Plastic surgery at the Johns Hopkins Hospital in the 1940s: personal reflection on a period of transition.
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Baltimore↗
Biomedical subjects
W P Longmire
Publications and source records attributed to W P Longmire.
We tried it once. Recollections of an early government health care program.
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History, 20th Century↗
A current view of gastric cancer in the US.
In the US, the remarkable decline in the incidence of gastric cancer during the mid-portion of this century has leveled off during the last two decades as an equally remarkable and poorly understood increase in the percentage of the generally more unfavorable cardia cancers has become apparent. The importance of H. pylori infection is being actively investigated and treatment to reduce the infection may offer a means of decreasing the disease, particularly in areas of high incidence. The potential danger of inciting gastric cancer by the prolonged use of drugs that severely reduce or eliminate gastric acid has been mentioned, but the degree of risk must await the passage of years before it can be properly evaluated. "Early gastric cancer" or, probably more appropriately, "superficial gastric adenocarcinoma" continues to comprise a relatively small segment of gastric cancers in the US and most Western countries. Seventeen per cent of cases in the ACS series were classified as stage I, a much higher incidence than reported for early gastric cancer in most individual North American series. The ACS report suggests "special education of the surgeon in the requisites for adequate gastrectomy with node dissection, coupled with effective adjuvant therapy" as a means of improving results in the US. This is a significant consideration because, unfortunately, gastric surgery for ulcer or cancer no longer plays the important role it did in past decades in many US surgical training programs. As has been demonstrated in Japan and in certain larger US series, excellent surgical technique, particularly for cardia tumors, plays an important role in obtaining improved results. The value of radical lymph node dissection continues to be controversial in US cases, and a successful chemotherapeutic regimen has yet to be found. Subtotal gastric resection, as noted in the ACS report, continues to be the procedure of choice in the US for most gastric cancers, even for cardia cancers. Although there is no improvement in survival, quality of life is thought by some to be better after total gastrectomy for cardia cancers rather than proximal subtotal esophagogastrectomy. However, equally important for improved survival is the ACS recommendation of earlier referral for gastric surgery patients with precursor lesions, but the lack of improvement in the pathological stage of disease in the two ACS time periods suggests that little progress is being made in this country in this regard.
Environment↗
Management of bile duct strictures. An evolving strategy.
In an effort to determine the role of interventional radiologic and endoscopic techniques in the management of benign biliary strictures, a retrospective analysis was carried out on 194 consecutive patients with bile duct strictures treated at UCLA between 1955 and 1990. Patients were classified as group 1 (1955 through 1979; n = 138) or group 2 (1980 through 1989; n = 56). Follow-up was for a minimum of 24 months and was in excess of 3 years in 179 patients (92%). Although the incidence of recurrent strictures was similar in the two groups (21% and 23%), the reoperation rate was significantly lower (P less than .02) in group 2 (6%) than in group 1 (21%). Percutaneous transhepatic biliary dilatation, used in 20 patients in group 2, was successful in 13 (93%) of 14 patients with anastomotic strictures and three (50%) of six patients with primary strictures (P less than .05). We conclude that surgical reconstruction remains the standard therapy for patients with primary bile duct strictures. Percutaneous transhepatic biliary dilatation has limited usefulness for these patients, but may be more appropriate for those with anastomotic strictures.
Adolescent↗
The natural history of carcinoma of the bile duct in patients less than forty-five years of age.
Traditionally regarded as a disease of the elderly, the natural history of carcinoma of the bile duct in young patients has not been well defined. Of 186 patients (mean age of 62 years) treated at UCLA (1954 to 1988) for carcinoma of the bile duct, 26 were less than 45 years old. Younger patients had symptoms for an average of 4.5 +/- 0.8 months prior to diagnosis, as compared with 2.3 +/- 0.2 months for patients more than 45 years old (p less than 0.03). Of the younger patients, 96 per cent were managed surgically with either resection, surgical palliative bypass or laparotomy and tube drainage. Among the younger patients who underwent resections, 92 per cent were alive at one year, as compared with 60 per cent of patients who underwent palliative bypass procedures. Two patients who underwent tumor resections survived four years or longer. We conclude that carcinoma of the bile duct is not limited to the elderly and occurs in a significant number of young patients. In the younger population, carcinoma of the bile duct is characterized by delays in diagnosis. Early suspicion and aggressive management of young patients with obstructive jaundice are essential to ensure the best possible outcome for patients with this disease.
Adult↗
Carcinoma of the ductus choledochus.
