Primary Indication For Surgery Research Articles

Fractures of the tibial tuberosity in adolescents.

The cases of fourteen adolescents with fifteen physeal fractures of the tibial tuberosity were reviewed to more accurately define specific fracture patterns, to establish treatment for the different types, and to determine the incidence of complications. A modified classification scheme with a greater emphasis on intra-articular extension of the fracture and communution of the tuberosity was devised. Closed or open reduction, as necessary, gave satisfactory results. The primary indications for surgery were: (1) displacement of one or more fragments of the tuberosity anterosuperiorly, and (2) extension of the fracture through the proximal tibial ossification center into the knee joint, with disruption of the joint surface. There appears to be an increased incidence of pre-existing Osgood-Schlatter disease (ipsilateral and contralateral) in patients who have an acute tuberosity injury. Complications are rare. The theoretical possibility of the subsequent development of genu recurvatum appears unlikely, since most of these injuries occur when the physis of the tuberosity is undergoing normal closure.

Life Change and the Postoperative Course of Duodenal Ulcer Patients

Abstract This study of the natural history of peptic ulcer disease reports on the association of medical and surgical data with life change data generated by the Schedule of Recent Experience (SRE). Surgery tended to follow increasing life change and symptomatic complaints, and intractable pain as the primary indication for operation portended a less favorable surgical result. Distribution of postoperative illness within the population was not random, but rather tended to be confined to a susceptible segment of the population in which the more symptomatic patients were inclined to have both gastrointestinal and nongastrointestinal symptoms. There was no association between type of operation (hemigastrectomy vs. drainage procedure) and post-operative clinical course with respect to gastrointestinal and nongastrointestinal symptoms. Postoperative magnitude of life change was associated with a preponderance of postoperative gastrointestinal symptoms. An unstable and/or decreasing trend in the patient's estim...

Hemoptysis and Pulmonary Aspergilloma: Operative versus Nonoperative Treatment

The clinical experience with 42 patients with pulmonary aspergilloma evaluated at the Vanderbilt University Affiliated Hospitals in a 22-year period was reviewed to determine the necessity and advisability of pulmonary resection. Twenty-nine patients (69%) had sustained one or more episodes of gross hemoptysis. Eleven of the 42 patients were treated operatively with lobectomy, wedge resection, or cavernostomy. Five of them had had hemoptysis preoperatively, but in only 1 patient was massive hemoptysis the primary indication for operation. The single death among these 11 patients occurred in the patient undergoing operation for control of massive hemoptysis. Nonoperative treatment was selected in 31 patients because of advanced chronic lung disease. Twenty-four of these 31 patients experienced 41 episodes of gross hemoptysis during observation periods up to 8 years (average, 32 months). Superimposed bacterial infection usually accompanied the episodes of hemoptysis, and medical therapy with bedrest, antibiotics, and postural drainage was successful in controlling the hemorrhage in 40 of the 41 episodes. One patient died from massive hemoptysis. On the basis of this experience, pulmonary resection for aspergilloma in patients with hemoptysis seems rarely indicated.

Collis-Belsey reconstruction of the esophagogastric junction: Indications, physiology, and technical considerations

Twenty-four patients underwent combined Collis-Belsey reconstruction of the esophagogastric junction. The primary indication for operation in 19 patients was gastroesophageal reflux. Three patients had achalasia, one diffuse spasm, and one an incarcerated combined sliding and paraesophageal hernia. Postoperatively, symptoms were relieved in all 19 patiients undergoing repair for gastroesophgeal reflux with or without peptic strictures of the esophagus, and barium swallows showed no gastroesophageal reflux. Preoperative average mean and peak pressures in the distal esophageal high pressure zone (HPZ) were 1.38 and 2.72 mm. Hg, respectively; two thirds had no measurable HPZ. Postoperative mean and peak pressures were 6 and 12.36 mm. Hg, respectively; average HPZ length was 2.81 cm. Of 19 patients with massive reflux preoperatively, postoperative acid reflux testing demonstrated no reflux in 14 and minimal to moderate reflux in five. Collis-Belsey reconstruction ot the esophagogastric junction effectively relieves symptoms and controls the complications of gastroesophageal reflux.

