Barnett presented the clinical application of this method in several patients before the Southern Surgical Association. The article appeared in the Annals of Surgery (159:794, 1964). I am very much in accord with the invited editorial comments that fol¬ lowed the Archives article and agree wholeheartedly with Dr Nardi that in many instances the problems of the difficult duodenal stump can be avoided by performing vagotomy with drainage. However, with a modest experience covering 25 years in deal¬ ing with difficult duodenal ulcers, I believe that in the vast majority of cases a Billroth I reconstruction cart be safely carried out. In our experience, we leave most of the penetrating posterior ulcers attached to the pan¬ creas and do not attempt to mobilize the duodenum distally. The gastric pouch can simply be brought over the ulcer crater and anastomosed to the duodenum. The ulcer crater is thus marsupialized or exteriorized on the pancreatic bed. I think that this method is far safer than attempting a Nissen closure of the duodenal stump or carrying out a Strauss maneuver on the posterior duodenal wall in order to gain more tissue posteriorly to carry out a stump closure. Even in deep penetrating duodenal ulcers that have bled, we transfix the bleeder and then perform end-to-end gastroduodenostomy with
safety.
J. LYNWOOD HERRINGTON, Nashville, Tenn
JR, MD
In Reply.\p=n-\Imust apologize to Dr William O. Barnett for failure to cite his description of Roux-en-Y duodenojejunostomy for duodenal stump closure as kindly point out by Dr
shared
by
both forms of
duodenojeju-
nostomy. We believe though, for ulcer
occurring at the ampulla, some tension
an
level of the
may be
un-
avoidable in a Billroth I anastomosis even in the face of extensive mobilization. At the Southern Surgical Association's meeting some 13 years ago, Dr Barnett's paper1 evoked a reaction identical to the comments of Drs Nardi and Herrington. I submit that the point is rather easily missed. RAPHAEL CHUNG, MD Iowa City 1. Barnett WO, Tucker FH: Management of the difficult duodenal stump. Ann Surg 159:794\x=req-\ 801, 1964.
tip pointing centrally (Figure). By withdrawal and readvancement of the
Balloon Flotation Catheter
To the Editor.\p=n-\SinceSwan and Ganz advocated the use of the balloon flotation catheter for measurement of pulmonary artery pressure in monitoring critically ill patients, the importance of this method has been well demonstrated by many investigators. It has also been noted that pulmonary wedge pressure has occasionally been unobtainable, despite seemingly adequate positioning of the catheter tip, without reasonable explanation other than balloon rupture. In the following case we observed a complication previously unknown to us. A 73-year-old man underwent total gastrectomy, splenectomy, and esophagojejunostomy for carcinoma of the stomach. Postoperatively, he developed pancreatitis, sepsis, and acute renal failure. He was transferred to the Shock and Trauma Unit for exten-
Herrington. While agreeing unreservedly about everything that was said in both Dr
Nardi's editorial comment and Dr Herrington's letter, I nevertheless would like to point out that both rather missed the point of the article. Undoubtedly, the best way to deal with a difficult situation is to avoid it, but in the meantime what should the inexperienced and the unwary do when he discovers that it is too late to follow the counsel of perfection? Dr Herrington has emphasized the superiority of Billroth I reconstruction under such circumstance, a principle
sive monitoring. A No. 7 French Swan-Ganz catheter was inserted through the subclavian vein, using the Seldinger technique. Four days later, pulmonary wedge pressure was unob¬ tainable due to balloon rupture. A second catheter of similar size was then placed, and chest x-ray film confirmed its proper position. How¬ ever, wedge pressure was still unob¬ tainable. Since the balloon was felt to be intact, 1.5 ml of a mixture of diatri¬ zoate sodium and diatrizoate meglu¬ mine (Renografin 40) was injected into the balloon, and chest x-ray film was taken to confirm its integrity. It was discovered that the catheter tip had made a 180-degree turn with the
catheter, the tip was uncoiled, and the
wedge pressure was recorded. It is important to recognize this possibility if a fresh catheter, seem¬ ingly in proper position on the chest x-ray film, fails to record pulmonary wedge pressure. Confirmation could be made safely by injecting a small amount of contrast material into the
balloon
and
repeating
x-ray.
