Major problems in clinical surgery最新文献

The early postprandial dumping syndrome can be prevented or minimized by the appropriate selection of the operative procedure to fit the patient and the peptic ulcer problem he presents, and by proper attention to diet in the early postoperative period. When it does occur, the syndrome usually responds favorably to dietary management and tends to spontaneously regress in severity with time. For these reasons further surgery is seldom required for the early postprandial dumping syndrome. In the patient who fails to improve with diet therapy and time and has disabling symptoms often accompanied by progressive malnutrition, revisional surgery should be undertaken. It is the objective of the surgeon to alter the reconstruction in such a way that emptying from the stomach or gastric remnant is delayed. Therefore, the upper small intestine dose not receive a large, rapidly introduced hyperosmolar bolus to initiate the release of humoral substances causing the syndrome. All revisions utilized are potentially ulcerogenic and if vagotomy has not been a part of the original procedure, it should routinely be performed at the time of revision. Patients who have primarily has a Billroth II gastrectomy will frequently improve markedly with simple conversion to a Billroth I reconstruction. This is particularly true when the residual stomach is moderately large (i.e., after antrectomy) and when the gastrojejunal stoma is larger in diameter than the normal jejunum. Under such circumstances approximately 80 per cent of patients will improve sufficiently so that a more complex procedure need not be utilized at once. Under all other conditions we prefer a 10 cm. segment of reversed jejunum anastomosed proximally to the gastric stump and distally to a 40 cm. isoperistaltic Roux-en-Y jejunal limb. This procedure is so successful that one can justify its use as first recourse even in the anatomically favorable Billroth II patient. It should be pointed out emphatically that an isoperistaltic jejunal interposition (Henley loop) has little or no effect on the early postprandial dumping syndrome and should not be considered. Plicated loops of intestine to recreate a gastric reservoir frequently fail to empty satisfactorily and the incidence of satisfactory results is too low to consider their utilization in surgical treatment of the dumping syndrome.

The afferent loop syndromes result from obstruction to the afferent jejunal loop. Acute ALS results from complete obstruction, usually occurs early after surgery and runs a devastatingly lethal course unless promptly treated by reoperation. In chronic ALS the obstruction is intermittent and produces a clinical syndrome from which a diagnostic histroy can usually be obtained. Although the exact incidence is unknown, it is certainly not rare, especially in antecolic Billroth II gastrectomies. Treatment consists of doing away with the afferent loop. In gastroenterostomy alone takedown of the anastomosis with a Weinberg pyloroplasty is the treatment of choice. The safest and simplest treatment for patients whose original operation was Billroth II gastrectomy is conversion to a Roux-en-Y procedure. In all cases vagotomy should be added unless previously performed. No medical treatment is available and patients with no other contraindication should have revisional surgery if symptoms are clinically significant. Both acute and chronic afferent loop syndromes should be completely prevented by appropriate choice of the initial operative procedure. The vagotomized stomach should be drained by pyloroplasty, not gastrojejunostomy. Vagotomy and antrectomy should be reconstructed with a Billroth I gastroduodenostomy. The Braun enteroanastomosis should be utilized after subtotal gastrectomy for carcinoma. The wider application of parietal cell vagotomy for duodenal ulcer deserves close observation and further consideration.

Although electrical burns of the upper extremity comprise a small percentage of all thermal injuries, they present formidable clinical problems. The physician must not be lulled into a false sense of security because the visible cutaneous burn is not great. Sound surgical principles, such as the control of bacterial proliferation with topical chemotherapy, débridement of dead tissue, and timely wound closure, in conjunction with the expertise necessary in caring for thermally injured patients, are necessary for a maximally rehabilitated patient.