Major problems in clinical surgery最新文献

The development of the radioimmunoassay for gastrin has resulted in significant increases in our knowledge of the physiology of the stomach and antrum, and in an objective recognition of the interaction of the gastrin and vagus mechanisms. Recent identification of multiple species of gastrin in the circulation, however, raises questions as to the significance of early experimental results. Until the various aspects of gastrin and their relative contributions in the normal state and in pathologic processes are identified, the significance of gastrin levels in the evaluation of patients with uncomplicated ulcer disease is unclear. Although many investigators have attempted to correlate changes in serum gastrin levels in response to various stimuli with the completeness of vagotomy or the likelihood of recurrence, it is too early to give any clinical significance to these reports. Several points in particular seem worthy of emphasis: 1. Preoperative serum gastrin levels are currently of no value in selecting an operation for the treatment of duodenal ulcer disease. 2. The difference in serum gastrin levels in response to feeding that may be shown to exist between groups of normal subjects and duodenal ulcer patients is not a value in diagnosing ulcer disease in a specific patient, nor in differentiating duodenal ulcer from other conditions. 3. The measurement of serum gastrin levels in association with Hollander tests, while perhaps of potential future benefit, does not improve the accuracy of the Hollander test nor do results necessarily relate to vagal innervation. 4. Postoperative serum gastrin levels are increased after vagotomy. The degree of hypergastrinemia after vagotomy does not correlate with risk of ulcer recurrence. 5. Hypergastrinemia (greater than 1000 pg. per ml.) in the presence of hyperacidity is essentially pathognomonic of the Zollinger-Ellison syndrome. Calcium and secretin infusions do not add to the diagnosis if clear-cut clinical and laboratory data are present. These differential tests are of value in identifying the Zollinger-Ellison patient who has borderline serum gastrin levels and in differentiation from the syndrome of the retained antrum. 6. In a patient with a recurrent ulcer following surgery in whom a drug-induced ulcer can be excluded and gastric outlet obstruction cannot be demonstrated, a serum gastrin level may be indicated. A serum gastrin value greater than 300 pg. per ml. (normal less than 200 pg. per ml.) in a fasting morning serum sample is significantly elevated, even after vagotomy, and warrants further investigation. Provocative testing of the gastrin response to calcium and secretin should elucidate the etiology of the recurrent ulceration in this type of patient.

Our present concept of the pathogenesis of the early postprandial dumping syndrome is well summarized by Jesseph. Resection, division or bypass of the sphincter mechanism at the gastric outlet permits rapid passage of hyperosmolar material into the upper small intestine. This provides direct stimulation of the enterochromaffin (argentaffin) cells in the mucosa, which are highly concentrated here. The hyperosmolarity pulls fluid into the intestine resulting in a fall in plasma volume and distention of the intestine, further stimulating secretion by the argentaffin tissue. The plasma volume per se probably has little, if anything, to do with the symptoms produced although the outpouring of intravascular fluid into the intestinal lumen probably contributes to intestinal hyperperistalsis and the resultant symptoms of intestinal hurry. Although other sources are possible, studies to date would indicate that the argentaffin cells are the major source of humoral agents. In addition to serotonin, at least one vasoactive polypeptide, bradykinin, has been identified. It is likely that others are present and pharmacologic therapy will probably not be successful until these are more completely identified and characterized. The known biologic effects of serotonin and the kinins can certainly account for all the vasomotor and gastrointestinal symptoms characterizing the early postprandial dumping syndrome.

Infection invariably accompanies thermal injury. The degree to which a patient is jeopardized by infection is related to the size and depth of the burn, the density and virulence of the microorganisms colonizing the burn wound, and the competence of his immune defenses. The aim of topical therapy is to limit microbial colonization of the burn wound to levels below those associated with invasive infection of the viable tissue beneath the eschar. The use of effective topical and systemic antimicrobial agents has been associated with the emergence of other bacterial, fungal, and viral infections and a delay in separation of the eschar, presumably caused by the suppression of bacterial débribement of the burn wound. The treatment of fractures in thermally injured patients may require compromise to permit optimal wound care and alertness toward the development of osteomyelitis. Because of the frequency of suppurative thrombophlebitis in burned patients, particular care is needed in the management of intravenous cannulae. The treatment of burns is largely the control of infection. Awareness of the septic complications of thermal injury and constant vigilance against them is critical in successful burn management.

A rational approach to the restoration of function of the upper extremity has been outlined for the burned patient. If these guidelines are followed and the joints of the upper extremity approached individually with a goal of restoring as much range of motion as possible, great functional improvement may be anticipated. The surgical procedures must be augmented with vigorous PT and strong patient motivation. With this combination improvement of function of the upper extremity can be provided that is gratifying to both the surgeon and the patient.

