Archives of Surgery

NYHUS, LLOYD M.

doi: 10.1001/archsurg.1983.01390120003001pmid: 6651512

Abstract Proximal gastric vagotomy (PGV) is now popular among surgical gastroenterologists as an operation for the treatment of duodenal ulcer. Does PGV deserve this popularity, making it golden, or should it be considered dross, shunned by all? Conceptually, PGV should be the answer to our search for an operation with low morbidity and low mortality that removes the stigma of duodenal ulcer disease from our patients. There is no question that PGV can be performed with totally acceptable short- and long-term morbidity and operative mortality. The ever-increasing rate of ulcer recurrence, as reported in the world literature, concerns all of us.1 When the problem of recurrent ulcer first became apparent, many were convinced that it was a matter of inadequate or imperfect operative technique, particularly when subsequent reports from the same authors showed a marked decrease in recurrence following a change in technical approach. The matter of technical expertise is References 1. Rheault MJ: The difficulty in assessing the rate of recurrence after proximal gastric vagotomy . Can J Surg 1983;26:202-203. 2. Nyhus LM: The role of the antrum in the surgical treatment of peptic ulcer . Gastroenterology 1960;38:21-25. 3. Debas HT: Proximal gastric vagotomy interferes with a fundic inhibitory mechanism: A hypothesis for the high recurrence rate of peptic ulceration . Am J Surg 1983;146:51.Crossref 4. Griffith CA, Harkins HN: Partial gastric vagotomy: An experimental study . Gastroenterology 1957;32:96-102. 5. Wolfler A: Gastro-enterostomie . Zentralbl Chir 1881;8:705. 6. Lewisohn R: The frequency of gastrojejunal ulcer . Surg Gynecol Obstet 1925;40:70.

doi: 10.1001/archsurg.1983.01390120004002pmid: N/A

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract Error in Figures.—In the article titled "Femoropopliteal and Tibioperoneal Artery Reconstruction Using Human Umbilical Vein," published in the September Archives (1983;118:1039-1042), Figs 5 and 6 were incorrect. On page 1042, at the top of the page, the graph on the right actually depicts the patency rate, and that on the left depicts the limb-salvage rate.

Wahlstrom, Erik;Yadegar, Joseph;Amodeo, Pamela;O'Connell, Michael;Morgenstern, Leon

doi: 10.1001/archsurg.1983.01390120005003pmid: 6689119

Abstract • Application of the topical hemostatic agents microfibrillar collagen hemostat (Avitene), oxidized cellulose (Surgicel), and absorbable gelatin sponge (Gelfoam) to the periureteral regions in dogs did not incite an adverse inflammatory or fibrotic reaction when used in standard, recommended fashion. No instances of ureteral obstruction resulted from such application. The addition of a small amount of sterile urine in the same area with the topical agent did not influence the degree of reaction. We concluded that these useful hemostatic agents, when used properly, are absorbed with only slight or no residual tissue reaction. The adverse tissue reaction occasionally reported probably can be ascribed to either improper use of the hemostatic agent, other concomitant noxious influences such as infection, or admixture with abnormal collections of body fluids. (Arch Surg 1983;118:1375-1377) References 1. Sanfilippo JS, Barrows GH, Yussman MA: Comparison of Avitene, topical thrombin, and Gelfoam as sole hemostatic agent in tuboplasties . Fertil Steril 1980;33:311-316. 2. Raftery AT: Absorbable haemostatic materials and intraperitoneal adhesion formation . Br J Surg 1980;6:57-58.Crossref 3. Larsson B, Nisell H, Granberg I: Surgicel-an absorbable hemostatic material: In prevention of peritoneal adhesions in rats . Acta Chir Scand 1978;144:375-378. 4. Chung AF, Menon J, Dillon TF: Acute postoperative retroperitoneal fibrosis and ureteral obstruction secondary to the use of Avitene . Am J Obstet Gynecol 1978;132:908-909. 5. Park SA, Giannattasio C, Tancer ML: Foreign body reaction to the intraperitonal use of Avitene . Obstet Gynecol 1981;58:664-667. 6. Ohlsen L: Retroperitoneal fibrosis due to leakage of urine: A contribution to the etiology of idiopathic retroperitoneal fibrosis . Acta Soc Med Upsal 1965;70:231-240. 7. Mitchinson MJ, Bird DR: Urinary leakage and retroperitoneal fibrosis . J Urol 1971;105:56-58. 8. Cerny JC, Scott T: Non-idiopathic retroperitoneal fibrosis . J Urol 1971;105:49-55.

