Biomedical subjects
Publications and source records attributed to L Morgenstern.
A system of image amplification with television fluoroscopy and 100 X 100 mm cut film technique is presented for use in the operating room. Biliary surgery has benefited from this equipment as operative cholangiography has been improved and unnecessary extension of operating time avoided. Applications of the equipment for other procedures are discussed.
During the past several decades, there has been a shift in the distribution of colorectal cancer toward the right side, with an increase in colon lesions on the right side and a marked decrease in rectal lesions. In 1,009 cases studied between 1966 and 1977, this change in distribution pattern is illustrated. A revision of widespread current concepts of colonic cancer detection is indicated.
A case of a solitary meningocerebral metastasis from an esophageal carcinoma is described and the rarity of such an occurrence, as compared with cerebral metastases from other organs, is stressed. A possible metastatic pathway from the esophagus to the brain through the vertebral veins is postulated.
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Operative cholangiography as currently performed in many hospitals in the United States may be a cumbersome procedure yielding less than optimal information. For maximal accuracy and diagnostic yield, operative radiographic examination of the biliary tract should include fluoroscopic observation and aimed spot films. The advantages gained by using modern radiologic equipment and technics are increased image clarity, increased capability for functional assessment of a dynamic system, increased efficiency, and decreased radiation hazard. In a series of 100 patients undergoing operative cholangiography by our technic, only one retained stone was demonstrated by postoperative studies. Five anomalies of the ductal system were easily identified and possible injury to the anomalous ducts averted. Considering the morbidity and mortality attendant upon inadequate or inappropriate biliary tract operations, investment in the sophisticated equipment necessary for optimal operative radiography is small indeed.
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Microfibrillar (Avitene) is a new absorbable topical hemostatic agent whose mechanism of action is platelet entrapment and activation of platelet clotting factors. It adheres to moist tissue surfaces to form a firm, flexible hemostatic coagulum. It has been used clinically in 36 patients with hepatic bleeding of diverse etiology, including bleeding from the gallbladder fossa, lacerations, resectional surfaces, biopsy sites, capsular denudations, and hepatic tumors. Although not intended to control major hemorrhage were major vessel ligation or resection is properly indicated, its topical use for diffuse small vessel bleeding may be life-saving. It is exceptionally useful in such conditions as cirrhosis and in thrombocytopenic or thrombasthenic coagulopathies. One treatment failure out of 36 occurred.
Liver biopsy was done at the time of operation in 125 consecutive upper abdominal procedures to assess the incidence of unsuspected or undiagnosed hepatic abnormalities. Specifically excluded were hepatic lesions unexpectedly identified at laparotomy. Sixty-seven percent of the liver biopsy specimens were abnormal, the most frequent findings being fatty metamorphosis, cholestasis, triaditis, fibrosis, inflammatory infiltrate, cholangitis, cirrhosis, and hepatitis. The most frequent operation performed was cholecystectomy. In 63 patients with chronic cholecystitis, there was a 51% incidence of abnormal liver histology, while in nine patients with acute cholecystitis, the incidence was 78%. In 83% of all other operations, abnormal liver biopsy specimens were identified. Bile leakage, hemorrhage, and infection did not occur in this series, despite inclusion of patients with severe biliary obstruction, abnormal clotting factors, and intra-abdominal sepsis. New techniques of histochemical enzyme analysis and electron microscopy are expected to enhance the clinical correlation of occult hepatic lesions. We conclude that liver biopsy in a safe, informative adjunct to all upper abdominal procedures.
With the extended indications for abdominal and pelvic radiation therapy, administered at higher dosage levels, an increased incidence of radiation injury to the intestine can be anticipated. Increased efforts are urgently needed to develop innovative methods in the detection, prevention, and management of radiation-induced intestinal injury. Fifty cases of radiation enteropathy have been reviewed to highlight problems in management and to suggest preventive and therapeutic measures, both surgical and nonsurgical.
Operative injury to the spleen and consequent accidental splenectomy is neither an infrequent nor an inconsequential occurrence. It still accounts for 25 per cent of all splenectomies performed. The morbidity rate resulting from this accident is well above 50 per cent, and the mortality may be as high as 15 per cent. Appreciation of the peritoneal anatomy of the spleen with prophylactic division of the splenoperitoneal folds will lessen the incidence of capsular avulsion injuries. When capsular avulsion injuries do occur, they may be effectively treated with topical hemostatic agents, such as microfibrillar collagen, Avitene. Twenty-one instances in which splenectomy for capsular avulsion injury was averted have been reported. In the last 15 of these, the topical hemostatic agent used was Avitene.
Ingestion of fruit pit must be a frequent and innocuous phenomenon, judging from the expected frequency of such occurrences and the relative dearth of medical reports to the contrary. Reported here are four cases in which fruit pits of varied nature completed an otherwise incomplete intestinal obstruction. On of these was in the terminal ileum, with incomplete obstruction due to regional ileitis, in which the offending pit was seen radiologically but was not recognized as such. The other three were in the transverse colon, at the site of annular carcinomatous lesions. The completion of the obstruction by the fruit pits eventuated in earlier symptoms, diagnosis, and treatment. In one case, the fruit pits were multiple; in the remainder, they were single.
A circular stapling apparatus was especially designed for use in low colorectal anastomoses. In shape and size it resembles a slightly oversized proctosigmoidoscope. After the tumor-bearing segment is resected in the standard manner, the instrument is introduced via the anus through the distal segment into the abdomen. The proximal and distal segments are apposed and mechanically anastomosed. A secure anastomosis is thus performed more quickly and more reliably than by standard suture methods. The method has been used successfully in 20 dogs, without evidence of leakage or stenosis. In 165 human operations for low rectal carcinoma performed in Russia from 1967 to 1972, the mortality was 2.4% and the leakage rate was 3.6%. No stenosis or late stricture occurred.
Five hundred consecutive cases of breast carcinoma were studied to determine the incidence of multicentric lesions in the resected specimens. When residual tumor in juxtaposition to the primary tumor or biopsy cavity is excluded, 41.6 per cent of specimens exhibited multicentric foci of tumor; 31 per cent of such foci were in sectors or quadrants remote from the primary tumor. In more than half of these cases the lymph nodes were uninvolved and cure rate would have been maximal had these multicentric tumor foci been removed. These findings confirm previous similar studies and we consider tylectomy an inappropriate mode of therapy for breast cancer.
The value of biliary endoscopy was determined in 100 consecutive patients undergoing choledochotomy. Using a compact, rigid, right-angled choledochoscope with a rod-lens optical system the biliary tract was inspected for residual stomes following conventional exploration. Completion operative cholangiography and postoperative T-tube cholangiography were performed in all patients. Of 52 patients undergoing primary choledocholithotomy, the duct was cleared of all calculi in 51. A small residual stone was found by postoperative cholangiography in one patient. Exploration revealed no calculi in the ducts of the remaining 30 patients. Biliary endoscopy was of benefit to the surgeon in the majority of patients. In 17 patients, calculi missed by standard exploration were detected; in five of these, the calculi could be retrieved only under endoscopic control. In 11 patients, interpretation of operative cholangiograms was aided, while in three the endoscopic findings clarified operative strategy. The use of biliary endoscopy did not increase the postoperative morbidity or mortality rates beyond those oridinarily encountered in choledocholithotomy. Current experience indicates that the new choledhchoscope overcomes limitations of previous endoscopes and should serve as the definitive diagnostic tool for operative biliary endoscopy. The addition of this technique to the armamentarium of the biliary surgeon will play a significant role in overcoming the age-old problem of the retained common duct stone.
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