Current aspects of sterilization: The selection and application of various surgical methods of sterilization

A partial analysis of 4,270 female sterilizations performed during a 7 year time period was described as related to changing patterns of application according to a sterilization program. Special attention was given to such factors as type of procedure, reasons for selection of procedures, ancillary conditions, mortality rate, and follow-up. A plea is made for accuracy when a sterilization is truly used as the primary indication for surgery and for flexibility and individualization in the application of sterilization techniques.

Coronary artery bypass in patients over 70 years of age: Indications and results

With recent advances in all phases of coronary care and the increasing success of coronary arterial surgery, operative treatment of coronary artery disease is more readily recommended, even for patients over 70 years of age. In a series of 3,730 patients who underwent aortocoronary bypass from November 1969 through June 1974, there were 95 patients who were 70 years of age or older. The primary indication for surgery was severe angina, which was present in 88 patients. The mean coronary arterial score was 9.51. Associated valvular lesions were treated surgically in 21 patients, and a left ventricular aneurysm was resected in 7. Improvements in surgical technique and postoperative care are responsible for the hospital mortality rate of only 4.8 percent in the 21 patients operated upon during the first 6 months of 1974 compared with the overall mortality rate of 22.1 percent in all 95 patients. Long-term follow-up among the 95 patients includes data from 33 patients: 9 patients whose condition improved, 21 who were asymptomatic and 1 “coronary death”.

Effects of temporal-lobe surgery on behavior.

When Mr. Murray Falconer moved from New Zealand to London, his neurosurgical unit based jointly in two major London teaching hospitals and at the Maudsley Hospital, one of the leading psychiatric centers of the world, began a methodical study of surgery in the control of temporal-lobe epilepsy. Although the primary indication for surgery was uncontrolled seizures, the presence of behavioral changes in a large fraction of the 250 patients operated on has permitted the accumulation of considerable data on the clinical pictures of these personality changes and the effects of surgery. This study has had the advantage of independent assessment . . .

Femorotibial vein bypass.

Sixty-five patients underwent femorotibial saphenous vein bypass and were observed a minimum of 18 months. The primary indication for operation is limb salvage in patients otherwise facing amputation. In 54% of the patients, preservation of the extremity was accomplished. The operative mortality was 3%.

Diverting ileostomy or colostomy in the management of Crohn's disease of the colon.

Thirteen patients who had Crohn's disease of the colon and rectum were treated surgically by a diverting colostomy or ileostomy. Primary indications for surgery were severe perianal complications in eight patients, retardation of growth and development in two, and failure of medical management to effect a satisfactory remission in three. Improvement in clinical condition has occurred in all patients, but four have subsequently undergone proctocolectomy because perirectal complications, particularly perianal and rectovaginal fistulas, persisted or worsened. Two patients have had intestinal continuity reestablished by closure of colostomy. One has had recurrence which required further surgery, and the other one has remained well. In the remaining seven patients the symptoms and signs of Crohn's disease have not subsided completely.

Resection of the distal ulna in rheumatoid arthritis.

AbstractForty‐two wrists in patients with rheumatoid arthritis were subjected to distal ulnar resection, and follow‐up examinations were made. Failure of conservative medical therapy, subluxation or dislocation of the distal ulna with pain or limited motion, persistent synovitis, and tendon involvement are the primary indications for surgery. These painful, deformed joints experienced an increased range of motion and improved strength and function postoperatively. There was no recurrence of pain or synovitis, and tendon rupture has not occurred. No operative or postoperative complications occurred.

Cardiac surgery in bacterial endocarditis.

