[A case of human dirofilariasis (D. repens) of the spermatic cord].

A 52 year old man, living in the province of Trapani (Sicily), presented with right hydrocele and slight orchialgia. The patient underwent epididymectomy and resection of T. vaginalis. The "tunica" was involved by a granulomatous process, containing a parasite of genus Dirofilaria (D. repens). Dirofilaria repens is a filarial nematode. Dogs, foxes and cats are the definitive hosts and principal reservoirs of the parasite. In humans the parasite dies before reaching sexual maturity and the result is an inconspicuous granulomatous reaction in the subcutaneous tissue. S. Pampiglione et al. (Cattedra di Parassitologia Veterinaria dell'Università di Bologna-Italy) reported from 1971 more than 30 cases of human Dirofilariasis in Italy, suggesting that the parasite is able to migrate from the inoculation site to other districts (lung, eye etc.). The case is exceptional for the localization of the parasite (never reported) and can contribute to a better knowledge of the disease.


[Aneurysm of the renal artery mimicking a cyst].

Renal artery aneurysms are not frequent, insidious clinico-pathological entities. They are often asymptomatic and cannot be readily differentiated from renal cysts on routine US. The Author presents a case with fatal outcome and stresses the need of Doppler testing before cyst puncture for diagnostic or therapeutic purpose.


[A case of retroperitoneal leiomyosarcoma].

The Authors present a case of retroperitoneal leiomyosarcoma, diagnosed because of the early symptomatic hydronephrosis due to the compression of the tumour on the lumbar ureter. Some general clinical aspects of retroperitoneal sarcomas are discussed too. In the case presented adjuvant therapy was not advised, because of the small volume of the tumour and the possibility of its complete excision.


[Hemo-rheologic changes following treatment with human recombinant erythropoietin in chronic hemodialysis patients].

Human recombinant erythropoietin constitutes a remarkable improvement in the treatment of uraemic anemia. Nevertheless, it causes haemorheological changes, which in turn may affect smaller blood vessel circulation. Our study was conducted on a pool of chronic uraemic patients under hemodialytic treatment who were given erythropoietin therapy. Substantial increases in overall blood viscosity and red cell aggregation were recorded, with no change in erythrocyte deformation. An increase in cardiovascular morbidity might occur in these patients who are already liable to this condition. Several years will have to elapse and thorough studies will have to be conducted on a large number of patients, to have conclusive evidence on this point.


[Clinical evaluation of 12 months of biofiltration in an elderly group].

Biofiltration (BF) was performed on 8 elderly uraemic patients (mean age 73.75 +/- 8.72 years; dialytic age 75.00 +/- 38.42 months) to improve cardiovascular stability and to reduce the dialytic session time. Small molecules (nitrogen, creatinine, uric acid, phosphorus) depuration, heamogasanalysis and PA monitoring, were compared against previous datum obtained by the same group that had undergoing acetate dialysis (AC. HD) for a year. Small molecules showed no significant differences; in BF the incidence of symptomatic hypotensions and the dialytic session time were reduced (30% and 30 min. respectively), with a better metabolic acidosis correction versus AC.HD. Our results showed that BF is better than AC.HD in elderly uraemic patients.


[Efficacy and safety of simvastatin in the treatment of hyperlipidemia in uremic patients undergoing hemodialysis treatment].

The efficacy, tolerability and safety of simvastatin in the treatment of hyperlipemia in uremic patients undergoing hemodialysis were evaluated in 6 patients; a further 6 patients were treated with placebo and represented the control group. All patients treated completed the study. No clinical or laboratory side-effects were noted during the entire period of observation. Simvastatin caused a significant 26% reduction in total cholesterol, a 36% reduction in LDL cholesterol and a 28% reduction in triglycerides; HDL cholesterol and Apolipoprotein A increased by 19% and 12% respectively.


[Neoplasia of the testis: surgical, radiological, and chemotherapeutic approach. Analysis and results of a retrospective study].

The Authors report the results of a retrospective study in patients with testicular cancer admitted to hospital between January 1979 and July 1991. A total of 59 cases of testicular cancer were treated: 42 seminomatous and 17 non-seminomatous. Radiotherapy was carried out with satisfactory results in patients with stage 1 and 2 seminoma (22 cases). A "wait and see" policy was adopted in 2 cases. The majority of non-seminomatous tumours underwent retroperitoneal lymphadenectomy followed by chemo- and/or radiotherapy (9 cases). Retroperitoneal lymphadenectomy plays a vital role in correct pathological staging and the evaluation of neoadjuvant chemotherapy.


[Squamous metaplasia as a prognostic factor in urothelial carcinoma of the bladder].

The Authors report a retrospective review of 224 cases of transitional cell carcinoma of the bladder observed between 1986 and 1990. Squamous metaplasia was present in 45 case. This histological feature was found especially in association with poorly differentiated and invasive tumours: the presence of extensive areas of squamous metaplasia (metaplastic areas = or greater than 50% of neoplastic surface) was always found in association with high grade neoplasms and with a disease-free period shorter than transitional cell carcinoma. The Authors conclude that squamous metaplasia in transitional cell carcinoma of the bladder is a really unfavourable prognostic factor.


Long term results of percutaneous catheter drainage of pancreatic pseudocysts.

Percutaneous catheter drainage (PCD) has become an established and often preferred alternative to surgical treatment in the management of pancreatic pseudocysts. However, the long term results of percutaneous drainage of pancreatic pseudocysts remain uncertain. In an effort to determine the long term outcome of this therapy, 42 patients undergoing PCD of a pancreatic pseudocyst were analyzed retrospectively. Forty-two pancreatic pseudocysts were drained percutaneously in 42 patients. Sixty-seven percutaneous drainage procedures were performed--22 patients underwent one, 15 had two and five patients required three procedures. Percutaneous drainage was considered not to be effective when the pseudocyst persisted or when it recurred after initial resolution. Twenty-three pseudocysts were infected at the time of drainage and 19 were not infected. In 30 patients, the cause of the pseudocyst was alcoholic pancreatitis. There were no deaths related to the procedures and seven complications occurred, including hemorrhage, pancreatic fistula and empyema. Mean follow-up evaluation time of the patients was ten months. In nine patients, the pseudocyst was successfully drained and resolved. There were 33 treatment failures, among which 26 pseudocysts failed to resolve and seven recurred after initial resolution. Eventually, 25 patients underwent a surgical procedure, 20 for persistent pseudocyst and five for recurrence. Using contingency table analysis, the size of the pseudocyst, amount of fluid drained, amylase concentration in the aspirate, presence of infection, number of drainage procedures performed and duration of catheter drainage had no influence on the likelihood of success in long term pseudocyst resolution after PCD. Pseudocysts not related to alcoholic pancreatitis seemed to be less likely (p < 0.05) to resolve with percutaneous drainage than those caused by alcohol. PCD is a safe and valuable procedure in the acute management of patients with pancreatic pseudocyst. However, the current data suggest that despite early success with percutaneous drainage, the lack of resolution and recurrence rate of pancreatic pseudocyst is high. Therefore, it should not be considered as the definitive form of therapy in most patients. Close surveillance of patients undergoing percutaneous drainage and communication between surgeons and radiologists are critical in the management of pancreatic pseudocysts.


Management of periareolar abscess and mamillary fistula.

During a 15 year period, 18 patients with 28 mamillary fistulas were treated. In eight women, periareolar abscess had preceded recognition of a fistula. Ten patients were primarily diagnosed as having mamillary fistula. In six patients, when the underlying fistula tract was not identified and excised at the time of operation, discharging sinus reoccurred. Twenty-two fistulas were completely excised together with an extensive lactiferous duct system. Operative wound was primarily closed using antibiotic cover. Periareolar abscess and mamillary fistula should be treated primarily by complete excision of the fistula tract and extensive duct system of the breast.


Venous and arterial anomalies of the lower extremities diagnosed by duplex scanning.

The complex embryologic development of the vascular system often results in a myriad of clinically relevant anomalies. It has been stated that the classic anatomic venous pattern in the lower extremity is found in only 16 percent of patients. Previous studies on this topic are limited to isolated venous dissections or phlebography that lack complete anatomic detail. The recent introduction of high resolution duplex scanners for the assessment of veins of the lower extremity provides a unique opportunity to determine the incidence of anatomic variation. The current prospective study was done to identify venous or arterial anomalies apparent during routine duplex scanning of the lower extremity performed to rule out deep venous thrombosis (DVT). Limbs that had evidence of acute or chronic extensive DVT were excluded. Of 1,600 consecutive extremity scans, 946 extremities (59 percent) had no evidence of DVT. Of these, there were 43 patients with 64 anomalies in 57 extremities. The mean age of the group was 53.4 years. There were 24 women (55.8 percent) and 19 men (44.2 percent). There were 59 (92.2 percent) venous and five (7.8 percent) arterial anomalies. Duplication of the superficial femoral vein was the most common anomaly noted. Duplication of the deep femoral and popliteal vein was also noted. Unilateral anomalies were more common than bilateral anomalies, namely 67.4 versus 32.6 percent, respectively. Pain and swelling, common complaints in the patients with an anomaly, were noted in 71.4 and 45.7 percent, respectively. The frequency of deep venous anomalies of the lower extremities may be less than previously reported. Knowledge concerning the incidence and distribution of venous anomalies may lead to improved assessment and treatment of venous disease.


Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique.

Surgeons have developed many methods for the repair of direct inguinal hernias. The Cooper's ligament (McVay) repair and the Shouldice repair are widely used techniques. To determine the recurrence rates with differing techniques performed in a surgery residency program, we conducted a prospective randomized study for elective adult direct inguinal herniorrhaphies. Three hundred and eight elective direct inguinal herniorrhaphies in 269 adult patients were performed by residents in general surgery supervised by staff surgeons. Patients had yearly follow-up physical examinations (compliance rate of 87 percent) during an average follow-up period of 36.4 months. The recurrence rate was 8.8 percent for the McVay repair and 6.6 percent for the Shouldice repair (not significant). Bilateral inguinal hernias (repaired six weeks apart) had a recurrence rate of 12.8 percent, while the recurrence rate for unilateral repairs was 5.6 percent (p = <0.05). We found no significant difference in recurrence rates between the McVay and Shouldice herniorrhaphy techniques. However, there was an increase in hernia recurrence with either technique when bilateral direct inguinal herniorrhaphies were performed.


The risk of perforation when children with possible appendicitis are observed in the hospital.

