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General surgical complications after cardiac surgery
General Surgical Complications After Cardiac Surgery Thomas W. Lawhoene, Jr, MD, Baltimore, Maryland J. Lucian Davis, MD,* Baltimore, Maryland Gardner W. Smith, MD, FACS, Baltimore, Maryland
The literature documents numerous complications that occur after cardiac surgery, including hematologic [I], respiratory [2,3], renal [4,5], hepatic [6,7], and neuropsychiatric [8,9] problems. However, there are few reports of general surgical complications [IO,II], which although unusual, constitutea serious source of morbidity and mortality in patients who have recently undergone cardiac surgery. These complications demand prompt diagnosis and treatment since the results may be catastrophic. Among approximately 2,500 patients who underwent cardiac surgery at The Johns Hopkins Hospital from July 1970 to June 1976, general surgical complications were identified in fifteen. Clinical Material and Results
Of these fifteen postoperative cardiac patients, eleven were male and four were female. Mean age of the patients was fifty years (range, 6 to 81 years). Complications included gastroduodenal ulcers in four patients and peripheral vascular insufficiency in four others. The remaining complications were intestinal ischemia (2 patients), ruptured spleen (l), colonic perforation (I), ruptured abdominal aortic aneurysm (I), cholecystitis (l), and anal fissure (1). (Table I.) Of the four patients presenting with gastroduodenal ulcer, only one had a previous history of peptic ulcer disease. Complications in the four patients were equally divided between gastroduodenal perforation and bleeding. The two perforations were treated by laparotomy and plication; however, only one of the patients survived. Both patients with massive hemorrhage {more than 10 units) were successfully managed by nonoperative means, including intraarterial injection of Pitressinm and autologous blood
From the Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Reprint requests should be addressed to Thomas W. Lawhorne, Jr, MD, Department of Sugery, Blalock 658. The Johns Hopkins Hospital, Baltimore, Maryland 21205. Present address: 604 Lynwood Boulevard, Nashville, Tennessee 37205. l
254
clot. The only death occurred in a patient after a second mitral valve replacement with renal failure and hepatic and pulmonary insufficiency in whom a duodenal ulcer perforated. The patient died in the early postoperative period. The four postoperative peripheral vascular complications were associated with preoperative evidence of peripheral vascular disease, prolonged postoperative low output syndrome, or cardiogenic emboli. Two distal occlusions were diagnosed late, and these patients underwent distal amputations. Two other patients had iliac artery occlusions, one embolic and the other atherosclerotic. These were recognized promptly and then successfully managed with transfemoral embolectomy in one patient and femorofemoral bypass in the other. There were no deaths in this group. Two patients presented with intestinal infarction. One patient, with an initial postoperative low cardiac output syndrome in whom nonocclusive mesenteric vascular ischemia and ileal necrosis developed, underwent successful resection, A second patient with candida endocarditis sustained multiple septic emboli in his mesenteric vessels with attendant bowel necrosis. Despite appropriate bowel resections and replacement of his infected heart valve, the patient died from sepsis and renal failure. There were two iatrogenic complications (ruptured spleen and perforated colon) that were related to the insertion of chest tubes. Uneventful splenectomy was performed in the former patient and the latter died from sepsis related to delayed recognition of the colon injury. Two complications were not recognized until autopsy. The first patient had a ventricular aneurysm and an asymptomatic 6 cm abdominal aortic aneurysm. The cardiac lesion was resected, and on the fourth day after surgery, hypovolemic shock unexpectedly developed, and the patient died. At necropsy, rupture of the abdominal aortic aneurysm was found. In the second patient, closure of an acquired ventriculoseptal defect was complicated by mediastinitis, fever, abnormal liver chemistries, and leu-
The American Journal of Surgery
Surgical
TABLE I
General Surgical Complications After Cardiac Surgery
Age WV Case ._-__ 1
Complications
Race/ Sex 63/White/F
2
G/Black/M
3
46lWhitelM
4
al/White/M
5
66IWhitelF
6
56lWhiteIM
7
47fWhitefF
a
65lWhitelM
9
lS/Black/F
10
62IWhitelM
11
14fWhitelM
12
54fWhitelM
13
71lWhitefM
14
53lWhiteIM
15
56lWhitelM
