MANAGEMENT OF RESECTABLE LESIONS OF THE SMALL BOWEL

During a 12-year period at the Los Angeles County General Hospital there were 364 cases of resection and anastomosis of the small intestine which were classified and studied. Particular attention was paid to the methods of anastomosis. There were more wound infections, fistulas and otherwise faulty anastomosis with the open than with the closed technique. In the presence of a peritoneal cavity not previously contaminated by bowel content, a closed anastomosis is better and safer than an open anastomosis.     

Detection of unsuspected ovarian pregnancy by wedge resection

Five follicular ovarian implantations occurred among 200 ectopic pregnancies encountered during a 14-year period. Abortions from impregnated follicles may cause hemoperitoneum more often than is generally suspected. Wedge resection or cystectomy to ensure hemostasis provides tissue for histological examination, without which ruptured ovarian pregnancy may masquerade as rupture of a corpus luteum with hemorrhage (“ovarian apoplexy”). Including patients reported here, IUCD users have within the past five years accounted for about 10% of all ovarian pregnancies recorded in English.     

The Risk of Rh Isoimmunization in Ruptured Tubal Pregnancy

In 9 (24%) out of 38 African women who had suffered a ruptured tubal pregnancy significant numbers of fetal erythrocytes (5 or more per 150,000 maternal cells) were found in the maternal circulation. This is a higher incidence than occurs after abortion and indicates that rupture of a tubal pregnancy is a potential source of Rh isoimmunization. The finding of fetal cells in the peritoneal cavity suggests that this is the main source of the fetal blood found in the maternal circulation. At operation on Rh-negative patients with ruptured tubal pregnancies, therefore, complete removal of the peritoneal blood should be attempted and the blood recovered should never be transfused into the patient, who should always receive prophylactic Rh immunoglobulin.     

A SURVEY OF THE RESULTS OF TREATMENT OF GASTRIC CANCER IN SAN FRANCISCO

A survey was made of all patients treated for gastric cancer on the clinic services of the Stanford University Hospital during the 30-year period 1919 to 1948. During the last decade of the survey there were impressive gains in the surgical treatment of this disease. It was possible from 1944 to 1948 to do a gastric resection on half the patients seen with cancer of the stomach. Also, there was a pronounced decrease in resection mortality so that from 1939 to 1948 the mortality rate for subtotal gastrectomy for cancer was 3 per cent.The over-all five-year survival rate was discouragingly low—4.6 per cent. On the other hand, 23 per cent of those surviving gastric resection lived for five years.A survey of the management of carcinoma of the stomach from 1939 to 1948 was made in 11 general hospitals in San Francisco. A wide range of resectability and resection mortality rates was observed. The cases from these hospitals were combined with those from Stanford for the same period to form a composite group of 1,128 patients. Analysis of this group of cases from 12 representative hospitals in San Francisco showed encouraging trends toward higher resectability rates with a lower resection mortality.     

N-Butyl Cyanoacrylate Is Very Effective for Massive Haemorrhage during the Perinatal Period

Objective

The liquid embolic agent n-butyl cyanoacrylate (NBCA) is a tissue adhesive used as an immediate and permanent embolic agent when mixed with oil-based contrast medium. In this study, the preservation of fertility with TAE using NBCA for massive haemorrhage during pregnancy or the peripartum period and the utility of this therapy were investigated.

Methods

Cases from January 2005 to October 2010 in which TAE was performed for massive haemorrhage in pregnant women, particularly during the peripartum period, were investigated.

Results

TAE was performed in 27 pregnant women. The embolic agent used was GS only in five cases, NBCA only in 19 cases, and additional embolization with NBCA when the effect with GS was insufficient in three cases, one each of abruptio placentae, cervical pregnancy, and uterine atony.A comparison of mean blood loss when each embolic agent was used for haemostasis showed a significant difference between cases in which GS only was used and cases in which NBCA only was used. In a comparison of mean transfusion volume, a significant difference was seen between cases in which both GS and NBCA were used and cases in which NBCA only was used. In a postoperative follow-up survey, menses resumed in eight patients, including four patients who later became pregnant and three who delivered.

Conclusions

TAE with NBCA, which has an embolic effect unrelated to clotting dysfunction for massive haemorrhage during the peripartum period, is a minimally invasive and very effective treatment method for patients with severe DIC.     

