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Background: In a significant percentage of patients, radiologic evaluation other than plain abdominal films are required to confirm or exclude the presence of small bowel obstruction. Methods: Over a 1-year period, 55 patients had both computed tomography and small bowel follow-through studies. Patients were classified as having (1) paralytic ileus, (2) low-grade obstruction, (3) high-grade obstruction, or (4) complete mechanical obstruction. The gold standard for diagnosis was celiotomy in 42 patients and clinical follow-up in 13 patients. Results: Thirty-six out of 42 patients had proven intestinal obstruction at the time of celiotomy. Computed tomography identified 32 out of the 36 high-grade and complete mechanical obstructions. Computed tomography was superior to small bowel follow-through in identifying masses, malignancies, and features of strangulation. Small bowel follow-through correctly identified “insignificant obstructions” when contrast reached the cecum within 4 hours in 18 of 19 patients. Conclusions: In patients with equivocal findings of small bowel obstruction, computed tomography should be used initially and then small bowel follow-through if computed tomography is not diagnostic. Computed tomography was superior in this study for detecting the cause of the intestinal obstruction and presence of strangulation.

Importance Surgical disease is a global health priority, and improving surgical care requires local capacity building. Single-institution partnerships and surgical missions are logistically limited. The Alliance for Global Clinical Training (hereafter the Alliance) is a consortium of US surgical departments that aims to provide continuous educational support at the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (MUHAS). To our knowledge, the Alliance is the first multi-institutional international surgical collaboration to be described in the literature. Objective To assess if the Alliance is effectively responding to the educational needs of MUHAS and Muhimbili National Hospital surgeons. Design, Setting, and Participants During an initial 13-month program (July 1, 2013, to August 31, 2014), faculty and resident teams from 3 US academic surgical programs rotated at MUHAS as physicians and teachers for 1 month each. To assess the value of the project, we administered anonymous surveys. Main Outcomes and Measures Anonymous surveys were analyzed on a 5-point Likert-type scale. Free-text answers were analyzed for common themes. Results During the study period, Alliance members were present at MUHAS for 8 months (1 month each). At the conclusion of the first year of collaboration, 15 MUHAS faculty and 22 MUHAS residents completed the survey. The following 6 areas of educational needs were identified: formal didactics, increased clinical mentorship, longer-term Alliance presence, equitable distribution of teaching time, improved coordination and language skills, and reciprocal exchange rotations at US hospitals. The MUHAS faculty and residents agreed that Alliance members contributed to improved patient care and resident education. Conclusions and Relevance A multi-institutional international surgical partnership is possible and leads to perceived improvements in patient care and resident learning. Alliance surgeons must continue to focus on training Tanzanian surgeons. Improving the volunteer surgeons’ Swahili-language skills would be an asset. Future efforts should provide more teaching coverage, equitably distribute educational support among all MUHAS surgeons, and collaboratively develop a formal surgical curriculum.

Population-based studies have demonstrated better outcomes for carotid endarterectomies at high-volume hospitals.This is a 2-year retrospective review of carotid procedures at two low-volume hospitals (n = 156) and one high-volume hospital (n = 404) in the metropolitan area of Portland, Oregon.There were no significant differences in 30-day mortality and stroke rates for carotid endarterectomies when comparing low- and high-volume hospitals (P = 0.59). These were comparable rates despite the fact that the low-volume hospitals had significantly older patients (P0.001), more smokers (P0.001), more patients with an indication of a previous nondisabling stroke (P0.01), and fewer patients who were asymptomatic (P0.01).The regionalization of carotid endarterectomy into high-volume hospitals is not justified by the findings of this study. Carotid endarterectomy performed by well-trained, experienced surgeons in low-volume hospitals is a safe procedure.

The Portland experience with patients requiring proctocolectomy for chronic ulcerative colitis in association with primary sclerosing cholangitis has been reported. Nineteen patients had conventional ileostomy reconstruction, 5 of whom had development of stomal varices with recurrent hemorrhage due to cirrhosis and portal hypertension. When this combination of conditions exists, the therapeutic options must be carefully weighed. Perhaps ileal pouch to anal anastomosis should be considered when proctocolectomy becomes mandatory. Ileostomy is presently a contraindication to liver transplantation. In patients with ileostomies, control of hemorrhage by local measures, including ileostomy revisions, proved to be of only temporary value, yet it should be the preferred management of patients with a severely limited life expectancy. Successful shunts directed at portal decompression have always prevented further ileostomy hemorrhage, however, they have commonly accelerated liver failure and thus death. Furthermore, such shunts seriously complicate liver transplantation if it is considered.

