Perioperative hemodynamic changes in ischemic heart disease patients undergoing dental treatment.

Twenty patients with stable ischemic heart disease in functional capacity Class II-IV underwent dental treatment. Scaling was performed in seven patients without local anesthesia. In the remaining 13 patients, pain control for restoration placement was obtained by local anesthesia: in seven patients, the anesthetics contained epinephrine, while in six this drug was omitted. Heart rate, blood pressure, and electrocardiograph were continuously monitored during the dental session. All patients had elevated systolic blood pressure and rate pressure product during treatment. In the patients who received plain local anesthetics only, the elevation in systolic blood and rate pressures was, however, significantly lower than the ischemic threshold. Arrhythmia or ST segment depression of > or = 1 millimeter were not recorded in any of the subjects. In severely compromised ischemic heart disease patients undergoing routine dental procedures of limited chair time, plain local anesthesia seems to be the preferred analgesic modality.


A dentist's social responsibility to diagnose elder abuse.

Because of the high prevalence of dental disease and consequent need for dental care in the elderly, dentists are in frequent contact with the elderly, thus providing an opportunity for realizing their social obligation to become more involved in diagnosing and reducing elder abuse. Current estimates of the incidence of elder abuse in the US indicate that nearly 10% of the elderly population is affected, and this incidence rate is steadily increasing. Problems of vague definitions regarding abuse, elusiveness of the problem, and limited interest on the part of health care professionals may have deterred dentists from more involvement in the past. Apathy, tunnel vision, and vested interests of dental professionals may also contribute to the poor oral health of the elderly and consequently decrease the elders' quality of life. However, by developing a clear understanding of possible etiologies and by knowing physical and behavioral indicators of abuse, dentists can better fulfill their moral and social obligations and greatly reduce the incidence of elder abuse.


Effects of hyposalivatory medications on saliva flow rates and dental caries in adults aged 65 and older.

Institutionalized adults aged 65 or older often receive medications that have been associated with decreased saliva flow. Flow rates depressed by hyposalivatory medications are thought to increase susceptibility to dental caries. In this study, a cross-sectional comparison was made of stimulated whole saliva rates and coronal and root caries prevalence in a group of older adults, in a long-term care facility, taking hyposalivatory medications vs. a control group. No significant differences were found between the two groups in masticatory or gustatory stimulated flow rates or in mean decayed coronal or root surfaces.


The lack of efficacy of a foam brush in maintaining gingival health: a controlled study.

Foam brushes have been used in the oral care of hospitalized patients for many years. However, no controlled study of their efficacy has been conducted. A randomized crossover study, comparing the effectiveness of a foam brush with that of a toothbrush, was carried out. The gingival condition and presence of plaque in the mouths of 29 volunteers were followed. It was shown that a toothbrush was more effective in controlling plaque levels and gingivitis.


Surgical management of a patient with cleidocranial dysplasia: a case report.

Cleidocranial dysplasia is associated with the formation of many supernumerary teeth which usually fail to erupt. In later life, cysts may form around the embedded teeth. The following report describes the management of such a case with a method which promotes satisfactory prosthodontic rehabilitation.


The use of vacuum-molded polyvinyl acetate-polyethylene copolymer (PVAC.PE) for a handicapped patient.

This paper provides a survey of recent literature on the use of mouth sticks for patients who have little or no use of their limbs. Criteria for mouth stick design, types of appliances, and the fabrication of such devices are described. Details are given of a case of a young child with arthrogryposis multiplex congenita, in whom a novel approach was used to allow the safe intra-oral retention of writing implements.


Streptococcus mutans, lactobacilli, and caries experience in older adults.

This study investigated salivary levels of Streptococcus mutans, lactobacilli, and caries experience in a random sample of 448 black and 362 white older dentate adults living in North Carolina. Significant proportions of the participants had stimulated salivary flow rates less than 1.0 mL/min, salivary buffering capacity less than 4.0, S. mutans levels of 10(5) cfu/mL or more in stimulated whole saliva, or lactobacilli levels of 10(5) cfu/mL or more. Each of these factor levels could be considered, on a clinical basis, to increase caries risk. In general, people with higher levels of S. mutans or lactobacilli had more untreated coronal and root caries, but not greater total caries experience.


Erythema multiforme: a literature review and case report.

Erythema multiforme is a florid mucocutaneous disease characterized by oral, cutaneous, and ocular manifestations. The cutaneous lesions are pathognomonic because of their unique "target-like" appearance. A severe form of EM has been termed "Stevens-Johnson Syndrome". Although the etiology of EM is unknown, much of the research suggests an immunological association with HSV. The diagnosis of EM is based on signs and symptoms, and a differential diagnosis should include other ulcerative, mucocutaneous diseases, such as erosive lichen planus, pemphigus, varicella zoster, ANUG, TEN, aphthous stomatitis, and primary HSV. Therapeutic measures are palliative, including a soft bland diet, topical anesthetics, and corticosteroids. A case of EM is described which underscores the appearance of the disease and its clinical course.


