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Hypothesis Parastomal hernia is a common complication following colostomy. The lowest recurrence rate has been produced when repair is with a prosthetic mesh. This study evaluated the effect on stoma complications of using a mesh during the primary operation. Design Randomized clinical study. Methods Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. The mesh used was a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material. Results Twenty-seven patients had a conventional stoma, and in 27 patients the mesh was used. No infection, fistula formation, or pain occurred (observation time, 12-38 months). At the 12-month follow-up, parastomal hernia was present in 13 of 26 patients without a mesh and in 1 of 21 patients in whom the mesh was used. Conclusions A lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the stoma site is not associated with complications and significantly reduces the rate of parastomal hernia.

Stenosis of the tracheostoma following laryngectomy is not an infrequent complication. It may occur immediately after the operation, or it may develop years later. The stenosis, especially with the addition of crusting, can lead to an emergency situation, and can, on occasion, result in asphyxia. Careful construction of the stoma, oblique transection of the trachea, and removal of excessive fat and skin reduce the incidence of stenosis. In addition to the above, I feel that early omission of the tracheostomy tube (i.e., on the fifth to seventh postoperative day) is of value. Common causes of stenosis are: (1) excessive scar tissue (usually as a result of postoperative infection or fistula formulation); (2) keloid formation; (3) excessive fat around the stoma; (4) defec Fig. 1. A , skin flaps are elevated on each side of the stenosed stoma. B , scar tissue and fat are excised around the stomal orifice. C , if necessary

ONE OF the most distressing complications of laryngectomy is stenosis of the tracheostoma. This complication, which may occur at any time in the postoperative period, is most often seen months or years following surgery, although one sees constriction begin and progress rapidly in the first several postlaryngectomy weeks, particularly in patients who have had heavy preoperative doses of irradiation. It rarely presents as an emergency airway problem, but the progressive obstructive feature of this condition with its resultant compromised respiratory exchange can be a frightening experience for the patient. In addition, the patient who has a small stoma is usually required to wear some form of foriegn body in the stoma, generally a laryngectomy tube or "stomal button." Patients do not complain of a stoma being too large. In reviewing the literature, it is apparent that much more emphasis has been placed on the reconstruction of the microstomia than on

To the best of my knowledge there is no report in the literature of a perforation of the stomach or of the jejunum induced by the Wolf-Schindler gastroscope with a rubber finger tip. Five perforations of the stomach have occurred with the round rubber or sponge tip of Henning on the Wolf-Schindler gastroscope. 1 Three of these perforations were observed by Dr. Rudolf Schindler of the University of Chicago Clinics. The Henning tip has been discarded by most men doing gastroscopies since the report of these accidents. The subject of the present report had been examined gastroscopically six months before, and at this time the Henning tip had been used. The gastroscope was introduced without any force into the jejunum and was then withdrawn so that the stoma could be observed. The patient had had a resection for carcinoma, and since it is my policy to examine these cases gastroscopically

• Obstruction of the small Intestine caused by peritoneal carcinomatosis is properly palliated by resection, bypass, and stoma formation. If none of these procedures is applicable, palliation may be achieved by the permanent placement of a long intraluminal decompressive (Baker) tube. Twelve patients have been treated in this manner, nine of them living long enough to exhibit the capacity to eat and drink without repetitive vomiting. The Baker tube was passed across the abdominal wall, inserted into the proximal jejunum, and then passed as far as practical down to the surgically nontreatable obstruction. Venting of the small intestine distally allows continuing decompression, which thereby permits mucosal functions proximally. This technique allows the surgeon to do something beneficial for these unfortunate patients when the established maneuvers of bypass, resection, or stoma formation are pointless. ( Arch Surg 1986;121:1081-1082)

