The LeVeen Peritoneojugular Shunt in the Treatment of Ascites (De peritoneojugulaire shunt volgens LeVeen voor de behandeling van ascites). R.J. T.H. Ouwendijk, S.W. Schaim, A. G.C. Bauer and others. Ned. Ti/dschr. Geneeskd., 1982, 126: 940-943.
SEVEN PATIENTS with cirrhosis and ascites were treated with implantation of LeVeen peritoneo­jugular shunts. All patients had diuresis, lost weight and had the circumference of their abdomen diminish. Two patients had disseminated intravascular coagulation develop, two became febrile from bacterial infection, and two had fever of undetermined origin.
Four patients died within six months. Three are alive with much improved health six to 33 months after the implantation. The LeVeen shunt appears to be valuable for some patients with cirrhosis and refractory ascites if complications can be prevented.
William B. Callagher

Late Mortality After Surgery for Peptic Ulcer. A.Hugh McLean Ross, Michael A. Smith, John R. Anderson and William P. Small. N. EngL J. Med., 1982, 307: 519-522.
IN THIS REPORT from Edinburgh, the authors assail the prediction that the introduction of parietal cell vagotomy will lead to a longer life expectancy for patients with peptic ulcer because the procedure is associated with fewer late complications. Men between 30 and 59 years old undergoing operation for ulcer in a single hospital from 1947 to 1965 were studied. Patients were excluded from the study if death occurred within one year of operation, if only a simple closure was performed or if the ulcer recurred. Of the 779 patients reyiewed, 600, 86 per cent, had some form of gastrectomy, while the remainder had some form of drainage with or without vagotomy. The patients were divided into cohorts by age those patients 30 to 39 years old at operation, those 40 to 49 years and those 50 to 59 years and actuarial survival curves were prepared. These were compared with appropriate life table figures.
Indeed, the survival curves were less than those of the general population for all three decades. The mean curve displacement was slightly over nine years. However, the causes of death seemed to have little to do with the kinds of excess mortality which might be anticipated after an operation for ulcer. For example, the incidence of carcinoma of the stomach was actually less than that predicted, although the decrease was without statistical significance. In fact, the increase in mortality correlated best with disease related to smoking and reflected the disproportionately high number of smokers in the population with ulcer, 83 per cent. Deaths resulting from suicide, carcinoma of the colon and cirrhosis which could not be easily related to smoking increased significantly.
Thus, mortality among patients treated surgically for peptic ulcer increased, but the increase cannot be attributed directly to the operation and only indirectly to the ulcer diathesis. It is concluded that the introduction of parietal cell vagotomy will not improve the length of survival because 80 per ent of patients with ulcer today smoke.
Ronald C. Merrell

Primary Cancer of the Small Bowel; Review of a 40-Year Experience in a Community Hospital and of a 10-Year Experience in All of the Hospitals in Monroe County. Raymond J. Lanzafame, Jean E. Long and J. Raymond Hinshaw. N Y. State.J.Med., 1982, 82: 1325-1329.
PRIMARY malignant lesions of the small intestine account for only 1 per cent of all instances of carcinoma of the gastrointestinal tract. Patients presented with chronic symptoms of a duration of two months or more, and 53 per cent compplained of pain, 37 per cent of nausea and 28 per cent of weight loss. Results of laboratory examination revealed anemia in 38 per cent and elevated alkaline phosphatase levels in 48 per cent. Series of roentgenograms of the upper gastrointestinal tract and results of follow-through studies of the small intestine were diagnostic for 72 per cent of the patients, and endoscopic results were diagnostic for 80 per cent. Adenocarcinoma was most common, and carcinoids were second. Synchronous or metachronous primary lesions were present in 18 per cent of the patients withmalignant diseases of the small intestine and in 14 per cent of the patients with carcinoma of the colon. The over-all five year survival rate was 43 per cent.
Robert K. T. Liem