Chemiluminescence response of β-glucan stimulated leukocytes isolated from different tissues and peritoneal cavity of Dicentrarchus labrax

The respiratory burst of leukocytes isolated from sea bass (Dicentrarchus labrax) pronephros, peritoneal cavity (P.C.), spleen and blood, was measured by a chemiluminescence (CL) assay after stimulation with β-glucan. The CL response by P.C. and pronephros leukocytes was significantly higher than that expressed by a similar number of cells separated from spleen and blood. This probably reflects the observation that the proportion of macrophages and neutrophils was highest in the populations of leukocytes from peritoneal cavity and pronephros. Comparative observations showed a higher degree of yeast phagocytosis by leukocytes taken from peritoneal cavity than the pronephros. Moreover phagocytic index evaluated by microscopical observations, indicated that peritoneal macrophages internalised more yeast cells than neutrophils (identified by the peroxidase reaction). Scanning electron microscopy observations were also carried out.Inhibition experiments by a myeloperoxidase inhibitor sodium azide, iodonium-diphenyl-chloride which inhibits NADPH-oxidase, and exogenous superoxide dismutase, which catalyses O−2 dismutation to H₂O₂, supported the correlation between CL and respiratory burst. Treatment with ouabain and DNP suggested that in this response, Ca⁺⁺ pump channels and calmodulin are involved in a metabolic energy-dependent pathway.     

The intraperitoneal delivery of radiolabeled monoclonal antibodies: studies on the regional delivery advantage

Summary The i.p. delivery of murine monoclonal antibody was compared with i.v. delivery in normal mice and rats, in normal nude mice and in those with i.p. human ovarian carcinoma xenografts. In normal rats, all classes of antibodies and antibody fragments evaluated were cleared from the peritoneal cavity at comparable rates. The regional delivery (Rd¹) advantage to the peritoneal cavity following i.p. delivery was thus most dependent on the rate of clearance of the antibody or fragment from the blood stream. Determining the exact i.p. delivery advantage was problematic due to the difficulty in reliably obtaining peritoneal fluid later than 9–10 h after i.p. injection in normal animals. During the first 9 h following i.p. injection, the Rd(0–9/0–9) was, for a murine IgG2ak Fab>F(ab)₂>IgG (at 13.6>10>7.9). Two murine IgMs evaluated differed in Rd(0–9) at 27.1 and 9.2 respectively. When blood levels were extrapolated to infinity, these Rd (0–9/) values were considerably lower with the Fab having the highest Rd at 4.67. The i.p. Rd advantage was almost solely due to the i.p. antibody levels seen in the first 24 h after injection, as after that time, blood levels become comparable to those seen following i.v. injection. Normal tissues obtained at sacrifice 5–7 days after i.p. injection. Normal tissues obtained at sacrifice 5–7 days after i.p. or i.v. injection in rats showed comparable levels of radioantibody activity, whether the injection was i.p. or i.v. (except for higher diaphragmatic levels following i.p. delivery). In nude mice with i.p. human-derived ovarian tumors, intact IgG clearance from the peritoneal cavity to the blood was considerably slower than in normal animals, and early i.p. tumor uptake of specific antibody was significantly higher than that following i.v. antibody delivery. With higher early tumor uptake and lower systemic exposure, early tumor/nontumor ratios were significantly greater than those for i.v. delivery, though not beyond 48 h after i.p. injection. This study demonstrates the pharmacokinetic rationale for i.p. monoclonal antibody delivery, especially for agents cleared rapidly from the blood, such as antibody fragments. In addition, definite i.p. delivery benefit for antibody specific to i.p. tumors in the i.p. ovarian cancer system was shown soon after injection. These data regarding i.p. antibody delivery should be useful in rationally planning diagnostic and therapeutic studies involving the i.p. delivery of unmodified and immunoconjugated monoclonal antibodies.Rd is area under the curve (AUC) for peritoneal fluid activity/AUC for blood radioactivity. Rd (0–9/0–9) is the Rd measured from 0 to 9 h for both peritoneal fluid and blood. Rd (0–9/) is the conservative estimate of Rd with i.p. fluid AUC measured to 9 h, with blood levels extrapolated to infinity. Rd₂ is Rd/(AUC i.p. fluid (0–9)/AUC blood (0–9)) after i.v. injection.     

Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study

Objective: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Design: Population based study. Setting: Western Australia. Subjects: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Main outcome measures: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. Results: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. Conclusion: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

Key messages

• Background mortality for conditions such as abdominal aortic aneurysm in elderly patients needs to be taken into account when assessing long term survival after surgery
• Relative survival methodology can correct for background mortality
• The five year relative survival for patients surviving beyond 30 days of elective surgery for abdominal aortic aneurysm was 95% for men and 88% for women
• For octogenarians, five year survival after elective surgery was greater than that expected of an age matched population
• Age over 80 years should not preclude consideration for elective surgery for abdominal aortic aneurysm

     

Neutralisation of Peritoneal IL-17A Markedly Improves the Prognosis of Severe Septic Mice by Decreasing Neutrophil Infiltration and Proinflammatory Cytokines

Purpose

The current study aimed to elucidate the role of peritoneal fluid IL-17A in septic mice, and the effects of intraperitoneal or intravenous blockade of the IL-17A pathway by anti-IL17A antibody on survival, plasma, and peritoneal cavity cytokine profile in a murine caecal ligation and puncture (CLP) sepsis model. The main source of peritoneal fluid IL-17A in septic mice was identified.

Methods

Male C57BL/6 mice that underwent severe CLP or sham surgery were intraperitoneally or intravenously administered anti-IL17A antibodies or isotype antibodies. The survival rates were observed. IL-17A, TNF-α, and IL-6 cytokine levels were measured by ELISA. Surface and intracellular IL-17A immunofluorescence stains were detected by flow cytometry to identify the IL-17A–producing cells.

Results

The IL-17A level was elevated much higher and earlier in peritoneal fluid than in the blood of the CLP mice. The intraperitoneal IL-17A blockade more significantly protects against CLP-induced mortality than intravenous blockade because of decreased TNF-α and IL-6 levels both in peritoneal fluid and blood, neutrophil infiltration in the peritoneal cavity, and lung injury. γδ T lymphocytes were identified to be the main source of IL-17A in the peritoneal fluid of septic mice.

Conclusions

The earlier and higher elevated IL-17A derived from γδ T cells in peritoneal fluid plays a critical role during polymicrobial severe sepsis and effect of intraperitoneal IL-17A antibody administration superior to intravenous administration on survival of severe CLP-induced septic mice. The intraperitoneal blockade of IL-17A decreases proinflammatory cytokine production, neutrophil infiltration, and lung injury, thereby improving septic mice survival, which provides a new potential therapy target for sepsis.     

Curschmann's spirals in pleural and peritoneal effusions

Curschmann's spirals were found in smears and cell block preparations of five spontaneously occurring pleural and peritoneal fluids. The spirals were similar to those seen in the respiratory tract, although generally much smaller. In three of the five cases, the fluids also contained mucus-secreting adenocarcinoma cells; it is postulated that the spirals formed from mucus secreted by these cells. In the other two cases, there was evidence of serosal inflammation; it is suggested that the spirals in these cases developed from submesothelial connective tissue mucosubstances that entered the serosal cavity through a mesothelium of increased permeability due to the inflammation. No simple explanation can be accepted as to the exact mode of spiral formation, which is presumed to be a complex physical and biochemical phenomenon.     

SALIVARY GLAND TUMORS

In a review of a series of 248 salivary gland tumors, seen over a 28-year period, all pathologic material was brought up to date by reclassification according to more recent criteria and nomenclature. In parotid tumors, a probable lowered recurrence rate and a definite decrease in incidence of permanent facial nerve paralysis was found in the more recent cases in which the “Y” incision was used, with identification of the seventh nerve as it leaves the stylomastoid foramen. The five-year recurrence rate for primary mixed tumor was 8.3 per cent, and in recurrent cases it was found to be 18.1 per cent.Of 44 patients with malignant salivary gland tumors in all sites who were observed for five years or more, 32 or 72.7 per cent survived five years.     

Further Haemorrhage after Admission to Hospital for Gastrointestinal Haemorrhage

During 1967 and 1968 817 episodes of acute alimentary tract haemorrhage were treated in Aberdeen hospitals. In 229 cases further haemorrhage occurred in hospital, with a mortality of 28·8%; the mortality among patients who did not have this complication was 7·8%. This was true of any kind of further haemorrhage. As judged by transfusion requirements and mortality the severity of the further haemorrhage was unaffected by its occurrence as haematemesis and melaena or as melaena only or by whether it took place before or after 48 hours from the time of admission. The occurrence of further haemorrhage did not appear to be affected by the sex or blood group of patients, by aspirin ingestion, or by a history of a previous haemorrhage.The effects of the occurrence of further haemorrhage, of the age being over 60 years, or of coincidental disease being present were of descending importance in regard to mortality.Among 151 patients with peptic ulcer and further haemorrhage half required urgent surgery and 20% died. Further haemorrhage is a dangerous condition and its occurrence should immediately signal the need for vigilance and for urgent consultation between physician and surgeon. Any delay in treatment entails increased mortality.     