The morbidity rate from perforation demands that appendicitis be diagnosed promptly in children with abdominal pain. Although admitting and observing uncertain instances of appendicitis can refine the diagnostic accuracy, it is often claimed, but not proved, that this necessitates increasing the number of perforations. To assess the risk of perforation while observing uncertain instances of childhood appendicitis, we admitted 150 consecutive referrals during a period of one and one-half years. Immediate appendectomy was performed for 74 patients (49 percent) with convincing clinical signs and symptoms for appendicitis. The remaining 76 (51 percent) with unconvincing clinical signs and symptoms were observed as inpatients. One-third of the patients admitted for observation (26 of 76) underwent appendectomy after an average period of 12 hours. Two-thirds (50 of 76) of the patients got better and were discharged from the hospital without an appendectomy after an average admission of two days. Seven of the 100 appendices removed were normal. Three of the observed patients had perforations, one of whom may have perforated during observation, but that child went on to do well. The 50 patients who got well without appendectomy were similar to the patients with appendicitis, but significantly less likely to have peritoneal signs (8 versus 70 percent), tenderness in the right lower quadrant (48 versus 81 percent) and guarding (19 versus 75 percent). We conclude that admission and active observation in the hospital of children with possible, but unconvincing, signs and symptoms of appendicitis is a safe and effective way to determine which patients need an operation.


Palpable abnormalities of the breast not requiring excisional biopsy.

The evaluation of a patient with a palpable abnormality of the breast typically includes physical examination, mammography and fine needle aspiration biopsy (FNAB) with cytologic interpretation of the aspirate. If the findings of these three diagnostic modalities are negative for malignancy, the current standard of care is to proceed to surgical biopsy to confirm the benign nature of the lesion. The current study was done to identify a subset of patients who could be safely observed without surgical (histologic) biopsy. These patients fulfilled specified criteria on physical examination, mammogram and needle sensation when the FNAB needle entered the lesion. Results of the cytologic studies of the FNAB were used as a corroborative rather than as a diagnostic test. Of 305 patients with mammary abnormalities, 106 were identified with "subsuspicious" lesions. Seven of the latter patients underwent surgical biopsy, four because the results of cytologic studies of FNAB revealed cytologic atypia. One of the four patients had infiltrating ductal carcinoma. All other patients have had follow-up evaluation for a mean of 61 months (range of 43 to 74 months). No carcinomas have developed at the subsuspicious site. The current study is the first to clearly define a subset of patients with palpable abnormalities of the breast who do not require surgical biopsy.


Effect of prostaglandin E on immune function in normal healthy volunteers.

Prostaglandin E (PGE) has been hypothesized to be the endogenous metabolite that results in the immunosuppression seen in patients with tumor and trauma. This has resulted in multiple investigators proposing that administration of PGE inhibitors, such as aspirin and indomethacin, might improve immune function in such patients. We administered a long acting PGE analog, misoprostol, to nine normal healthy volunteers for five days and assayed immune function before and after therapy. The PGE analog improved lymphocyte blastogenesis and increased tumor necrosis factor production. The PGE analog also resulted in the volunteers having symptoms similar to those seen in patients with sepsis. The results of these studies indicate that elevated levels of PGE do not seem to result in impairment of immune function, but may be the endogenous metabolite responsible for the symptologic factors seen in infected patients.


Prospective randomized study to compare a closed vault technique using absorbable staples at the time of abdominal hysterectomy versus open vault technique.

The current prospective randomized study in 102 women having a hysterectomy compared closed vault technique using absorbable staples with open vault technique. Fifty-six patients had the cuff stapled while 46 patients had the vault sutured open. The groups were equivalent with respect to indications for operation as well as other surgical procedures performed in conjunction with the hysterectomy, although more patients were randomized to open vault. No patient left the study. Operating time in the group with staples was 24 minutes (standard deviation of seven minutes) compared with 33 minutes (standard deviation of eight minutes) with the group with the open vault (p<0.0001). Hemostasis was also better in the group with staples (p<0.0001). The frequency of postoperative granulation tissue at the apex of the vaginal vault and the incidence of vaginal discharge during 12 weeks of follow-up evaluation were also less in the group with staples.


Hemodynamic, hematologic and eicosanoid mediated mechanisms in 7.5 percent sodium chloride treatment of uncontrolled hemorrhagic shock.

Hypertonic saline solution (HTS) (7.5 percent sodium chloride [NaCl]) treatment (5 milliliters per kilogram) of rats subjected to uncontrolled hemorrhagic shock (n = 7) caused an initial partial recovery of blood pressure (+38 +/- 5 percent, p<0.05) and cardiac index (+48 +/- 6 percent, p<0.01) followed by increased bleeding (+53 +/- 5 percent versus rats treated with 0.9 percent NaCl, p<0.05), secondary shock (mean arterial pressure [MAP] 23 +/- 7 millimeters of mercury, p<0.01) and decreased survival (-54 +/- 15 minutes versus control, p<0.05). The increased blood loss resulted from: 1, increased vascular pressure and vasodilatation (total peripheral resistance index -27 +/- 5 percent, p<0.05), as initial bleeding occurred when MAP and cardiac index are increased compared with the control group (+88 +/- 10 percent, p<0.05 and +82 +/- 7 percent, p<0.01, respectively) and as the concomitant infusion of angiotensin II, a potent vasoconstrictor, delayed the HTS-induced bleeding (resumed at 60 minutes), and 2, a defect in platelet aggregation reflected by decreased adenosine diphosphate (ADP)-induced maximal aggregation (-79 percent versus rats treated with 0.9 percent NaCl, p<0.05) and increased EC50 of ADP (+159 percent, p<0.05). These hemodynamic and hematologic responses might be mediated at least in part by prostacyclin, a vasodilator and antiplatelet aggregator, as HTS-treated rats markedly elevated the 6-keto-PGF1 alpha per thromboxane B2 ratio (+140 +/- 12 percent, p<0.01) and pretreatment with indomethacin decreased blood loss and improved MAP and survival. These data point out potential untoward hemodynamic and hematologic consequences of HTS treatment in traumatic injury in which control of bleeding cannot be confirmed.


Serum amylase levels in gynecologic patients with acute abdominal pain.

Total amylase and salivary (S) type isoamylase were measured in serum from 80 women with acute abdominal pain admitted to the Department of Gynecology. Fifty-seven patients had verified gynecologic diseases, including 21 patients with inflammation of the internal genitals and 11 with ectopic pregnancy. Twelve patients had an intrauterine pregnancy in the first trimester. None of the 80 patients showed hyperamylasemia.


A single technique for polypropylene mesh hernioplasty of inguinal and femoral hernias.

The main factor in the repair of groin hernias is the reinforcement of posterior wall defects of the inguinal canal, including the femoral ring, because the normal insertion of the transversalis fascia and transversus abdominis muscle is on Cooper's ligament and not Poupart's ligament. In approximately one-half of primary femoral hernia repairs in men, a coincidental ipsilateral inguinal hernia existed. Recurrence after inguinal herniorrhaphy is usually femoral. Forty-three patients with direct, large indirect or femoral hernias (primary or recurrent) had a Marlex mesh hernioplasty to treat the inguinal and femoral region simultaneously.


Long term central vascular access through the gonadal vein.

A technique for long term central venous access through the gonadal vein is described. It has been used five times in four patients with consistently satisfactory results.


The wandering spleen.

Wandering spleen is an unusual entity, occurring in both sexes and at any age, but is more frequent in women of reproductive age and in children. Wandering spleen is probably most often a result of congenital anomalies of development of the dorsal mesogastrium, but acquired factors may have a role in certain instances. Patients present most commonly with an asymptomatic mass, mass and subacute abdominal or gastrointestinal complaints or with acute abdominal findings. Clinical diagnosis can be difficult, but noninvasive imaging procedures, such as sonography, nuclear scintigraphy, computed tomography and magnetic resonance imaging are usually diagnostic. Laboratory tests are usually nonspecific, but may occasionally reveal evidence of hypersplenism or functional splenia. Symptoms may remain limited or absent for long periods of time, but complications related to torsion or compression of abdominal organs by the spleen or the pedicle are quite common. Splenomegaly is usually a result of torsion of the pedicle and splenic sequestration. Significant morbidity and mortality rates seem to be considerably less than described in 1933 and limited primarily to patients presenting initially with acute abdominal findings. Management recommendations have varied, but recognition of a significant risk of postsplenectomy sepsis supports a conservative approach. Patients with limited symptomatology may be medically managed until they exhibit worsening symptoms indicating progressive splenic torsion or gastrointestinal compression. Detorsion and splenopexy may be considered a reasonable surgical option even in patients presenting with acute abdomen, if there is no evidence of infarction, thrombosis or hypersplenism. Splenic preservation is especially recommended in extremely young patients who are at particular risk for postsplenectomy sepsis. However, it should be noted that follow-up evaluation data on splenopexy patients are notably lacking. Splenectomy is ideally reserved for patients presenting with acute abdomen and splenic infarction or thrombosis or with hypersplenism and patients in whom splenopexy is technically unfeasible. Subtotal splenectomy and splenic autotransplantation may be of limited value. Pneumococcal, Hemophilus and meningococcal vaccines are indicated before elective splenectomy and shortly after nonelective splenectomy. Antibiotic prophylaxis is recommended for those at particular risk. Prospective studies are unlikely, but extended follow-up information on patients already reported, particularly those managed expectantly or with conservative surgical measures, is needed.


The immunologic properties of epidermal Langerhans cells as a part of the dendritic cell system.

Dendritic cells form a system of antigen-presenting cells that is widely distributed in the body. They constitute trace populations in lymphoid and non-lymphoid tissues and in the circulation. They are characterized by their typical dendritic and "veiled" morphology, by their constitutive expression of high levels of major histocompatibility complex class II molecules on their surface, and by their outstanding capacity to initiate primary immune responses. Dendritic cells occur in two states of differentiation. In the immature state they are highly specialized for processing foreign protein antigens; in the mature state they efficiently stimulate resting antigen-specific T cells. Dendritic cells can migrate from the non-lymphoid tissues, where they reside in the immature state, via the afferent lymphatics or the blood to the T cell-dependent areas of the lymphoid organs (lymph nodes, spleen). There, they appear as mature dendritic cells. Therefore, dendritic cells are ideally suited to mediate important aspects of immunogenicity: they can acquire antigens in the tissues and process them in an immunogenic form; they can carry the immunogen to the lymphoid organs; and they can find and efficiently activate antigen-specific T cell clones and thus generate an immune response. Studies of epidermal Langerhans cells have greatly helped in establishing this concept. They can be investigated freshly isolated from the epidermis where they represent immature (tissue) dendritic cells. After 2-3 days in culture they develop into mature dendritic cells. The mechanisms of dendritic cell maturation, which can be studied best using epidermal Langerhans cells, and the specific functions of Langerhans cells in immunogenicity are discussed.