Endoscopy in X-Ray Negative Dyspeptic Patients; Study of 300 Cases. Mustaea M. Shennak, Ahrnad Armouti, Musleh S. Tarawneh and Samir S. Amr. .J. Kuwait Med. Assoc., 1982. 16: 77-84.
THE AUTHORS report upon 300 consecutive endoscopic procedures of the upper gastrointes. tinal tract which were performed upon Jordanian patients with dyspepsia: Dyspepsia is defined as pain or discomfort following meals. All patients had undergone singlç contrast roentgenographic procedures of the upper gastrointestinal tract within seven days of the endoscopic procedure, and those roentgenograms had been reported as normal. Endoscopic findings with pathologic examination of biopsy material were abnormal in 206 patients, 69 per cent. Gastritis, duodenal ulceration,duodenitis, esophagitis and gastric ulceration were the most frequent findings. Two patients were found to have adenocarcinoma of the stomach. The authors believe that these findings justify their recommendation for endoscopic procedures upon all dyspeptic patients.
BruceA. Buck

Incidence of Local Recurrence After Curative Operations for Cancer of the Rectum. J. Tonak, F.P. Gall, P. Hermanek and T.H. Hager. Aust. N. Z .J. Surg., 1982, 52: 23-26.
THE INCIDENCE of local recurrence following resection of carcinoma of the middle portion of the rectum was investigated in this study of 248 patients who underwent apparently curative operations. The over-all local recurrence rate of 21 per cent was not related to the type of procedure performed -abdominoperineal resection or low anterior resection-providing the margin below the tumor was at least 3 cm. in patients undergoing the low anterior resection.
The pattern of growth of the primary tumor was significant; ulcerating lesions had a recurrence rate of 23 per cent, as compared with 6 per cent for exophytic lesions. Lesions limited to the muscularis propria recurred locally in 12 per cent of the patients, whereas those penetrating into the subserosa or perirectal tissues recurred in 21 per cent. The presence of metastases to the lymph nodes significantly in-creased the rate of recurrence from 17 to 33 per cent.
Thomas W. Newsome

Antibiotic Management of Surgically Tested Cangrenous or Perforated Appendicitis; Comtamicin and Clindamycin Versus Cefamandole Versus Cefoperazone. Thomas V. Berne, Albert W.Yellin, Maria D. Appleman and Peter N.R. Heseltine.Am. .J. Surg., 1982,144.8-13.
ONE HUNDRED AND THIRTY PATIENTS with gangrenous or perforated appendicitis were entered into a randomized, double blind study so that the clinical and bacteriologic efficacy of cefamandole or cefoperazone as sole agents could be compared with the efficacy of clindamycin and gentamicin. Only minor side-effects were noted in patients in all three groups. The thera. peutic efficacy of the antibiotics was evaluated by comparing certain factors that suggested continuing infection. These factors included the duration of fever for more than six days after operation and the number of days after operation without oral alirnentation. Other criteria included wound infection, intra.abdominal abscess and clinical sepsis. The results of this study reveal that the combination of clindamycin and gentamicin is clearly more advantageous than either cefamandole or cefoperazone for preventing infectious failure.
Gerald T. Ujiki

The Role of Internal Sphincter in Chronic Anal Fissures. Herand Abcarian, Shanmugam Laksh­manan, Don R. Read and Peter Roccaforts. Dis. Colon Rectum, 1982, 25: 525--528.
EIGHT PATIENTS with chronic anal fissures were studied with a manometric pressure device before operation and six individuals who served as control patients. The patients were studied when they were in the left lateral decubitus position, and simultaneous pressure recordings were obtained at the level of the internal and external sphincters by means of a double balloon device with twoseparate compartments. A third balloon was placed in the rectum to determine the effect of rectal distention upon sphincteric pressure. Among the patients with fissure in ano, the preoperative resting pressure at the internal sphincter level ranged from 50 to 105 mm. Hg, as compared with 40 to 110 mm. Hg pressure among the control patients. The postoperative resting pressures at the internal sphincter level ranged from 50 to 85mm Hg. The results showed no appreciable difference between the resting internal sphincter pressures of patients with anal fissures and those of the control patients.
Distention of the rectum produced relaxation of the internal sphincter and a brief contraction of the external sphincter; this response was obtained in both patients with fissures and control patients. The therapeutic effect of sphincterotomy is postulated to be related to anatomic widening of the anal canal, which may allow the healing of fissures and pain-free defecation.
Frederick W. Preston