• A retrospective review of 610 consecutive patients with intestinal stomas constructed at Cook County Hospital, Chicago, was carried out to analyze early local complications with respect to stoma type and to compare complication rates by surgical specialty. A total of 197 complications were recognized in 158 patients for a corrected complication rate of 25.9%. Peristomal skin irritation (42.1%) was the most frequently recognized early complication in this study. Ileostomy was associated with the highest morbidity (40%) of any type of stoma. Emergency stoma formation seems to be associated with the highest complication rates, probably because of suboptimal stoma placement. The morbidity of stoma formation seems to be related to the amount of formal training in gastrointestinal tract surgery. Technical guidelines for stoma construction are presented to help minimize these complications. (Arch Surg1985;120:1145-1147)

A retrocolic side-to-side duodenojejunostomy has been a generally accepted standard operative procedure for the correction of congenital duodenal atresia and stenosis. However, this operation has the complication of delayed anastomotic function that often requires a use of transanastomotic feeding tube or intravenous hyperalimentation. A diamond-shaped side-to-side duodenoduodenal anastomosis has been performed in nine consecutive cases of congenital duodenal obstruction, with satisfactory results. A transverse incision is made in the dilated proximal duodenum, and a longitudinal incision in the duodenum distal to the obstruction. The stoma is fashioned by approximating the end of each incision to the appropriate midportion of the other incision. Transanastomotic feeding tubes were not used and oral feedings were easily tolerated. This technique offers the theoretical advantage of providing a more physiological gastrointestinal pathway.

To the Editor .—One of the main conclusions in the article by Pearl and colleagues was that "The morbidity of stoma formation seems to be related to the amount of formal training in gastrointestinal tract surgery." I believe that this statement was unsupported because the authors did not specify which member of the operating team performed the stoma or the amount of "formal training" that surgeon previously had received. The authors compared groups of surgical specialties but failed to support their conclusions by documenting either the years of formal training for each group or the number of actual gastrointestinal procedures performed by each specialist during the training years. One of the authors' reasons for the above conclusions was the higher complication rate, 36.9%, observed in the gynecologic oncology surgical specialty. The authors assumed but did not show that this surgical group had less formal training in gastrointestinal tract surgery. Furthermore

• I describe a method of reestablishing bowel continuity by anastomosis of an end stoma and mucous fistula without formal laparotomy. Both the end colostomy or ileostomy and mucous fistula are mobilized and a tunnel is created by blunt dissection along the anterior parietal peritoneum between the two sites. The more easily mobilized stoma is then drawn through the tunnel and out the other site and the anastomosis is performed. Advantages of the procedure include zero mortality in the present series, very minimal morbidity, early ambulation, feeding, and discharge from the hospital as well as minimal postoperative discomfort. Six patients underwent this procedure during the past three years. All results were considered satisfactory. The use of the intraperitoneal tunnel is an effective and safe method of restoring bowel continuity that precludes many of the complications associated with long laparotomy incisions. (Arch Surg115:1420-1422, 1980)

To the Editor .—The recent article by Bluett et all that evaluates staple lines in gastric surgery was most interesting and informative. I write to protest regarding theInvited Editorial Commentat the end of the article. I would like to know how Dr Ravitch arrived at his conclusions. It may well be that the bursting pressures' and resistance to tension disruption are irrelevant to the clinical situation in the vast majority of gastrointestinal operations, as the forces are disproportionate to the physiologic stresses. However, with bariatric surgery, this is certainly not the case. It would seem logical to assume that the pressures to which the staple line and proximal pouch are subjected after, eg, Mason vertical banded gastroplasty, are going to be high, particularly in these difficult, often noncompliant patients. The exact magnitude of these pressures is unknown, but if the stoma does become obstructed, it is possible that

To the Editor.—Increasing use of stapling devices has prompted us to devise a simplified method for performing a defunctionalizing colostomy. Often the loop colostomy is employed by the surgeon as a compromise for complete fecal diversion in sick patients because of its simplicity, efficiency, and lack of complications. The technique we use converts this to a completely diverting colostomy by bringing out a loop of bowel through the abdominal wall; placement of a glass rod below the loop of bowel through an avascular segment of mesentery and onto the abdominal wall; ligation of the distal part of the bowel with the 30- or 55-mm automatic stapler (Figure, A); and formation of the A, Ligation of distal part of bowel with 30- or 55-mm automatic stapler. B, Formation of proximal limb stoma by opening bowel wall with cautery 24 to 48 hours postoperatively. proximal limb stoma by opening the bowel