Cutaneous lymphoproliferative disorders: strategies for molecular biological analysis and their major findings.

This article focuses on the principal molecular biological methods that have been devised to study cutaneous lymphoid infiltrates. These methods involve analysis of antigen receptor gene rearrangements, chromosomal translocations and proviral integration using Southern blot analysis and gene amplification techniques. The major findings are discussed that pertain to early diagnosis, staging, disease monitoring, the development of new immunopathological assays and the detection of tumor-associated retroviruses.


Recent advances on the 180-kDa epidermal antigen in autoimmune subepidermal bullous skin diseases.

The blistering skin disease bullous pemphigoid (BP) is an example of how autoantibodies from patients can be used as tools to improve our knowledge of the molecular structure of normal skin. BP autoantibodies bind to the basement membrane zone of normal human skin and usually react with two main epidermal antigens of approximately 230-kDa and 180-kDa. From recent studies, it is now established that the 180-kDa polypeptide is distinct from the 230-kDa BP antigen and is a major component of hemidesmosome. In this article, the recent data regarding the localization and structure of the epidermal 180-kDa BP antigen are reviewed in detail, together with its clinical significance, since it appears to be also a target antigen for pemphigoid (herpes) gestationis and, perhaps, cicatricial pemphigoid autoantibodies.


[Athletic capacity after surgical management of acromioclavicular joint separation].

Acromioclavicular separation is a common injury in sports. This study was done to show the activity and problems of athletes after operative treatment of this kind of injury. Between 1986 and 1989 21 athletes with acromioclavicular separation had been treated by operation. The coracoclavicular ligaments had been sutured and augmented by a PDS cord. The acromioclavicular ligaments had also been reattached and the ac-joint had been transfixed with a Kirschner-wire. The results show 18 athletes doing their sports on the same level as preoperatively. Two athletes with a frequency of sporting activity once a week could not continue their sporting activity. One athlete changed the disciplines to less shoulder stressing kind of sport. The comparison of clinical and radiological results showed no correlation, even patients with an osteoarthrosis of the ac-joint and coracoclavicular ossifications had best clinical results. We recommend therefore operative treatment for acromioclavicular separation in athletes.


International longevity comparisons.

Japan leads the world in life expectancy with an average future lifetime of 78.9 years. Iceland is next, followed by Sweden and Switzerland. The United States ranks 11th at 75.4 years. In the past decade, United States' men generally narrowed the expectation of life gap among other industrialized nations, but for the country's women the experience was uneven. These international longevity disparities for men and women in the United States narrowed considerably at later years of age. For instance, the United States-Japan expectancy gap is currently 2.0 years at age 45 and declines to about 0.9 years at age 65.


Coronary artery bypass grafts: 1990 charges update.

During 1990, coronary artery bypass graft (CABG) operation charges among MetLife group health policyholders and dependents averaged $43,370. Among the 16 states with at least 50 CABGs, the total charges ranged from a high of $59,870 in California, to a low of $32,500 in Wisconsin. Three-fourths of the total was due to the hospital bill, with wide variation by state. The New York hospital proportion of total charges was the lowest (64 percent), whereas hospital charges in Alabama averaged 80 percent of the bill for a CABG. Physician charges averaged $11,220 across the country, ranging from $15,170 in California to $8,280 in Tennessee. Hospital stay averaged 11.6 days; patients in California and Alabama remained hospitalized for 10.2 and 10.3 days, respectively, whereas those in New Jersey had hospital stays of 16.1 days.


[Nuclear magnetic resonance tomography diagnosis of changes in the glenoid process in patients with unstable shoulder joints].

In 4 fresh specimens and in 14 healthy volunteers we studied normal anatomy of the glenoid labrum by MRI. In a total of 124 patients we examined the shoulder joints by MRI. 69 patients had any kind of subacromial pathology. 55 patients showed a glenohumeral instability. All MRI findings were compared with the surgical findings during arthroscopy and during open surgery. 44 patients showed a recurrent anterior instability, 7 patients showed a multidirectional instability, 2 patients showed a posterior instability, and 2 patients presented acute anterior dislocation. We found significant variability in the labral shape as well as significant variability of anterior capsular attachment. The pathologic changes of the glenoid labrum were classified in four different types. In 78% we found a concomitant Hill-Sachs lesion of various diameter. 5 patients suffered from an additional complete rotator cuff tear. Compared to the intraoperative findings MRI had a sensitivity of 95%, a specificity of 94%, an accuracy of 94%, a positive predictive value of 91%, and a negative predictive value of 96% in detecting labral pathology. Presenting a high diagnostic value for detecting Bankart lesions, MRI may replace other diagnostic modalities like CT-arthrography.


U.S. longevity at a standstill.

Life expectancy in the United States did not increase during 1991, remaining at the 1990 level of 75.4 years. For boys, it was 72.0 years and for girls, 78.8 years. On the other hand, the infant mortality rate continued downward when a new benchmark was achieved--an all-time low, 8.9 per 1,000 live births. Also encouraging was a marked improvement in longevity among black Americans that significantly narrowed the white-nonwhite differential.


[Monteggia injuries in athletes. Causes, classification, results].

Monteggia-fractures are serious combination injuries to the forearm. Sport injuries are being increasingly observed; the reason for this, besides the general expansion of mass sports, is the increasing burden of high-performance sports. Monteggia fractures can occur during a fall on an outstretched arm, for example in motor or bicycle sport injuries, but also when falling from gymnastic equipment. Generally, it is easy to diagnose the monteggia injury. Considerable secondary damage could occur from the frequent failure to notice the involved radiohumeral joint. It should be demanded that in case of an uluar fracture the adjoining joints should be x-rayed on two planes in order not to overlook the possibility of a chisel fracture. The different forms of this combination injury, its classification and the results of our own medical bulletins are presented.


[Isolated injuries of the pulley of the finger flexor tendon sheath--injuries in extreme climbing sports].

Injuries of pulleys are quite common in mountain climbing. The clinically diagnosed rupture of a pulley can now be verified by MRI. Partial ruptures, which in MRI always showed as scars, can frequently lead to intrinsic bow-stringing. The injuries were primarily treated non-surgically. With regard to chronic, recurring cases or large ruptures, however, annular ligament plastics have to be considered. As a prophylaxis we recommend special training exercises for climbers on wide ledges with changing exertion patterns and a tape-bandage for the fingers. During climbing, the PIP-joint should best not be strained in an obtuse angle. Warming-up and stretching exercises before climbing are absolutely necessary.


[Ultrasound image of the Lachman test in lesions of the anterior cruciate ligament].

The sonographic examination of the knee-joint can, in many pathological alterations of the knee-joint, supply additional informations. In the standardized ultrasound examination of the knee-joint ventral and dorsal sectional planes will be adjusted (4, 7, 14, 17). For the examination of the lesions of the anterior cruciate ligament direct adjustment techniques in the aere of origin of the anterior cruciate ligament (15, 16) and indirect examination methods are known (7, 8, 9, 20). While Hien chose a direct medial parapatellaric horizontal sagittal sectional plane in the course of the lig. patellae (8), we carry out our examination in a ventral infrapatellaric sagittal plane. The examinations were conducted with an ultrasound unit of the type Siemens Sonoline SL 2 with a linear transducer with a frequency of 5 MHz without a stand off pad. In the course of a prospective clinical examination an anteromedial test of stability of both knee-joints was conducted on 360 patients with the help of a sonographic Lachman-test. Two examination groups were formed: in group 1 60 patients with a arthroscopically secured lesion of the anterior cruciate ligament were registered and set against 300 probationers with "empty" anamnesis of the knee-joint of group 2. In the group of patients with a cruciate ligament injury a tibia translation of 5.3 mm in the Lachman-test was found; the side difference between the leg injured and the one uninjured amounted to 3.0 mm. In the control group the tibia translation amounted to 2.9 mm with a side difference of 0.9 mm.(ABSTRACT TRUNCATED AT 250 WORDS)


[Tarsal tunnel syndrome in athletes].

Pain in the hindfoot due to overuse has many causes. One uncommon cause is the entrapment of the posterior tibial nerve: the tarsal tunnel syndrome. Pain when palpating posterior the medial malleolus and pain in the abductor hallucis muscle are typical symptoms. Application of a local anaesthetic leads to immediate pain relief. The distal motoric latency is prolonged, but not in all cases. First of all, treatment consists of local and oral antiphlogistics, orthopaedic arch-support and physiotherapy. In case of therapy-resistant pain over more than three months period, surgical decompression of the tibial nerve should be performed. In the last three years we treated 18 patients with a tarsal tunnel syndrome: 6 of 8 patients were symptom-free after surgical intervention, whereas only 3 of 10 were symptom-free after conservative treatment.


Anti-arthritic medication usage: United States, 1991.

In 1991, about 70.3 million prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs) were filled across the United States to treat arthritis and related musculoskeletal problems. The retail costs exceeded $2.2 billion in 1991 and were 6 percent higher than the costs in 1990 despite a 2.2 percent decrease in volume of prescriptions written. Per capita consumption averaged 278.6 prescriptions per 1,000 population with substantial variation by state. Kentucky led with 380.9 per 1,000 population and the District of Columbia had the lowest rate, 177.0. Ibuprofens were the most frequently prescribed class of NSAIDs, with Motrin capturing 20 percent of this generic class. Naproxen (Naprosyn) was the second most frequently prescribed class accounting for 19 percent of the NSAIDs.


[Traumatology and athletic injuries in basketball].

This analysis outlines the facts concerning sports injuries and damages of 473 active basketball players covering a 5-year period in more than 100 clubs in southern Germany. The average age was 26.8 years and 34.5% were women. 658 medically treated basketball injuries were described in detail. With 40.7% distortions were the most frequent injuries followed by ruptures of ligaments in 24.6% and fractures in 9.3%. In the majority of cases the lower extremities were involved (65.3%), of which most commonly the ankle joint was injured (45.6%). Another 14% were lesions to the fingers and 12.9% trauma to the knee. In 3600 reported cases players did not consult a physician after inflicting distortions to a ankle or a finger. Aside from interaction with adversaries (41%) also the relatively heavy ball (650 g) caused 11.9% accidents. Survey shows, that younger players and "center"-players were most often subject to injuries. More than 2/3 of actives in question suffer from permanent pain due to basketball activities. 43.8%, mainly younger players, report continues pain in the knee and 28.1%, predominantly older players, suffer from permanent damage of the ankle joint, caused by repeatedly occurring, however light, distortions of the ankle.


