TRACHEOTOMY IN CHILDREN—A Controlled,Planned Emergency Procedure

The value of tracheotomy as a life-saving operation has been increased greatly in recent years by a broadening of the indications for its use. It is made safer for the patient by performing it reasonably early, and, in any event, under planned emergency conditions. The first is made possible by experience and judgment in choosing the time, mainly from close observation of the patient; the second by preceding the operation with tracheal intubation. Meticulous post-operative care is of great importance.     

DERMABRASIVE ABLATION OF ACNE SCARS

Dermabrasion offers cosmetic improvement of acne pits and scars, but only well-adjusted patients should be selected for this esthetic improvement. In the dermabrasion operation the deep cup-shaped pits are made shallow by saucerization, for the deep sharp shadows are eliminated as the pits are shallowed. It is the elimination of the shadow effect which is so gratifying to the patient.Although dermabrasion is a superficial skin operation, it involves dangerous instruments and thousands of minute incisions. The procedure is a surgical operation, whether done in an office or in a hospital. The author performs the operation entirely as a hospital procedure, using pentothal anesthesia with meperidine added in small increments during the operation. Thus the operation may be unhurriedly and meticulously performed.     

Accuracy of hospital activity analysis operation codes.

The accuracy of operation codes on hospital activity analysis printouts has been compared with unit and patient records. Inaccurate information is being provided by the hospital activity analysis in a significant number of cases. The same mistake is often repeatedly made, suggesting deficient monitoring procedures. These lapses occurred despite a unit policy of medical staff entering the operation and diagnostic details on the HMRI(IP) sheet and the checking of all entries by a consultant.     

PALLIATIVE TREATMENT OF PROSTATISM

A study of 310 patients with prostatism who were not operated upon within a month following the first examination, was made in an effort to determine indications for operation in the patient with mild symptoms of prostatism. This study showed that long duration of symptoms, residual urine of more than 60 cc. and enlargement of the gland beyond Grade I are criteria for the necessity of operation. Palliative treatment is not always indicated. Patients with a soft, boggy prostate and those with more than a slight amount of infection in the prostate are benefited by light prostatic massage once weekly and stilbestrol given in doses of 1 mg. twice daily. Severe infection is treated by chemotherapy and bladder irrigations.     

Severe Colonic Bleeding

Patients requiring emergency operation for severe acute colonic hemorrhage usually arrive in the operating room inadequately studied and the point of bleeding not known. A well planned procedure for making an operative diagnosis is lacking.The fact that diverticular disease is the most common cause of massive colonic bleeding, dominates the surgical management of this problem. A critical interpretation of the color and the consistency of the stools must be made by the surgeon. Since the bleeding lesion is usually otherwise clinically silent, the character of the stools may be the only indication of the level of bleeding and the rate and the amount of the blood loss. A proctoscopic examination, followed by an emergency barium enema study if possible, is always done before subjecting a patient to laparotomy.The indications for emergency operation include acute exsanguinating hemorrhage, less severe but persistent colonic bleeding and recurrent colonic bleeding. The steps for the operative diagnosis and the surgical procedure utilized for a specific situation are discussed.     

ABSENCE OF THE LEFT PERICARDIUM, SPONTANEOUS PNEUMOTHORAX, AND PATENT DUCTUS ARTERIOSUS

A 19-year-old male patient with congenital absence of the left pericardium, spontaneous pneumothorax, and a patent ductus is presented. The diagnosis of absence of the left pericardium was made at operation but should have been entertained preoperatively because of the concomitant occurrence of a left spontaneous pneumothorax.     

COMBINED CORRECTION OF TETRALOGY OF FALLOT AND CORONARY ARTERY OCCLUSIVE DISEASE: CASE REPORT

A 49-year-old patient with known tetralogy of Fallot for which an aortopulmonary anastomosis (Pott's shunt) had been performed 23 years previously, underwent simultaneous myocardial revascularization for severe coronary occlusive disease and total correction of his congenital anomaly. The operation and postoperative course were uneventful, and he made a full recovery.     