Selective management of 465 patients with stab wounds limited to the posterior abdomen is reviewed. Celiotomy was based primarily on clinical findings. Tenderness not localized to the area of injury and absent or rare bowel sounds best identified patients with serious injuries. Peritoneal lavage and local wound exploration were used infrequently. All fatally injured patients were operated upon or expired within 5 hours of admission. Diagnosis was delayed in three serious injuries: one retroperitoneal colon perforation, and two diaphragmatic lacerations. The colonic and one diaphragmatic injury were identified and treated successfully in the initial hospital admission. The other diaphragmatic hernia was repaired uneventfully 3 months after injury. Eight per cent of the patients never required surgery. Fourteen per cent had significant organ injury. The flank was more vulnerable than the back. The colon was the most common organ injured. Six per cent had "nonessential' celiotomies. The overall morbidity was 11%, and mortality rate, 1.1%. Selective management of posterior abdominal stab wounds is a prudent and reliable approach. Language: en

An 11 year study of 1,035 elective colon resections reaffirmed the value of oral antibiotic prophylaxis. Five antibiotic regimens were used in 88 percent of the patients. The most effective and most frequently used regimen was the combination of parenteral cephalosporin with oral erythromycin and an aminoglycoside. The overall infection rate with this regimen was 11 percent and the wound sepsis rate was 2.5 percent. The use of parenteral cephalosporins alone was not effective. Furthermore, resistant bacteria were cultured from the wound infections of parenteral cephalosporin patients. A nondirective annual review of these data and each surgeon's infection rate resulted in a change in the antibiotic ordering practices and decreased infection rates. It is no longer acceptable surgical practice to omit antibiotic prophylaxis in colon operations.

The extraperitoneal approach is not usually used for reconstruction of the abdominal aorta; however, herein we have made an attempt to influence vascular surgeons to modify this practice. The results in 200 patients approached extraperitoneally have been compared with those of 70 patients explored by the traditional transperitoneal route. The expeditious technique of extraperitoneal exploration described results in significantly less postoperative morbidity due to the pulmonary complications of atelectasis and pneumonia. Intestinal ileus is uniformly brief, and rarely requires nasogastric suction. Patients explored extraperitoneally have demonstrably less pain and were discharged from the hospital sooner. Furthermore, prosthetic graft patency and mortality were comparable in both groups. Thus, the retroperitoneal approach should be the preferred method of aortoiliac reconstruction since the postoperative convalescence period is smoother and shorter.

Summary This review of 900 patients who underwent colon resection for carcinoma identified 33 patients who were explored with the preoperative diagnosis of appendicitis. In 19 patients, the appendix was acutely inflamed secondary to obstruction of the appendiceal lumen. The other 14 patients had perforating or obstructing cancer of the ascending colon or cecum. The clinical clues of a prolonged symptom history, weight loss, anemia, and a palpable mass were frequently, but not invariably, present. Results of contrast enema, computerized axial tomography, and colonoscopy in this select group were frequently misleading. The diagnosis is best made in the operating room by the thoughtful appendectomist. I recommend prompt resection and an appropriate cancer procedure in these patients. Carcinoma masquerading as appendicitis occurs more often than is generally realized and will be seen more frequently as our aging population increases.

Thirty patients with carcinoid tumors of the ileum over a recent 10-year period have been analyzed. Seventeen patients were symptomatic and 13 others were found to have tumors incidentally at autopsy or celiotomy. Patients with symptoms almost invariably had metastatic disease, yet preoperative diagnosis was rarely achieved. Arteriography in five patients with intestinal angina demonstrated encasement, kinking, and irregularity of mesenteric branches due to nodal metastasis. In five patients, each with liver metastasis, the classic carcinoid syndrome developed. Multiple primary carcinoid tumors were found in 9 of 30 patients (30 percent); 14 had an associated second malignant neoplasm (47 percent), most frequently colorectal carcinoma. En block surgical excision was the only effective therapy. Despite a prolonged natural history, the 5-year actuarial survival rate from the date of diagnosis was only 31 percent.

Trauma due to motor vehicles accident and urban violence have made distal arterial reconstruction an increasingly important part of the surgeon's work. During the 20 month period from October 1980 to May 1982, 13 patients with below the knee and 2 patients with forearm trauma had nonviable extremities despite fastidious vascular and orthopedic reconstruction. A continuous intraarterial infusion of tolazoline into the femoral or brachial arteries restored vascular perfusion and viability in 13 of 15 patients (87 percent), with eventual limb salvage in 67 percent. Seven of 15 patients (47 percent) had transient systemic hypertension. There was no mortality. There exists in patients with these catastrophic injuries a local low-flow state due to a combination of distal arterial spasm and venous outflow obstruction. Tolazoline, a peripheral alpha-adrenergic blocking agent, increases blood flow, albeit nonnutritionally, and thus theoretically prevents thrombosis due to stasis in the repaired distal vessel. When limb loss seems inevitable, a trial of intraarterial tolazoline is justified.

This is a retrospective study of 13 patients with sclerosis of the common bile duct seen over a ten-year period at the Hospital of the Good Samaritan Medical Center. Histologic examination of the common bile duct in eight patients permitted a clear-cut diagnosis of sclerosing carcinoma. In the remaining five patients, glandular atypia and sclerosis were suggestive, but not diagnostic, of carcinoma. Three of these were eventually established as carcinoma at autopsy. The diagnosis in the last two patients, who are still alive, remains equivocal. This study emphasizes the difficulty of separating benign from malignant disease of the common bile duct and suggests that the majority of patients diagnosed as having primary sclerosing cholangitis will eventually be proved to have carcinoma. It further identifies the protracted course that some of these patients exhibit.