Search

The value of decompression of the stomach and small bowel by means of nasal tubes passed into these organs has been proved in the treatment of paralytic ileus and the various types of peritonitis. Stricture of the esophagus is seen occasionally when nasal tubes have been kept in place for several days. A commoner complication is seen in persons who have bronchiectasis, chronic rhinitis, upper respiratory tract infection, or a poor cardiac reserve. With the use of a nasal tube in such patients, postoperative collapse of the lung or bronchopneumonia is a constant danger. Aged and debilitated patients may have a poor cough reflex, and, following laparotomy, it is often necessary to remove the nasal tube to give the patient a much needed rest and to keep the airways clear of mucus. When performing a laparotomy in such patients, I have used the following maneuver with great success (see the

• Two varieties of surgical operation are applied to high-lying gastric ulcers. One consists in resecting the ulcer (if it is on the lesser curvature) with all or part of the lesser curvature and a sufficient part of the greater curvature to give a two-thirds resection; this is followed by repair according to either the type 1 or type 2 Billroth operation. The other consists in leaving the ulcer undisturbed, resecting the distal one-half or two-thirds of the stomach, and concluding according to either the Hofmeister or the type 1 Billroth operation; the ulcer heals without trouble in most instances. Both varieties of operation have given excellent long-term results. In either case, specimens of tissue must be obtained and examined for malignancy, which is the greatest problem in the treatment of high-lying gastric ulcers. The unexpected finding of malignancy by microscopic examination is most common in small ulcers. Concomitant gastric and duodenal ulcers are frequent, and among 98 cases of this kind there was marked retention. When obstruction occurs it must be relieved. The temporary insertion of a gastrotomy tube for feeding is to be considered if obstruction is severe, and a posterior gastroenterostomy may be advisable in poor-risk patients.

Surgeons have been reluctant to perform ileostomy for intractable ulcerative colitis in young women because the existence of the ileostomy was believed to militate against pregnancy and subsequent parturition. This belief is unsettled by a study of seven patients with ileostomy and colectomy. In all there were 13 subsequent pregnancies, of which 3 terminated in early spontaneous abortions while 10 went on to term and resulted in live births. In 9 of the 10 term pregnancies the patient was delivered per vaginam, and only one had to be delivered by cesarean section. There was no maternal mortality. In the past, unpredictable exacerbations of ulcerative colitis have been a serious danger in pregnancy. The experiences here recorded show that young women with otherwise intractable colitis can be treated by ileostomy and colectomy without fear of subsequent inability to bear children.

• Experience with 189 patients aged 70 years or older undergoing major abdominal surgery is analyzed as to factors affecting the prognosis and safeguards to be recommended. The largest group consisted of 109 patients operated on for diseases of the colon and rectum, and the operation most frequently required in this group was intestinal resection. The commonest cause for emergency surgery in aged patients was massive gastrointestinal hemorrhage necessitating gastric resection. In the 21 patients who died, the most frequent cause of death was pulmonary embolism and the second most frequent was chronic infection. Elderly patients did not tolerate chronic infections, and emergency operations carried a much higher risk than did elective surgery, but in general neither age nor sex, nor coexisting chronic cardiovascular, pulmonary, or renal disease, significantly altered the mortality rate. On the basis of this experience, a list of seven safeguards is stated that have materially reduced the mortality and morbidity rates in the aged patient.

It is generally conceded that in spontaneous hypoglycemia of islet cell origin a surgical attack on the pancreas, designed to remove the hyperfunctioning incretory tumor, remains the therapy of choice. However, the need for accurate medical management is of great importance during the preoperative period, and it becomes of paramount importance when prolonged medical therapy is necessitated by the rejection of a definitive operation by the patient or when the surgical risk is believed too great. Moreover, the progressive systemic effects of functioning metastatic islet cells lying beyond the scope of ablative surgery may provoke even a greater challenge to the physician despite an ultimate grave prognosis. Three cases of insulinoma (insulin-secreting islet cell adenoma) are reviewed. Although each patient was ultimately treated by surgery, 1 experimental observations were made during the preoperative and interim hospital course on the clinical response to dietary, alloxan, corticotropin (ACTH), and cortisone therapy. It