Transplacental passage of fetal red cells in abortion; increased incidence after curettage and effect of oxytocic drugs

In a study of early abortions (less than 16-week pregnancies) no significant increase in fetomaternal haemorrhage was found in patients having either threatened or incomplete abortions. A statistically significant increase in fetal cells in the maternal circulation, however, occurred after curettage. The administration of oxytocic drugs in conjunction with curettage in cases of incomplete abortion did not increase the incidence of transplacental passage of fetal erythrocytes when compared with curettage alone. Of the 81 patients curetted following abortion four had a feto-maternal haemorrhage of more than 0·2 ml. The largest amount of fetal blood found in the maternal circulation was 0·4 to 0·5 ml. Preliminary data evaluating the indirect Coombs test and enzyme-treated red cells in Rh-negative post-abortion cases suggest that this amount of blood is not a primary immunizing dose but a “booster” to preformed antibody.     

Five-year winter chemoprophylaxis for chronic bronchitis

Seventy-nine patients with chronic bronchitis were randomly allotted to four treatment regimens—placebo throughout the winter months for five years; tetracycline for the first two winters and placebo for the next three; placebo for the first two winters and tetracycline for the next three; and tetracycline for five winters. In addition all groups recevied a five-day course of tetracycline for any acute exacerbation. There was a significant reduction in the number of exacerbations among the more susceptible patients—that is, those who suffered more than one exacerbation each winter. Though the average decline in F.E.V.₁ over the five-year period was less in the treated groups this was not statistically significant. There was no significant difference between the groups in respect of lung volumes, diffusing capacity, and blood gases.     

Pancreaticoduodenectomy Combined with Vascular Resection and Reconstruction for Patients with Locally Advanced Pancreatic Cancer: A Multicenter,Retrospective Analysis

Objective

The aim of this study was to present the therapeutic outcome of patients with locally advanced pancreatic cancer treated with pancreatoduodenectomy combined with vascular resection and reconstruction in addition to highlighting the mortality/morbidity and main prognostic factors associated with this treatment.

Materials and Methods

We retrospectively analyzed the clinical and pathological data of a total of 566 pancreatic cancer patients who were treated with PD from five teaching hospitals during the period of December 2006–December 2011. This study included 119 (21.0%) patients treated with PD combined with vascular resection and reconstruction. We performed a detailed statistical analysis of various factors, including postoperative complications, operative mortality, survival rate, operative time, pathological type, and lymph node metastasis.

Results

The median survival time of the 119 cases that received PD combined with vascular resection was 13.3 months, and the 1-, 2-, and 3-year survival rates were 30.3%, 14.1%, and 8.1%, respectively. The postoperative complication incidence was 23.5%, and the mortality rate was 6.7%. For the combined vascular resection group, complications occurred in 28 cases (23.5%). For the group without vascular resection, complications occurred in 37 cases (8.2%). There was significant difference between the two groups (p = 0.001). The degree of tumor differentiation and the occurrence of complications after surgery were independent prognostic factors that determined the patients’ long-term survival.

Conclusions

Compared with PD without vascular resection, PD combined with vascular resection and reconstruction increased the incidence of postoperative complications. However, PD combined with vascular resection and reconstruction could achieve the complete removal of tumors without significantly increasing the mortality rate, and the median survival time was higher than that of patients who underwent palliative treatment. In addition, the two independent factors affecting the postoperative survival time were the degree of tumor differentiation and the presence or absence of postoperative complications.     

Protection of Renal Function During Surgery of the Abdominal Aorta

The operative and postoperative urinary output of 55 patients who underwent surgery for ruptured abdominal aortic aneurysms, unruptured abdominal aortic aneurysms, and aorto-iliac occlusive disease was recorded. There were five cases of postoperative anuria among 28 patients who received no free fluid in the immediate preoperative period. No case of anuria occurred in 27 patients who received either: (1) a water load of 5% dextrose in water or (2) 20% mannitol solution. The patients who received mannitol had a markedly greater operative and postoperative urinary output.Intravenous infusion of mannitol is recommended during the preoperative and operative period in patients with ruptured aneurysms of the abdominal aorta.     