[Radiochemotherapy concepts in advanced carcinomas of the mouth, oro- and hypopharynx].

Among combined radiochemotherapy regimens of advanced head and neck tumors four modalities can be discriminated: 1. Induction chemotherapy, 2. simultaneous radiochemotherapy, 3. adjuvant chemotherapy, 4. accelerated hyperfractionated radiotherapy and chemotherapy. The results of the presently available randomized trials are as follows: 1. Induction chemotherapy has no influence on long-term recurrence-free survival. 2. With respect to simultaneous radiochemotherapy, recurrence-free survival has been unproved with 5-FU and Mitomycin C. 3. There is evidence that adjuvant cisplatin therapy improves recurrence-free survival. 4. No results are available to date using hyperfractionated accelerated radiotherapy regimens in combination with chemotherapy.


Unusual combination of Cis platinum and radiotherapy followed by a three fractions per day irradiation in splitcourse: a phase I-II study in brain glioma patients.

An unusual protocol based on a preliminary clinical study on cylindromas metastasized to the lung was proposed to brain glioma patients: Day 2 100 mg/m2 i.v. Cis platinum (Cis PII) followed at days 3 and 5 by 6 Gy irradiation (RT) in two fractions and three days. Five cycles were scheduled at 21 days interval. On disease progression a three fractions per day radiotherapy regimen (3 FRT) in split-course (two series of 22.50 Gy in 15 fractions and five days separated by a two weeks period of rest) was then delivered to the patients. All patients had a measurable mass on the CT scan. 19 were entered into the study: 13 as first line therapy (group A) and six for salvage treatment (group B). Tolerance was globally good. Eight patients were considered responders at the end of five cycles of Cis PII-RT. They were all group A patients. Median symptom-free interval was six months for the whole population. Survival was twelve months. The 3 FRT was well tolerated but does not seem to have improved the therapeutic gain of the chemoradiotherapy combination. The present study concerns patients whose prognosis was poor on inclusion: surgery inadvisable or unsatisfactory and diagnosis mainly based on biopsy only. The number and the duration of responses justify further study into Cis PII as first line therapy as either an effective cytotoxic drug or a potential radio enhancer.


Long-term follow-up in 39 patients with an ependymoma after surgery and irradiation.

1954 to 1989, 33 patients with intracranial ependymomas had primary treatment in our hospital with surgery and postoperative radiotherapy. Five- and ten-year survival rates were 48% and 34% in 25 patients with a high-grade ependymoma and for low-grade ependymomas was maintained at 78% for both the five- and ten-year follow-up period. Cumulative frequency of local or intracranial recurrence was 70% (high-grade) and 20% (low-grade). Despite the fact, that only three of 25 patients with high-grade ependymomas had spinal irradiation with 19.5 to 30 Gy, there was only a single patient with clinical signs of spinal metastases simultaneously with an intracranial recurrence. Twelve out of 13 living patients without signs of tumor have been classified according to the neurological performance: Performance was good or very good in five patients, satisfying in three with an independent life, fair in two patients working in a sheltered office and dependent on some assistance and poor in two patients. Published results are discussed and compared with the own observations and our current treatment policy is given.


[Transrectal sonographic (TRUS) prostatic volumetry in assessing tumor response to radiation].

The aim of this study was to document the grading-related response of carcinoma of the prostate to radiotherapy, especially in views of the fact that the PSA values of hormonal therapy are not evaluable if hormonal therapy is done prior to radiotherapy or in patients with high likelihood of metastatic spread. Controls were done on 55 patients before, during and after primary external radiotherapy of carcinoma of the prostate with volumetric analysis of transrectal ultrasound (TRUS) of the prostate. There were significant differences between G1 and G2 tumors on the one hand and G3 tumors on the other hand. The latter had a much larger volume to start with and their volume reduced more rapidly after therapy.


[The value of adjuvant irradiation in lymphatic vessel invasion in patients with a cervical carcinoma in histopathological stage Ib and with negative lymph nodes].

The present retrospective study attempts to evaluate the significance of adjuvant radiotherapy as a prognostic factor for stage Ib cervical carcinoma without lymph node metastases but with lymph-vascular space invasion. 54 patients fulfilled the inclusion criteria: histopathological stage Ib, radical hysterectomy with pelvic lymphadenectomy, negative pelvic lymph nodes and lymph-vascular space involvement. Though larger tumors were found (tumor infiltration of the cervix greater than 2/3) in the irradiated group (chi 2-test p = 0.003), there was no significant difference in the five-year overall survival (92% five-year survival without vs. 90% with adjuvant irradiation). In contrast statistical significant difference was found in recurrence-free interval between these groups (Wilcoxon test p = 0.02).


[Pseudotumor orbitae--a chameleon in diagnosis and therapy?].

Between 1972 and 1988, 25 patients were diagnosed and treated for "pseudotumor orbitae" in the Departments of Radiotherapy and Ophthalmology of Münster University Clinics. All cases had been initially confirmed by histology. Later in seven cases (28%) the histology showed a definitive alteration, and eventually turned to malignancy in five patients. Criteria indicating such a shift are seen in higher age, subacute onset of the disease, low pain, minor signs of inflammation, low echoes in ultrasound diagnostics, and the absence of "Dutcher bodies" in histiocytes, if these are evident in histology. These patients at increased risk of malignant transformation should be considered for radiotherapy at an earlier stage than prescribed by the current routine.


[Case reports on the importance of the locoregional radiotherapy of Merkel cell tumor].

The Merkel cell tumor is becoming an increasingly diagnosed primary neoplasm of the skin. This subepidermal tumor is commonly located on the head and neck or extremities of elderly patients. Occasionally misinterpreted as cutaneous metastases, they show a high rate of local recurrence (27 to 52%) and distant metastatic spread (18 to 52%). The definitive diagnosis can be made with immunohistochemistry. Wide surgical excision with postoperative irradiation to the local site and regional lymphatics is the therapy of choice. In seven patients we describe management strategies and discuss their clinical results.


[The special aspects in the planning and use of an electron linear accelerator facility for intraoperative radiotherapy (IORT)].

Limiting conditions for the planning of the installation of an electron linear accelerator in an operating theatre are described taking into account the radiotherapeutical and surgical requirements based on the example of the Essen facility for intraoperative radiotherapy (IORT) with electrons. Special features of the facility like a non-contact electron applicator system with television monitoring, table-top trolley, which is used also during irradiation, are explained in detail. Measured isodose curves for all tubes and all electron energies serve for the radiotherapist as criteria for decision on tube size and electron energy selection during surgical operation. The influence of misalignments of the tube on dose distributions is investigated. Limit values of alignment tolerances are deduced. Daily constancy tests for monitor calibration, electron energy, and tube alignment system are to be performed for quality assurance. Tables of the planned and realized treatments and of a representative time schedule of an IORT give a survey on the indications and the necessary time effort and staff. Completion of the set of tubes as well as optimization of the tube fixation accessory and of the table-top trolley are main subjects for future developments.


Primary colorectal anastomosis with the intracolonic bypass tube.

Intracolonic bypass with primary colocolonic or colorectal anastomosis may be an effective option in the operative management of complicated colonic disease when adequate bowel preparation is not possible. A pliable latex tube is anchored to mucosa and submucosa 3 centimeters proximal to a site of colocolonic anastomosis and later spontaneously evacuated by way of the rectum. Twenty-nine consecutive patents who required urgent colorectal operations in the presence of unprepared bowel underwent left colon resection with intracolonic bypass and primary anastomosis. These patients would have otherwise undergone multistage procedures for the management of the colorectal disorders. Demographic data, APACHE II scores, and type and frequency of complications were recorded. Between July 1, 1990, and June 30, 1991, 31 patients were eligible for entry in the study. Two patients ultimately had contraindications for the use of intracolonic bypass. The causes encountered included complicated diverticular disease, colonic carcinoma, sigmoid volvulus, and iatrogenic colorectal injury. Complications included wound infection (7), myocardial infarction (2), prolonged ileus (1), deep vein thrombosis (2), and anastomotic leak (2). Postoperative myocardial infarction and subsequent multiorgan system failure were responsible for the only death in this study. Intracolonic bypass permits a safe primary anastomosis where multistage procedures would otherwise be required. Avoidance of colostomy and the attendant socioeconomic benefits warrants further study of this method.


Radioimmunoguided surgery challenges traditional decision making in patients with primary colorectal cancer.

Initial experience with the radioimmunoguided surgery system (RIGS) has been found to impact on decision making in patients with recurrent colorectal cancers. Reported here is experience with RIGS-influenced therapeutic decisions in patients with primary colorectal cancer. Thirty-six evaluable patients with primary cancers were injected with the second-generation anti-tumor-associated glycoprotein antibody CC49 labeled with 1 to 2 mCi iodine 125. Pharmacokinetic determination and precordial counts were obtained after injection and weekly until levels were less than 20 counts/2 sec. At surgery abdominal and pelvic explorations were performed, first traditionally by inspection and palpation and then with the hand-held, gamma-detecting probe. RIGS-positive tissue was considered cancerous and removed if possible. Thirty patients (83%) had positive antibody localization at surgery. Of those patients with localization, in 24 (80%) additional information was obtained at the time of surgery. In 11 patients (34%) staging changes were made as a result of RIGS exploration. New findings resulted in operative changes in nine patients (25%). Eleven (30%) of the original 36 patients became eligible for adjuvant chemotherapy based on current recommendations because of RIGS findings. In conclusion, the RIGS system provides immediate staging information that impacts on therapeutic interventions, challenging the adequacy of traditional procedures alone for primary colorectal cancer exploration.


Total parenteral nutrition-induced changes in gut mucosal function: atrophy alone is not the issue.

