Biomedical subjects
Publications and source records attributed to K C Westbrook.
From this study we conclude that melanoma has a more favorable outcome today than 20 years ago, 2 cm margins around the tumor achieve acceptable survival and local recurrence rates, primary closure is preferred when possible, elective regional node dissection is of questionable value, and further trials are warranted to determine optimal therapy for intermediate thickness melanoma.
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Bile drainage through normal lymphatic pathways has been described, but bile drainage from the liver to the duodenum via lymphatic collaterals has not. We have described a patient with a common bile duct stricture and lymphatic drainage of bile into the duodenum.
Theories concerning cures for breast cancer vary from the concept that no patients are cured, to the idea that the hazard to patients who have survived eight years is no greater than that for the population as a whole. To test these concepts as well as our modification of the concept of cure, we assumed that a proportion (P) of the population of patients is cured and have the same mortality experience as that for the population as a whole. The remaining proportion Q = 1 - P experience mortality as do the population and also that due to cancer. The hazard rate due to cancer is assumed to be constant. When survival experience for the 804 female patients with breast cancer admitted during 1958 through 1960 and that predicted from our model are plotted, the fit is excellent, particularly for survivals up to 15 years. As to whether some patients with breast cancer are cured of their disease, the answer is yes, using our definition of cure.
Our experience with 16 retroperitoneal tumors seen over a 13 year period has been reported. Patients presented with either an abdominal mass or abdominal pain associated with a large retroperitoneal tumor. Delineation of the tumor is best accomplished with computerized tomography and venacavography. Exploration and resection is possible in most patients. Postoperative radiotherapy and chemotherapy are recommended in most patients. Local recurrence frequently occurs and should be diagnosed early and resected aggressively if found.
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This report summarizes experience with 19 posterior approaches to the rectum including nine trans-sacral (Kraske) and ten trans-sphincteric (Mason) procedures. This study included 12 men and 7 women, ranging in age from 18 to 89 years. Surgical indications included villous tumors in nine patients, various benign problems in four patients, primary carcinomas in three patients, and recurrent cancer in three patients. Eight complications developed in the 19 patients including: four fecal fistulae, two wound dehiscences, one rectal stricture, and one sacrococcygeal hernia. Spontaneous closure of the fecal fistulae occurred in two patients, and two patients required proximal colostomies. Fecal continence was achieved in 18 of the 19 patients. No patient died as a complication of the procedure. No recurrent tumors have developed. The conclusion is that a posterior approach to the rectum is a safe and effective procedure for various benign and for selected malignant conditions. It is particularly suitable for villous tumors that are too high for transanal resection and too low for transabdominal resection. It is an effective procedure for small, exophytic, mobile carcinomas of the lower 10 cm of the rectum in selected patients.
From our retrospective review of 30 patients having hepatic resection, we have made the following conclusions: (1) Hepatic resection is an uncommon procedure. (2) The majority of liver injuries require only drainage or suture ligation and drainage. (3) Midline incision, early arterial occlusion, and resectional debridement should be used for massive liver trauma. (4) Resection for tumor requires preoperative arteriography, transverse incision, and anatomic resection. (5) Wide irrigation with drainage is used after liver resection. (6) Reperitonealization of raw liver should be done. (7) Postoperative support should include administration of blood products, glucose, and albumin.
Based on our review we conclude the following concerning breast masses in young women under 30 years of age: (1) Breast masses are nearly always benign. (2) Mammograms are not helpful in most patients. (3) Needle aspiration or needle biopsy is rarely indicated. (4) Excisional biopsy should be performed through a circumareolar or other cosmetic incision. (5) Preparation for frozen section and mastectomy is not indicated. (6) the breast should be reconstructed in layers without drains. (7) Further manifestations of benign disease can be expected in 15 percent of the cases.
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Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.
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Review of our experience with twenty-two bile duct injuries and the literature leads us to the following conclusions: (1) Most biliary strictures follow surgery and can be avoided by adequate exposure, accurate dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. (2) Injuries diagnosed at the time of surgery should be repaired by end-to-end anastomosis over a T tube if length is adequate or by Roux-en-Y choledochojejunostomy if length is inadequate. (3) The diagnosis of biliary injury should be suspected when jaundice, biliary fistula, or cholangitis occur in the postoperative period. (4) IVC, PTC, ERCP, or fistulography should be used when possible to delineate the site of injury or stricture and assist in planning the operative repair. (5) Surgery should be performed as soon as the diagnosis is made and the patient is in satisfactory condition for operation. (6) Early reoperation may be necessary to establish drainage and prepare for a later definitive procedure. In some cases, definitive repair can be performed this time. (7) Most late strictures should be repaired with a choledochojejunostomy to a defunctionalized limb of jejunum when resection and primary end-to-end repair cannot be accomplished.
Based on our experience with four cases of liver cysts and review of the literature, the following conclusions are reached: (1) Diagnosis can be established with routine and special radiologic studies. (2) Laparotomy is indicated for patients with symptoms or uncertain diagnosis. (3) Surgical management should be guided by cyst size, location, and content. (4) Definitive surgical treatment is indicated only for cysts larger than 10 cm.
Hypocalcemia persists as a problem after thyroidectomy. We reviewed our experience with 245 thyroidectomies to define the spectrum of hypocalcemia, elucidate the mechanisms of hypocalcemia, and formulate a rational basis for its management. Postoperative hypocalcemia occurred in 8.6% of all patients undergoing thyroid surgery with incidence the highest in patients with total thyroidectomy for cancer (28%) and those with subtotal thyroidectomy for thyrotoxicosis (23%). Incidence was low in patients having subtotal thyroidectomy for other diseases (1.5%) and lobectomy (0%). The high incidence of hypocalcemia following subtotal thyroidectomy for thyrotoxicosis but not for other diseases suggests that a mechanism other than removal or damage of the parathyroids is responsible for the hypocalcemia. This may well be thyrotoxic osteodystrophy. This hypocalcemia usually occurs early, is of moderate degree, and is transient. Management includes calcium gluconate for acute symptoms and calcium lactate with vitamin D2 for chronic symptoms.
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Our experience with five cases of cystic dilatation of the extrahepatic bile ducts is reported and compared with the literature. The following conclusions have been reached: (1) The etiology of this anomaly is primarily congenital but may involve an acquired component. (2) Diagnosis should be suspected when any of the triad of abdominal pain, right upper quadrant mass, or jaundice is present. (3) The diagnosis can usually be made in infants based on the clinical picture and routine radiologic studies. (4) Retrograde cholangiopancreatography is a useful tool in making the diagnosis in older children and adults. (5) Roux-en-Y choledochocystojejunostomy is the procedure of choice for type I cysts, excision for type II, and choledochocystoduodenostomy for type III.