Surgeons have for many years attempted decompression of the stomach after gastroenterostomy or subtotal gastric resection. This was finally accomplished with the Wangensteen suction method, and the morbidity and mortality of gastric surgical procedures were materially reduced. However, experimental work by Peters and others has shown that acid ions (chiefly chlorides), when removed from the stomach by prolonged vomiting or by continuous suction drainage, cannot be replaced by the parenteral administration of saline solution, because of the cellular depletion of acid ions with the resultant base retention and cellular edema. It was thus shown that the disrupted acid-base equilibrium can be reestablished only after prolonged oral administration of the required acid components. The continued maintenance, therefore, of the acid-base equilibrium from the time of the operation is likely to prevent to some degree the usual edema at the stoma. The obvious answer to the problem is replacement of the normal

The old cliche, "the operation was a success, but the patient expired," may well have had its origin in the experience of surgeons losing patients due to biochemical derangements after performing a technically successful gastrointestinal surgical procedure. Diseases of the gastrointestinal tract that result in obstruction, perforation, fistula formation, or severe diarrhea and vomiting often are first seen with marked water, electrolyte, and acid-base imbalances that must be corrected before surgery. Additionally, the biochemical consequences of altering the continuity of the gastrointestinal tract by creating artificial stoma, removing diseased portions of the gut, or bypassing segments of small and large bowel can be formidable. Thus, the surgeon often must deal with complicated electrolyte and metabolic disturbances before he can apply his surgical skills, and the surgical procedure he performs may result in additional problems. These factors emphasize that the biochemical status of the patient, before as well as after surgery

It has been shown that ulcers resulting from deviation of duodenal, pancreatic, and biliary secretions are due primarily to the corrosive action of undiluted and unneutralized gastric juice. A clear example of this corrosive effect is observed in those cases of Meckel's diverticulum containing heterotopic gastric mucosa with a peptic ulcer in the ileum adjacent to the entrance of the diverticulum. This corrosive action of gastric juice was demonstrated experimentally by Matthews and Dragstedt * by anastomosing Pavlov pouches to the ileum of dogs. Stoma ulcers occurred in 100% of the cases. A similar result was obtained by Barry and Florey, 3 working with cats and pigs. In the experiments of Gage, Ochsner, and Hosoi 4 ulcers occurred in only 71% of the animals when the Heidenhain pouches were constructed from the lesser curvature of the stomach. This can be explained by the greater acidity of the gastric juice secreted from

Since gastro-enterostomy came into general use in the treatment for peptic ulcer and its complications, certain nosologic entities previously practically unknown have loomed into prominence. Gastrojejunal ulcer, a unique and unimportant lesion prior to the era of gastro-enterostomy, is now accorded a great deal of space in treatises on peptic ulcer. High intestinal obstruction accompanied by symptoms of a vicious cycle evoked little attention until the universal adoption of gastro-enterostomy, after which an enormous literature appeared on the subject. To these more common sequelae of the anastomosis can be added carcinoma of the stoma, an extremely rare but interesting condition. The occurrence of a malignant growth at the site of a gastrojejunal anastomosis was mentioned by Schwarz 1 in a paper dealing with observations at operation in gastro-enterostomized persons. The author gave an account of a patient who had an anterior gastro-enterostomy performed in 1909 for pyloric ulcer. The patient

THIS PAPER will report on a preliminary investigation of the adaptation patients make to total colectomy and to the resulting permanent ileostomy on colostomy. Total colectomy is a procedure that results in the complete removal of the colon, and most often, the rectum as well, so that a permanent, artificial means of defecation has to be created (ileostomy or colostomy). An ileostomy is formed by bringing an end of small intestine through the abdominal wall to serve as an opening for the intestines. The discharged intestinal contents are unformed and cannot be regulated, requiring an appliance over the stoma which must be worn continually. A colostomy is formed by bringing an end of the large intestine through the abdominal wall to serve as an intestinal orifice. The contents are more formed. Our purpose was to study how patients react to these procedures in terms