Metastatic colon carcinoma to oral soft tissues.

Metastatic tumors to the oral cavity are uncommon. Most of these cases involve the mandible or the maxilla. Rarely, metastasis occurs to the oral soft tissues from a distant primary tumor. The lung and breast are the most common primary sites. It is extremely rare to have an oral soft-tissue metastasis from a carcinoma of the colon. A case of primary adenocarcinoma of the colon with metastasis to the soft tissues of the mouth is described. Three similar case reports are reviewed. A metastatic lesion to the oral cavity could be the first indication of the presence of a primary tumor.


A national survey of medical risk assessment instruction in general practice residency programs (Part I).

Formal and structured training in medical risk assessment (MRA) has been a requirement in general practice residency (GPR) programs since their inception in 1972. Institutions offering GPR programs frequently differ in the levels and types of available resources necessary to implement this training. Program directors have expressed significant concerns that this training is difficult to provide, especially in the area of physical examination. The literature has not yet established how or if programs have organized their curricula to conform to accreditation standards in MRA established by the American Dental Association's Commission on Dental Accreditation. The purpose of this study was to conduct a nationwide survey of all GPR programs to identify program characteristics and resources, didactic and clinical educational methods, and perceived achievement of ADA Standard Fourteen for MRA training. Recommendations for further research are also given. Results will be reported in this paper, the paper following in this issue, and an additional paper to be published in a forthcoming issue.


The role of salivary function on oropharyngeal colonization.

Aspiration of oropharyngeal flora is the most common route of acquiring Gram-negative pneumonia, a major nosocomial infection. Epidemiologic studies indicate that the elderly are at increased risk for developing these life-threatening pneumonias. The primary objective of this study was to determine the effects of salivary oral defenses against Gram-negative colonization. The study population consisted of 41 male outpatients, age 70 and older, seen at the Denver VAMC. The group included subjects with both diminished and normal salivary flow. Each subject answered a questionnaire regarding overall health, medication use, and symptoms of salivary dysfunction. We then collected whole saliva, unstimulated and stimulated parotid saliva, and performed a throat swab on each patient. For each throat culture, analysis was done to identify Gram-negative bacteria. Flow rates between colonized (n = 6) and noncolonized subjects (n = 34) were compared. While there were no significant differences in the flow rates between the two groups, a trend was noticed in that flow rates were lower for all three flow measures in the colonized group (whole, 22% decrease; unstimulated, 22% decrease; and stimulated, 28% decrease). These preliminary findings suggest that subjects with diminished salivary flow may possibly be at increased risk for oropharyngeal Gram-negative colonization. Research on the role that saliva plays in oropharyngeal bacterial colonization is continuing.


A national survey of medical risk assessment instruction in general practice residency programs (Part II).

This is the second part of a three-part series reporting a national survey of general practice residency directors and their evaluation of the medical risk assessment (MRA) instruction curriculum in their programs. The purpose of Part II is to evaluate the degree of success of the implementation of the ADA Commission on Accreditation's standard for MRA programs. Acceptable levels of achievement were attained in most areas of basic and intermediate-level skills. However, approximately one-third to one-half of general practice residency directors report that they are not achieving the standard for some intermediate or advanced assessment skills. When various instructor categories were compared, physicians scored significantly higher than oral and maxillofacial surgeons or other dentists in their ability to achieve acceptable outcomes in MRA instruction. The results of this survey, coupled with available literature concerning medical risk assessment instruction, support that changes in the undergraduate curriculum, a mandatory additional year of training, or modification of defined goals and outcomes should be considered.


Dietary and salivary factors associated with root caries.

In this pilot study, dietary habits, microbial factors, and salivary factors in 20 older adults who had active decay on root surfaces were compared with those of 20 adults who had inactive or no root caries. In this case-control study, the groups were matched by sex and were of similar age. Subjects using medications known to induce dry mouth were excluded. Subjects completed a nutrition interview and a four-day food diary. Stimulated whole saliva flow rate, buffering capacity, levels of salivary lactobacilli with use of the Dentocult method, and S. mutans cultured on MSB agar were determined. The root caries group had a greater mean number of eating occasions per day (6.1 vs. 4.6), more frequent exposures to fermentable carbohydrates (5.8 vs. 4.2), and higher average daily sugars intake (133 g/day vs. 105 g/day) than the control group. Root caries subjects had significantly higher lactobacilli counts and less salivary buffering capacity. Within the root caries group, significant correlations were found with Root Caries Index and lactobacilli (r = 0.56) and S. mutans counts (rs = 0.50). These results show that frequent intake of simple sugars, high lactobacilli counts, and low saliva buffering capacity may be risk factors associated with root caries in older adults.