A retrospective review of patients treated for carcinoma of the common bile duct has demonstrated improvement in diagnostic capabilities, leading to earlier management by resectional therapy. The ability to resect these tumors is directly translatable to improved long-term survival. Efforts to obtain proof of malignancy prior to resection are often frustrated by the inability to obtain adequate representative tissue for frozen section. Choledochoscopic biopsies and incisional biopsies have given the highest yield of positive diagnoses. In experienced hands, a program of fewer preoperative tests with emphasis on early operation, diagnosis, and definitive treatment may be more cost-effective in the management of patients with common bile duct cancer.
Adenocarcinoma↗
Can a clinician be a scientist?
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Clinical Medicine↗
Whither the solid tumors. James Ewing lecture.
Improvement in survival rates for solid tumors, the cancers of greatest concern to the surgeon, has lagged far behind the dramatic advances that have been made in the treatment of leukemias, lymphomas, and certain childhood tumors. The application of new technical procedures and an aggressive approach to certain metastatic lesions offer chances for improving operative results, but the greatest contribution to curing cancer that can be made by surgeons at this time is the complete removal of the small localized primary tumor. By more active participation in "early detection programs" surgeons can increase their opportunities to treat cancer at this stage. The American College of Surgeons, in consultation with the National Cancer Institute, has conducted a detailed survey that analyzes the lack of surgical participation in clinical trials with a view toward developing a more active surgical interest in evaluating new methods of treatment for the solid tumors. One of the current efforts to improve the outcome of these recalcitrant cancers involves increasing the number of trained surgical scientists in the field of cancer.
Clinical Protocols↗
Pylorus preserving pancreatoduodenectomy: an overview.
Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3.8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8.6 per cent), and marginal ulceration (3.6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy.
Duodenum↗
Surgical palliation for pancreatic cancer. The UCLA experience.
We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group I), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.
Adolescent↗
Changing patterns in diagnosis and management of bile duct cancer.
An analysis of 186 patients treated for bile duct cancer at UCLA Medical Center from November 1954 to December 1988 demonstrated improvements in several areas of diagnosis and management. Comparison of 96 patients treated between 1954 and 1978 (group 1) with 90 patients treated between 1978 and 1988 (group 2) showed earlier diagnosis and treatment in group 2 (2.1 months from onset of symptoms) than in group 1 (4.9 months; p less than 0.05) and this was correlated with increased use of ultrasonography, computed tomographic (CT) scans, transhepatic cholangiography, and endoscopic retrograde cholangiopancreatography. Operative mortality rates were lower in group 2 (4%) than in group 1 (12%) and the difference was most marked in patients with upper-third lesions, where resections in group 1 had a 23% operative mortality rate but group 2 resected patients had zero mortality (p less than 0.001). A program of operative staging and selection of patients for resection or palliative procedures has resulted in better operative risks with no deterioration in survival.
Adenoma, Bile Duct↗
Long-term evaluation of pylorus preservation during pancreaticoduodenectomy.
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Adult↗
Recurrent hepatic hemangiomas. Possible association with estrogen therapy.
Hemangiomas are the most common benign tumors occurring in the liver. However, the natural history of hepatic hemangiomas has not been well defined. Four patients (3 women, 1 man) with recurrent giant liver hemangiomas underwent either surgical or radiation therapy as initial treatment for the primary tumor. The average time until recurrence was 14 years, and each tumor weighed more than 600 g. Each of the female patients had been given chronic estrogen (Premarin) replacement therapy. Three of the four patients underwent surgical resection for intractable symptoms or progressive enlargement. It is believed that estrogen replacement therapy may play a role in the pathogenesis of these tumors. Furthermore, operative intervention should be considered in patients with recurrent giant liver hemangioma.
Aged↗
Pancreaticojejunostomy after Whipple's operation--in vivo evaluation of long-term patency: a preliminary report.
Evaluation of the patency of the pancreaticojejunostomy was conducted in four patients who had undergone Whipple's procedure. Three patients had a mucosa-to-mucosa anastomosis, and in one patient the pancreatic remnant had been invaginated into the jejunal loop. The longest interval between the operation and the present study was 9.7 years. After intravenous infusion of secretin (1 microgram/kg), the temporal changes in the pancreatic ductal caliber were measured by means of either ultrasonography (two patients) or computed tomography (two patients). The presence of adequate functional pancreatic tissue was assumed in all four patients on the basis of their clinical status and the normal ductal caliber before the secretin provocation. In two patients, the ductal system showed an initial dilatation following secretin administration and then gradually emptied. There were no changes of the Wirsung duct in the other two patients. These data suggest that the pancreaticojejunal anastomoses were patent in all four patients but had different degrees of stenosis. The present method allows a safe and noninvasive evaluation of the anastomosis in vivo. Since long-term patency of the pancreaticojejunostomy is feasible, it should be attempted whenever possible in patients undergoing Whipple's procedure.