Yellin, Albert E.;Lundell, Caroline J.;Finck, Ethel J.

doi: 10.1001/archsurg.1983.01390120008004pmid: 6651513

Abstract • Fourteen patients with posttraumatic pelvic hemorrhage underwent therapeutic transcatheter embolization of bleeding vessels. Six of them were victims of blunt trauma, six had penetrating trauma, and two had iatrogenic hemorrhage. Eleven patients had a celiotomy prior to angiographic embolization, and large retroperitoneal hematomas were evident in nine patients. Bleeding persisted postoperatively. It was initially controlled by embolization in all patients, but two rebled and were successfully reembolized. Two patients died because of traumatic injuries. There were no complications directly associated with the embolization procedures. Transcatheter embolization is a safe, effective method for controlling pelvic hemorrhage in patients with unstable or multiple pelvic fractures whose conditions fail to respond to more conventional forms of therapy. (Arch Surg 1983;118:1378-1383) References 1. Rothenberger DA, Fischer RP, Perry JF Jr: Major vascular injuries secondary to pelvic fractures: An unsolved clinical problem . Am J Surg 1978;136:660-662.Crossref 2. Rothenberger D, Velasco R, Strate R, et al: Open pelvic fracture: A lethal injury . J Trauma 1978;18:184-187.Crossref 3. Flint LM Jr, Brown A, Richardson D, et al: Definitive control of bleeding from severe pelvic fractures . Ann Surg 1979;189:709-716.Crossref 4. Keller FS, Rosch J, Baur GM, et al: Percutaneous angiographic embolization: A procedure of increasing usefulness . Am J Surg 1981;142:5-13.Crossref 5. Ricketts RR, Finck E, Yellin AE: Management of major arteriovenous fistula by arteriographic techniques . Arch Surg 1978;113:1153-1159.Crossref 6. McNeese S, Finck E, Yellin AE: Definitive treatment of selected vascular injuries and post traumatic arteriovenous fistulas by arteriographic embolization . Am J Surg 1980;140:252-259.Crossref 7. Brotman S, Soderstrom CA, Oster-Granite M, et al: Management of severe bleeding in fractures of the pelvis . Surg Gynecol Obstet 1981;153: 823-826. 8. Patterson FB, Morton KS: The cause of death in fractures of the pelvis: With a note on treatment by ligation of the hypogastric (internal iliac) artery . J Trauma 1973;13:849-856.Crossref 9. Ravitch MM: Hypogastric artery ligation in acute pelvic trauma . Surgery 1964;56:601-602. 10. Hare WS, Holland CJ: Paresis following internal iliac artery embolization . Radiology 1983;146:47-51.Crossref 11. Schrumpf JD, Sommer G, Jacobs RP: Bleeding simulated by the distal internal pudendal artery stain . AJR 1978;131:657-659.Crossref 12. Matalon TS, Athanasoulis CA, Margolies MN, et al: Hemorrhage with pelvic fractures: Efficacy of transcatheter embolization . AJR 1979; 133:859-864.Crossref 13. Jander HP, Russinovich NA: Transcatheter Gelfoam embolization in abdominal retroperitoneal and pelvic hemorrhage . Radiology 1980;136:337-344.Crossref 14. Lang EK: Transcatheter embolization of pelvic vessels for control of intractable hemorrhage . Radiology 1981;140:331-339.Crossref 15. Ring EJ, Athanasoulis CA, Waltman AC, et al: Arteriographic management of hemorrhage following pelvic fracture . Radiology 1973;109: 65-70.Crossref