Renal hyperparathyroidism.

The indications for surgical treatment of renal HPT in patients with chronic endstage renal failure are symptomatic disease or failed medical management. The indications for patients who have had a kidney transplant are symptomatic disease and persistent hypercalcemia. It should be noted, however, that the current approach favored in the literature in asymptomatic, mild post-transplant hyperparathyroidism is conservative. Total parathyroidectomy with autotransplantation is the most popular surgical method reported. I have done subtotal parathyroidectomy and reserved total parathyroidectomy for selected patients. My recurrence rate is comparable to that reported. The actual survival rate in our two groups of patients was 58 percent for the dialysis patients and 79 percent for the transplant patients. The actuarial survival rates at 1, 5, and 10 years in the two groups were 95 and 92 percent; 59 and 67 percent; and 32 and 67 percent. The use of diphosphonates and medical rather than surgical control needs further study, as do the long-term effects of conservative treatment of asymptomatic post-transplant hyperparathyroidism.


Fluid and electrolyte management in the pediatric surgical patient.

The following is a quick guide to the perioperative fluid program discussed 1. Always assess the state of fluid repletion in any patient presenting for surgical management (Note: This does not necessarily mean operative management). 2. If the patient is hypovolemic or if there is the possibility of hypovolemia and you are uncertain, restore volumes equal to 25% of the patient's blood volume with a fluid push made up of an osmotically active electrolyte solution modified for the additional requirements of red cell carrying capacity or clotting factors. If this results in a urine output and correction of hypoperfusion or hypotension, maintain an increased fluid administration program until a stable urine output and good perfusion are achieved. If the patient is normovolemic at the time of presentation, particularly if the patient is having an elective operative procedure and does not have an intravenous line in place, calculate the insensible losses that will occur during the time of fluid restriction before surgery and correct at least 50% of these during the operative procedure. 3. Develop the postoperative fluid program as a combination of 24-hour insensible loss replacement (maintenance fluid), restoration of measured losses, and an estimate (guess) as to the volume requirements for third-space fluid shifts. Restore blood losses if appropriate or administer additional volumes of balanced electrolyte solution at a 3-to-1 ratio to replace measured blood loss. 4. Total the insensible loss measurement, the measured losses, and the estimate of third-space requirement and divide this volume by 24 to get an initial hourly fluid administration rate. 5. Select the most osmotically active fluid that you intend to use and administer it first at the calculated rate. Carefully monitor the patient's urine output. 6. Increase or decrease the fluid administration rate to bring the hourly urine output within the guidelines for the appropriate hourly urine output (milliliters) for the particular patient based on size (kilograms). 7. When the urine output falls within the appropriate range, maintain that rate of fluid administration, and recalculate the volumes required because of insensible loss, measured loss, and third-space shifts by subtracting the amount of fluid already administered from the volume that will be required in the remainder of the 24 hours; this will yield the volumes of additional maintenance, measured loss, and third-space fluids that will make up the remainder of the fluids needed for the 24 hours.(ABSTRACT TRUNCATED AT 400 WORDS)


Update on anesthesia management for infants and children.

This review aims at providing the pediatric surgeon with an update on the most important issues in pediatric anesthesia and the changes that have taken place over the last few years. Many practices, entrenched in tradition, are being modified in the light of research that has provided new knowledge, drugs, and techniques. Pediatric anesthesia requires dedication, a sense of anticipation, meticulous attention to detail, and an individual who derives enormous satisfaction from the pleasure to be had from dealing with these small patients and their families.


Surgical management of children with hemoglobinopathies.

Sickle hemoglobinopathies include sickle cell disease, sickle-C disease, and sickle-beta thalassemia. Patients with these disorders commonly suffer a multitude of destructive events to vital organs, especially to the central nervous system, the spleen, the kidney, the lung, and the heart as a result of microvascular plugging by the sickled erythrocytes. Thoughtful preparation for anesthesia and operation, especially when directed by experienced individuals, can greatly reduce the hazard of inducing the sickle crises that formerly plagued individuals with sickle hemoglobinopathies who faced major operations under general anesthesia. The patient must be free of any acute illness, especially one involving the respiratory system. Adequate hydration preoperatively combined with avoiding perioperative hypoxia, hypothermia, and acidosis, the triggers for sickling, will go far toward avoiding sickle-induced complications. Modern transfusion therapy, consisting of multiple small transfusions of Hb A erythrocytes administered over several weeks prior to the operation, not only corrects the chronic anemia but suppresses erythropoiesis of cells containing Hb S in the patient's bone marrow and leaves him or her with a majority of cells containing Hb A. This provides a safety net in case a sickle-inducing insult occurs despite the best efforts to avoid one. Individuals with sickle hemoglobinopathies may require any of the operations common to all children, for example, herniorrhaphy, appendectomy, tonsillectomy, and circumcision, but a significant number will develop calcium bilirubinate cholelithiasis and possibly cholecystitis as a result of the continual increased load of bile salts resulting from the shortened lifespan of the cells containing Hb S. Also, although most individuals with Hb S will gradually suffer splenic infarction by late childhood, a significant number of infants will experience acute splenic sequestration crisis, a life-threatening entity, the recurrence of which is prevented by splenectomy. Several publications have demonstrated that such surgical procedures can be performed in large numbers of patients with sickle hemoglobinopathies without deaths and with minimal morbidity.