Cardiac Procedure Mitral valve replacement Repair of coarctation Mitral valve replacement Ventricular aneurysmectomy; closure of ventriculoseptal defect Coronary artery bypass Mitral valve replacement Mitral commissurotomy Coronary artery bypass Total correction of tetralogy of Fallot Aortic valve replacement Aortic valve replacement Aortic valve replacement Ventricular aneurysmectomy Closure of ventriculoseptal defect Coronary artery bypass
General Surgical Procedure
--
Outcome
Perforated duodenal ulcer Perforated duodenal ulcer Bleeding duodenal ulcer Bleeding gastric ulcer
23 da
Plication
Died
3 da
Plication
Recovered
25 da
Nonoperative
Recovered
10da
Nonoperative
Recovered
Gangrenous toes
22 da
Recovered
Gangrenous foot
31 da
Transmetatarsal amputation Below-knee amputation Embolectomy
1 hr
Iliac artery occlusion Iliac artery occlusion Intestinal infarction
1 hr 14da
Intestinal infarction Ruptured spleen
124 da, 130 da 31 da
Colonic perforation
15da
Ruptured abdominal aortic aneurysm Acute cholecystitis
14da
Anal fissure
55 da
kocytosis. Two weeks after surgery he died, and postmortem examination revealed acute cholecystitis with bile peritonitis. A large anal fissure developed in one patient during quinidine-induced diarrhea, and the lesion was refractory to conservative management. Operative excision and debridement were required. Subsequently, rectal biopsy demonstrated evidence of inflammatory bowel disease. The mortality of 33 per cent (5 of 15 patients) in this group attests to the significant risk that results when general surgical complications intervene in the period after cardiac surgery. Although two of the deaths, in retrospect, were probably unavoidable, three patients might have survived with earlier diagnosis, These were the patients with ruptured aneurysm, perforated colon, and cholecystitis.
Volume 136, August 1978
Surgery
-__ Interval Between Cardiac Procedure and General Surgery or Diagnosis of Complication
General Surgical Complication
After Cardiac
Recovered Recovered
Femorofemoral bypass Bowel resection
Recovered
Bowel resections
Died
Splenectomy
Recovered
Colostomy
Died
4 da
Recovered
Died Died
Excision
Recovered
Comments
Gastroduodenal ulcerations are well recognized complications in “stressed” patients. The reported incidence in cardiac surgical patients varies from less than 1 to 3 per cent [IO-121. Children appear to be more susceptible to these ulcerations [12,13]. Usually symptoms and bleeding respond to antacid therapy [13-151, but conservative measures have been preferred when surgery is required. Using vagotomypyloroplasty or resection, Taylor, Loop, and Hermann [I I] reported a 30 per cent mortality in twenty-six patients undergoing surgery for gastroduodenal ulcers after heart surgery. Perhaps this mortality might be reduced by simply oversewing perforations and by a preliminary trial of controlling hemorrhage with intraarterial catheter technics.
255
Lawhorne, Davis, and Smith
Both of our patients with massive gastroduodenal bleeding were treated successfully with nonoperative means. Certainly, we would agree with the Cleveland Clinic experience [11] that pyloroplasty seems more appropriate than gastric resection in this setting. Ischemic insults to extremities or viscera after cardiac surgery are related to both anatomic and functional defects in perfusion. The common mechanical lesions include cardiogenic emboli, microthrombi, and preexisting atherosclerotic vascular disease. Functional hypoperfusion occurs with severe shock and with vasoconstriction, which is often accentuated by the vasoactive drugs used to treat low cardiac output. These mechanisms can manifest themselves in extremity or bowel ischemia. Recently, postoperative pancreatitis in cardiac surgical patients has also been ascribed to an ischemic mechaliism [16]. Furthermore, Stremple et al [15] consider gastrointestinal mucosal ischemia to be a major link in the stress ulcer syndrome. Glenn [17] lists ischemia as a cause of acute cholecystitis, and several reports [18,19-221 of cholecystitis after unrelated surgery document an increased incidence of acalculous cholecystitis that is perhaps related to ischemia. Our case of cholecystitis, however, was associated with cholelithiasis. Much has been written about jaundice and liver dysfunction immediately after cardiac surgery [6,17]. Chronic passive congestion, hemolysis, infection, vasoconstriction, obstruction of venous cannula, and low cardiac output have all been implicated. Merendino and Manhas [19] have drawn attention to the increased incidence of cholelithiasis secondary to hemolysis in the late postoperative period after cardiac valve replacement. Among the numerous reports of postoperative cholecystitis after unrelated surgery, there were only four patients in whom cholecystitis developed shortly after heart surgery [10,18,21]. The fifth patient, reported herein, emphasizes that persistent fever, leukocytosis, and hyperbilirubinemia should alert the physician to the possibility that extrahepatic biliary tract disease may be the cause.
