Gallbladder torsion is a rare surgical emergency occurring primarily in elderly women. The anatomical background is a variation in the attachment of the gallbladder to the inferior margin of the liver. Increasing life span will probably lead to an increasing number of cases, and gallbladder torsion must be kept in mind in patients with sudden onset of pain in the upper right quadrant, nausea, vomiting, and a palpable mass. None of the laboratory routines or noninvasive examinations enables one to make the right preoperative diagnosis. Treatment is cholecystectomy. Promptly treated, the prognosis is good.
Three cases of small-intestinal leiomyosarcoma are presented. The neoplasms were located within 50 cm from the ligament of Treitz and the only symptoms was severe recurrent gastrointestinal bleeding. All the tumours were demonstrated at mesenteric angiography and were removed by simple resection of the tumour-bearing segment.
Increase in intestinal blood flow was observed in a patient with postprandial hypotension. Simultaneous measurement of hemodynamic parameters and plasma levels of gut hormones revealed that the release of various vasoactive substances and resulting vasodilation of abdominal organs were responsible for the vasomotor changes of early dumping syndrome.
The need for drainage after primary thyroid or parathyroid surgery was evaluated in a prospective study in which 100 consecutive patients were randomly allocated to drainage or no drainage. Seroma developed in the wound in seven of the 50 patients without drainage and in two of the 50 with drainage. There were no residual effects of the seromas, which resolved spontaneously. The incidence of wound complication was unrelated to the surgeon's opinion on the need for drainage. The study provided no statistical report for routine use of drains in primary thyroid or parathyroid surgery.
Basal and ACTH-stimulated release of aldosterone and cortisol was studied in slices of adrenocortical adenomas and adrenal cortex from 16 consecutive patients with Conn's syndrome (n = 7), Cushing's syndrome (n = 5) or no signs of steroid hypersecretion (n = 4). Clinical data were reviewed and histologic examination was repeated. The adrenal cortex and all tumours but one (non-hyperfunctioning) secreted cortisol. Cortisol release increased after addition of ACTH in 13/15 tumours and all cortex slices. Aldosterone was secreted from the adrenal cortex in all patients and was increased by ACTH in 75% of the tissue specimens. Adenomas from patients with hyperaldosteronism showed the highest basal aldosterone secretion. This secretion was further increased by ACTH. Tumours from patients without signs of corticosteroid excess also released steroids and responded to ACTH. It is concluded that in vitro studies of steroids released from adrenocortical tumours contribute to their diagnostic and functional evaluation.
Of 483 patients treated by proximal gastric vagotomy (PGV) between 1972 and 1986 four (0.8%) developed lesser curve necrosis with perforation and one died of diffuse peritonitis. Gastroscopy 3-6 days after PGV in 26 patients between November 1985 and May 1987 showed that five had developed ischemic ulcers on the lesser curve (19%). One further patient developed lesser curve necrosis with perforation before endoscopy, giving a total of six lesser curve lesions after 26 vagotomies (23%). Endoscopy also showed that most patients had some gastric retention. Ulcers with maximal diameters of 0.4-2 cm were asymptomatic. One patient with a large ischaemic ulcer (3 cm) had an abrupt fall in haemoglobin concentration (from 148 to 73 g/l) as did two patients who developed lesser curve necrosis with perforation and peritonitis (143 to 93, and 159 to 71, respectively). We conclude that ischemic ulcers are relatively common after PGV, that small ulcers are asymptomatic and do not perforate, and that an upper GI bleeding after PGV strongly suggests that lesser curve necrosis has developed.
In a 60-year-old woman, endoscopic retrograde choledochography with sphincterotomy was followed by appearance of gas in the portal venous system. Venous bleeding was seen immediately after completion of sphincterotomy. The patient recovered well. Even in the absence of duodenal perforation, sphincterotomy may be complicated by hepatic portal venous gas.
The effect of metoclopramide on postoperative colonic ileus was evaluated in a randomised, double-blind study in 20 patients after cholecystectomy. The start of propulsive colonic motility and colonic transit time after operation were measured by radio-opaque markers and serial abdominal radiographs. Metoclopramide 20 mg given intravenously three times a day until the fourth postoperative day (n = 10) did not significantly reduce the duration of postoperative colonic paralysis compared with control patients (n = 10), nor were there any differences between the groups when the time of first postoperative passage of gas and faeces were compared. In conclusion, the use of metoclopramide in the postoperative period did not result in a quicker return of propulsive motility in the right or left colon as judged by the radio-opaque markers and serial abdominal radiographs.
One hundred and fifty-eight elective hepatectomies carried out between 1976 and 1989 for hepatocellular carcinoma were classified into three groups according to age: group I (n = 20) under 30 years of age; group II (n = 102) 30 to 60; and group III (n = 36) over 60. The number of operations carried out on patients in group III has increased since 1983, and the types of hepatic resection in the three different age groups were slightly but not significantly different. The incidence of small tumours (diameter less than 5 cm) and associated cirrhosis were relatively low in the younger patients. Postoperative complications developed in 4 patients (20%) in group I, 18 (18%) in group II and 8 (22%) in group III, the main ones being hepatic failure and intraabdominal sepsis. Operative mortality was 4%; one patient (5%) died in group I, 4 (4%) in group II, and 2 (6%) in group III, and the principal causes were hepatic failure and massive haemorrhage. Hepatic resection for hepatocellular carcinoma in most patients over 60 years old was associated with slightly higher operative morbidity and mortality, but the risks were such that we recommend that operation should not be denied to selected patients in this age group.
We adopted Wattenberg's definition of natural anticarcinogens: naturally occurring agents which prevent activation of precursors of carcinogens, interfere with the effect of carcinogens on target cells, or suppress or delay multiplication of cancerous cells. To accommodate flavonoids within this framework, a subgroup with unknown mode of action must be added. Natural anticarcinogens inhibit a variety of cancers in rodents as well as some malignant cell lines in vitro. Dietary natural anticarcinogens have not been shown to prevent or inhibit clinical cancer of humans. Neither has it been ruled out that the compounds may play a role in the continuous defense against cancer going on throughout life. The chemical composition of the natural anticarcinogens is extremely varied, suggesting the existence of a multitude of mechanisms by which the inhibition may be accomplished. In feeding experiments with rats it is possible to raise the concentration of the free anticarcinogen, quercetin, in the colonic content. In fact, levels 10 times above concentrations considered anticarcinogenic are easily achieved. The quercetin containing diet is well tolerated for a 6-month period.
Intra-arterial ultrasound is a new real-time imaging technique using a miniaturized transducer in a catheter to image diseased arteries. The small size and close proximity to the structures being imaged allow the use of frequencies from 20-40 MHz, resulting in high resolution images. In addition to the stenotic lumen, it is possible to examine the composition and eccentricity of the plaque, as well as structures outside of the vessel. Such information can be used for planning and evaluating vascular interventions. The addition of Doppler measurements allows the evaluation of function as well as anatomy. Research applications include studies of lesion progression, measurement of arterial elasticity, quantitative blood flow velocities and study of intra-arterial flow patterns. Although this technique is in its infancy, it is highly probable that it will prove to be a useful aid to the vascular surgeon.