Metabolism and nutritional frontiers in pediatric surgical patients.

The successful treatment of pediatric surgical disease requires an understanding of the acute metabolic stress response. Poor clinical outcome can result when the metabolic demands of acute injury exceed the ability of endogenous host mechanisms to compensate. Appropriate exogenous supplementation may provide the metabolic and nutritional support crucial to recovery. As knowledge in this area grows, more effective treatment strategies are evolving. The potential for further advances, especially in the infant critical care population, offers the hope for substantial progress in the near future.


Vascular access techniques and devices in the pediatric patient.

Vascular access is a sine qua non in the management of pediatric surgical patients. The indications, as well as the number of available access routes, types of devices, and their use, have expanded over the last two decades. This article is an overview intended to allow the surgeon to match the safest and most effective access to the child's therapeutic needs. It also contains descriptions of sites for percutaneous and cut-down vascular access in children, as well as the author's personal approach to central venous access. Vascular access in children requires skill, time, patience, and the appropriate equipment. Fortunately, with attention to detail, most complications can be avoided.


Gastrostomy techniques and devices.

Gastrostomies play an important role in the management of a wide variety of surgical and nonsurgical conditions of childhood. Many techniques and gastrostomy devices are available. In our experience, percutaneous endoscopic gastrostomy has proved safe and effective, and the gastrostomy button has eliminated most of the catheter-related problems. Candidates for gastrostomy, particularly children with foregut dysmotility, must be carefully selected, undergo preoperative studies aimed at determining the degree of gastroesophageal reflux, and have appropriate long-term follow-up. Attention to technical detail is essential to avoid operative complications. A good working relationship between the surgeon, gastroenterologist, nurse, and patient's family is essential to minimize long-term morbidity, particularly stoma-related problems.


Evolving uses of laparoscopy in children.

As the technology evolves, the number of procedures that can be performed laparoscopically will continue to expand (Table 3). The impact on the field of pediatric surgery, which encompasses surgical oncology, gastrointestinal surgery, trauma, and gynecologic surgery, will be significant. There are several hurdles for the pediatric surgeon to overcome before beginning operative laparoscopy. The acquisition of the initial instrumentation is expensive, and the credentialing process may be time-consuming. And there remains a healthy suspicion on the part of many pediatric surgeons that these techniques represent a fad. We believe that operative laparoscopy has advantages and disadvantages. Some of the procedures require more time and are frequently tedious, thus trying the patience of the surgeon. It is difficult for experienced surgeons to subject themselves electively to the learning curve associated with a new procedure. While the benefits are mostly in the postoperative period, we believe exposure is vastly improved in obese patients. Patients appear to have less pain and postoperative ileus, and they may return to unrestricted activity sooner. We are still discovering which laparoscopic procedures can be done safely to the patient's advantage. Solving the dilemma of what procedures should be performed using laparoscopic techniques will require extensive experience and study, and minimally invasive surgery will be a subject of controversy and debate for many years. It is difficult to imagine that open cholecystectomy would once again become the standard. We predict that we will see a continued expansion in the types of procedures to be performed using minimal-access techniques. And in the future, we may have to justify our opening of a patient's abdomen when the procedure could have been performed laparoscopically, as is now the case for cholecystectomy in some areas of the country.


Lasers in pediatric surgery.

The use of lasers in a variety of surgical disciplines has added new dimensions to operative techniques, allowing increased precision, improved hemostasis, and less tissue injury. Although lasers offer no significant benefit over some conventional pediatric surgical techniques, there are other procedures and disease conditions in which the use of laser technology provides major advances and improves outcome. The physics of laser technology and the unique characteristics and applications of the currently available lasers are discussed along with current and future applications in pediatric surgery.


Uses of extracorporeal membrane oxygenation in nonneonatal respiratory patients. An update.

Neonatal extracorporeal membrane oxygenation (ECMO) has progressed rapidly from the experimental stage to a standard of care for certain infants who fail to respond to maximal conventional management. A broad diagnostic group of nonneonatal patients has now been supported by several different modes of ECMO with encouraging results. Selection criteria for nonneonatal patients that differ from those used for neonatal patients are emerging. Prospective randomized clinical trials are needed.