Primary tuberculosis of the parotid gland

A very unusual presentation of Mycobacterium tuberculosis in the parotid gland substance is described to suggest reexamination of the place of tuberculosis in the differential diagnosis of a parotid mass. In this patient, diagnosis was made postoperatively only by histologic examination of the excised specimen. When M. tuberculosis etiology is suspected, either clinically or at operation, culture confirmation should be tried, and a Mantoux test should be performed to complete the investigation.     

PROBLEMS IN VENTILATION IN THE IMMEDIATE POSTOPERATIVE PERIOD

In the present day practice of surgical anesthesia, drugs and techniques are used which require or lead to cessation of voluntary respiration by the patient. Respiration is then controlled by the anesthesiologist. At the termination of operation many patients do not breathe adequately for variable periods of time. The causes include obstruction, excessive sedation, muscle relaxants, the effect of controlled respiration itself and various miscellaneous factors. A diagnosis is made by taking into consideration the drugs and techniques which have been used and the character of the patient''s respiratory efforts, if any. The cause may then be treated. In some cases antidotes are available. However, until truly adequate spontaneous respiration is observed for some time the patient must have his efforts assisted. High oxygen concentrations must not be substituted for adequate ventilation.     

CARCINOMA OF THE COLON

In a study of statistical data on 1,215 patients with carcinoma of the colon observed at a university hospital in a twenty-year period, it was noted that the overwhelming majority of patients who were living five years after operation had had no demonstrable extension to lymph nodes at the time of operation. In an increasing proportion of cases in the latter years of the period, diagnosis was made before the lesion was beyond an operable stage.What with today''s better surgical techniques that make it possible to adapt operation to a variety of situations that may be encountered when the diseased area is visualized, and with better methods of preparing a patient and of sustaining him during operation, the wide excision so often necessary for cure may now be carried out deliberately and without hurry.The site of the lesion has great bearing on the prognosis, owing to the limits upon the extent of operation in some locations as against the possibility of wide excision of the original lesion and areas of metastasis in others.     

Carcinoma of the colon

In a study of statistical data on 1,215 patients with carcinoma of the colon observed at a university hospital in a twenty-year period, it was noted that the overwhelming majority of patients who were living five years after operation had had no demonstrable extension to lymph nodes at the time of operation. In an increasing proportion of cases in the latter years of the period, diagnosis was made before the lesion was beyond an operable stage. What with today's better surgical techniques that make it possible to adapt operation to a variety of situations that may be encountered when the diseased area is visualized, and with better methods of preparing a patient and of sustaining him during operation, the wide excision so often necessary for cure may now be carried out deliberately and without hurry. The site of the lesion has great bearing on the prognosis, owing to the limits upon the extent of operation in some locations as against the possibility of wide excision of the original lesion and areas of metastasis in others.     

SURGICAL MANAGEMENT OF THE INJURED LARGE BOWEL

Many of the observations made in the management of large bowel injuries during World War II are applicable to similar cases encountered in civilian practice.Early administration of whole blood to combat shock cannot be overemphasized.The patient should be adequately examined for associated injuries.Ether-oxygen is the anesthetic agent of choice, and a closed technique should be used.Vertical incision offers the best exposure for the operation and is most rapidly performed.The surgical principles of exteriorization and/or a proximal colostomy to completely divert the fecal stream are the important features in the technical management of the injured large bowel.A method of colostomy closure is presented.     

Intestinal obstruction

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus. Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation. Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

INTESTINAL OBSTRUCTION

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus.Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation.Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

Prediction of Hypothyroidism after Partial Thyroidectomy for Thyrotoxicosis

Hypothyroidism is one of the major complications after thyroidectomy for thyrotoxicosis, but the factors responsible are not well defined. In an attempt to define these factors 278 patients operated on in 1965-9 were studied in detail. The overall incidence of hypothyroidism was 49%. The high incidence of hypothyroidism during 1965-6 led to a policy of leaving larger remnants in the later years of the study, and it became apparent that the most important aetiological factor in postoperative hypothyroidism was small remnant size. There seemed to be an association between the incidence of hypothyroidism and the presence of antithyroglobulin antibodies, but this association was not statistically significant. The data suggested that blood group O might be more common and blood group A less common in hypothyroid patients. The incidence of hypothyroidism seemed to be uninfluenced by the age or sex of the patient, the size of the gland, or the amount and duration of preoperative antithyroid drug therapy.Though a reasonable prediction of the incidence of hypothyroidism can be made for a group of patients on the basis of remnant size, the fate of the individual can be predicted only within very wide limits. An indication of the future status of the individual patient at one year and subsequently does, however, seem possible from serum protein-bound iodine estimations at one and four months after operation. Hypothyroidism developing later than one year after operation has not been observed in this series. The ability to assess thyroid status early after surgery is of some merit in the long-term supervision of the postoperative thyrotoxic patient, and in this respect surgical treatment seems to have some advantage over radioiodine therapy.     