Harley, Daniel P.;Mena, Ismael;Miranda, Rodrigo;Nelson, Ronald J.

doi: 10.1001/archsurg.1983.01390120014005pmid: 6651514

Abstract • We prospectively studied 35 patients with blunt chest trauma using ECG multi-gated and first-pass nuclear angiography. Radionuclide angiography (RNA) is a sensitive test of myocardial function demonstrating right and left ventricular ejection fractions. First-pass angiography, in addition, shows left ventricular segmental wall motion, a qualitative as well as anatomic indicator of left ventricular function. We saw RNA abnormalities in 26 patients (74.2%). Eight patients (22.8%) had ECG abnormalities, and these findings correlated with RNA, suggesting that this technique is a very sensitive indicator of myocardial dysfunction following trauma. These studies warrant further experimental and clinical evaluations to determine the cause, significance, and long-term prognosis of posttraumatic myocardial dysfunction. (Arch Surg 1983;118:1384-1387) References 1. Akenside M: Account of blow upon heart and its effects . Philos Trans R Soc Lond 1764;53:353.Crossref 2. Lasky II, Nahum AM, Siegel AW: Cardiac injuries incurred by drivers in automobile accidents . J Forensic Sci 1969;14:13-33. 3. Beck CS: Contusions of the heart . JAMA 1935;104:109-114.Crossref 4. Bright EF, Beck CS: Non-penetrating wounds of the heart . Am Heart J 1935;10:293-321.Crossref 5. Parmley LF, Manion WC, Mattingly TW: Nonpenetrating traumatic injury of the heart . Circulation 1958;18:371-396.Crossref 6. Jones JW, Hewitt RL, Drapanas T: Cardiac contusions: A capricious syndrome . Ann Surg 1975;181:567-579.Crossref 7. Sigler LH: Traumatic injury to the heart: Incidence of its occurrence in 42 cases of severe accidental bodily injury . Am Heart J 1945;30:459-478.Crossref 8. Viano DC, Artinian CG: Myocardial conduction system dysfunction from thoracic impact . J Trauma 1978;18:452-459.Crossref 9. Hale HW, Martin JW: Myocardial contusion . Am J Surg 1957;93:558-564.Crossref 10. Watson JH, Bartholomae WM: Cardiac injury due to nonpenetrating chest trauma . Ann Intern Med 1960;52:871-880.Crossref 11. Weisz GM, Glumenfield Z, Barzilai A: Electrocardiographic changes in traumatized patients . J Am Coll Emerg Physicians 1976;5:329-331.Crossref 12. Reynolds M, Jones JW: CPK-MB isoenzyme determinations in blunt chest trauma . J Am Coll Emerg Physicians 1979;8:304-306.Crossref 13. Peare W, Blair E: Significance of the electrocardiogram in heart contusion due to blunt trauma . J Trauma 1976;16:136-140.Crossref 14. Lindsey D, Nivin TR, Finley PR: Transient elevation of serum activity of MB isoenzyme of creatine phosphokinase in drivers involved in automobile accidents . Chest 1978;74:15-18.Crossref 15. Gonzalez AC, Waldo W, Harlaftis N, et al: Imaging of experimental myocardial contusion: Observations and pathologic correlations . AJR 1977; 128:1039-1040.Crossref 16. Mirabal PT, Greenberg JC, Brown JC, et al: Spectrum of myocardial contusion . Am Surg 1982;48:383-392. 17. Jengo JA, Mena I, Blaufuss A, et al: Evaluation of left ventricular function (ejection fraction and segmental wall motion) by single pass radioisotope angiography . Circulation 1978;57:326-332.Crossref 18. Stein PD, Sabbah HN, Viano DC, et al: Response of the heart to nonpenetrating cardiac trauma . J Trauma 1982;22:364-373.Crossref 19. Anderson AW, Doty DB: Cardiac trauma: An experimental model of isolated myocardial contusion . J Trauma 1975;15:237-244.Crossref 20. DeMuth WE, Lerner EH, Liedtke AJ: Nonpenetrating injury of the heart: An experimental model in dogs . J Trauma 1973;13:639-644.Crossref 21. Cane RD, Schamroth L: Prolongation of the Q-T interval with myocardial contusion . Heart Lung 1978;7:652-656. 22. Brantigan CO, Burdick D, Hopeman AR, et al: Evaluation of technetium scanning for myocardial contusion . J Trauma 1978;18:460-463.Crossref 23. Roberts R, Gowda S, Ludbrook P, et al: Specificity of elevated serum MB creatine phosphokinase activity in the diagnosis of acute myocardial infarction . Am J Cardiol 1975;36:433-437.Crossref 24. Mathey D, Bleifeld W, Buss H, et al: Creatine kinase release in acute myocardial infarction: Correlation with clinical electrocardiographic and pathologic findings . Br Heart J 1975;37:1161-1168.Crossref 25. Dixon SH, Limbird LE, Roe CR, et al: Recognition of postoperative acute myocardial infarction . Circulation 1973;47-48( (suppl 3) ):137-140. 26. Alderman EL, Matlof HJ, Shumway NE, et al: Evaluation of enzyme testing for the detection of myocardial infarction following direct coronary surgery . Circulation 1973;48:135-140.Crossref 27. Go RT, Chiu CL, Doty DB, et al: Radionuclide imaging of experimental myocardial contusion . J Nucl Med 1974;15:1174-1175. 28. Cohn PF, Garlin R: Dynamic ventriculography in the role of ejection fraction . Am J Cardiol 1975;36:529-531.Crossref 29. Sutherland GR, Calvin JE, Driedger AA, et al: Anatomic and cardiopulmonary responses to trauma with associated blunt chest injury . J Trauma 1981;21:1-12.Crossref 30. Herman MV, Heinlu RA, Klein MD, et al: Localized disorders in myocardial contraction . N Engl J Med 1967;277:222-232.Crossref 31. Hamilton GW, Murray JA, Kennedy JW: Quantitative angiocardiography in ischemic heart disease . Circulation 1972;45:1065-1080.Crossref 32. Theroux P, Ross J, Franklin D, et al: Regional myocardial function in the conscious dog during acute coronary occlusion and response to morphine, propranolol, nitroglycerine and lidocaine . Circulation 1976;53:302-314.Crossref