Summary
General surgical complications present significant risk to life, limb, and viscera in the postoperative cardiac surgery patient. Whether they are the product of hypoperfusion, intercurrent disease, or iatrogenie mishap, their management is often complicated by other problems such as anticoagulation, potentially infected prostheses, and the general state of ill health of some cardiac surgical patients. These
256
complications are a challenge because even though they occur infrequently, they demand prompt diagnosis in order to render appropriate treatment and to avoid the disaster of delay. Conservatism should be the hallmark of treatment in these patients. With prompt diagnosis and judicious surgical intervention, the mortality and morbidity of these unusual but serious complications may be reduced. Acknowledgment: We would like to thank Dr. Vincent L. Gott for his advice and editorial assistance in the preparation of this manuscript. References 1. Bayrd ED: Hematologic complications of cardiac surgery. Adv Intern Med 19: 57, 1974. 2. Brown K, Johnston AE, Conn AW: Respiratory insufficiency and its treatment following paediatric cardiovascular surgery. Can Anaesth Sot J 13: 342,1966. 3. Provan JL, Austen WG, Scannell JG: Respiratory complications after open heart surgery. J 77wrac Cardiovasc Surg 51: 626, 1966. 4. Johannsson L, Lundberg S, Sijderlund S: Renal complications following heart surgery with extracorporeal circulation. &and J Thorac Cardiovasc Sure 1: 52. 1967. 5. Yeboah ED, Petrie A, Pead JL: Acute renal failure and open heart surgery. Br A&d J 1: 415, 1972. 6. Gautam HP: Jaundice following cardiopulmonary bypass. J Cardiovasc Surg ( Torino) 10: 404, 1969. 7. Sanderson RG, Elllson JH, Benson JA, Starr A: Jaundice following open heat-t surgery. Ann Surg 165: 217, 1967. 6. Branthwaite MA: Neurological damage related to open heart surgery. A clinical survey. Thorax 27: 748, 1973. 9. Freyhan FA, Fiannelli S Jr, O’Connell RA, Mayo JA: Psychiatric complications following open heart surgery. Compr f’sychiatry 12: 181, 1971. 10. Harjola P, Siltanen P, Appelqvist P, Laustela E: Abdominal complications after open heart surgery. Ann Chir Gynaecol Fenn 57: 272, 1968. 11. Taylor PC, Loop FD, Hermann RE: Management of acute stress ulcer after cardiac surgery. Ann Surg 178: 1, 1973. 12. Konrad RM: Gastroduodenal haemorrhage and perforation following cardiovascular surgery in children. Arch D/s Child 38: 158, 1963. 13. Gilbert JW Jr, Morrow AG: Gastrointestinal bleeding after cardiovascular operations in children. Surgery 47: 685, 1960. 14. Lepley D Jr, Weisel W, Gorman WC: Massive gastrointestinal bleeding as a complication of open heart surgery in chilben. Dis Chest 42: 446, 1962. 15. Stremple JF, Mori H, Lev R, Glass GBJ: The stress ulcer syndrome. Curr Rob/ Surg April, 1973. 16. Feiner H: Pancreatitis after cardiac surgery. Am J Surg 131: 684, 1976. 17. Glenn F: Acute cholecystitis. Surg Gynecol Obstet 143: 56, 1976. 18. Howard RJ, Delaney JP: Postoperative cholecystitis. Dig Dis 17: 213, 1972. 19. Merendino KA, Manhas DR: Man-made gallstones: a new entity following cardiac valve replacement. Ann Surg 177: 694, 1973. 20. Ottinger LW: Acute cholecystitis as a postoperative complication. Ann Surg 184: 162, 1976. 21. Thompson JW Ill, Ferris DO, Baggenstoss AH: Acute cholecystitis complicating operation for other disease. Ann Surg 155: 489, 1962.
