July 1985, Volume 35, Issue 7

Case Reports

Selected Abstracts

Treatment of Carcinoma of the Gallbladder in Japan. Seiki Tashiro, Toshimitsu Konno, Mizuho Mochinaga and others. Jpn. .J. Stag., 1982, 12: 98-104.
ONE HUNDRED surgical institutes were contacted, and the records of 2,567 patients with primary carcinoma of the gallbladder were reviewed. The patients had been treated during the past 19 years. Eighty-seven per cent were over 50 years old. Women exceeded men by a ratio of 2:1. Gallstones were present in 59 per cent.
Radical resection, ranging from simple cholecystectomy to extended right lobectomy or pancreaticoduodenectomy, was performed upon 21 per cent of the patients for a five year survival rate of 45 per cent. However, the preoperative diagnosis was made of only 77 of these patients, 16 per cent. Results of angiography were diagnostic for 37 patients, percutaneous transhepatic cholangiography for 21, endo scopic retrograde cholangiography for 13, ultrasonography for 12 and laparoscopy for nine. All patients whose cancer had spread through the muscle layers of the gallbladder had metastases to the lymph nodes. It is concluded that earlier diagnosis is necessalty, and this requires auxiliary procedures, angiography in particular. If no peritoneal seeding is present, more radical surgical procedure, including right hepatectomy and pancreaticoduodenectomy, should be undertaken.
Raymond C Read

Infective Complications After Choledochotomy; Incidence After T-Tube Drainage of the Common Bile Duct or After Choledchoduodenostom. N.J. Lygidakis. JR. Coil. Surg. Edinb., 1982, 27: 233-237.
ONE-HUNDRED AND EIGHTY-TWO consecutive patients from Athens, Greece, were reviewed. These patients underwent positive exploration for stones of the common bile duct between the years 1974 and 1980. The mean age of the 120 women and 62 men was 67 years. One hundred patients whose common bile duct measured greater than 1.5 cm. in diameter underwent drainge of the common bile duct by choledochoduodenostomy. The 82 patients whose bile duct was less than 1.5 cm. in diameter had drainage by a T tube at the completion of the procedures.
Samples of bile were removed for culture during each operation, and positive bile cultures corresponded with postoperative infective complications to a high degree. Prophylactic anti­biotics consisting of gentamicin were given to all patients 12 hours before operation and three times daily for the first four to five days after operation. Cultures were taken from both the gallbladder and the common duct and were processed aerobically and anaerobically. Of the patients who had choledochoduodenostomy at the closing procedure, 60 per cent had positive bile cultures, and of these, 12 per cent had wound infections, with 2 per cent demonstrating bacteremia; the over-all infection rate was 15 per cent. Of the 82 patients who had drainage of the common bile duct by a T tube, 33 per cent had positive bile cultures, 11 per cent had wound infections and 20 per cent had bacteremia, an over-all infection rate of 60 per cent. None of the patients who underwent choledochoduodenostomy died, and the mortality was 2.5 per cent among those patients with T-tube drainage.
It is noted that choledochodenostomy was associated with a low mortality despite the higher incidence of biiary infection in the group of patients who underwent the procedure. The author believes that the immediate free drainage established by choledochoduodenostomy and exogenous acquisition of environmental organisms may explain the high rate of infective morbidity after operation among patients with drainage by a Ttube.
W.Clayton Davis

Elective Splenectomy-. a Comparison of Management in Children and Adults. A. Alwmark, B. Edwards, 1. Hohuin and C.M. Kullendorff. Ann. Chir. Gynaecol., 1982, 71: 108-111.
IN THIS STUDY from the University of Lund, Sweden, the authors attempt to define the dif­ferences between the management of elective splenectomy in children and its management in adults. Between 1969 and 1979, 39 children and366 adults underwent elective splenectomies. Among the adults, indications included blood diseases and lymphoma in 46 per cent, Hodgkin’s disease in 41 per cent and pancreatitis in 8 per cent. The indications for the children included blood disease and lymphoma in 61 per cent and Hodgkin’s disease in 21 per cent. Sex distribution, blood loss, drainage procedures and length of hospital stay were similar in both groups of patients. When hemostasis was complete, drainage could be avoided. Pediatric surgeons preferred subcostal incisions, and the surgeons of the adult patients preferred longitudinal incisions. Early ligation of the splenic artery above the pancreas and careful search for accessory spleen were advised for both groups of patients.. Two adults and one child had infection develop after splen­ectomy, which prompted the authors to emphasize the necessity of the preoperative administration of pneumococcal vaccine.
John H Wuslin

Splenectomy for Myelofibrosis. H. Jarvinen, E. Kivilaakso, E. Ikkala and others. Ann. Clin. 1982, 14: 66-71.
ThE MAJOR SYMPTOMS of myelofibrosis that require treatment include anemia, thrombocy­topenia, pressure symptoms from the enlarged spleen and portal hypertension. When patients present with these symptoms, splenectomy is commonly recommended. Because operation is associated with a significant risk of complication, the authors studied the role of splenectomy performed soon after the presentation of hematologic symptoms.
Thirty consecutive patients who underwent splenectomy for the aforemçntioned symptoms were studied. The operative mortality was 6.7 per cent. Thirty-seven per cent of the patients had postoperative complications. When operation was undertaken within one year of the diagnosis, th postoperative morbidity rate was 13.0 per cent. Among those patients who underwent operation late in the course of the disease, the corresponding morbidity rate was 67.0 per cent.A similarly significant difference was observed in the amount of intraoperative blood loss. Seventy-nine per cent of those patients operated upon for anemia or thrombocytopenia received a definite benefit from splenectomy for a period of two to 70 months, a median of ten months. Even though length of survival was, not shown to be increased by early splenectomy, it is believed that the decrease in intraoperative and postoperative complications found in this study warrant performing splenectomy upon patients with myelofibrosis as soon as cytopenia s present.
Bruce A. Buck

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