Stambuk, Edgar C.;Pitt, Henry A.;Pais, S. Osher;Mann, Linda L.;Lois, Juan F.;Gomes, Antoinette S.

doi: 10.1001/archsurg.1983.01390120018006pmid: 6197043

Abstract • We evaluated the risks and benefits of percutaneous transhepatic biliary drainage (PTD) in 44 patients. Patients were divided into two groups, palliative and preoperative, each of which had 22 patients. Major complications included bacteremia, hemobilia, and liver abscess and occurred in ten patients (23%). A liver abscess along the catheter tract may have contributed to the death of one patient with an advanced malignant neoplasm. Major complications were more likely to develop in palliative-group patients (36% v 9%) and those patients were more likely to die within 30 days of the procedure (27% v 0%). Four (57%) of seven palliative-group patients and none of six preoperative-group patients with pre-PTD bilirubin levels higher than 20 mg/dL died within 30 days after PTD. Liver function test results improved within seven days in approximately 85% of the patients. Twenty-one patients (95%) in the preoperative group survived surgery. We concluded that the risk of PTD may outweigh the benefit in the subset of patients with advanced malignant neoplasms and a bilirubin level higher than 20 mg/dL. Even then, however, PTD may be justified if pruritus is incapacitating. Pending results of further randomized trials, we have continued performing PTD preoperatively in patients whose bilirubin levels exceed 10 mg/dL. (Arch Surg 1983;118:1388-1394) References 1. Molnar W, Stockum AE: Relief of obstructive jaundice through percutaneous transhepatic catheter: A new therapeutic method . AJR 1980;122:356-367.Crossref 2. Nakayama T, Ikeda A, Okuda K: Percutaneous transhepatic drainage of the biliary tract: Technique and results in 104 cases . Gastroenterology 1978;74:554-559. 3. Pollock TW, Ring ER, Oleaga JA, et al: Percutaneous decompression of benign and malignant biliary obstruction . Arch Surg 1979;114:148-151.Crossref 4. Smale BF, Ring EJ, Freiman DB, et al: Successful long-term percutaneous decompression of the biliary tract . Am J Surg 1981;141:73-76.Crossref 5. Denning DA, Ellison EC, Carey LC: Preoperative percutaneous biliary decompression lowers operative morbidity in patients with obstructive jaundice . Am J Surg 1981;141:61-65.Crossref 6. Dooley JS, Dick R, Olney J, et al: Non-surgical treatment of biliary obstruction . Lancet 1979;2:1040-1044.Crossref 7. Ferrucci JT Jr, Mueller PR, Harbin WP: Percutaneous transhepatic biliary drainage: Technique, results, and applications . Radiology 1980;135: 1-13.Crossref 8. Hansson JA, Hoevels J, Simert G, et al: Clinical aspects of nonsurgical percutaneous transhepatic drainage in obstructive lesions of the extrahepatic bile ducts . Ann Surg 1979;189:58-61.Crossref 9. Harrington DP, Barth KH, Maddrey WC, et al: Percutaneously placed biliary stents in the management of biliary obstruction . Dig Dis Sci 1979;24:849-857.Crossref 10. Takada T, Hanyu, F, Kobayashi S, et al: Percutaneous transhepatic cholangial drainage: Direct approach under fluoroscopic control . J Surg Oncol 1976;8:83-97.Crossref 11. Tylén U, Hoevels J, Vang J: Percutaneous transhepatic cholangiography with external drainage of obstructive biliary lesions . Surg Gynecol Obstet 1977;144:13-18. 