The American Journal of Surgery
The literature documents numerous complications that occur after cardiac surgery, including hematologic [I], respiratory [2,3], renal [4,5], hepatic [6,7], and neuropsychiatric [8,9] problems. However, there are few reports of general surgical complications [IO,II], which although unusual, constitutea serious source of morbidity and mortality in patients who have recently undergone cardiac surgery. These complications demand prompt diagnosis and treatment since the results may be catastrophic. Among approximately 2,500 patients who underwent cardiac surgery at The Johns Hopkins Hospital from July 1970 to June 1976, general surgical complications were identified in fifteen. Clinical Material and Results
Of these fifteen postoperative cardiac patients, eleven were male and four were female. Mean age of the patients was fifty years (range, 6 to 81 years). Complications included gastroduodenal ulcers in four patients and peripheral vascular insufficiency in four others. The remaining complications were intestinal ischemia (2 patients), ruptured spleen (l), colonic perforation (I), ruptured abdominal aortic aneurysm (I), cholecystitis (l), and anal fissure (1). (Table I.) Of the four patients presenting with gastroduodenal ulcer, only one had a previous history of peptic ulcer disease. Complications in the four patients were equally divided between gastroduodenal perforation and bleeding. The two perforations were treated by laparotomy and plication; however, only one of the patients survived. Both patients with massive hemorrhage {more than 10 units) were successfully managed by nonoperative means, including intraarterial injection of Pitressinm and autologous blood
From the Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Reprint requests should be addressed to Thomas W. Lawhorne, Jr, MD, Department of Sugery, Blalock 658. The Johns Hopkins Hospital, Baltimore, Maryland 21205. Present address: 604 Lynwood Boulevard, Nashville, Tennessee 37205. l
254
clot. The only death occurred in a patient after a second mitral valve replacement with renal failure and hepatic and pulmonary insufficiency in whom a duodenal ulcer perforated. The patient died in the early postoperative period. The four postoperative peripheral vascular complications were associated with preoperative evidence of peripheral vascular disease, prolonged postoperative low output syndrome, or cardiogenic emboli. Two distal occlusions were diagnosed late, and these patients underwent distal amputations. Two other patients had iliac artery occlusions, one embolic and the other atherosclerotic. These were recognized promptly and then successfully managed with transfemoral embolectomy in one patient and femorofemoral bypass in the other. There were no deaths in this group. Two patients presented with intestinal infarction. One patient, with an initial postoperative low cardiac output syndrome in whom nonocclusive mesenteric vascular ischemia and ileal necrosis developed, underwent successful resection, A second patient with candida endocarditis sustained multiple septic emboli in his mesenteric vessels with attendant bowel necrosis. Despite appropriate bowel resections and replacement of his infected heart valve, the patient died from sepsis and renal failure. There were two iatrogenic complications (ruptured spleen and perforated colon) that were related to the insertion of chest tubes. Uneventful splenectomy was performed in the former patient and the latter died from sepsis related to delayed recognition of the colon injury. Two complications were not recognized until autopsy. The first patient had a ventricular aneurysm and an asymptomatic 6 cm abdominal aortic aneurysm. The cardiac lesion was resected, and on the fourth day after surgery, hypovolemic shock unexpectedly developed, and the patient died. At necropsy, rupture of the abdominal aortic aneurysm was found. In the second patient, closure of an acquired ventriculoseptal defect was complicated by mediastinitis, fever, abnormal liver chemistries, and leu-
The American Journal of Surgery
Surgical
TABLE I
General Surgical Complications After Cardiac Surgery
Age WV Case ._-__ 1
Complications
Race/ Sex 63/White/F
2
G/Black/M
3
46lWhitelM
4
al/White/M
5
66IWhitelF
6
56lWhiteIM
7
47fWhitefF
a
65lWhitelM
9
lS/Black/F
10
62IWhitelM
11
14fWhitelM
12
54fWhitelM
13
71lWhitefM
14
53lWhiteIM
15
56lWhitelM
Cardiac Procedure Mitral valve replacement Repair of coarctation Mitral valve replacement Ventricular aneurysmectomy; closure of ventriculoseptal defect Coronary artery bypass Mitral valve replacement Mitral commissurotomy Coronary artery bypass Total correction of tetralogy of Fallot Aortic valve replacement Aortic valve replacement Aortic valve replacement Ventricular aneurysmectomy Closure of ventriculoseptal defect Coronary artery bypass