Course and Prognosis After Colectomy and ileostomy for Inflammatory Bowel Disease in Child­hood and Adolescence. Jeffrey S. Hyams, Richarçl J. Grand, Arnold H. Colodny and other. J.Pediatr. Surg., 1982, 17: 400-405.
A REVIEW was done of the hospital records of 32 patients who were nine to 21 years old underwent colectomy and ileostomy for inflammatory bowel disease. These patients were 13 per cent of the patients with this diagnosis during the 16 year study period. Eighteen patients had ulcerative colitis, and 14 patients had Crohn’s disease. No significant differences between the patients in the two groups were found regarding age at the onset of symptoms, duration of disease before operation or age at the time of ileostomy. Proctocolectomy was performed upon 72 per cent of the patients with ulcerative colitis and 64 per cent of those with Crohn’s disease. No patient with Crohn’s disease had gross or histologic disease III the nonresected small intestine. Postoperative complications occurred with equal frequency among patients with ulcerative colitis and Crohn’s disease. Formation of abscess was the most common complication.
The mean follow-up interval for patients in each group was five years.Importence did not occur in any of the six sexually active males who underwent proctocolectomy. Only patients with Crohn’s disease, 42 per cent, had recurrence of disease which was documented histologically or radiologically. These patients required additional ileal resection and creation of a new ileostomy. The presence of ileal disease at the time of colectomy was associated with a poor prognosis; five of seven such patients had recurrent disease compared with one of six patients who had disease initially limited to the colon. All four long term survivors with ulcerative colitis in whom the rectum was preserved ultimately underwent proc­tectomy. Three of the five patients with Crohn’s disease whose rectum was spared had subsequent proctectomy. Eighty per cent of the patients described a sense of relief after operation. Over-all, 75 per cent of the patients believed the quality of life was improved by colectomy and ileostomy. All seven patients with a disease interval before operation of more than five years noted an improved quality of life.
Clayton H. Shatney

Intussusception in Adults; an Analysis of 92 Cases. Lou Chuijun. Chinese Med. J., 1982, 95: 297-300.
AIR CONTRAST STUDY under fluoroscopic guidance was used for the diagnosis and treatment of adult patients with suspected intussusception at or distal to the ileocecal region. Insufflation of air at 60 to 120 mm. Hg was used to relieve the intussusception. The radiographic recognition of various types of intussusception are discussed.
Ninety-two patients with intussusception were analyzed. Thirty who did not undergo ro entgenographic examination were operated upon. Of the remaining 62 patients available for air contrast studies and reduction, 38 were treated successfully, while the other 24 required operation. Results of air reduction showed that the rate of cure was greatest among those patients whose intussusception was of one to three days of duration, 87.88 per cent; the cure rate fell off dramatically to 30.77 per cent for patients who had a duration of the three to six days and 31.25 per cent for those with a duration of seven days.
It is concluded that nonoperative reduction is feasible if organic lesions are ruled out and if patients with complications from intestinal obstruction or perforation are excluded from the procedure. The air contrast method is described to be safer, more effective, simpler and less expensive than barium enema.
Albert Barrocas