12. Mueller PR, van Sonnenberg E, Ferrucci JT,Jr: Percutaneous biliary drainage: Technical and catheter-related problems in 200 procedures . AJR 1982;138:17-23.Crossref 13. Hatfield ARW, Tobias R, Terblanche J, et al: Preoperative external biliary drainage in obstructive jaundice: A prospective controlled clinical trial . Lancet 1982;2:896-899.Crossref 14. Berquist TH, May GR, Johnson CM, et al: Percutaneous biliary decompression: Internal and external drainage in 50 patients . AJR 1981;136:901-906.Crossref 15. Clark RA, Mitchell SE, Colley DP, et al: Percutaneous catheter biliary decompression . AJR 1981;137:503-509.Crossref 16. McPherson GAD, Benjamin IS, Nathanson B, et al: Advantages and disadvantages of percutaneous transhepatic biliary drainage as part of a staged approach to obstructive jaundice , abstracted. Gut 1981;22:427. 17. McPherson GAD, Benjamin IS, Habib NA, et al: Percutaneous transhepatic drainage in obstructive jaundice: Advantages and problems . Br J Surg 1982;69:261-264.Crossref 18. Norlander A, Kalin B, Sundblad R: Effect of percutaneous transhepatic drainage upon liver function and postoperative mortality . Surg Gynecol Obstet 1982;155:161-166. 19. Ishikawa Y, Oishi I, Miyai M, et al: Percutaneous transhepatic drainage: Experience in 100 cases . J Clin Gastroenterol 1980;2:305-314.Crossref 20. Monden M, Okamura J, Kobayashi N, et al: Hemobilia after percutaneous transhepatic biliary drainage . Arch Surg 1980;115:161-164.Crossref 21. Druy EM: Hepatic artery-biliary fistula following percutaneous transhepatic biliary drainage . Radiology 1981;141:369-370.Crossref 22. Pennington L, Kaufman S, Cameron JL: Intrahepatic abscess as a complication of long-term percutaneous internal biliary drainage . Surgery 1982;91:642-645. 23. Koyama K, Takagi Y, Ito K, et al: Experimental and clinical studies on the effect of biliary drainage in obstructive jaundice . Am J Surg 1981;142:293-299.Crossref 24. Kadir S, Baassiri A, Barth KH, et al: Percutaneous biliary drainage in the management of biliary sepsis . AJR 1982;138:25-29.Crossref 25. Dawson JL: Acute postoperative renal failure in obstructive jaundice . Ann R Coll Surg Engl 1968;42:163-174. 26. Pitt HA, Cameron JL, Postier RG, et al: Factors affecting mortality in biliary tract surgery . Am J Surg 1981;141:66-72.Crossref 27. Pitt HA, Postier RG, Cameron JL: Consequences of preoperative cholangitis and its treatment on the outcome of surgery for choledocholithiasis . Surgery 1983;94:447-452. 28. Fargion SR, Podda M, Cappellini MD, et al: Immunità cellulare nelle colestasi intra- ed extra-epatiche . Minerva Dietol Gastroenterol 1976;22: 261-265. 29. Tompkins RK, Pitt HA: Surgical management of benign lesions of the bile ducts . Curr Probl Surg 1982;19:322-400.Crossref