General Surgical Procedure
--
Outcome
Perforated duodenal ulcer Perforated duodenal ulcer Bleeding duodenal ulcer Bleeding gastric ulcer
23 da
Plication
Died
3 da
Plication
Recovered
25 da
Nonoperative
Recovered
10da
Nonoperative
Recovered
Gangrenous toes
22 da
Recovered
Gangrenous foot
31 da
Transmetatarsal amputation Below-knee amputation Embolectomy
1 hr
Iliac artery occlusion Iliac artery occlusion Intestinal infarction
1 hr 14da
Intestinal infarction Ruptured spleen
124 da, 130 da 31 da
Colonic perforation
15da
Ruptured abdominal aortic aneurysm Acute cholecystitis
14da
Anal fissure
55 da
kocytosis. Two weeks after surgery he died, and postmortem examination revealed acute cholecystitis with bile peritonitis. A large anal fissure developed in one patient during quinidine-induced diarrhea, and the lesion was refractory to conservative management. Operative excision and debridement were required. Subsequently, rectal biopsy demonstrated evidence of inflammatory bowel disease. The mortality of 33 per cent (5 of 15 patients) in this group attests to the significant risk that results when general surgical complications intervene in the period after cardiac surgery. Although two of the deaths, in retrospect, were probably unavoidable, three patients might have survived with earlier diagnosis, These were the patients with ruptured aneurysm, perforated colon, and cholecystitis.
Volume 136, August 1978
Surgery
-__ Interval Between Cardiac Procedure and General Surgery or Diagnosis of Complication
General Surgical Complication
After Cardiac
Recovered Recovered
Femorofemoral bypass Bowel resection
Recovered
Bowel resections
Died
Splenectomy
Recovered
Colostomy
Died
4 da
Recovered
Died Died
Excision
Recovered
Comments
Gastroduodenal ulcerations are well recognized complications in “stressed” patients. The reported incidence in cardiac surgical patients varies from less than 1 to 3 per cent [IO-121. Children appear to be more susceptible to these ulcerations [12,13]. Usually symptoms and bleeding respond to antacid therapy [13-151, but conservative measures have been preferred when surgery is required. Using vagotomypyloroplasty or resection, Taylor, Loop, and Hermann [I I] reported a 30 per cent mortality in twenty-six patients undergoing surgery for gastroduodenal ulcers after heart surgery. Perhaps this mortality might be reduced by simply oversewing perforations and by a preliminary trial of controlling hemorrhage with intraarterial catheter technics.
255
Lawhorne, Davis, and Smith
Both of our patients with massive gastroduodenal bleeding were treated successfully with nonoperative means. Certainly, we would agree with the Cleveland Clinic experience [11] that pyloroplasty seems more appropriate than gastric resection in this setting. Ischemic insults to extremities or viscera after cardiac surgery are related to both anatomic and functional defects in perfusion. The common mechanical lesions include cardiogenic emboli, microthrombi, and preexisting atherosclerotic vascular disease. Functional hypoperfusion occurs with severe shock and with vasoconstriction, which is often accentuated by the vasoactive drugs used to treat low cardiac output. These mechanisms can manifest themselves in extremity or bowel ischemia. Recently, postoperative pancreatitis in cardiac surgical patients has also been ascribed to an ischemic mechaliism [16]. Furthermore, Stremple et al [15] consider gastrointestinal mucosal ischemia to be a major link in the stress ulcer syndrome. Glenn [17] lists ischemia as a cause of acute cholecystitis, and several reports [18,19-221 of cholecystitis after unrelated surgery document an increased incidence of acalculous cholecystitis that is perhaps related to ischemia. Our case of cholecystitis, however, was associated with cholelithiasis. Much has been written about jaundice and liver dysfunction immediately after cardiac surgery [6,17]. Chronic passive congestion, hemolysis, infection, vasoconstriction, obstruction of venous cannula, and low cardiac output have all been implicated. Merendino and Manhas [19] have drawn attention to the increased incidence of cholelithiasis secondary to hemolysis in the late postoperative period after cardiac valve replacement. Among the numerous reports of postoperative cholecystitis after unrelated surgery, there were only four patients in whom cholecystitis developed shortly after heart surgery [10,18,21]. The fifth patient, reported herein, emphasizes that persistent fever, leukocytosis, and hyperbilirubinemia should alert the physician to the possibility that extrahepatic biliary tract disease may be the cause.