A newly designed ileostomy bag has the following features: (1) it is made of nonporous material that, unlike rubber, does not absorb odors; (2) it fits air-tight and water-tight to the skin about the ileostomy stoma without causing cutaneous irritation, escape of fluids or odor and prolapse of the stoma; (3) the bag or the drainage receptor is small and disposable; (4) the parts can be assembled and disassembled with ease, and (5) it is economical (figs. 1 and 2). The body engaging plate is of plastic material and the opening is made to fit the individual stoma; it is held in place by means of double-faced adhesive cellulose tape. After the engaging plate is affixed to the skin about the stoma, additional support is afforded by means of a special belt (fig. 2). The bag is made of disposable plastic material; it may be discarded with the fecal material

WHIPPLE 1 and Blakemore 2 in 1943 began to restudy the problem of the surgical approach to the distressing complications of portal cirrhosis. Eck 3 initiated the study in 1877 when he performed the first recorded successful anastomosis of the portal vein to the inferior vena cava. It remained for Blakemore, 4 Whipple 5 and later Blalock, 6 Linton 7 and others 8 to devise varied shunts between the portal and caval systems and to perfect the technics of the procedures, as well as the indications for their use. The technical feasibility of such anastomoses, as well as the rationale for their choice, has been established. Because of the large stoma and the lessened chance for thrombus formation most authors favor the end to side portacaval shunt. The following communication describes the use in two cases of such an anastomosis, as well as the advantages of the right thoracoabdominal approach

In previous articles,1a method was described for the total removal of the liver from the dog, and a brief summary was made of the data obtained from a series of studies on the completely hepatectomized animal. The present report deals more in detail with one phase of our experiments; namely, the effect of hepatectomy on the sugar concentration of the blood. Method for Total Removal of the Liver of the Dog. —Since the method of removal of the liver has been fully described,1only a brief description will be given. The liver is removed in two stages. All operations are performed under ether anesthesia with aseptic surgical technic. The first operation consists of a reverse Eck fistula, that is, lateral anastomosis of the portal vein and the vena cava and ligation of the latter on the cephalic side of the stoma. At first a considerable portion of the blood

A method of treating functional gastric retention following partial gastrectomy and vagotomy with subcutaneously administered bethanechol is presented. Five of six patients with this complication were successfully treated with bethanechol. The sixth patient had mechanical obstruction of the gastroduodenal stoma and did not respond to bethanechol; revision of the anastomosis effected a cure. No significant complications were encountered from this therapeutic regimen.

Innumerable studies have been made on the subject of gastrojejunal ulcer. The majority of them, however, have been concerned principally with the diagnosis and treatment of the condition, and little has been written on the pathologic findings. We are presenting the pathologic as well as the clinical features of gastrojejunal ulcer in 100 cases in which tissue showing the gastroenteric stoma and the ulcer was available. In all 100 cases, the specimens had been removed between 1932 and 1944. Two blocks were cut from each of the 100 specimens, and the sections made from these blocks were stained with hematoxylin and eosin. One block was made through the anastomotic junction extending through the ulcer, unless the size of the ulcer prohibited. The other section was made through that portion of the anastomotic ring in which no gross ulceration was present. REVIEW OF LITERATURE Walton 1 in 1934 concluded on the

BENIGN papilloma of the peritoneum is a rare lesion, seldom noted except incidental to laparotomy or to postmortem examination. In fact, it is improbable that a diagnosis of this lesion can be made except by direct visualization of the peritoneum. A review of the literature reveals confusion with regard to this tumor and the more commonly reported mesothelioma of the peritoneum to which it bears a poorly understood relationship. So far as can be reasonably determined, this lesion was first recognized by Wells, 1 in 1935, who described the tumor as a benign, branching villous papilloma. The lesion was noted as an incidental finding at autopsy of a 79-year-old man whose death was secondary to suprapubic prostatectomy. Wells found this tumor to consist of numerous villous processes, covered by cuboidal cells continuous with the mesothelium of the peritoneum; the stoma was coarse, composed of connective tissue, and multiple lesions were