Trends in pediatric trauma management.

Injuries are the leading cause of death in children 1 to 14 years old and result in permanent disabilities for thousands of children each year. Blunt trauma accounts for more than 60% of childhood injuries. Head trauma is most common, but the most severely injured children have multisystem injuries, frequently of the extremities, chest, and abdomen. The child's response to injury differs from that of the adult, and specific patterns are seen with blunt injury; recognition of these patterns is essential for proper management. The general surgeon coordinates the total care of the injured child, including the efforts of a variety of medical specialists, to provide cohesive and efficient care.


Current surgical considerations in gastroesophageal reflux disease in infancy and childhood.

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.


Current management of anorectal anomalies.

A significant amount of new information has been obtained concerning the early management of anorectal malformations. The surgical approach also has changed and improved the functional prognosis of children with these defects. Recommendations are made based on a series of 632 cases. A simplified approach to avoid the most common errors in the management of these defects is emphasized. Yet, there are still many children born with severe anatomic deficiencies who cannot expect normal bowel function; however, for this group, a bowel management program is available to help improve their quality of life.


Review of head and neck lesions in infancy and childhood.

Common congenital and infectious lesions of the head and neck in infancy and childhood have been discussed. Those that are present at birth, asymptomatic, and frequently cystic are clearly benign lesions that require operative management for the potential complications of enlargement and infection. Solid lesions, particularly those of the lymph nodes, must be differentiated from neoplasms, particularly Hodgkin's disease and non-Hodgkin's lymphoma. Suppurative lymphadenitis is obvious from its local inflammatory signs, but the subacute and chronic adenopathies may be difficult to distinguish from neoplasia. An attitude that unless the benign nature of a lesion is clearly demonstrated, early excisional biopsy for histopathologic evaluation must be the rule will avoid delays in diagnosing those neoplastic lesions that can be treated successfully if managed early and aggressively.


The changing role of amputation for soft tissue sarcoma of the extremity in adults.

The role of amputation in soft tissue sarcoma of the extremity has decreased at Memorial Sloan-Kettering Cancer Center during the last 20 years. In an attempt to determine the reasons for this change in therapy, an analysis of two separate databases involving 1,057 patients compiled during the periods of 1968 to 1978 and 1982 to 1990 was performed. The patients requiring amputation for soft tissue sarcoma of the extremity in the two databases (n = 233) were compared in an attempt to determine any significant differences between the two time periods. The groups were specifically compared for differences in risk factors, indications for amputations and the effect a decreasing incidence of amputation in the 1982 to 1990 group had on local recurrence and overall survival between the two groups. Despite similarity of risk factors and indications for amputation, the decreased incidence of amputation during the 1982 to 1990 period was associated with a significant decrease in local recurrence after amputation and no significant change in overall survival compared with the 1968 to 1978 group. Absence of local recurrence was associated with significant improvement in survival. Possible reasons for the shift in therapy, as well as the present and future role of amputation in soft tissue sarcoma of the extremity, are discussed.


Appendiceal mucoceles and pseudomyxoma peritonei.

Mucoceles of the appendix and associated pseudomyxoma peritonei are a heterogeneous group comprising various histopathologic lesions with differing prognoses. Between 1983 and 1990, we treated eight patients with appendiceal mucocele, three cystadenomas and five cystadenocarcinomas, three of which had accompanying pseudomyxoma peritonei. All patients were more than 50 years of age. Women outnumbered men by seven to one. Preoperative diagnosis was acute appendicitis or appendiceal abscess in all instances of mucocele unaccompanied by pseudomyxoma peritonei. Ultrasound of the abdomen, together with paracentesis, diagnosed pseudomyxoma peritonei in two of three patients. Elevated carcinoembryonic antigen levels were found in six of the eight patients and monitoring of this parameter was useful in the early detection of the two recurrences observed. The three patients with cystadenomas remain free of disease after appendectomy. Of the five patients treated for cystadenocarcinoma by right colectomy, two underwent reoperation after recurrence of disease. One patient died 41 months later of intestinal obstruction caused by pseudomyxoma peritonei. Pseudomyxoma peritonei significantly decreases survival of patients with appendiceal mucocele. In these patients, aggressive initial surgical management, repeated if need be, is indicated.


A prospective randomized trial of single versus multiple drains in the axilla after lymphadenectomy.