Over 1200 cases of carcinoma of the gastric remnant have been reported in the literature. There is an increase of this type of carcinoma in postoperative stomachs with atrophic gastritis and intestinal metaplasia. The cause and effect relationships remain to be fully elucidated. In patients with late postgastrectomy symptoms, carcinoma of the gastric remnant should be considered in the differential diagnosis. In a study of 350 asymptomatic patients who were more than 20 years from Billroth II gastric resection, 14 carcinomas were discovered in the region of the stoma. Preoperatively, gross endoscopic appearance and multiple biopsies will usually provide the diagnosis. At the time of revisional surgery, frozen section of gastric biopsies or the resected specimen may be necessary to exclude the diagnosis. At present there is widespread interest in several procedures in the treatment of benign ulcer disease. In selected patients, proximal gastric vagotomy is receiving particular interest. It remains to be determined what, if any, gastric mucosal alterations occur. Since the pyloric mechanism is intact, no stoma is created and no portion of the stomach resected; long-term followup of these patients will be of interest. Information as to the cause of gastric remnant carcinoma can be forthcoming only by evaluation of all groups of patients requiring gastric surgery for benign disease. At the same time, further investigation of patients with gastric carcinoma without prior resection who have atrophic gastritis and intestinal metaplasia is also necessary. The histologic type of carcinoma that develops in the gastric remnant is usually more favorable for surgical cure than those seen in the intact stomach. This means that early diagnosis by radiologic and endoscopic study of postgastrectomy patients developing symptoms is highly desirable. Because of the long interval between gastrectomy and gastric remnant carcinoma these patients are often in the older age group. The location of the lesion in the remaining proximal stomach will nearly always require total gastrectomy. This plus the age factor means that the operative mortality will be rather high. We are unable to explain why in 22 years of observing postgastrectomy patients we have seen only one case of gastric remnant carcinoma. This patient was successfully treated by left transpleural transdiaphragmatic total gastrectomy with Roux-en-Y esophagojejunostomy. This method is particulary easy in the patient who has has an antecolic Billroth II gastrectomy. If the jejunum cannot be adequately mobilized through a radial incision extending laterally from the esophageal hiatus, we use a peripheral diaphragmatic incision in circumferential fashion. This gives excellent exposure of the upper abdominal contents and also preserves the phrenic nerve. As a result, ventilatory function of the left leaf of the diaphragm is preserved postoperatively.

Severe upper extremity burns may mean an indefinite interruption in the style of life to which an individual is accustomed, and the occupational therapist can help the thermally injured patient to regain purposeful activity. Even a simple temporary prosthesis for the amputee, enabling him to write (Fig. 12-17), permits meaningful activity that can reduce boredom, dependence, preoccupation with death, and depression. A vigorous progressive physical and occupational therapy program producing tangible results does more for the patient's morale than any verbal encouragement could possibly do. Finally, the therapist can be more than the "mechanic" of the burn team. In his daily contact with the patient, he can be a "good listener" to whom the patient can verbalize his hostility, anger, resentment, and fear. When appropriate, he may convey this information to the physician, who can help the patient gain insight into some of the problems manifested by his behavior.

Any surgical procedure that ablates the pyloric sphincter mechanism permits increased reflux of duodenal fluid into the stomach or gastric remnant. Although it is reported as most common with Billroth II gastrectomy, our experience indicates that reflux is nearly as frequent after Billroth I gastroduodenostomy and is not at all infrequent after pyloroplasty. The precise constituents of duodenal fluid which damage the gastric mucosa remain controversial. The best present evidence is that the bile acids are probably essential, but that one or more other constituents of duodenal content are also necessary. The clinical history differs significantly from chronic afferent loop syndrome in that the quality of pain is different, pain tends to be more continuous and less closely related to food-taking, and bile vomiting does not provide dramatic relief, often containing food due to coexistent interference with gastric emptying. Diagnosis is confirmed by gross endoscopic findings and characteristic histopathologic changes in the endoscopic biopsies. Treatment with an interposed isoperistaltic jejunal segment has been disappointing. Only four of ten patients experienced lasting relief, indicating that the relatively short 10 to 12 cm. of jejunum does not adequately prevent duodenogastric reflux. We have, therefore, shifted to the Roux-en-Y duodenal diversion implanting the afferent limb 40 cm. caudad to the gastrojejunostomy. Results have been excellent in 24 of 25 cases with prompt improvement in gastric emptying, absence of bile vomiting, progressive regression in abdominal distress and progressive improvement in nutrition. Endoscopic evaluation at three to four months has indicated marked gross improvement and striking histologic improvement in 23 of 25 cases. The question is raised whether the Roux-en-Y reconstruction should not be used primarily, particularly if both vagotomy and antrectomy are to be performed for peptic ulcer. Both the afferent loop syndrome and alkaline reflux gastritis would be prevented, and it is doubted that the incidence of marginal ulcer would increase appreciably.