Total parenteral nutrition (TPN) has been implicated in gut atrophy and breakdown of barrier function leading to bacterial translocation (BT) in animals. BT during TPN, however, is not found consistently, and it has therefore been suggested that macromolecular permeability may occur independently of BT during TPN. Male Sprague-Dawley rats were administered isocaloric standard TPN enterally, parenterally, or split equally between the two routes or allowed food ad lib. A second group of rats was administered isocaloric TPN with and without 4% lipids, and changes in gut barrier function were assessed by measuring lactulose permeability. Rats receiving TPN both enterally and parenterally maintained histologic intestinal structure to the same degree as rats fed enterally and those allowed food. Although parenteral feeding led to significant gut atrophy and cecal bacterial overgrowth, BT was not increased. Gut permeability to lactulose, however, was increased significantly in the TPN groups. Lipid content did not affect outcome. These results suggest that gut atrophy, BT, and permeability to macromolecules are not necessarily related. Gut-origin septic states during TPN or trauma may be caused by an increased escape of macromolecules from the gut, and BT may be an end result rather than a primary cause of such septic episodes.


Comparison of minimally invasive methods of parietal cell vagotomy in a porcine model.

Parietal cell vagotomy (PCV) is an accepted therapy for peptic ulcer disease. Traditional operative PCV results may be obtained laparoscopically or endoscopically. The purpose of this study was to quantitatively evaluate newer methods of PCV. Variations in PCV, gastroscopic chemoneurolysis and laparoscopic photoneurolysis, were evaluated in 20 to 25 kg pigs. Traditional operative PCV was performed by laparotomy and served as the operative control. With a posterior truncal vagotomy, a PCV was performed laparoscopically by an anterior seromyotomy with either operative division of the neurovascular bundles with titanium clips or with a defocused CO2 laser. Transesophageal gastroscopic PCV was performed by transmucosal injections of the chemoneurolytic agents, 0.75% cobaltous chloride or 0.1% benzalkonium chloride. Adequacy of PCV at the time of operation was assessed by endoscopic Congo red testing. Two weeks later, repeat Congo red testing was performed by open gastrotomy. Quantitation of completeness of PCV and statistical comparison was determined by photographing the pentagastrin-stimulated gastric mucosa 5 minutes after Congo red application and subsequent comparison of innervated area versus total gastric mucosal area by a computer-driven digitized area-calculation program. All PCV techniques studied produced significant acid-secretory reduction, and both laparoscopic and gastroscopic PCV denervated the parietal cells in a manner comparable with operative PCV. Laser photoneurolysis could only be accomplished by producing full-thickness necrosis of the gastric wall. Submucosal injection of cobaltous chloride produced granulomatous nodules with foreign body crystals. Unlike operative and laparoscopic PCV, transmucosal gastroscopic benzalkonium PCV did not produce gross gastroparesis. All evaluated laparoscopic and endoscopic PCV techniques effectively denervated the parietal cells of the porcine stomach when evaluated at 2 weeks after treatment. Gastroscopic submucosal injection of benzalkonium chloride produced effective denervation with no evident histologic tissue changes and suggestive evidence of normal gastric emptying. Further evaluation with more extended periods of observation of these new techniques of performing PCV appear warranted.


Natural history of recurrent and residual stenosis after carotid endarterectomy: implications for postoperative surveillance and surgical management.

Noninvasive surveillance of patients after carotid endarterectomy is practiced routinely to detect recurrent stenoses. Many authors advocate repair of asymptomatic severe stenoses so detected. The likelihood of these lesions causing neurologic symptoms is unknown. Our aims were to (1) define the incidence of lesions, (2) determine the frequency of associated neurologic symptoms, and (3) identify patient-dependent factors that might predict restenosis. Data on the status of 449 carotid arteries after endarterectomy were reviewed. The number of recurrent and residual severe (greater than or equal to 80%) stenoses was identified. Interval to development of symptoms was determined by life-table analysis. Patient-dependent factors (age, gender, smoking, diabetes, and patch closure) were evaluated by univariate and multivariate analysis to identify possible associations with severe lesions. Severe (greater than or equal to 80%) stenoses were seen in 35 patients (7.9%). Residual lesions were seen in 17 cases (eight occlusions and nine stenoses); recurrent lesions were identified in 18 patients (3.9%). Symptoms developed in five cases (14%) (one residual and four recurrent) 35, 48, 68, 98, and 103 months after surgery. The likelihood of developing symptoms associated with stenosis at 5 years was 6%. No factors correlated with residual stenosis. Age less than 60 years, female gender, primary closure, and absence of diabetes were more common in patients with recurrent lesions. Severe lesions can be found after carotid endarterectomy in at least 8% of patients and consist of residual defects, as well as recurrent stenoses. Recurrent lesions are more common in specific patient subgroups. These lesions are stable for long periods and the majority remain asymptomatic. Operation is not indicated unless symptoms develop in these patients. Intraoperative completion evaluation may be indicated to reduce the incidence of residual disease. Early noninvasive evaluation is useful as a quality-control measure. Repeated surveillance may provide data on the course of restenosis or contralateral disease progression but is of limited clinical benefit.


A preliminary experience with use of magnetic resonance angiography in assessment of failing lower extremity bypass grafts.

This study evaluates the ability of magnetic resonance angiography (MRA) to detect hemodynamic failure of lower extremity bypass grafts and questions whether conventional angiography is necessary for this purpose. A prospective surveillance protocol with segmental plethysmography and color flow Doppler scanning has been used to detect hemodynamic graft failure in 110 patients with 120 lower extremity bypass grafts (90 vein, 30 polytetrafluoroethylene). Twenty (17%) bypass grafts fit the criteria for impending failure (drop in ankle/brachial index determination greater than or equal to 0.15; velocity less than 45 cm/sec; focal velocity two to three times mean graft flow). Intraarterial digital subtraction angiography and MRA studies were performed on all 20 grafts. Intraarterial digital subtraction angiograms showed graft occlusion in two grafts, severe native artery progression in three grafts, graft wall defects in six grafts, and anastomotic strictures in nine grafts. MRA results showed an exact correlation in 15 (75%) of 20 cases. False-positive tests occurred in four cases (20%), and false-negative tests occurred in one case (5%). Common reasons for interpretation error were metallic clips and field-of-view limitations. These problems are preventable. When MRA results were compared with color flow scan data, overall accuracy improved to 95%. Our studies suggest that MRA can be useful in graft surveillance and that the need for conventional angiography may be reduced in the future.


Internal carotid artery occlusion: operative risks and long-term stroke rates after contralateral carotid endarterectomy.

To determine the short- and long-term benefits of carotid endarterectomy (CEA) contralateral to an occluded internal carotid (ICA), we reviewed our experience since 1976. In 66 (13.8%) of 478 patients undergoing 544 CEAs, the contralateral ICA was occluded. Mean follow-up was 50.1 months (range, 1 to 165 months). Complete follow-up was available in 83.0% of patients. Operative death occurred in one (1.5%) of 66 patients with contralateral occlusion and six (1.3%) of 478 patients without contralateral occlusion (p = 0.99). Operative strokes occurred in two (3.0%) of 66 patients with contralateral occlusion and 14 (2.9%) of 478 without contralateral occlusion (p = 0.99). Life-table stroke-free rates at 1, 3, 5, and 8 years were 96.8%, 93.0%, and 93.0% in patients with contralateral occlusion and 95.9%, 94.2%, 91.1%, and 88.0% in patients without contralateral occlusion (p = 0.36). Five- and 8-year stroke-free rates were 100% and 100% in the asymptomatic subgroup with occlusion, 95.9% and 92.2% in the asymptomatic subgroup without occlusion (p = 0.45), 91.2% and 91.2% in the symptomatic subgroup with occlusion, and 89.7% and 86.8% in the symptomatic subgroup without occlusion (p = 0.47). Life-table survival rates at 5 and 8 years were 72.5% and 56.0% in patients with contralateral occlusion and 81.8% and 69.0% in patients without contralateral occlusion (p = 0.15). CEA performed in patients with and without symptoms with a contralateral ICA occlusion produces short- and long-term mortality and stroke morbidity rates comparable to those of similar patients without contralateral ICA occlusion. The indications for CEA in patients with contralateral ICA occlusion should not differ from those applied to patients without contralateral occlusion.


Management of myasthenia gravis by extended thymectomy with anterior mediastinal dissection.

Thymectomy has continued to gain acceptance as definitive treatment for myasthenia gravis. Because of the nature of thymic embryology with scattered rests throughout the anterior mediastinum, we advocate a transsternal thymectomy with extended anterior mediastinal dissection. A series of 48 patients with myasthenia gravis treated by thymectomy between 1979 and 1991 were reviewed. The mean length of duration of disease from onset to operation was 48.7 +/- 11.3 months, and the mean length of follow-up was 51.6 +/- 6.5 months. The operation was associated with a 21% morbidity rate (4% major morbidity) with no deaths. Forty-five patients (94%) have improved, requiring decreased medication. The overall drug-free remission rate was 42%. Of the 20 patients in remission, three had thymomas and four had hyperplastic glands. All of the patients who achieved drug-free remission were classified as Osserman's I or II. An aggressive surgical approach to myasthenia gravis can result in a high percentage of overall improvements and drug-free remissions. The best results are achieved in patients with lower-stage disease. Therefore transsternal extended thymectomy for myasthenia gravis appears to be the procedure of choice and should be advocated as soon as the diagnosis is made and the patient stabilized.


Long-term follow-up of patients with node-negative breast cancer treated only by regional therapy.

This study examines the potential impact of intercurrent diseases on survival after adjuvant chemotherapy for node-negative (N0) breast cancer in light of 30-year follow-up results in 136 patients with N0 disease receiving only regional therapy at the University of Texas M.D. Anderson Cancer Center between 1958 and 1960. We made a retrospective review of treatment records. Thirty-nine women (28.6%) died of the initial breast cancer, including 12 (22%) of 54 premenopausal women, 15 (43%) of 35 perimenopausal women, and 12 (25%) of 47 postmenopausal women (p less than or equal to 0.09). Six (12%) of 49 patients with T1 disease died of the initial breast cancer versus 27 (38%) of 70 patients with T2 disease and 6 (35%) of 17 patients with T3 disease (p less than or equal to 0.006). Five of 10 women died of metachronous contralateral breast primary lesions. Deaths from other cancers occurred in 11%, 2.8%, and 6.4% of premenopausal, perimenopausal, and postmenopausal women, respectively. Deaths from nonmalignant conditions occurred in 22%, 20%, and 59% of premenopausal, perimenopausal, and postmenopausal women, respectively. Overall survival at 30 years was 35 (26%) of 136 patients. Given these statistics, if one postulates that adjuvant chemotherapy reduces the death rate from an initial breast cancer by 30% to 77% (estimates based on data from adjuvant chemotherapy trials in patients with N+ or N0 disease), a 5% to 12.9% increase in the 30-year survival would have resulted.