Most surgical procedures for treatment of peptic ulcer are used in an endeavor to cause reduction in gastric acidity or in the length of time the ulcer is exposed to the gastric content. These results are brought about either by increasing the speed with which the stomach empties or by causing mixing of the alkaline duodenal sections with the gastric content through an altered or artificial stoma. In all probability few, if any. of the procedures employed affect directly the secretory mechanism involved in the production of hydrochloric acid. It would seem more logical in uncomplicated cases to perform some procedure which would reduce the ability of the stomach to produce hydrochloric acid. With this hypothesis in view experimental work was carried out on dogs in an effort to determine what effect removal of varying portions of acid-secreting mucous membrane has on the acidity of the gastric and duodenal content.

The creation of an isolated gastric pouch in experimental animals has contributed more than any other procedure to the present understanding of the physiology of gastric secretion. The extraordinary usefulness of the pouch depends on the fact that it permits quantitative collection of secretion uncontaminated by material from either the esophagus or the duodenum. In no human being, even one with a chance abnormality of the stomach, has a quantitative collection of uncontaminated gastric secretion been obtainable. In patients with pyloric obstruction, for example, gastric secretion is contaminated by saliva; in patients with esophageal obstruction and gastric fistulas the secretion is contaminated by unknown quantities of duodenal contents. In such patients the disease has usually produced nutritional disturbances not conducive to normal secretory function. The gastric pouch itself, however, has presented drawbacks. Digestion of the abdominal wall by the gastric secretion has prevented maintenance of a sphincter at the outlet

CONNER,1in 1884, probably performed the first total gastrectomy. Recently, total gastrectomy has been more frequently done for carcinoma of the stomach, especially for those lesions in the midportion of the stomach or higher. Lahey2now advocates radical total gastrectomy for all operable carcinomas of the stomach and reports a decided increase in the three-year survival rate. The technic has been standardized; the management has become more physiologic, and the mortality rate has steadily decreased. Certain disadvantages, related to nutritional deficiency, weight loss, anemia, and reflux esophagitis, are associated with total gastrectomy. Various modifications of the standard procedure of anastomosing the small bowel to the esophagus have been suggested to diminish some of these problems. Hoffman,3in 1922, made a small stoma between the two limbs of the jejunal loop. This afforded a partial bypass of the duodenal contents and reduced the incidence of reflux esophagitis. Orr

In three previous publications1certain deductions were drawn relative to the origin of primary renal calculi. These deductions seem to have been thoroughly supported and proved by the research work performed and therein reported. As subsequent studies have further substantiated these facts, it is pertinent to restate them at this time: It was shown that all clinical data and all reasoning from the point of view of pathology require that a primary renal calculus must be stationary and attached while beginning and acquiring growth. Small renal calculi, when examined under a magnifying lens, almost always show such a stoma, or facet, of mural attachment. X-ray studies in proper cases repeatedly show that such primary renal calculi have their origin in the minor calices. It was postulated and subsequently proved that an initiating lesion would be found. It was postulated and subsequently proved that the

In 5 cases which I have encountered, severe gastro-intestinal hemorrhages from hemorrhagic and ulcerative gastrojejunitis occurred eighteen to thirty years following gastroenterostomy for congenital pyloric stenosis. Four of the patients were men and 1 was a woman. In all 5 cases after the gastroenteric anastomosis was disconnected and the region of hemorrhagic or ulcerative gastrojejunitis was excised, the opening in the jejunum was closed. Partial gastrectomy was performed with removal of at least half and up to two thirds of the stomach, including the site of the gastroenteric stoma. A Billroth I (von Haberer) type of anastomosis was made between the remainder of the stomach and the duodenum. In the von Haberer modification the entire cut end of the stomach is sutured to the cut end of the duodenum. The circumference of the stomach is decreased by interrupted reefing sutures. Excellent results followed this operation in every case. The first