Increasing duration and amount of postoperative fluid formation after axillary lymphadenectomy delays final healing. We postulated that multiple drains (instead of a single drain) might decrease postoperative fluid accumulation by their greater proximity to points of leakage. We randomized 65 women with clinical stage I or II carcinoma of the breast to single or multiple drains. They were stratified for axillary dissection or modified radical mastectomy. For axillary dissection, randomization to multiple drains meant placement of four catheters in the axilla, and randomized to the single drain, one catheter in the axilla. For modified radical mastectomy, the patients randomized to multiple drains received four catheters in the axilla and one catheter under the inferior flap; the patients randomized to single drains had one catheter in the axilla and one catheter under the inferior flap. All catheters exited separately. The two arms (single versus multiple drains) were determined to be homogeneous in other variables that may affect postoperative fluid formation--age, size of the breast, weight, height, obesity, presence of previous surgical biopsy, excision of pectoralis minor muscle, excision of thoracodorsal complex, level of axillary dissection, number of lymph nodes, number and proportion of positive lymph nodes and whether or not the dominant hand was on the side operated upon. Single versus multiple drains had no clinically significant effect on the amount or duration of drainage, as an inpatient or outpatient, or total. We recommend a single drain to the axilla after lymphadenectomy.


Comparison of intraoperative and endoscopic manometry of the sphincter of Oddi.

Despite the potential utility of intraoperative manometry of the sphincter of Oddi, limited data are available validating its use. The current study was undertaken to validate the method of intraoperative sphincter of Oddi manometry by comparing the pressure tracings obtained at operation (transduodenal sphincteroplasty and transampullary septoplasty) and endoscopy (preoperative) in the same group of patients. Seventy-four patients with idiopathic pancreatitis or unexplained disabling pancreaticobiliary pain had sphincter of Oddi manometry performed endoscopically and intraoperatively within six weeks of each other. Thirty-five patients had manometric evaluation of the bile duct segment of the sphincter of Oddi. The mean basal sphincter pressure determined endoscopically and intraoperatively was 41.1 +/- 6.4 millimeters of mercury (mean plus or minus standard error of the mean) and 42.0 +/- 6.8 millimeters of mercury (not significantly different, p > 0.05), respectively. There was no significant difference between the biliary sphincter phasic pressure, phasic frequency and phasic duration, as recorded by the two techniques. Fifty-five patients had manometric evaluation of the pancreatic duct sphincter. The mean basal sphincter pressure determined endoscopically and intraoperatively (after biliary sphincteroplasty) was 111.9 +/- 9.9 millimeters of mercury and 102.7 +/- 8.7 millimeters of mercury, respectively (not significantly different, p > 0.05). There was no significant difference in the pancreatic sphincter phasic duration and phasic frequency determined by the two techniques. However, the pancreatic sphincter phasic pressure was significantly higher when measured endoscopically (p < 0.001). Overall, 70 percent of patients benefited from surgical sphincter ablation therapy. Patients with an elevated basal sphincter pressure determined intraoperatively were more likely to improve than those with a normal basal sphincter pressure.(ABSTRACT TRUNCATED AT 250 WORDS)


Success with sacrospinous suspension of the prolapsed vaginal vault.

Sacrospinous ligament fixation of the prolapsed vaginal vault has proved very useful, but the complications of failure, hemorrhage, infection, nerve damage, incontinence and dyspareunia are reported. Experience with 51 operations performed by staff, and residents with supervision, has shown the value of certain preoperative and technical steps to avoid complications, including candidate selection; repair of enterocele; retropubic positioning of the bladder neck; repair of all pelvic support defects, and perineorrhaphy. Technical modifications are described. Results in these instances are tabulated: no recurrent prolapse; no transfusions; four narrow vaginas; two with stress incontinence; one pelvic cellulitis, and one ventricular fibrillation on the third postoperative day. We believe that most complications are preventable.


Clinical use of synthetic absorbable cuff material for peripheral vascular anastomosis.

End to end arteriovenous (AV) fistulas were created using the cuff technique for hemodialysis in 12 patients with end stage renal disease. The cuff used was made of a synthetic biodegradable material, a lactic glycolic acid co-polymer with the same composition as absorbable surgical suture. Cephalic vein radial artery fistulas in the forearm were created electively in six patients to convert a Scribner shunt to a fistula in three patients and because of malfunction of a fistula created previously in three patients. Eleven patients underwent hemodialysis, with pump speeds of more than 200 milliliters per minute, and were evaluated for 129 to 477 days. These subcutaneous AV fistulas were maintained as patent functional veins and continued to function without complication. After five weeks, one patient had conversion to a prosthetic AV fistula because of poor venous maturation. The overall patency rate was 92 percent. The diameter of the AV anastomosis increased gradually with time. At 20 weeks, however, it reached more than 70 percent of the diameter of the radial artery lumen. These observations led us to believe that the cuff material used is biodegraded until 20 weeks and gives sufficient flexibility. In the future, the cuff method is expected to be clinically developed as another approach for vascular anastomosis.


Treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis.