Liver transplantation for alcoholic liver disease.

Alcoholism is the leading cause of end-stage liver failure in the United States, but the application of liver transplantation to the treatment of alcoholic liver disease remains controversial because of medical and ethical concerns. Information about the outcome of patients who undergo transplantation for alcoholic cirrhosis would help to resolve these concerns. The results of 41 patients (Group 1) with alcoholic liver disease were compared with those of patients who underwent liver transplantation for other medical problems (group 2) at this center. Thirty of the 32 survivors from group 1 and 30 matched subjects from group 2 were interviewed to assess substance dependence, recidivism, and activity level. Compared with control subjects, patients with alcoholic liver disease had equivalent patient and graft survival rates and achieved an equal level of postoperative health. These results were achieved even though patients with alcoholic liver disease had significantly worse liver failure and more morbidity before surgery, and one third of the patients in this group were not abstinent before transplantation. We conclude that patients with alcoholic liver disease merit equal consideration for liver transplantation compared with other causes of liver failure. Treatment of the addictive disorder should be included before and after surgery.


Preoperative risk factor assessment in liver transplantation.

Despite the increasing success of liver transplantation, there is lack of objective data defining appropriate candidate suitability. This study was undertaken to determine preoperative risk factors that independently or in combination affected outcome after orthotopic liver transplantation. We reviewed data on 229 consecutive adult liver transplant recipients. Thirty-one preoperative risk factors recorded at the time of listing and immediately before transplantation were analyzed. Outcome variables included hospital mortality rates, bacterial or fungal sepsis, and the need for renal support. The overall hospital mortality rate was 15.7%. Patients who were in the intensive care unit immediately before transplantation had the highest hospital mortality rate (32.6%; p = 0.006), incidence of bacterial sepsis (51%; p = 0.001), fungal infection rate (27.6%; p = 0.001), and need for renal support (38.7%; p = 0.001). Preoperative renal dysfunction was significantly associated with sepsis and was reflected in higher hospital mortality rates (29.5%; p = 0.011). Child-Pugh class C was associated with higher mortality rates (23.9%; p = 0.017), an increased incidence of bacterial (37.2%; p = 0.020) and fungal infection (20.3%; p = 0.049), and a 30.4% requirement for postoperative renal support (p = 0.004). These results emphasize the need for earlier referral and transplantation in patients with advanced liver disease. Further studies are needed to refine identified risk profiles and devise strategies to decrease morbidity and mortality rates.


The role of intrahepatic cholangiojejunostomy in liver transplant recipients after extensive destruction of the extrahepatic biliary system.

Extensive destruction of the extrahepatic biliary system after liver transplantation can be a catastrophic event. We present our experience with the use of intrahepatic cholangiojejunostomy (IHCJ) in this setting. From July 1985 through December 1991, 668 liver transplantations were performed in 583 patients. Seven patients required IHCJ. This technique involves creating an anastomosis between the jejunal mucosal and hepatic parenchyma/capsule with the use of a Roux-en-Y limb of bowel. There were four adults and three children. The clinical presentation included bile leak (n = 4), subhepatic abscess (n = 2), and intrahepatic abscess (n = 1). The probable cause of these events included hepatic arterial thrombosis (n = 4), occult bile leak (n = 2), and fungal cholangitis (n = 1). After IHCJ, six of the seven patients are currently alive, with a mean follow-up of 28 months. The current liver function test results include a mean bilirubin of 0.7 mg/dl (range, 0.4 to 1.9 mg/dl), serum glutamic pyruvic transaminase of 69 units/L (range, 32 to 118 units/L), and gamma-glutamyltranspeptidase of 118 IU/L (range, 111 to 265 IU/L). These results suggest that IHCJ is a safe and effective alternative to retransplantation in liver recipients with extensive destruction of the extrahepatic biliary system.


Cause and management of upper gastrointestinal bleeding after distal splenorenal shunt.

The aims of this study were to determine the causes of recurrent upper gastrointestinal hemorrhage (UGH) after distal splenorenal shunting (DSRS) and to summarize our experience in the prevention and management of this complication. This study is based on a retrospective review of 145 consecutive patients undergoing DSRS from 1978 through 1991. Recurrent UGH developed in 19 patients (13%), most frequently secondary to residual portal hypertension (84%). Eight patients had shunt thrombosis and 11 had patent shunts. The incidence of shunt thrombosis was significantly greater in patients whose splenic vein was less than or equal to 8 mm in diameter (44%) than those whose splenic vein was greater than 8 mm (7%, p less than 0.001). The frequency of shunt failure from 1985 through 1991 was significantly lower (2%) than from 1978 through 1984 (10%, p less than 0.05). Five patients, all with occluded shunts, underwent surgical treatment for recurrent UGH and three died (60%). Fourteen patients were managed nonoperatively, with a mortality rate of 38%. Recurrent UGH after DSRS occurs in patients with patent shunts and in those with occluded shunts; DSRS thrombosis is more frequent when the splenic vein diameter is less than or equal to 8 mm; DSRS thrombosis decreases with operative experience; and the mortality rate for this complication is high with both operative and nonoperative management.


Familial nonmultiple endocrine neoplasia medullary thyroid carcinoma: an evolving clinical entity.

A rare kindred of familial nonmultiple endocrine neoplasia medullary thyroid carcinoma arising from a 73-year-old proband case is reported to further define this distinct entity. Twenty-four family members across four generations, four with medullary thyroid carcinoma (MTC) and two with C-cell hyperplasia (CCH), were studied. Basal calcitonin levels were elevated in three patients with MTC and were normal in one patient with microscopic MTC and two patients with CCH who had persistent subtle elevation in calcium and/or pentagastrin-stimulated calcitonin levels. One patient had unilateral MTC without CCH. Associated abnormalities included papillary carcinoma (2), thyroiditis (4), adenoma (2), and colloid nodule (1). Minimum treatment was total thyroidectomy. Two patients with MTC and marked hypercalcitonemia have recurrent disease at 2.5-year and 11-year follow-up. Two patients with MTC and normal or minor elevations in basal calcitonin and two with CCH had normal provocative calcitonin testing at 6 to 18 months follow-up. Unilateral MTC without CCH and MTC in the elderly do not preclude a familial cause. Microscopic MTC or CCH may be seen with subtle elevations in stimulated calcitonin levels, and recognition allows for curative thyroidectomy. Other apparent dominant thyroid pathologic conditions may occur concomitantly with familial medullary thyroid carcinoma and thus routine calcitonin, and immunohistochemical testing should be performed in patients with an appropriate family history.


Necessity and safety of completion thyroidectomy for differentiated thyroid carcinoma.

The diagnosis of thyroid carcinoma during the course of lobectomy for a dominant nodule occasionally cannot be rendered on the basis of frozen section. Once the diagnosis of carcinoma is made, the question of completion thyroidectomy arises. The decision to perform completion thyroidectomy and the timing, safety, and efficacy of this procedure are reviewed. During the past 25 years (1965 to 1990), we operated on 351 consecutive patients with thyroid carcinoma. One hundred of these patients (84 women and 16 men) were initially treated by unilateral thyroid lobectomy for the previously stated reasons. Histopathologic examination of the permanent sections of the initial thyroid lobectomy specimen demonstrated papillary carcinoma in 70 patients and follicular carcinoma in 30 patients. Within a few months, a completion thyroidectomy was performed. The completion thyroidectomy specimen contained papillary carcinoma in 33 (47%) of the 70 patients with papillary carcinoma and 10 (33%) of the 30 patients with follicular carcinoma. Overall, 43 of these 100 patients harbored thyroid carcinoma in the contralateral lobe. Complications of completion thyroidectomy were transient recurrent nerve paresis in two patients and temporary hypoparathyroidism in three patients, requiring calcium and vitamin D therapy for a few months. Although the significance and treatment of papillary carcinoma are debated on the basis of size and grade of the primary lesion and age and sex of the patients, once the diagnosis is made in one lobe we believe that a completion thyroidectomy should be considered, not only for papillary carcinomas but also for follicular carcinomas because 47% (papillary) to 33% (follicular) of these patients will harbor the neoplasm in the contralateral lobe.


Choledochal duct cyst: resection with physiologic reconstruction.

The accepted surgical treatment of choledochal duct cyst is complete excision and enteric drainage through an intestinal conduit. Peptic ulceration and fat malabsorption have been reported after Roux-en-Y reconstruction. Such long-term complications may be avoided by a technique that simulates normal physiology. Twenty-one patients have undergone resection of a choledochal duct cyst in the past 12 1/2 years. The pathologic duct is resected to the level of normal mucosa. A short segment of jejunum with a intussusception valve (1.5 to 2 cm) is interposed between the common hepatic duct and the duodenum. The medical records and all radiographs of each patient were reviewed. Eighteen children were reexamined or the parents were contacted by phone. Twenty of 21 patients recovered without major perioperative complications. Twelve of them are well and have no symptoms at 3 to 12+ years (mean, 6 years) after operation. Four children are currently well 6 to 19 months after operation. Three children were well when lost to follow-up. Two patients have radiographic evidence of incompetence of the interposition valve. One of these, who initially underwent operation at 9 months of age, was reexplored at 10 months and at 10 years for a stricture at the hepaticojejunal anastomosis. The other, a 7-year-old girl who was admitted with jaundice and pancreatitis, has had episodic abdominal pain for 7 years after operation but is well. The valved jejunal interposition hepaticoduodenostomy offers superior biliary reconstruction after excision of a choledochal duct cyst. Normal physiology is simulated, with bile draining directly into the duodenum. A short conduit prevents stasis, and biliary reflux is minimized with the addition of an intussusception valve.


Conservative management of large ovarian cysts in children: the value of serial pelvic ultrasonography.