Berci, George;Hamlin, J. Andrew;Grundfest, Warren S.

doi: 10.1001/archsurg.1983.01390120025007pmid: 6651515

Abstract • Sixty-one patients were referred in the postoperative period for stone extraction through the T-tube tract. In four patients the calculi passed spontaneously. One patient had a papilloma and another a blood clot mimicking a stone. Of the remaining 55 cases, all but three were successfully treated by removal of all calculi from the ductal system, a success rate of 94.5%. No major complications occurred in this series. We believe the combined fluoroendoscopic approach to be the preferred method of extracting stones throught the T-tube tract because of the greater precision possible when manipulating under direct vision and the reduction in radiation exposure of patients and personnel. (Arch Surg (1983;118:1395-1397) References 1. Burhenne JJ: Nonoperative retained bilary stone extraction . AJR 1973;117:388-390.Crossref 2. Yamakawa T, Komaki F, Shikata J: Experience with routine postoperative choledochoscopy via the T-tube sinus tract . World J Surg 1978;2:379-384.Crossref 3. Berci G, Hamlin JA: A combined fluoroscopic and endoscopic approach for retrieval of retained stones through the T-tube tract . Surg Gynecol Obstet 1981;153:237-240. 4. Berci G, Hamlin JA: Retrieval of retained stones , in Berci G, Hamlin JA (eds): Operative Biliary Radiology . Baltimore, Williams & Wilkins Co, 1981, pp 147-158. 5. ood M: Eponyms in biliary tract surgery, presidential address . Am J Surg 1979;138:746-749.Crossref 6. Smith SW, Engel C, Averbrook B, et al: Problems of retained and recurrent common bile duct stones . JAMA 1957;164:231-236.Crossref 7. Berci G, Hamlin JA: Biliary ductal anomalies , in Berci G, Hamlin JA (eds): Operative Biliary Radiology . Baltimore, Williams & Wilkins Co, 1981, pp 109-138. 8. Mack E, Patzer EM, Crummy AB, et al: Retained biliary tract stones: Nonsurgical treatment with Capmul 8210, a new cholesterol gallstone dissolution agent . Arch Surg 1981;116:341-344.Crossref 9. Thistle JL, Carlson GL, Hofmann AF, et al: Monooctanoin, a dissolution agent for retained cholesterol bile duct stones: Physical properties and clinical application . Gastroenterology 1980;78:1016-1022. 10. Berci G: Endoscopic retrograde sphincterotomy , in Gitnick GL (ed): Current Gastroenterology and Hepatology . Boston, Houghton Mifflin Co, 1979, vol 1, pp 79-85.