We reviewed an experience with treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis to identify clinical and computed tomography (CT) parameters that are helpful in the selection of patients for treatment and to assess treatment outcome. The extent of CT abnormalities determined a CT severity score (mild = 1, severe = 4). From 1985 to 1990, 650 patients were hospitalized with acute pancreatitis; a peripancreatic fluid collection was found in 36 patients (5.5 percent). Ten of 11 patients with successful outcome after no invasive treatment (group 1) had a low CT severity score of 1 or 2; mean serum albumin was 4.0 gram percent. Of 25 patients who had some form of drainage, 12 had a high CT severity score of 3 or 4 (p < 0.05) and a mean serum albumin of 3.4 grams percent (p < 0.05). Nine patients had only operative drainage (group 2) and 16 had CT-directed percutaneous catheter drainage (group 3). In group 3, percutaneous catheter drainage successfully drained the fluid collection in six patients, while ten patients needed an operation, in addition to percutaneous drainage, to effectively débride and drain the necrotizing pancreatic problem. As a result of the current review, we propose an algorithm for treatment of these patients.


Axillary versus combined axillary and pectoral drainage after modified radical mastectomy.

Initial attempts to obliterate dead space and minimize fluid accumulation in patients after mastectomy using closed suction drainage, used insertion of a single axillary drain. Today, surgeons often insert two drains in the postoperative wound, one in the axilla and the other beneath the pectoral flaps. The current study was done to determine whether or not there is an advantage in using two drains rather than a single axillary drain after mastectomy. A randomized, clinical trial was conducted with 84 women undergoing modified radical mastectomy. Thirty-seven patients had one axillary drain and 47 had two drains placed postoperatively, one in the axilla and the other beneath the pectoral flaps. Follow-up results were obtained four weeks postoperatively for complication data, including seroma and hematoma formation, flap necrosis and infection. The average total drainage was 870.4 milliliters per patient in the group with one drain and 997.4 milliliters per patient in the group with two drains (p value not significant). The overall complication rate in the group with one drain was 35.0 percent compared with a rate of 31.9 percent for all complications observed in the group with two drains. These differences did not reach statistical significance. Comparing the frequency of each complication in the two groups again showed no significant difference. However, the data suggest a trend toward an increased incidence of flap necrosis in the group with two drains that used a drain beneath the pectoral flaps. Use of a single axillary drain after modified radical mastectomy seems to result in no increase in postoperative complications, is less costly and may assist in reducing the incidence of flap necrosis.


Effects of pentagastrin and of the somatostatin analog (SMS 201-995) on growth of CT26 in vivo adenocarcinoma of the colon.

This study was done to investigate the effects of pentagastrin and of somatostatin analog (SMS 201-995) on growth of CT26 adenocarcinoma of the colon implanted in mice. Eighty Balb C mice were inoculated subcutaneously with 100,000 cells. Four groups of 20 mice each were treated with 0.1 milliliters of saline solution every eight hours; 250 micrograms per kilogram of pentagastrin every eight hours; 100 micrograms per kilogram of SMS 201-995 every 12 hours; 250 micrograms per kilogram of pentagastrin every eight hours, plus 100 micrograms per kilogram of SMS 201-995 every 12 hours. Tumoral weight, volume and deoxyribonucleic acid (DNA) content and mean survival rates were determined for each group. Control mice had tumors weighing 1,619 +/- 179 milligrams, of 1.47 +/- 0.2 milliliters to the third power and with 12.9 +/- 1.1 milligram of DNA, at 30 days after inoculation. The mean survival rate was 42.5 days. Pentagastrin administration increased the three parameters of tumoral growth by 40 percent and reduced survival time to 29.6 days (p < 0.01), while SMS 201-995 inhibited growth by 40 percent and prolonged survival time to 48.5 days (p < 0.01). Simultaneous administration of both peptides had no effects. These data suggest that pentagastrin has a trophic effect and SMS 201-995 an inhibitory effect on CT26 adenocarcinoma in mice.


Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract.

A study of 83 patients admitted with massive bleeding in the lower part of the gastrointestinal tract is presented using a diagnostic approach primarily of angiography and colonoscopy with the adjunctive investigations of scintigraphy, small intestine series and computed tomographic scan. The source of bleeding was identified preoperatively in 74 patients. Nine patients had a diagnostic laparotomy and the cause was found in an additional seven. A source was not identified in two patients at exploration and a blind resection was not performed. The two patients have not had recurrent bleeding four and nine years postlaparotomy. The sites of bleeding were colon in 44 patients, small intestine in 24 and the anorectum in 11. Sixty-five patients were treated operatively, two by angiographic embolization and two by endoscopic electrocoagulation. Fourteen patients were managed conservatively. The mortality rate was 10.8 percent and five patients rebled after treatment. We conclude that a thorough systematic assessment of patients with bleeding in the lower part of the gastrointestinal tract is important to localize the site of the hemorrhage. Exploratory laparotomy is the final diagnostic modality, and if a source has not been identified, a blind colonic resection should not be performed.