The management of large ovarian cysts in children is controversial and complicated by a poorly understood natural history. The purpose of this study was to determine the course of sonographically detected large ovarian cysts in a pediatric population. All pelvic ultrasonograms in which an ovarian cyst was detected during a 6-year period were reviewed. Large cysts were defined as those of more than 5 cm in any dimension or a volume of more than 13 cc. Clinical data and follow-up was derived from either the hospital chart or by telephone interview. Large ovarian cysts were detected in 92 of 191 patients (48.2%). The average age was 14.9 years (range, 3 to 22 years). Eight patients were premenarchal. In 23 patients, surgery was performed, with findings of neoplasm in 10. In patients managed without surgery and with follow-up, 46 of 51 cysts (90%) decreased in size or completely resolved. Both complex and simple cysts resolved. Most large ovarian cysts in children (simple or complex) may be safely followed with serial pelvic ultrasonography, because most cysts will either decrease in size or resolve. Neither the character of the cyst nor the size reliably predicted clinical outcome. The decision for surgical intervention should not be based solely on ultrasonographic characteristics, but other factors such as severe symptoms, complications associated with the large mass, other evidence suggestive of neoplasm, ovarian source in doubt, or whether the cyst fails to resolve or decrease in size on follow-up ultrasonography.


Pentoxifylline preserves small-intestine microvascular blood flow during bacteremia.

Intestinal mucosal ischemia with subsequent mucosal dysfunction has been implicated in the pathogenesis of ongoing sepsis and multiple systems organ failure. We have previously reported vasoconstriction and hypoperfusion in the intestinal microcirculation during sepsis. Efforts to improve microcirculatory blood flow during sepsis may lead to more effective treatment or prevention of multiple systems organ failure. Pentoxifylline improves survival and visceral organ perfusion in experimental sepsis and hemorrhage. The purpose of this study was to determine whether pentoxifylline would improve microvascular blood flow in the small intestine during bacteremia. In vivo videomicroscopy was used to quantitate alterations of the small-intestine microcirculation during Escherichia coli bacteremia in rats pretreated with either intravenous pentoxifylline or saline solution. Systemic hemodynamic and microvascular variables were measured every 15 minutes for 2 hours. Tachycardia and increased cardiac output developed in bacteremic rats while they remained normotensive. Intestinal vasoconstriction and hypoperfusion occurred in bacteremic rats treated with saline solution. Microvessel diameters and blood flow remained within 5% to 10% of baseline in bacteremic rats pretreated with pentoxifylline. Pentoxifylline in nonbacteremic rats resulted in intestinal vasodilation and increased blood flow. Pentoxifylline prevented small-intestine vasoconstriction and preserved microvascular blood flow during hyperdynamic sepsis. Pentoxifylline in nonbacteremic rats increased microvascular blood flow.


Occult gastrointestinal malignancies producing metastatic Clostridium septicum infections in diabetic patients.

Clostridial soft-tissue infections usually occur from traumatic injury but may be related to unrecognized gastrointestinal malignancy. Overwhelming sepsis with Clostridium septicum developed in five diabetic patients within 24 hours of onset of disease, and their course is reviewed. The personal experience of the author in four cases is reviewed. Patients were seen within 12 to 24 hours of the onset of the disease with painful, rapidly spreading, gas-producing infection of the lower extremity (three patients), upper extremity (one patient), or pelvis (one patient), with severe sepsis in four of five patients. Three of the five patients had pertinent past histories that should have led to the prevention of the disease. Urgent laparotomy should be performed in otherwise healthy diabetic patients who had rapidly progressive, necrotizing, gas-producing infections with no obvious source. Metastatic spread can recur if the focus is not eradicated. All diabetic patients with guaiac-positive stools should have a gastrointestinal evaluation, including colonoscopy if barium enema is normal.


Hemorrhagic shock inhibits lipopolysaccharide-induced myelopoiesis in both germ-free and conventional rats.

Bacterial translocation has been implicated in the alteration of the immune response after shock and trauma. This study examined the effect of bacterial translocation on myelopoiesis after hemorrhagic shock in germ-free and conventional rats. Awake, unrestrained germ-free and conventional rats were bled to a mean arterial pressure of 30 mm Hg until the animal required infusion of 10% of the shed blood. Rats were resuscitated with shed blood and crystalloid. Sham rats were catheterized but not bled. Twenty-four hours after shock or sham, rats were administered lipopolysaccharide 100 micrograms or saline intraperitoneally. Twenty-four hours later, bone marrow cells were cultured for growth of granulocyte-macrophage colony-stimulating factor (CFU-GM). Lipopolysaccharide increased the number of CFU-GM/femur in sham germ-free rats (801 +/- 129 versus 455 +/- 110; p less than 0.05) and conventional rats (1458 +/- 200 versus 492 +/- 59; p less than 0.05) compared with saline-treated rats. In contrast, hemorrhagic shock inhibited lipopolysaccharide-induced CFU-GM growth in both germ-free and conventional rats. Shock, itself, was a stimulus for CFU-GM growth in germ-free but not conventional rats. Bone marrow white blood cell counts were unaffected by shock, lipopolysaccharide administration, or the germ-free state. Hemorrhagic shock inhibited lipopolysaccharide-induced CFU-GM proliferation independent of the germ-bearing status of the rat, and bacterial translocation exerted no influence on myelopoietic dysfunction after hemorrhagic shock.


Splenic abscess associated with endocarditis.

Refractory or recurrent sepsis in patients with endocarditis may be from splenic abscess. The purpose of this review is to assess this relationship. Of 564 patients treated for documented endocarditis between 1970 and 1990, splenic abscesses developed in 27 patients. The mean age of the 18 men and nine women was 37 years. Etiologic factors included street drugs, dental abscess, and rheumatic fever. Symptoms included fever, myalgia, chills, and dyspnea; the prodrome averaged 2 weeks. Typical signs were heart murmur, left lower-lobe infiltrate, and leukocytosis. Splenomegaly was found in three patients. All patients had valve lesions, which involved the aortic valve alone in 10 patients, the mitral valve alone in eight patients, and multiple valves in nine patients. A splenic defect on computed axial tomographic scan was diagnosed correctly as an abscess in 10 patients, was indeterminant in three patients, and was incorrectly called an infarct in four patients. Thirteen patients died. All 10 patients treated without splenectomy died, including five patients who underwent valvular replacement. In contrast, only three of 17 patients treated by splenectomy with (11 patients) or without (six patients) valvular surgery died. Splenic abscess often accompanies endocarditis. The diagnosis is suspected by refractory fever and confirmed by abdominal computed axial tomography scan. Splenectomy is warranted before or after valvular surgery, depending on the patient's clinical response to antibiotics.


Duration of antibiotic therapy for penetrating abdominal trauma: a prospective trial.

The optimal duration of antibiotic use in penetrating abdominal trauma is incompletely defined. It is generally accepted that short-term antibiotics are appropriate for low-risk wounds. However, with colon injury and significant degree of injury, abdominal trauma index (ATI) more than 25, concern exists that short-term treatment is not adequate. The study was a prospective double-blind trial of 24-hour treatment (cefoxitin or cefotetan) compared with 5-day treatment in 515 patients. Major abdominal infections (MAI) included abscess, necrotizing fasciitis, and diffuse peritonitis. MAI occurred in 8% of those patients with 1-day therapy and 10% with 5-day therapy. Subgroup analysis of high-risk groups (colon wounds and ATI of more than 25) showed the following MAI rates: colon, 1-day therapy, 14%; 5-day therapy, 15%; ATI of more than 25, 1-day therapy, 17%; 5-day therapy, 30%. Regardless of contamination and degree of injury, 24-hour antibiotic therapy is satisfactory for all penetrating abdominal trauma.


Clinical value of endoscopy and histology in the diagnosis of duodenogastric reflux disease.

The endoscopic observation of a bile lake in the stomach, antral gastritis, or ulcerations and the histologic finding of foveolar hyperplasia or chronic gastritis have been implicated as indicators of excessive duodenogastric reflux. The accuracy of these criteria was evaluated in 135 patients with nonspecific symptoms in the foregut suggestive of duodenogastric reflux and no evidence for alcohol- or drug-induced gastric mucosal injury. The presence of excessive duodenogastric reflux was objectively determined by means of both gastric pH monitoring and cholescintigraphy with cholecystokinin stimulation. Endoscopy showed antral gastritis in 67 patients, gastric ulcers in 19, and a bile lake in the stomach in 39 (total of 135 patients). Of 90 patients who underwent biopsy, histologic findings showed foveolar hyperplasia in 26, chronic gastritis in 19, and active gastritis in 28 patients. The latter condition was associated with Helicobacter pylori in 20 patients. When gastric pH monitoring, cholescintigraphy, or both were used as "gold standard," the sensitivity, specificity, accuracy, and positive predictive value of endoscopic and histologic criteria to diagnose the presence of excessive duodenogastric reflux were poor except in the rare case of active gastritis but no Helicobacter pylori. The presence of duodenogastric reflux disease cannot be accurately diagnosed with endoscopic or histologic criteria. The diagnosis should be made with objective techniques, particularly when surgical therapy is considered.


Use of the appendix for urethral reconstruction in children with congenital anomalies of the bladder.

The presence of the cecal appendix offers a unique opportunity for the achievement of urinary continence and stable access to the reconstructed urinary bladder. We have reviewed the cases of 17 children treated over a 56-month period whose urinary anomalies have required the construction of a neourethra. Fourteen of these patients underwent neourethral reconstruction by use of the appendix. All neourethras are easily catheterized, and all are continent. The ease of application of this reconstructive modality along with its high success rate makes incidental appendectomy contraindicated in children with congenital anomalies of the bladder.


Preoperative screening with ultrasonography for laparoscopic cholecystectomy: an alternative to routine intraoperative cholangiography.

Laparoscopic management of choledocholithiasis is not routinely successful. A prospective study was undertaken to determine if preoperative screening with ultrasonography and liver function tests (LFTs) could minimize the incidence of unsuspected choledocholithiasis. One hundred twenty-one patients were studied. Patients with a common bile duct greater than 6 mm and either clinical symptoms or elevated LFT results were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). Ten patients (8%) were referred for preoperative ERCP, of whom seven had choledocholithiasis, two had papillary stenosis, and one had a normal examination (90% positive ERCPs). One hundred eight patients underwent successful laparoscopic cholecystectomy. Nine patients underwent postoperative ERCP dictated by increasing common bile duct size, elevated enzyme levels, or symptoms. Four patients (3%) had choledocholithiasis that was successfully treated endoscopically. One patient had papillary stenosis, one had oriental cholangitis, and three had normal results on examination. In this study ultrasonography and LFTs identified patients at high risk for choledocholithiasis, allowing preoperative referral for endoscopic stone extraction.


Laparoscopy: the preferred method of cholecystectomy in the morbidly obese.