Orkin, Bruce A.;Fonkalsrud, Eric W.;Salusky, Isidro B.;Ettenger, Robert B.;Hall, Theresa;Jordan, Stanley C.;Fine, Richard N.

doi: 10.1001/archsurg.1983.01390120028008pmid: 6651516

Abstract • Based on clinical experience with 35 subjects younger than 21 years of age who underwent continuous ambulatory peritoneal dialysis (CAPD) during a two-year period at our institution, this procedure was found to be superior to hemodialysis in children because it allowed great freedom of activity and produced fewer complications requiring hospitalization. Moreover, CAPD appeared to be less expensive than hemodialysis, and no mortality or significant morbidity occurred during the 386 patient-months of catheter usage. Exit site infections, peritonitis, and abdominal hernias were the most common complications, often requiring minor surgical repairs. Using a specific operative technique for catheter placement and smaller volumes of dialysate during the first week after placement, these complications were minimized. Thus, CAPD is an effective, advantageous method for treatment of end-stage renal disease in children. (Arch Surg 1983;118:1398-1402) References 1. Putnam TH: The living peritoneum as a dialyzing membrane . Am J Physiol 1922;64:548. 2. Devine H, Oreopoulos DG, Izatt S, et al: The permanent Tenckhoff catheter for chronic peritoneal dialysis . Can Med Assoc J 1975;113:219-221. 3. Roxe DM, Argy WP Jr, Frost B, et al: Complications of peritoneal dialysis . South Med J 1976;69:584-587.Crossref 4. Rubin J, Oreopoulos DG, Lio TT, et al: Management of peritonitis and bowel perforation during chronic peritoneal dialysis . Nephron 1976;16: 220-225.Crossref 5. Karanicolas S, Oreopoulos DG, Pylychuk G, et al: Home peritoneal dialysis: Three years' experience in Toronto . Can Med Assoc J 1977;116: 266-269. 6. Baker RF Jr: Complications and management of dialysis for renal failure . Am Surg 1976;42:859-862. 7. Boen ST, Mion C, Curtis FK, et al: Periodic peritoneal dialysis using the repeated puncture technique and an automated cycling machine . Trans Am Soc Artif Intern Organs 1964;10:409. 8. Maxwell MH, Rockney RB, Kleeman CR, et al: Peritoneal dialysis: I. Technique and applications . JAMA 1959;170:917.Crossref 9. Palmer RA: Peritoneal dialysis by indwelling catheter for chronic renal failure: 1963-1968 . Can Med Assoc J 1971;105:376-386. 10. Vidt DG, Donald GV, Manning RF: Repeated peritoneal dialysis: Facilitation by a simple access device . Cleve Clin Q 1972;39:67-72. 11. Popovich RP, Moncrief JW, Ducherd JB, et al: The definition of a novel portable/wearable equilibrium peritoneal dialysis technique , abstracted. Trans Am Soc Artif Intern Organs 1976;5:64. 12. Saluski IB, Lucullo L, Nelson P, et al: Continuous ambulatory peritoneal dialysis in children . Pediatr Clin North Am 1982;29:1005-1012. 13. Palmer RA, Quinton WE, Grey JE: Preliminary communication: Prolonged peritoneal dialysis for chronic renal failure . Lancet 1964;1: 700-702. 14. Tenckhoff H, Schechter H: A bacteriologically safe peritoneal access device . Trans Am Soc Artif Intern Organs 1968;14:181-186. 15. Stricker G, Tenckhoff H: A transcutaneous prosthesis for prolonged access to the peritoneal cavity . Surgery 1971;69:70-74. 16. Oreopoulos DG, Robson M, Watt S, et al: A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD) . Trans Am Soc Artif Intern Organs 1978;24:484-489. 17. Black HR, Finkelstein FO, Lee RV: The treatment of peritonitis in patients with chronic indwelling catheters . Trans Am Soc Artif Intern Organs 1974;21:115-119. 18. Baum M, Powell D, Calvin S, et al: Continuous ambulatory peritoneal dialysis in children: Comparison with hemodialysis . N Engl J Med 1982;307: 1537-1542.Crossref 19. Alexander SR, Tank ES: Surgical aspects of continuous ambulatory peritoneal dialysis in infants, children and adolescents . J Urol 1982;127: 501-504. 20. Rubin J, Rogers WA, Taylor HM, et al: Peritonitis during continuous peritoneal dialysis . Ann Intern Med 1980;92:7-13.Crossref 21. Mandell IN, Ahern MJ, Kliger AS, et al: Candida peritonitis complicating peritoneal dialysis: Successful treatment with low-dose amphotericin B therapy . Clin Nephrol 1976;6:492-496.

