Biomedical subjects
Publications and source records attributed to G A Donaldson.
A case report of a patient who developed cauda equina syndrome following pelvic traction for acute sciatica is presented. A good outcome was obtained with prompt surgical decompression. This case illustrates the potential dangers of traction, which is frequently employed in the management of acute back pain.
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Case records of 237 patients treated by inferior vena cava (IVC) ligation (154), suture plication (27) or clip application (56) were reviewed. Indications for surgery included failure of anticoagulation or femoral vein ligation to control embolism and threat of potentially massive, septic or paradoxical emboli. Overall hospital mortality was 15% and recent operative mortality was 2%. The incidence of early postoperative leg swelling was 36% and late venous sequellae occurred in 50% of the follow-up group of 140 cases followed an average of 44.3 months. Morbidity secondary to IVC interruption was decreased by use of the prosthetic lip, but clip application was still associated with early leg swelling in 21% and late mild swelling in 24%. The incidence of proven or suspected recurrent emboli was 7.6% with no significant variation by type of IVC procedure, and recurrent emboli were fatal in 2.5%. Refinement of indications, operative methods and perioperative care for IVC interruption procedures over the years has substantially improved the surgical approach to prevention of life-threatening pulmonary embolism.
The complete autopsies of 145 patients dying of colorectal cancer are reviewed. Isolated local or distant metastases are infrequent, compared to disseminated disease. Solitary local recurrences are most common after resection of rectal tumors. Right colon tumors spread to local and distant sites in 90% of autopsies, and to distant sites alone in 10%. Rectal tumors spread locally only in 25% of cases, to distant site alone in 25%, and to both in 50%. Regardless of the origin of the primary tumor, the liver is the most common site of metastasis, followed by the regional lymph nodes and the lungs. Two-thirds of the patients with right colon lesions died of liver metastases, and three-quarters of those with rectal tumors succumbed to disseminated disease. The current curative and palliative treatment of recurrent colorectal cancer in clinical medicine by surgery, radiotherapy, and chemotherapy is reviewed. It is suggested that an understanding of the anatomic patterns of cancer recurrence will increase in importance as advances in the modalities of treatment are made,
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A series of 177 patients with recurrent colorectal cancer treated at the Massachusetts General Hospital is examined retrospectively. Two thirds of recurrences were observed by the second postoperative year, and 15% of patients were asymptomatic. Pelvic recurrences were usually attributable to rectal or sigmoid tumors, whereas right-sided carcinomas frequently spread to the liver. The commonest methods of clinical discovery of recurrence included findings of abdominal and pelvic masses, hepatomegaly, and positive chest films. The average survival after discovery of recurrence was only eleven months, but 23 patients having reresections for cure lived an average of thirty-three months. Seven patients (30%) undergoing reresection for cure represented probable cures. Chemotherapy with intravenous 5-FU provided poor palliation, but radiotherapy gave satisfactory relief of symptoms in approximately 50% of patients, particularly those with rectal or low colon lesions. A program of follow-up is offered since there is evidence that even the symptomatic patient may be well palliated or even cured by surgical resection of the recurrence or palliative therapy.
Twenty patients with suppurative cholangitis were seen at the Massachusetts General Hospital over a nine year period. Fifteen patients had acute obstructive suppurative cholangitis due to complete obstruction of the common duct, many with coma, hypotension, and positive blood cultures. Sixty per cent of patients were older than seventy years, and most had a history of biliary tract disease. Although most had jaundice, abdominal pain, and fever, clinical symptoms were variable. The diagnosis of cholangitis was made in only 30 per cent of patients before autopsy or surgery. Eighteen patients had calculi in the common duct, and two had primary fibrosis of the ampulla. Patients explored less than 24 hours after admission or deterioration died less often than those operated on after some delay. Most patients underwent common duct exploration and four had a concomitant sphincterotomy. In one instance, cholecystostomy only was performed and this patient died because of ongoing sepsis. The overall mortality was 40 per cent; of those subjected to operation, 25 per cent died in the hospital. Recovery was dramatic among most survivors, and calculous disease did not recur, except for two patients with retained stones. Prophylactic cholecystectomy is recommended to prevent the occurrence of this subtle and highly dangerous syndrome.
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Twenty-seven patients with Stage B and C carcinomas of the rectum and lower sigmoid received radiotherapy following radical surgery. Local control ratios for Stages B2, B3, and C (modified Duke's) were 7/9, 2/6, and 4/12, respectively. Nine of these 13 patients are alive with no evidence of disease 4-54 mo. after treatment; the other 4 died of unrelated causes. One died of complications attributable to irradiation 6 mo. after treatment; no tumor was found at autopsy. These results suggest that postoperative irradiation plays a significant role in Stage B lesions, but prognosis for Stage C disease does not appear to be altered.
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As further statistical evidence accumulates it is becoming evident that a major factor in the differing patient salvage between perforative and uncomplicated cancer of the colon and rectum is the element of infection. The absence of abdominal sepsis is undoubtedly responsible for the lessened morbidity and mortality found in the treatment of established fistulas. Surgical attention should therefore be directed first to the eradication of the primary source of infection, the perforated tumor. The safety with which an intestinal anastomosis may be made in the presence of edema and inflammation is a matter of mature judgement on the part of the operating surgeon. Postoperative suture line leakage should be avoidable. Extirpative surgery with or without anastomosis, coupled with the judicious drainage of the peritoneal cavity, antibiotic coverage, and blood volume support should continue to give improved results in the management of this distressing complication of cancer of the colon and rectum.
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