Prognosis in Patients with Obstructing colorectal Carcinoma. UEf Ohhman. Am.J. Surg., 1982, 143: 742-747.
A RETROSPECTIVE\\ STUDY was undertaken to analyze the management and outcome of patients with complete obstruction secondary to carcinoma of the colon and rectum and to elucidate the reasons for the poor outlook for these patients. Patients undergoing emergency operation for obstruction were compared with patients undergoing elective surgical treatmeht for nonobstructing lesions. The variables included age, sex, location and stage of the tumor, curability rate, surgical management and length of survival.
Complete obstruction was encountered in 14 per cent of the 1,072 patients studied. The highest incidence of obstruction occurred in the sigmoid, transverse and descending colon. The over-all five year survival rate was 16 per cent for patients with obstruction and 37 per cent for those with nonobstructing lesions. Among patients who underwent resection for cure, rather than palliation alone, the survival rate was 31 per cent for those with obstructing lesions and 50 per cent for those with nonobstructing tumors. The survival rate for patients with obstructing lesions was 19 per cent after resection of the primary lesions and 35 per cent after staged resection. Only 12 per cent of potentially curable obstructing lesions were classified as Dukes’ A tumors, whereas 50 per cent were Dukes’ C lesions; approximately one-third of the nonobstructing lesions were Dukes A, and one-third were Dukes’ C.
It is concluded that patients with obstruction of the large intestine secondary to carcinoma of the colon and rectum have low curability and survival rates primarily because of advanced disease at the time of treatment and diagnosis. Survival rates within tumor stages did not differ between the groups of patients; the difference in outcome was mainly a result of patients with obstructing lesions having fewer Stage A and more Stage C Lesions.
Philip W. Susann

The Unnecessary Laparotomy for Appendicitis- Can It Be Decreased? Ernest L. Dunn, Ernest E. Moore, Steven C. Elerding and James R. Murphy. Am. Surg 1982, 48: 320-323.
RESULTS of multiple reports indicate a diagnostic accuracy rate of 67 to 80 per cent for acute appendicitis, and no significant improvement in this rate has occurred during the past 25 years. The authors reviewed 434 patients who had a preoperative diagnosis of acute appendicitis during a period of five years.
The over-all diagnostic accuracy for appendicitis was 75 per cent; an additional 4 per cent of the patients had additional acute disease requiring a surgical procedure. From results of 21 per cent of the laparotomies, no disease was discovered. Menstruating female patients had the greatest rate of unnecessary laparotomies, 35 per cent, and were the focus of the analytic study of the authors. Anorexia, nausea, vomiting and pain in the right lower quadrant and a high white blood count were more frequent in the female patients with acute appendicitis who were 13 to 40 years old, but the cross-over of symptoms was significant.
The subset of patients who had a preliminary diagnosis of acute appendicitis and were menstruating females had a low rate of perforated appendixes, 17 per cent, compared with 32 per cent of pediatric patients and 50 per cent of geriatric patients who had such a diagnosis. Extensive preoperative re-examinations, diagnostic barium enema studies and diagnostic laparoscopic examinations have been suggested as ways to decrease the number of unnecessary laparotomies when the results of history, initial physical examinations and laboratory studies of ovulating females are inconclusive. Geriatric and pediatric patients, on the other hand, merit an aggressive operative approach to minimize the incidence of perforation
Albert Barrocas

Effect of Highly Selective Vagotomy on Pancreatic Exocrine Function and on Cholecystokinin and Gastrin Release. N.I. Ramus, R G. N. Williamson, J.M. Oliver and D. Johnston. Gut, 1982, 23: 553-557.
THE INTRODUCTION of highly selective vagotomy for the treatment of duodenal ulceration has greatly reduced the incidence of dumpting, diarrhea and steatorrhea. The effectiveness of highly selective vagotomy upon pancreatic exocrine function and the release of gastrin and cholecy stokinin were studied. Concentrations of both cholecystokinin and gastrin in serum increased significantly. Amylase concentration in the duodenal aspirate increased significantly, but trypsin concentration remained unchanged. The expected reductions in secretion of gastric acid were noted. Thus, highly selective vagotomy reduces acid secretion without impairing the exocrine function of the pancreas.
Robert K T. Liem