the
chest
VICTOR DY BUNICHI NAGAWAKA TERUO MATSUMOTO
Philadelphia in Lower Gastrointestinal Bleeding
Angiography
To the Editor.\p=n-\I must take issue with the BRIEF CLINICAL NOTE by Drs Vega and Lucas that appeared in the August issue of the Archives (111:913, 1976). In the "Comment," the authors question the value of angiography in massive lower gastrointestinal bleeding and point out that "since these patients are usually elderly, have other cardiovascular problems, do not tolerate undue delay, and can tolerate
only one major operative procedure," angiography is of questionable value.
This concept is contrary to more experience in dealing with massive lower gastrointestinal bleeding, the major point being that angiography not only offers a diagnostic modality in demonstrating the bleeding site, but also offers a very effective method of treating diverticular hemorrhage via the use of selective infusion of vasopressin (Pitressin). Casarella et al1 pointed out, as was the case in the patient described by recent
Balloon was visualized by injecting 1.5 ml of a mixture of diatrizoate sodium and diatrizoate meglumine (Renografin 40). Note 180-degree turn of catheter tip
(arrow).
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/22/2015
2
the authors, that demonstrable diverticular bleeding appears to occur more frequently in the right side of the colon. In addition, as reported by Casarella and co-workers and as is the personal experience of many angiographers involved with gastrointes¬ tinal hemorrhage, diverticular bleed¬ ing responds to vasopressin in a very high percentage of patients (90%). (In my personal experience with nine patients with massive lower gastroin¬ testinal bleeding, all patients re¬ sponded to vasopressin without recur¬
rence.)
In summary, these patients who are usually elderly, possibly debilitated, and with concomitant medical prob¬ lems, can poorly tolerate general anes¬
thesia, not to mention total abdominal colectomy. Selective superior mesen¬ teric and inferior mesenteric arteriography, in the hands of experienced angiographers, can be performed in relatively little time and provides both diagnostic and therapeutic benefits. One performs angiography in gas¬ trointestinal bleeding with two objec¬
tives in mind: (1) demonstration of the bleeding site and (2) cessation of the hemorrhage via vasopressor infusion. Extensive surgery (total colectomy) would seem appropriate only after these have failed. BARRY T. KATZEN, MD Alexandria, Va
1. Casarella WJ, Galloway SJ, Taxin RN, et al: Lower gastrointestinal tract hemorrhage: New concepts based on arteriography. Am J Roentgenol Radium Ther Nucl Med 121:357-368, 1974. 2. Casarella WJ, Kanter IE, Seaman WB: Right sided colonic diverticula as cause of acute rectal hemorrhage. N Engl J Med 286:450-453, 1972.
Reply.\p=n-\Theprime objective of this to reaffirm the principle that, once surgical inter-
In
BRIEF CLINICAL NOTE was
vention is decided on, total abdominal colectomy with ileoproctostomy is the only procedure that precludes rebleed-
ing; a secondary objective was to discourage time-consuming angiography, since identifying and resecting a portion of the colon containing the bleeding site will not prevent later rebleeding from another site. Identification of the active bleeding site, therefore, is not entirely pertinent to our disagreement, which centers around the
success
in control-
ling diverticular bleeding with intraarterial vasopressin infusion. My own experience at Detroit General Hospi-
tal has been less than satisfactory with this technique. Reasons for failure have included inability to cannulate either the superior mesenteric artery or the inferior mesenteric artery in patients with diffuse, occlusive disease, lack of response to a standard vasopressin infusion, and rebleeding after initial success either
following a vasopressin infusion. Comparable failure has occurred in other hospitals in the Detroit area where several experienced angiographers labor daily. Initial success at controlling active bleeding by this technique does not eliminate the underlying pathologic lesion, namely, during
had
and that seven were consistent with a herniated disk. It is essential to know which seven patients had this find¬
ing.
