of obstructing blood vessels other than those intended. Two cases of embolization, one arterial and one venous, are illustrated.
An epidemic of postoperative wound infections caused by Staphylococcus aureus in 15 patients during a four-month period in 1974 is reported. An unusual staphylococcal antibiogram served as a marker for the multiresistant strain of hospital-acquired infections and raised suspicion of a common source for the infections. The spread of infection began shortly after isolation was discontinued in the index case. An epidemiologic investigation showed that 14 patients were on the same ward, and one patient from another ward had opportunity for contact with the index case. The epidemic was controlled by prompt isolation of all infected patients, adherence to strict isolation techniques, aseptic technique for dressing changes and by treatment of nasal carriers among ward personnel with appropriate antibiotics.
Percutaneous transhepatic cholangiography (PTC) for jaundice of undetermined etiology was performed with the Chiba needle in 30 patients. Successful visualization of the biliary ductal system was accomplished in 26 patients (86.7%); two of six patients (33.3%) with normal biliary systems had ducts visualized, and the ducts were visualized in the 24 patients (100%) with obstruction. Bile leakage of 50 to 500 ml (average, 200 ml) was observed at laparotomy or autopsy in 12 patients (40%), nine (30%) of whom had symptoms of peritonitis. Six (20%) of these were transient and three (10%) progressed to an acute abdomen. Bacteremia occurred in seven patients (23.3%), in three (10%) it progressed to septic shock, with one death (3.3%). There were no complications in patients with nonobstructed ducts. This study suggests that PTC with the Chiba needle has little advantage over the larger sheathed needles, and surgical standby is indicated in suspected cases of obstructive jaundice.
Toxic megacolon developed in ten of 220 patients (4.5%) admitted for chronic ulcerative colitis over the past 11 years. Nine of these patients came under the care of the Surgical Department. Only three of these 10 patients had previously been treated with steroids. Steroid therapy reversed the acute process in three patients (33%). All three patients later came to surgery. Toxic megacolon developed during the first episode of ulcerative colitis in seven of ten patients (70%). Three of the seven (43%) had perforated their colons prior to operation. Two patients died after a subtotal colectomy and one without operation. A delayed diagnosis was associated with sepsis in five patients (50%) and with all three deaths. Seven patients survived proctocolectomy. Prolonged medical management without dramatic response appeared to correlate with a high postoperative morbidity. This study supports the concept of aggressive diagnosis and early surgical intervention for toxic megacolon.
In seven cases of congenital anomalies in adults, duodenal obstruction and peptic ulcer disease developed. There were two cases of congenital duodenal web, two of hypertrophic pyloric stenosis, two of annular pancreas, and one of a preduodenal portal vein. The diagnosis is seldom made preoperatively. In the four patients who had preoperative gastric analysis, the acid secretions were increased. Those patients who underwent endoscopy had changes consistent with hypertrophic secretory gastrophy and duodenitis. We believe that treatment should be directed toward relief of the duodenal obstruction and the reduction of basal acid secretion by truncal vagotomy in all such cases.
There were 8 patients with spinal cord injury in the last 100 consecutive patients with abdominal aortic aneurysm resected at the Long Beach Veterans Administration Hospital. Emphasis is placed upon the problems in management not found in individuals without spinal cord injury. A successful outcome is dependent upon: (a) aggressive control of foci of infection, (b) early diagnosis and planned surgical intervention, (c) continuous intraoperative arterial and central venous pressure monitoring and (d) alertness to the prevention of postoperative complications, with emphasis upon careful tracheal toilet and anticipation of delayed wound healing.
Seventy-five antrectomies were performed for recurrent duodenal ulcer after 1,515 vagotomy and drainage procedures. Eighty-four per cent of proved recurrences at reoperation were associated with positive acid secretory tests. Seventy-eight per cent of recurrences occurred in patients with intact vagal trunks. Incomplete vagotomy is implicated as the cause of recurrence.
Complications from barium enema are rare (0.035 per cent). A patient with venous intravasation during barium enema complicated by pylephlebitis and portal vein obstruction is the tenth to be reported on, the fourth to survive. This accident was associated with colon disease in eight of the patients studied, five of whom had diverticular disease.
Twenty-four patients with spinal cord injuries were studied to correlate their responses to intra-abdominal disease with the level and completeness of the cord lesion. Patients with complete cervical lesions and lesions of the upper part of the thoracic region (C-4 to T-6) usually responded by early noniocalized abdominal pain associated with signs of autonomic dysreflexia. As the disease progressed to involve the parietal peritoneum, these patients were more capable of localizing pain to the corresponding dermatome, whereas patients with incomplete lesions were able to localize their pain earlier. Patients with lumbar lesions and lesions of the lower part of the thoracic region (T-7 to L-3) were able to localize their pain earlier than those with lesions located higher in the thoracic region. All patients had delayed diagnoses except those with hemorrhage of the upper part of the gastrointestinal tract. Irrespective of level of cord lesion, increased pulse rate was themost prominent objective acute intra-abdominal pathologic finding. Shoulder pain in the quadriplegic is a most helpful sign.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.