Posterior gastro-enterostomy performed in properly selected cases has long been accepted as one of the most satisfactory procedures in the treatment of duodenal ulcer. Two reasons have generally been advanced in explanation of its efficacy. First, it has been stated that the formation of a gastro-enterostomy stoma allows the gastric contents to pass into the jejunum without going through the duodenum, thereby removing the irritation of acid and food and allowing the ulcer to heal. Roentgenologists have taught, however, that in most patients unless the pylorus is completely obstructed the gastric contents leave the stomach to a large degree not through the gastro-enterostomy stoma but through the pylorus; and in spite of the fact that the ulcer continues to be exposed to the irritation of gastric contents, though perhaps for not so long a time, it usually proceeds to heal. The second explanation which has been offered is that gastro-enterostomy

To the Editor.— When a decision is made to remove the tracheostomy tube from a patient, decannulation is performed in one of two ways. In the first, the tracheostomy tube is corked for one or more days while the patient is ambulatory. If the patient remains comfortable during this period and the need to uncork the cannula does not arise, the tube is removed and the stoma is covered with a dry dressing. While this method maintains a patent stoma during the trial period, the cannula inside the trachea will reduce the functional airway as the patient has to breath around it. In the second, the tube is removed without corking and the stoma is covered with a dry dressing. This is usually done after substituting successively smaller cannulae. While there is no encroachment on the airway, the stoma rapidly heals after decannulation. Premature decannulation may require another operation. The

The feasibility of reoperating to restore gastrointestinal continuity was studied in 30 patients who had suffered disabling complications after gastroenterostomy. The largest group consisted of 13 patients in whom the original operation was vagotomy and gastrojejunostomy. All of the 30 patients had symptoms so severe as to prevent them from carrying on gainful occupations, and in each case medical treatment had been given a thorough trial. The corrective operation consisted of closing the gastrojejunal stoma and frequently included end-to-end anastomosis for repair of the jejunum and end-to-end anastomosis between stomach and duodenum. Only one patient failed to obtain relief by the corrective operation; eight others were but partially relieved and required continued medical or dietary treatment. Twenty-one became free of symptoms, were relieved of the need for medication, and were able to return to work.

Considerable has been written during the past fifteen years on gastro-enterostomy. Much has been said about the indications, contraindications, location and size of the stoma. Straus has done some excellent work on the preparation of the stomach prior to a gastro-enterostomy. The importance of the position of the stoma has been stressed by many writers. Many have advised that the opening be placed at the most dependent part of the stomach, while others have found that the location of the stoma was of little importance if the most important indication for the gastro-enterostomy was present; namely, pyloric obstruction. There seems to be quite universal agreement among surgeons that obstruction at the pylorus or in the first part of the duodenum is the most important indication for a gastro-enterostomy. It is in this type of case that the best results are obtained. Frequent fluoroscopic observations lead one to believe that the

Intussusception of the small intestine into the stomach through the stoma of a gastro-enterostomy following operation is an infrequent occurrence. The literature contains only thirty-nine reported cases. The condition probably occurs more often but is not recognized because of a general lack of knowledge of the possibility of such a complication. Most of the reported cases were of the acute type, characterized by a sudden onset without any preliminary signs. The earliest case occurred six days after operation. 1 The symptoms and physical signs are those of high intestinal obstruction. The onset is with pain in the upper part of the epigastrium and vomiting, at first gastric contents, then bile and later blood. The abdomen becomes rigid, distended and tender. In some of the cases (about 50 per cent) a tumor mass is palpable. The course is rapidly downhill unless an immediate operation is performed. The usual operative procedure is

One of the greatest boons to the patient suffering from a major obstruction or malignant disease of the colon, particularly the left half of this viscus, is the hope of either permanent cure or prolonged comfort provided by an artificial stoma. Almost every intestinal surgeon and proctologist has studied the problem of providing a satisfactory colostomy, with special reference to some form of bowel control. Practically every portion of the abdominal wall and the perineum has been utilized for the location of the stoma. The number of different types of colostomies and the ingenuity expended in their formation would make exceedingly interesting and intriguing surgical history. The number of names attached to different types of colostomies resembles a roll call of most of the pioneers in intestinal surgery. Every surgeon or proctologist operating on a diseased colon has been hopeful of supplying a type of colostomy which would satisfactorily exclude