or
diffuse diverticula that have an increased propensity for bleeding. Rebleeding after discharge from the hospital is common in comparable patients; it is now clear that such rebleeding may be from different diverticula. Finally, total abdominal colectomy, although a major operation, is readily
completed by experienced
surgeons
within two to three hours, at about the time most patients studied angiographically would be having their second injection of a contrast mate¬ rial. CHARLES E. LUCAS, MD Detroit
Division of
Pyriformis
Muscle
To the Editor.\p=n-\Thegentlemanly editorial comment of R.N. Stauffer, MD, on Mizuguchi's article "Division of the Pyriformis Muscle for the Treatment of Sciatica" (Arch Surg 111:719, 1976) did not "fit the crime." Back pain(s) and therapy for same, even if limited to "sciatica," are very difficult to assess. Complete description of the physical findings before and after operation is important, and myelograms are actually an adjunctive
procedure. The discrepencies between the ref-
and the thesis of the author are noteworthy. For example, Robinson (reference; Am J Surg 73:355, 1947) recommended section of the pyriformis in the absence of lumbar lesions. The study group consisted of 14 patients who were divided into two groups described as (1) postlaminectomy and (2) osteoarthritis. Several patients in group 1 had previous operations, and perhaps all had myeloerences
Only three patients in group 2 myelograms\p=n-\presumedly the same three described as having "narrow spinal canals." The author states that all 14 patients had myelograms
grams.
a
One therapeutic failure occurred in patient with "a complete block at the
L2-3 level," who then underwent a muscle section and lastly a decompres¬ sion laminectomy at L-5—which seems strange. What happened to the com¬ y plete block at L2-3? Stauffer properly commented on the large placebo factor in such patients; thus, a few weeks' follow-up is inadequate. GEORGE E. MOORE, MD KARL STECHER, JR, MD Denver
Reply.\p=n-\Iappreciate the opportunity to comment on the letter by
In
Drs Moore and Stecher. A close review of my article (preliminary report) by them will answer many of their questions. At the eight-month follow-up since preparation of this article, all of these patients are doing well. I have performed this procedure on more than 50 patients who had previous laminectomies for herniated disk or who had sciatica due to osteoarthritis of the spine. Most of the patients had
considerable symptomatic improve-
changes in the follow\x=req-\ Repeated neurologic findings. ups over a long period of time are ment and favorable
scheduled. At a later date, these findings will be reported. At present, in properly selected patients, this procedure provides
symptomatic improvement.
TOMOJI MIZUGUCHI, MD Des Moines, Iowa
Bleeding
From Adenoma of the Liver
To the Editor.\p=n-\Thecase report by Andersen and Packer (Arch Surg 3:898, 1976) provides information on a bleeding but temporarily unresected liver cell adenoma in a woman taking oral contraceptives at the time of diagnosis. The failure to grow perceptibly or to undergo further hemorrhage before the subsequent resection 18 months later led the authors to question the need for routine resec-
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/22/2015
safety.
J. LYNWOOD HERRINGTON, Nashville, Tenn
JR, MD
In Reply.\p=n-\Imust apologize to Dr William O. Barnett for failure to cite his description of Roux-en-Y duodenojejunostomy for duodenal stump closure as kindly point out by Dr
shared
by
both forms of
duodenojeju-
nostomy. We believe though, for ulcer
occurring at the ampulla, some tension
an
level of the
may be
un-
avoidable in a Billroth I anastomosis even in the face of extensive mobilization. At the Southern Surgical Association's meeting some 13 years ago, Dr Barnett's paper1 evoked a reaction identical to the comments of Drs Nardi and Herrington. I submit that the point is rather easily missed. RAPHAEL CHUNG, MD Iowa City 1. Barnett WO, Tucker FH: Management of the difficult duodenal stump. Ann Surg 159:794\x=req-\ 801, 1964.