男性尿道直肠瘘数字化三维重建的初步应用

目的：基于CT扫描图象建立精确的男性尿道直肠瘘数字化模型,探讨其在临床诊断及治疗中的应用。方法：选择1例男性尿道直肠瘘病例,进行尿道CT连续断层扫描,扫描结果导入Mimics软件中进行三维重建,利用三维重建模型指导临床。结果：建立男性尿道直肠瘘及周围结构的三维立体模型,可以方便地从任意角度和方向观察瘘管情况,测量有关的数据;还可以在数字化模型上进行手术设计。结论：男性尿道直肠瘘的数字化三维模型能够更直观、准确地反映病变部位的三维立体结构。对男性尿道直肠瘘的诊断、手术规划等有较大帮助。     

女性尿道阴道瘘数字化三维重建在临床治疗中的初步应用

目的:基于CT扫描图象建立精确的女性尿道阴道瘘数字化模型,探讨其在临床诊断及治疗中的应用。方法:选择1例女性尿道阴道瘘病例,进行尿道CT连续断层扫描,扫描结果导入Mimics软件中进行三维重建,利用三维重建模型指导临床。结果:建立女性尿道阴道瘘及周围结构的三维立体模型,可以方便地从任意角度和方向观察瘘管情况,测量有关的数据;还可以在数字化模型上进行手术设计。结论:女性尿道阴道瘘的数字化三维模型能够更直观、准确地反映病变部位的三维立体结构。对女性尿道阴道瘘的诊断、手术规划等有较大帮助。     

TRANSECTION OF THE PANCREAS BY BLUNT TRAUMA

If a diagnosis of traumatic pancreatitis is made and the patient does not improve clinically during the first 24 hours, transection of the pancreas should be suspected. If this is found to be the case at operation, the distal pancreas should be resected and the proximal end of the pancreas closed carefully with interrupted mattress suture of non-absorbable suture material. Particularly, the pancreatic duct should be ligated to prevent the formation of an external fistula. Any attempt at reapproximation of the transected pancreas will invariably result in an external pancreatic fistula if the patient survives the immediate postoperative period.     

A method for self-assessment of disability before and after hip replacement operations.

A standardised form was developed to review the daily problems suffered by patients with arthritis of the hip and provide clinicians with information for planning treatment and in judging subsequent progress. The reports made by various patients in a preliminary study provided 81 statements on pain, restricted movements, and restricted activities that were then tested to identify the most reliable. The responses of 32 patients waiting for hip replacements and 66 patients who had undergone operation were compared with independent assessments of pain and physical limitations. The 33 statements eventually selected were chosen mainly on the basis of their sensitivity to differences between preoperative and postoperative patients and their correlation with the independent assessments. The final questionnaire provides a valid and concise summary of a patient''s disabilities and is simple enough for the patient to complete while waiting to see the doctor.     

Splenic peliosis – a potentially fatal condition which can mimick malignancy

Isolated splenic peliosis is an extremely rare occurrence, and this disease often manifests itself with spontaneous haemoperitoneum.We report a case where an otherwise healthy patient was found to have splenomegaly on clinical examination. On computerised tomography, a diagnosis of splenic malignancy was made, and the patient underwent a splenectomy. Histological examination gave the diagnosis of splenic peliosis, which had not been considered prior to the operation. In retrospect, splenectomy was the most prudent course of action, as the risk of spontaneous haemorrhage and fatality was eliminated. This case emphasises the need to retain an index of suspicion for this condition, even in otherwise healthy patients, and is a reminder of the usefulness of total splenectomy in the current era of minimally invasive diagnostic techniques.