Increase in the incidence of peritoneal collagen balls over a 10-year period

OBJECTIVE: To describe the detection of collagen balls in peritoneal washings over a 10-year period, revealing an unexpected and unexplained higher incidence than in the past. STUDY DESIGN: Reports of routinely processed, Papanicolaou-stained smears and cytospins and hematoxylineosin-stained cell blocks from peritoneal washes and ascitic fluids seen over an 8-year period (1995-2002) were reviewed, and the percentage of specimens in which collagen balls were noted was determined. To rule out a learning curve phenomenon, the first 100 consecutive peritoneal washings and ascitic specimens from years 1993-2001 plus 2002 were rescreened, and the percentage of specimens containing collagen balls was determined. RESULTS: The percentages of cases with collagen balls increased steadily beginning with 8 of 467 cases (3.2%) in 1995 to 185 of 650 (28.5%) in 2002, as reported in the case records. Rescreened cases also showed a similar increase, 4.0% in 1993 to 29% in 2002. No procedural modifications were made in specimen processing during this interval, nor are we aware of any procedural change in obtaining cytologic samples. CONCLUSION: An unexplained 7-fold increase in the percentage of peritoneal samples with collagen balls occurred over a 10-year period. This increase cannot be attributed to changes in specimen handling or to a learning curve phenomenon. This finding is of unknown significance and may warrant further investigation.     

Variations in Expression of Markers by Populations of Adherent Cells from Trypanosoma cruzi-Infected Mice1

The kinetics of differentiation and maturation of phagocytic cells during the acute and chronic stages of experimental Chagas' disease was examined by monitoring changes in expression of peroxidase (PO), nonspecific esterase (NSE), C3b receptors (CR), Fc receptors (FcR), and phagocytic ability of cells in the blood, spleen, and peritoneal cavity. The significant changes recorded in the blood were: marked increases in the percentages of CR- and FcR-positive adherent cells during both the acute and chronic phase; Ia-positive cells increased two-fold in the acute period and remained elevated in the chronic stage. In the spleen, the major alterations recorded during both the acute and chronic stages were: two- to three-fold increases in the percentages of NSE- and PO-positive adherent cells and three- to four-fold increases in the proportions of CR- and FcR-positive cells. In addition, Ia-positive cells increased from 70% to approximately 90% of the adherent cell population. In the peritoneal cavity, a two- to four-fold elevation in the percentages of both PO- and NSE-positive cells was observed. The number of Ia-positive cells increased from 10% before infection to 85–90% during the acute phase and to 96–98% during the chronic period. All of the changes described above occurred in the absence of noticeable increases in phagocytic ability except for an elevation in the percentage of circulating latex-ingesting cells seen during chronicity. These results indicate that infection with Trypanosoma cruzi alters the pathways of differentiation of cells of the mononuclear phagocyte lineage.     

周期型马来丝虫微丝蚴寿命的观察

将实验感染周期型马来丝虫的长爪沙鼠的微丝蚴蚴阳性腹腔稀释液,移注于正常沙鼠腹腔内,微丝蚴除能在腹腔内长期生存外,还可出现于外周血液中,其在外周血液内末次阳性检出时间最长可超过32周,在腹腔液内末次阳性检出时间最长为77周,故马来微丝蚴在沙鼠外周血液中的最长寿命不短于7.5月,而在腹腔液内的最长寿命可超过1.5年以上。     

Peripheral arteriosclerosis; arterial grafting procedures; indications and results. I. Arteriosclerotic aneurysms

In 32 cases aneurysms of the aorta and peripheral arteries were resected and replaced by grafts. The results from the use of homografts in 18 cases were more satisfactory than with the use of Ivalon in 14 cases. The abdominal aorta was the most frequent location of aneurysms. The current mortality rate of 5.5 per cent for resection of unruptured abdominal aneurysms indicates that resection and grafting are an effective means of reducing the high mortality of untreated aneurysms. Five ruptured aneurysms were excised, with a mortality rate of 40 per cent. The uniformly fatal outcome of untreated ruptured abdominal aneurysms makes it obligatory for the surgeon to operate immediately after the diagnosis is first made.