Malfunction and obstruction of gastroenterostomy exit stomas is a gravely serious complication of gastric resection. It is somewhat difficult to ascertain how often this trying complication occurs, since it is probably not reported as frequently as the gratifying results. In a discussion of the problem,* Orr and others stated that every surgeon who has done many gastric resections has had some difficulty with malfunctioning gastrojejunal stomas. In cases of apparent exit stoma obstruction reoperation and exploration have been done at various intervals following the initial gastrectomy. Edema of the stomal walls has been found in many of these cases and has been considered an important factor by many surgical clinics. Correction of the fluid, electrolyte, and protein balance has been proved of value in relieving the edema and correcting the obstruction. Actual mechanical obstruction of the stoma due to excessive cuff formation at the suture line has been encountered. Kinking

The complications resulting from gastrointestinal intubation were recently reviewed and supplemented by the papers of Chaffee 1 and Pool. 2 The complications reported include: sinusitis and otitis media; esophageal stricture; laryngeal obstruction; knotting of the tube; rupture of esophageal varix; ruptured viscus, including esophagus, stomach and small bowel; inability to withdraw the balloon-tipped tube; breakage of the mercury-filled bag, and coiling of the tube through the pylorus, duodenum and gastrointerostomy stoma, necessitating surgical removal. A review of the literature disclosed no report of a swallowed Miller-Abbott tube, as occurred in this case. REPORT OF CASE W. W., a Negro man aged 35, was admitted to the Cook County Hospital on Sept. 26, 1949 with epigastric discomfort and rapidly appearing distention of the abdomen, usually following meals. There had been five previous admissions for symptoms of a duodenal ulcer which had followed a severe attack of diarrhea in 1937. Medical management

THE VARIOUS methods used to reestablish gastroenteric continuity after subtotal gastrectomy still do not totally obviate unpleasant complications and sequelae. Complications such as obstruction or dysfunction of the efferent jejunal loop, dumping syndrome, and to some extent, nutritional deficiencies appear to be inherent in the surgical rearrangement of the gastroenteric continuity. It is a natural desire to eradicate and correct these disorders even though they occur in only a small percentage of patients after subtotal gastrectomy. This desire is evident in the introduction of the segmental resection of the stomach by Wangensteen1and the reemphasis of the Billroth-I procedure by Harkins.2The object of this clinical and anatomical study is to point out a specific mechanism of stomal dysfunction in the early postgastrectomy period. No doubt there are many causes of malfunction of the efferent jejunal segment. An obstruction may occur after any operative procedure devised for the

THE STEADILY increasing laboratory and clinical evidence that ulceration in the upper gastrointestinal tract is due to the corrosive effect of the gastric content is now so complete that it is no longer permissible to state that the cause of duodenal and gastric ulcers is unknown. Many problems, however, remain, and one of these has to do with the sites of predilection for these lesions. Ulcers near the stoma of a gastrojejunostomy or gastroduodenostomy may be accounted for since there is now proof that the normal duodenal and jejunal mucosa has less resistance to the digestive action of pure gastric juice than is the case with the gastric mucosa. Ulceration in the lower end of the esophagus and in the ileum opposite the entrance of Meckel's diverticulum containing heterotopic gastric mucosa is probably due to similar reasons. Why, however, do the large majority of ulcers occur along the lesser curvature

Massive hemorrhage from erosion of the innominate artery by a low-lying tracheostomy tube may be prevented by appropriate positioning of the tracheal stoma. Hemorrhage may be fatal unless promptly recognized and the bleeding controlled. In an emergency technique herein described, the innominate artery can be effectively occluded by finger dissection along the anterior tracheal wall and compression of the artery against the back of the sternum. The eroded innominate artery should be divided and oversewn. No neurologic sequelae from division of the innominate artery have been observed.