Summary
General surgical complications present significant risk to life, limb, and viscera in the postoperative cardiac surgery patient. Whether they are the product of hypoperfusion, intercurrent disease, or iatrogenie mishap, their management is often complicated by other problems such as anticoagulation, potentially infected prostheses, and the general state of ill health of some cardiac surgical patients. These
256
complications are a challenge because even though they occur infrequently, they demand prompt diagnosis in order to render appropriate treatment and to avoid the disaster of delay. Conservatism should be the hallmark of treatment in these patients. With prompt diagnosis and judicious surgical intervention, the mortality and morbidity of these unusual but serious complications may be reduced. Acknowledgment: We would like to thank Dr. Vincent L. Gott for his advice and editorial assistance in the preparation of this manuscript. References 1. Bayrd ED: Hematologic complications of cardiac surgery. Adv Intern Med 19: 57, 1974. 2. Brown K, Johnston AE, Conn AW: Respiratory insufficiency and its treatment following paediatric cardiovascular surgery. Can Anaesth Sot J 13: 342,1966. 3. Provan JL, Austen WG, Scannell JG: Respiratory complications after open heart surgery. J 77wrac Cardiovasc Surg 51: 626, 1966. 4. Johannsson L, Lundberg S, Sijderlund S: Renal complications following heart surgery with extracorporeal circulation. &and J Thorac Cardiovasc Sure 1: 52. 1967. 5. Yeboah ED, Petrie A, Pead JL: Acute renal failure and open heart surgery. Br A&d J 1: 415, 1972. 6. Gautam HP: Jaundice following cardiopulmonary bypass. J Cardiovasc Surg ( Torino) 10: 404, 1969. 7. Sanderson RG, Elllson JH, Benson JA, Starr A: Jaundice following open heat-t surgery. Ann Surg 165: 217, 1967. 6. Branthwaite MA: Neurological damage related to open heart surgery. A clinical survey. Thorax 27: 748, 1973. 9. Freyhan FA, Fiannelli S Jr, O’Connell RA, Mayo JA: Psychiatric complications following open heart surgery. Compr f’sychiatry 12: 181, 1971. 10. Harjola P, Siltanen P, Appelqvist P, Laustela E: Abdominal complications after open heart surgery. Ann Chir Gynaecol Fenn 57: 272, 1968. 11. Taylor PC, Loop FD, Hermann RE: Management of acute stress ulcer after cardiac surgery. Ann Surg 178: 1, 1973. 12. Konrad RM: Gastroduodenal haemorrhage and perforation following cardiovascular surgery in children. Arch D/s Child 38: 158, 1963. 13. Gilbert JW Jr, Morrow AG: Gastrointestinal bleeding after cardiovascular operations in children. Surgery 47: 685, 1960. 14. Lepley D Jr, Weisel W, Gorman WC: Massive gastrointestinal bleeding as a complication of open heart surgery in chilben. Dis Chest 42: 446, 1962. 15. Stremple JF, Mori H, Lev R, Glass GBJ: The stress ulcer syndrome. Curr Rob/ Surg April, 1973. 16. Feiner H: Pancreatitis after cardiac surgery. Am J Surg 131: 684, 1976. 17. Glenn F: Acute cholecystitis. Surg Gynecol Obstet 143: 56, 1976. 18. Howard RJ, Delaney JP: Postoperative cholecystitis. Dig Dis 17: 213, 1972. 19. Merendino KA, Manhas DR: Man-made gallstones: a new entity following cardiac valve replacement. Ann Surg 177: 694, 1973. 20. Ottinger LW: Acute cholecystitis as a postoperative complication. Ann Surg 184: 162, 1976. 21. Thompson JW Ill, Ferris DO, Baggenstoss AH: Acute cholecystitis complicating operation for other disease. Ann Surg 155: 489, 1962.
The American Journal of Surgery