Adult↗
Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of the pancreas.
For many years, the classical Whipple procedure has been the standard operative treatment for resectable periampullary cancer. Recently, the pylorus preservation operation has also been applied to periampullary tumours. This newer procedure has potential advantages in terms of ease of performance and postoperative physiology, but has yet to be proved as an adequate cancer operation. We, therefore, undertook the present retrospective analysis to compare the outcome following the pylorus preservation operation (n = 13) with that of the classical Whipple resection (n = 13) in 26 patients with histologically proved adenocarcinoma of the head of the pancreas. The two groups of patients were comparable for age, sex, pre-operative laboratory data, and resected margins free from tumour. More patients undergoing the classical Whipple resection had Stage I disease (10 versus 4, P less than 0.05). However, this difference would not be significant if the two patients in the pylorus preservation group with carcinomas in situ were considered to have stage I disease. Mean tumour diameter in the pylorus preservation patient group (3.2 +/- 0.6 cm) was smaller (P less than 0.05) than in the classical Whipple group (4.1 +/- 1.0 cm) but more patients in the pylorus preservation group also had metastases to the regional lymph nodes (54 versus 23 per cent). Overall operative morbidity (31 per cent) and mortality (4 per cent) was acceptable and did not differ between the two groups. Five year actuarial survival for pylorus preservation (25 per cent) was comparable to that observed for the Whipple procedure in this and other series.
Adenocarcinoma↗
Decreased morbidity and mortality after pancreatoduodenectomy.
In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.
Actuarial Analysis↗
Differentiation of pyogenic from amebic hepatic abscesses.
Recent immigration trends have resulted in an increased prevalence of amebic hepatic abscesses in southern states and in many northern American cities. Because amebic hepatic abscesses generally do not require drainage, differentiation from pyogenic hepatic abscesses is important. We, therefore, reviewed the records of patients admitted to the UCLA Medical Center from 1968 through 1983 to compare the clinical manifestations and to access the results of treatment of pyogenic and amebic hepatic abscesses. During this 15 year period, 82 patients (42 pyogenic and 40 amebic) with hepatic abscesses were admitted. Factors which distinguished patients with pyogenic abscesses included: age greater than 50 years; jaundice; pruritus; sepsis and shock; a palpable mass; elevated bilirubin level; elevated alkaline phosphatase level, and abnormal abdominal roentgenograms. Patients with amebic abscesses of the liver were more likely to have Mexican ancestry, recently traveled to an endemic area, abdominal pain, diarrhea, abdominal tenderness, hepatomegaly and positive amebic serology. Hepatic scans and ultrasonography were excellent methods of detecting the presence of but not the type of hepatic abscess. Over-all, the mortality was 40 per cent for patients with pyogenic abscesses whereas all 40 of the patients with an amebic abscess survived. However, operative mortality was only 4.5 per cent for the 22 patients with pyogenic abscess who were managed with systemic antibiotics and surgical drainage. We conclude that many clinical and laboratory parameters can aid in the differentiation and, as a result, management of patients with pyogenic and amebic hepatic abscesses.
Adolescent↗
Personal reflections on the surgical treatment of portal hypertension.
Reports, early in this century, on the treatment of portal hypertension by surgical diversion of the portal blood flow about the liver were largely ignored because of the anticipated high mortality. Whipple, Blakemore and Lord in the early 1940's described a technique of performing a splenorenal or portacaval shunt with an epithelial lined vitallium tube. Blalock, whom I assisted, was one of the first outside of the Whipple Group to successfully perform such an operation. Although he used the vitallium tube technique in his first cases he soon became convinced that the results were better with a direct suture anastomosis. Venous shunts, which seemed such a logical way to treat portal hypertension, were widely and quickly adopted. Little attention was paid to the problem of portal encephalopathy which had been described in experimental animals years before by Pavlov. As some of the follow up studies on these shunted patients began to appear it was evident that this was a common and at times a severe problem. Some of the earliest doubts about the shunt operation were expressed by surgeons in Japan. The most successful methods developed to date for the treatment of portal hypertension provided a shunt for blood from the esophageal variceal region while at the same time preserving portal blood flow through the liver. Two of these methods have been the distal or selective splenorenal shunt proposed by Warren & Zeppa and the coronary caval shunt first described by Inokuchi. These methods, although somewhat more difficult technically than end to side portacaval shunts, reduce portal hypertension and preserve blood flow through the liver thereby lowering significantly the incidence of encephalopathy.(ABSTRACT TRUNCATED AT 250 WORDS)
History, 20th Century↗