tip pointing centrally (Figure). By withdrawal and readvancement of the
Balloon Flotation Catheter
To the Editor.\p=n-\SinceSwan and Ganz advocated the use of the balloon flotation catheter for measurement of pulmonary artery pressure in monitoring critically ill patients, the importance of this method has been well demonstrated by many investigators. It has also been noted that pulmonary wedge pressure has occasionally been unobtainable, despite seemingly adequate positioning of the catheter tip, without reasonable explanation other than balloon rupture. In the following case we observed a complication previously unknown to us. A 73-year-old man underwent total gastrectomy, splenectomy, and esophagojejunostomy for carcinoma of the stomach. Postoperatively, he developed pancreatitis, sepsis, and acute renal failure. He was transferred to the Shock and Trauma Unit for exten-
Herrington. While agreeing unreservedly about everything that was said in both Dr
Nardi's editorial comment and Dr Herrington's letter, I nevertheless would like to point out that both rather missed the point of the article. Undoubtedly, the best way to deal with a difficult situation is to avoid it, but in the meantime what should the inexperienced and the unwary do when he discovers that it is too late to follow the counsel of perfection? Dr Herrington has emphasized the superiority of Billroth I reconstruction under such circumstance, a principle
sive monitoring. A No. 7 French Swan-Ganz catheter was inserted through the subclavian vein, using the Seldinger technique. Four days later, pulmonary wedge pressure was unob¬ tainable due to balloon rupture. A second catheter of similar size was then placed, and chest x-ray film confirmed its proper position. How¬ ever, wedge pressure was still unob¬ tainable. Since the balloon was felt to be intact, 1.5 ml of a mixture of diatri¬ zoate sodium and diatrizoate meglu¬ mine (Renografin 40) was injected into the balloon, and chest x-ray film was taken to confirm its integrity. It was discovered that the catheter tip had made a 180-degree turn with the
catheter, the tip was uncoiled, and the
wedge pressure was recorded. It is important to recognize this possibility if a fresh catheter, seem¬ ingly in proper position on the chest x-ray film, fails to record pulmonary wedge pressure. Confirmation could be made safely by injecting a small amount of contrast material into the
balloon
and
repeating
x-ray.
the
chest
VICTOR DY BUNICHI NAGAWAKA TERUO MATSUMOTO
Philadelphia in Lower Gastrointestinal Bleeding
Angiography
To the Editor.\p=n-\I must take issue with the BRIEF CLINICAL NOTE by Drs Vega and Lucas that appeared in the August issue of the Archives (111:913, 1976). In the "Comment," the authors question the value of angiography in massive lower gastrointestinal bleeding and point out that "since these patients are usually elderly, have other cardiovascular problems, do not tolerate undue delay, and can tolerate
only one major operative procedure," angiography is of questionable value.
This concept is contrary to more experience in dealing with massive lower gastrointestinal bleeding, the major point being that angiography not only offers a diagnostic modality in demonstrating the bleeding site, but also offers a very effective method of treating diverticular hemorrhage via the use of selective infusion of vasopressin (Pitressin). Casarella et al1 pointed out, as was the case in the patient described by recent
Balloon was visualized by injecting 1.5 ml of a mixture of diatrizoate sodium and diatrizoate meglumine (Renografin 40). Note 180-degree turn of catheter tip
(arrow).
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/22/2015
2
the authors, that demonstrable diverticular bleeding appears to occur more frequently in the right side of the colon. In addition, as reported by Casarella and co-workers and as is the personal experience of many angiographers involved with gastrointes¬ tinal hemorrhage, diverticular bleed¬ ing responds to vasopressin in a very high percentage of patients (90%). (In my personal experience with nine patients with massive lower gastroin¬ testinal bleeding, all patients re¬ sponded to vasopressin without recur¬
rence.)
In summary, these patients who are usually elderly, possibly debilitated, and with concomitant medical prob¬ lems, can poorly tolerate general anes¬
thesia, not to mention total abdominal colectomy. Selective superior mesen¬ teric and inferior mesenteric arteriography, in the hands of experienced angiographers, can be performed in relatively little time and provides both diagnostic and therapeutic benefits. One performs angiography in gas¬ trointestinal bleeding with two objec¬
tives in mind: (1) demonstration of the bleeding site and (2) cessation of the hemorrhage via vasopressor infusion. Extensive surgery (total colectomy) would seem appropriate only after these have failed. BARRY T. KATZEN, MD Alexandria, Va
1. Casarella WJ, Galloway SJ, Taxin RN, et al: Lower gastrointestinal tract hemorrhage: New concepts based on arteriography. Am J Roentgenol Radium Ther Nucl Med 121:357-368, 1974. 2. Casarella WJ, Kanter IE, Seaman WB: Right sided colonic diverticula as cause of acute rectal hemorrhage. N Engl J Med 286:450-453, 1972.