Unzeitig, Gary W.;Frankl, Gloria;Ackerman, Mona;O'Connell, Theodore X.

doi: 10.1001/archsurg.1983.01390120033009pmid: 6651517

Abstract • Of 296 occult breast cancers diagnosed at Kaiser-Permanente Medical Center, Los Angeles, in the last ten years, 80 were classified as minimal and 167 as nonminimal. Minimal cancers were intraductal, lobular in situ, or invasive and 0.5 cm or less in diameter. In the occult-minimal group, no woman had axillary node metastases, and there were no recurrences. In the occult-nonminimal group, 26% of the patients had axillary nodal involvement, with a recurrence rate of 13% and a mortality of 11.6%. Occult breast cancers differed significantly between minimal and nonminimal tumors in both treatment and prognosis. Nonminimal cancers should be treated as any palpable carcinoma. More conservative approaches could be considered for the minimal group, but prospective controlled studies should be done to determine the long-term risks of such treatment. (Arch Surg 1983;118:1403-1404) References 1. Gallagher HS, Farrow JH, Galante M: Early breast cancer: What is it? South Med Bull 1971;59:10-12. 2. Gallagher HS, Martin JE: An orientation to the concept of minimal breast cancer . Cancer 1971;28:1505-1507.Crossref 3. Bedwani R, Vana J, Rosner D, et al: Management and survival of female patients with 'minimal' breast cancer . Cancer 1981;47:2769-2778.Crossref 4. Rosen PP, Braun DW, Kinne DE: The clinical significance of pre-invasive breast carcinoma . Cancer 1980;46:919-925.Crossref 5. Letton AH, Mason EM: The treatment of nonpalpable carcinoma of the breast . Cancer 1980;46:980-982.Crossref 6. Moskowitz M, Pemmaraju S, Fidler J, et al: On the diagnosis of minimal breast cancer in a screened population . Cancer 1976;37:2543-2552.Crossref

Bertelsen, Carl A.;Korn, Edward I.;Morton, Donald L.;Kern, David H.

doi: 10.1001/archsurg.1983.01390120036010pmid: 6651518

Abstract • To determine whether in vitro chemosensitivities of clones from metastases of human tumors varied, biopsy specimens of two separate metastatic lesions were obtained from 75 patients. Significant tumor growth (>30 colonies per plate) occurred in both specimens in 49 of the 75 patients. Biopsies were performed simultaneously in 22 patients (synchronous) and sequentially in 27 patients (metachronous). Tumor samples were scored as being resistant (<50% inhibition of colony formation) or sensitive (>50% inhibition) to each drug. The two tumor samples from each patient were compared for differences in sensitivity after exposure with standard panels of chemotherapeutic agents. A total of 272 individual drug comparisons were possible. Variations were evident in 49 (40%) of 121 metachronous drug comparisons and in 42 (28%) of 151 synchronous drug comparisons. We concluded that multiple metastases of human tumors can vary in chemosensitivity in vitro; this finding seemed to reflect the heterogeneity of metastatic clones. (Arch Surg 1983;118:1406-1409) References 1. Schabel FM: Concepts for systemic treatment of micrometastases . Cancer 1975;35:15-24.Crossref 2. Citone MA, Fidler IJ: Correlation of patterns of anchorage-independent growth with in vivo behavior of cells from a murine fibrosarcoma . Proc Natl Acad Sci USA 1980;77:1039-1043.Crossref 3. Siracky J: An approach to the problem of heterogeneity of human tumor-cell populations . Br J Cancer 1979;39:540-577.Crossref 4. Vindeln LL, Hansen HH, Christensen IJ, et al: Clonal heterogeneity of small-cell anaplastic carcinoma of the lung demonstrated by flow-cytometric DNA analyses . Cancer Res 1980;40:4295-4300. 5. Fidler IJ, Kripka ML: Metastasis results from preexisting variant cells within a malignant tumor . Science 1977;197:893-895.Crossref 6. 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