Morbid obesity has been considered a contraindication to laparoscopic cholecystectomy (LC). To evaluate this we reviewed our first 201 patients undergoing LC and compared the operative procedure and outcome in morbidly obese (greater than or equal to 100 pounds over ideal body weight [IBW]) and nonobese patients. We also compared a group of morbidly obese patients who underwent standard open cholecystectomy (n = 11) with the obese group undergoing LC (n = 21). All groups were comparable in terms of age, sex, and symptoms (acute vs chronic). The obese groups undergoing LC and open cholecystectomy had similar weights (134.0 +/- 9.4 pounds over IBW [range, 100 to 286 pounds] and 133.8 +/- 6.0 pounds over IBW [range, 108 to 170 pounds], respectively) and were significantly different from the nonobese group undergoing LC (28.3 +/- 2.0 pounds over IBW [range, 23 to 98 pounds]). Parameters evaluated included operative time, resumption of normal diet, length of postoperative hospitalization, complications, conversion to open procedure, and ability to perform cholangiography. There were no statistically significant differences between the obese and nonobese groups undergoing LC in any parameters studied (operative time, 151.7 +/- 4.0 minutes vs 160.7 +/- 9.9 minutes; tolerance of diet, 1.2 +/- 0.1 days vs 1.1 +/- 0.1 days; time to discharge, 2.0 +/- 0.1 days vs 1.8 +/- 0.2 days; complications, 7.0% vs 0.0%). Operative time (117.6 +/- 11.6 minutes) was shorter (p = 0.45) in obese patients undergoing open cholecystectomy. However, time to normal diet and length of postoperative hospitalization were significantly longer (3.1 and 4.6 days, respectively; p less than 0.01), and there were more complications (18.2%). Rather than being contraindicated in the morbidly obese, LC appears to be the preferred method of cholecystectomy.


Secondary pancreatic infections: are they distinct clinical entities?

Infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have been proposed as distinct clinical entities in terms of treatment and outcome. To evaluate this classification, we reviewed the clinical course and bacteriologic findings of pancreatic infections. Of 1299 patients with pancreatitis or a related complication admitted over a 7-year period, 64 (4.9%) with culture-documented secondary pancreatic infections were reviewed with regard to cause, clinical course, bacteriologic findings, and outcomes. Group I consisted of 23 patients with infected pseudocysts; group II, 20 patients with pancreatic abscesses; and group III, 21 patients with infected pancreatic necrosis. The causes were alcohol in 36%, biliary tract disease in 30%, and postoperative in 16%, with no significant difference between groups. Patients in group I had abdominal pain or a mass without accompanying signs of sepsis, whereas patients in groups II and III had sepsis. In group I, 15 patients were treated with internal drainage, four with percutaneous drainage, and four with external drainage. In group II, three had percutaneous drainage, 15 operative drainage, and two open packing. In group III, 19 patients had operative drainage and two had open packing. Morbidity occurred in 26% of patients in group I, 40% in group II, and 90% in group III (p less than 0.001). Mortality rates were 9% in group I, 25% in group II, and 48% in group III (p less than 0.01). Enteric organisms were present in 66% of isolates, with no difference between groups, suggesting a common mode of infection. Despite similar bacteriologic findings, infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have significantly different presentations, clinical courses, and outcomes, confirming that they are distinct entities. This distinction is important when therapeutic outcomes are compared.


The expanding utility of endoluminal ultrasonography in the management of rectal cancer.

This study assessed the ability of endoluminal ultrasonography (ELUS) to determine extent of local invasion and lymph node (LN) metastasis of primary rectal tumors, to assist in ELUS-guided pelvic LN biopsies, and to assess invasion of locally recurrent rectal cancers compared to computed tomography (CT). Eighty-one patients with rectal adenocarcinoma (n = 67) or villous adenoma of more than 3 cm (n = 14) underwent ELUS with a 360-degree 7.0-MHz transducer For LN biopsy (n = 10), ELUS was used with an 18-gauge core biopsy needle passed transrectally. ELUS and CT were compared in 14 locally recurrent tumors. Staging for primary tumors (ELUS compared with pathologic examination, TNM system) revealed ELUS accurately predicted wall penetration and LN status with 95% confidence intervals of 0.88 to 0.99 and 0.87 to 0.99. Eight cancers were overstaged, and two were understaged by ELUS. ELUS-guided LN biopsy revealed carcinoma (n = 3) or lymphoid tissue (n = 3) in six of 10 patients. Extent of pelvic organ involvement was predicted in 11 of 14 ELUS and eight of 14 CT examinations in recurrent rectal cancer. ELUS is accurate in staging rectal cancers, can guide biopsies of pararectal LNs, and may be more reliable than CT in assessing local recurrence. The role of ELUS in the management of rectal cancer is expanding.


Indications for enteric conversion after pancreas transplantation with bladder drainage.

Bladder drainage has become the procedure of choice for 94% of transplant centers in North America. Bladder drainage is superior to other techniques as far as graft survival and technical success are concerned; however, the procedure is associated with significant urologic problems that might necessitate conversion to enteric drainage. This review summarizes the indications and results for enteric conversion at this institution. Between June 1982 and January 1992 a total of 240 pancreas transplantations were performed at our center. In 229 cases exocrine secretions were drained into the bladder. These cases were reviewed, and those with enteric conversions were further analyzed to delineate indications, complications, and results. Sixteen (7%) were converted to enteric drainage (side-to-side duodenojejunostomy). The reasons for conversion were urethral disruption (six), recurrent urine leaks (five), bleeding (four), and chronic urinary tract infection (one). Enteric conversions were performed between 1 1/2 and 32 months after the initial transplantation. With the exception of one anastomotic leak resulting in an intraabdominal abscess, no complications occurred. All patients undergoing enteric conversions had resolution of their problems and, in addition, were able to discontinue use of oral bicarbonate. We conclude that enteric conversion after pancreas transplantation with bladder drainage is safe and effective in the correction of urologic problems. Based on our experience, we recommend early enteric conversion if urologic problems do not resolve after an appropriate period of conservative therapy.


Fine structure of presynaptic axonal terminals in sympathetic autonomic ganglia of aging and diabetic human subjects.

The neuropathologic changes that may underlie autonomic nervous system dysfunction in nondiabetic elderly human subjects or as a complication of diabetes have been systematically examined in sympathetic ganglia of a series of autopsied human subjects. As in animal models of aging and diabetes, enormously swollen terminal axons were found closely apposed to the perikarya of principal sympathetic neurons in prevertebral superior mesenteric sympathetic ganglia of aged and diabetic human subjects. Dystrophic axons consisted of two stereotyped forms: the first was composed of large numbers of misaligned aggregates of neurofilaments surrounded by variable numbers of small dense core vesicles; the second was characterized by large numbers of mitochondria, vacuoles, and dense and multivesicular bodies. The fine structural characteristics of neuroaxonal dystrophy, its predilection for prevertebral rather than paravertebral sympathetic ganglia, and the tendency for multiple dystrophic axons to cluster preferentially around selected neurons were identical in aged and diabetic human ganglia and were similar to changes seen in animal models of aging and diabetes. Neither diabetic nor aging ganglia demonstrated evidence of neuronal degeneration. Such structural changes may represent a degenerative influence of diabetes and aging on the normal remodeling of nerve terminals in autonomic ganglia, i.e., the continually ongoing process of turnover and replacement of axonal terminals. Similarity of lesions in human diabetes and aging suggests the possibility of pathogenetic mechanisms that are common to diabetes and the aging process. The substantial parallels between humans and animal models provide support for the validity of testing some proposed pathogenetic mechanisms directly in animal models.


High-affinity binding of [125I]RTI-55 to dopamine and serotonin transporters in rat brain.

RTI-55 (3 beta-(4-iodophenyl)tropan-2 beta-carboxylic acid methyl ester), one of the most potent inhibitors of dopamine uptake reported to date, was radioiodinated and tested as a probe for the cocaine receptor in Sprague-Dawley rat brain. Saturation and kinetic studies in the striatum revealed that [125I]RTI-55 bound to both a high- and low-affinity site. The Kd for the high-affinity site was 0.2 nM, while the Kd for the low-affinity site was 5.8 nM. The corresponding number of binding sites in the striatum was 37 and 415 pmol/g protein. The pharmacological profile of specific [125I]RTI-55 binding in the striatum was consistent with that of the dopamine transporter. Additionally, [125I]RTI-55 was found to bind with high affinity to the cerebral cortex. Scatchard analysis revealed a single high-affinity component of 0.2 nM with a density of 2.5 pmol/g protein. The pharmacological profile demonstrated by [125I]RTI-55 in the cerebral cortex matched that of the serotonin transporter. Autoradiographic analysis of sagittal brain sections with [125I]RTI-55 binding was consistent with these findings. Specific binding of [125I]RTI-55 was blocked by dopamine uptake inhibitors in areas rich in dopaminergic nerve terminals. Conversely, serotonin uptake inhibitors blocked the binding of [125I]RTI-55 in brain areas rich in serotonergic neurons. These results demonstrate that [125I]RTI-55 may be a very useful ligand for the dopamine and serotonin transporters.


In vivo binding of [125I]RTI-55 to dopamine transporters: pharmacology and regional distribution with autoradiography.

Previous studies have demonstrated that para-substituted WIN 35,065-2 analogs of cocaine show high binding affinity for dopamine uptake sites both in vitro and in vivo, and inhibit DA uptake in vitro. These analogs also produce potent cocaine-like behavioral effects in various procedures. The purpose of the present studies was to evaluate the iodinated WIN 35,065-2 analog [125I]RTI-55 as an in vivo ligand for the DA transporter. Following intravenous injection in mice, [125I]RTI-55 showed highest accumulation in areas with high densities of dopamine uptake sites. Light microscopic autoradiography was used to examine binding with higher resolution. Displacement studies demonstrated that [125I]RTI-55 binding in dopamine containing regions, striatum and olfactory tubercles, was saturable and inhibited by other cocaine analogs. GBR 12909 and WIN 35,428 significantly inhibited [125I]RTI-55 binding in striatum, while paroxetine significantly inhibited hypothalamic binding but had little effect in striatum. The latter finding suggests that [125I]RTI-55 also binds to the serotonin transporter. Haloperidol had no effect on [125I]RTI-55 binding in any brain region measured. In addition, treatment of animals with the dopamine neurotoxin MPTP caused significant reductions in striatal [125I]RTI-55 binding. The results of these studies indicate that [125I]RTI-55 binds primarily to the dopamine transporter in the mouse striatum in vivo.