Open heart surgery has been performed at the Massachusetts General Hospital in 13 patients less than 6 months after the initiation of treatment for acute or subacute bacterial endocarditis. The endocarditis involved the aortic valve in 12 cases and a mitral valve prosthesis in the other. In two patients there was concomitant rupture of chordae tendineae of the mitral valve. One patient received no preoperative antibiotics, and four were still receiving their initial course of therapy at the time of surgery. The primary indication for surgery in all cases was progressive or intractable congestive heart failure. Ten underwent replacement of the aortic valve alone, two had both aortic and mitral valves replaced, and one had a mitral prosthesis replaced. Of the 13 patients, 10 are alive and doing well, although paraprosthetic insufficiency developed in three, two of whom required subsequent surgical repair. Three patients died, two in the early postoperative period, and one, 8 months after surgery from paraprosthetic regurgitation with hemolysis and heart failure. Antibiotics were given during and after surgery for as long as 6 weeks. In no case has recurrent sepsis been a problem. Our experience indicates that open heart surgery, when necessitated by progressive congestive heart failure due to valve destruction, can be safely and effectively performed during or shortly after treatment of bacterial endocarditis.

Crawford Adams Cup Arthroplasty

Fifty arthroplasties of the hip in forty-three patients with use of the Crawford Adams cup are reported. See Images in the PDF file. In general, the results have been satisfactory. Severe pain, the primary indication for operation, was relieved in forty-five of the fifty hips. The majority of excellent results occurred in hips with arthritis secondary to trauma. Necrosis of the head beneath the cup, recognized as a possibility at the beginning of this series, materialized in three patients. One of these represents the only case of infection in the series, and this was probably present at the time of arthroplasty. Two cups broke because of mechanical faults. The method of manufacture has been changed so that the cup is now constructed of one piece of metal.

Late results of hiatus hernia repair

One hundred patients with apparently symptomatic hiatus hernias were operated upon during the ten year period from 1947 to 1957. The patients were categorized according to the primary indication for operation into the following groups: dyspepsia, bleeding (acute hemorrhage and chronic anemia), esophageal dysfunction, and pain of anginal type. The source of bleeding was ascribed to esophagitis (with or without distinct esophageal ulcer) or gastritis (edema, congestion and hemorrhage of mucosa of herniated stomach revealed on biopsy) except for one case of gastric ulcer in the herniated stomach. Late follow-up studies in seventy-eight of ninety-eight surviving patients revealed a distressingly high incidence of recurrent herniation and/or symptoms despite earlier satisfactory results. The best late results as measured by clinical evaluation were in those patients who were operated upon because of pain of anginal type, acute bleeding or chronic anemia. Less favorable results were attained in patients who initially complained of symptoms of esophageal dysfunction and the least favorable results in patients whose preoperative symptoms were sufficiently nondescript to be considered dyspeptic in type. In some patients in this latter group it is suspected that the symptoms were partly or entirely due to some disorder other than hiatus hernia.

Surgical pathology of small ovarian cysts

1.1. A study is presented of 203 ovarian cysts other than endometriosis and less than 5 cm. in diameter removed over a two-year period at an open-staff general hospital.2.2. The incidence of neoplastic cysts in the series was 13, or 6.4 per cent.3.3. All of the cysts found in postmenopausal women were neoplastic.4.4. The incidence of neoplastic cysts in 198 premenopausal patients was 8, or 4 per cent. The incidence of neoplastic cysts in the 33 premenopausal patients operated upon primarily for ovarian cyst was 3, or 9.1 per cent. In the 165 cases, in which the ovarian cyst was found incidentally, 5, or 3.1 per cent, were neoplastic.5.5. No malignant neoplastic cysts were present in this series.6.6. Rapid increase in size of a cyst to approximately 5 cm. when observed over a period of three months or more, and fixation of the cyst, were observed in 2 of the 3 neoplastic cysts in patients in whom ovarian cyst was the primary indication for operation.7.7. Functional cysts constituted 93.6 per cent of the entire series and 96 per cent in the premenopausal group but were not found at all in the postmenopausal group.