Reply.\p=n-\Theprime objective of this to reaffirm the principle that, once surgical inter-
In
BRIEF CLINICAL NOTE was
vention is decided on, total abdominal colectomy with ileoproctostomy is the only procedure that precludes rebleed-
ing; a secondary objective was to discourage time-consuming angiography, since identifying and resecting a portion of the colon containing the bleeding site will not prevent later rebleeding from another site. Identification of the active bleeding site, therefore, is not entirely pertinent to our disagreement, which centers around the
success
in control-
ling diverticular bleeding with intraarterial vasopressin infusion. My own experience at Detroit General Hospi-
tal has been less than satisfactory with this technique. Reasons for failure have included inability to cannulate either the superior mesenteric artery or the inferior mesenteric artery in patients with diffuse, occlusive disease, lack of response to a standard vasopressin infusion, and rebleeding after initial success either
following a vasopressin infusion. Comparable failure has occurred in other hospitals in the Detroit area where several experienced angiographers labor daily. Initial success at controlling active bleeding by this technique does not eliminate the underlying pathologic lesion, namely, during
had
and that seven were consistent with a herniated disk. It is essential to know which seven patients had this find¬
ing.
or
diffuse diverticula that have an increased propensity for bleeding. Rebleeding after discharge from the hospital is common in comparable patients; it is now clear that such rebleeding may be from different diverticula. Finally, total abdominal colectomy, although a major operation, is readily
completed by experienced
surgeons
within two to three hours, at about the time most patients studied angiographically would be having their second injection of a contrast mate¬ rial. CHARLES E. LUCAS, MD Detroit
Division of
Pyriformis
Muscle
To the Editor.\p=n-\Thegentlemanly editorial comment of R.N. Stauffer, MD, on Mizuguchi's article "Division of the Pyriformis Muscle for the Treatment of Sciatica" (Arch Surg 111:719, 1976) did not "fit the crime." Back pain(s) and therapy for same, even if limited to "sciatica," are very difficult to assess. Complete description of the physical findings before and after operation is important, and myelograms are actually an adjunctive
procedure. The discrepencies between the ref-
and the thesis of the author are noteworthy. For example, Robinson (reference; Am J Surg 73:355, 1947) recommended section of the pyriformis in the absence of lumbar lesions. The study group consisted of 14 patients who were divided into two groups described as (1) postlaminectomy and (2) osteoarthritis. Several patients in group 1 had previous operations, and perhaps all had myeloerences
Only three patients in group 2 myelograms\p=n-\presumedly the same three described as having "narrow spinal canals." The author states that all 14 patients had myelograms
grams.
a
One therapeutic failure occurred in patient with "a complete block at the
L2-3 level," who then underwent a muscle section and lastly a decompres¬ sion laminectomy at L-5—which seems strange. What happened to the com¬ y plete block at L2-3? Stauffer properly commented on the large placebo factor in such patients; thus, a few weeks' follow-up is inadequate. GEORGE E. MOORE, MD KARL STECHER, JR, MD Denver
Reply.\p=n-\Iappreciate the opportunity to comment on the letter by
In
Drs Moore and Stecher. A close review of my article (preliminary report) by them will answer many of their questions. At the eight-month follow-up since preparation of this article, all of these patients are doing well. I have performed this procedure on more than 50 patients who had previous laminectomies for herniated disk or who had sciatica due to osteoarthritis of the spine. Most of the patients had
considerable symptomatic improve-
changes in the follow\x=req-\ Repeated neurologic findings. ups over a long period of time are ment and favorable
scheduled. At a later date, these findings will be reported. At present, in properly selected patients, this procedure provides
symptomatic improvement.
TOMOJI MIZUGUCHI, MD Des Moines, Iowa
Bleeding
From Adenoma of the Liver
To the Editor.\p=n-\Thecase report by Andersen and Packer (Arch Surg 3:898, 1976) provides information on a bleeding but temporarily unresected liver cell adenoma in a woman taking oral contraceptives at the time of diagnosis. The failure to grow perceptibly or to undergo further hemorrhage before the subsequent resection 18 months later led the authors to question the need for routine resec-
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/22/2015