Fibrin glue reduces seroma formation in the rat after mastectomy.

Fibrin glue is a biologic tissue adhesive that has been found to be useful in several areas of surgical treatment. Little has been written in the English literature, however, on its use in preventing postoperative fluid collections. We performed a prospective randomized trial to determine if fibrin glue could reduce postoperative fluid collections after mastectomy in a rat. Bilateral mastectomies and axillary lymph node dissections were performed upon 42 rats, one-half of which were treated with fibrin glue and one-half of which served as controls. The rats were sacrificed after seven days and inspected for quantity of fluid and adhesion formation. The mean plus or minus standard error of the mean fluid collections were 0.71 +/- 0.26 milliliter and 3.75 +/- 0.65 milliliter for the rats treated with fibrin glue and control rats, respectively. This was statistically significant (p < 0.0001). Seventeen of 21 rats treated with fibrin glue and four of 21 control rats were found to have fluid collections of less than 1 milliliter, again statistically significant (p = 0.00006). Furthermore, greater adhesion formation between the skin flap and chest wall was noted in the rats treated with fibrin glue. The results support the use of fibrin glue in clinical investigations to reduce postoperative fluid collections and also support the need to develop a standard reproducible method of producing fibrin glue or a commercial product free of transmissible disease.


An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema.

Postmastectomy lymphedema of the upper limb is usually managed conservatively. Patients are often advised to use elastic bandages or sleeves during the day: elastic compression is, in fact, generally considered the mainstay of lymphedema therapy by authors who advocate the addition of cyclical instrumental or physical treatments, such as pneumatic compression or manual lymphatic drainage. The results of elastic compression, however, have never been extensively analyzed. In the present study, we describe the patterns of response during six months of use of a standard elastic sleeve in a series of 120 patients with postmastectomy lymphedema. Univariate and multivariate analyses were performed to identify possible prognostic factors for a better or worse response. Overall, limb measurements were reduced by 14.7 percent, with weight gain after surgical treatment resulting as the only significant independent negative factor: patients who did not increase weight after mastectomy achieved nearly a 25 percent reduction of lymphedema. These results should be considered during the selection of patients for protocols of lymphedema treatment and the analysis of results.


Aseptic technique in microgravity.

Within the next decade, the United States will launch a space station into low Earth orbit as a preliminary step toward a manned mission to Mars. Provision of asepsis in the unique microgravity environment, essential in operative and invasive procedures, is addressed. An assessment of conventional terrestrial aseptic methods and possible modifications for a microgravity environment was done during the microgravity portion of parabolic flight on NASA KC-135 aircraft. During 110 parabolas on three flight days, a "surgical team" (surgeon, scrub nurse and circulating nurse) using a life size mannequin fastened to a prototype surgical "work station" (operating table), evaluated open and closed gloving (ten parabolas), skin preparation (six parabolas), surgical scrub methods (24 parabolas), gowning (22 parabolas) and draping (48 parabolas). Evaluated were povidone iodine solution, 1 percent povidone iodine detergent, Chloroxylenol with detergent, wet prep soap sponge, a water insoluble iodophor polymer (DuraPrep, 3M), disposable towels, disposable and reusable gowns, large and small disposable drapes with and without adhesive edges, disposable latex surgeon's gloves with and without packaging modifications and restraint mechanisms (tether, swiss seat, waist and foot restraint devices, fairfield and wire clamps and clips). Ease of use, provision of restraint for supplies and personnel and waste disposal were assessed. The literature was reviewed and its relevance to the space environment discussed, including risk factors, environmental contamination, immune status and microbiology. The microgravity environment, limited water supply and restricted operating area mandated that modifications of fabrication and packaging of supplies and technique be made to create and preserve asepsis. Material must meet stringent flammability and off-gassing standards. Either a chlorhexidine or povidone iodine detergent prepackaged brush and sponge would provide an adequate scrub plus preliminary cleansing of a dirty wound. Choice may depend on ease of removal from the water supply as well as sensitivity to each compound of individual crew members. Rinsing was achieved with sterile water soaked gauze. Drying would be more efficient with two small hand towels, which would be easier to manipulate in microgravity and require less stowage volume. Skin preparation highlighted unexpected packaging problems, as centrifugal force was required to "shake" the solution out of the container on to the mannequin. To minimize contamination, a gown should be folded in an accordion manner and fastened to the base of its sterile wrapper, so that an assistant can compensate for the lack of gravity by applying constant tension.(ABSTRACT TRUNCATED AT 400 WORDS)


Current clinical and pathologic perspectives on gastric stromal tumors.

Gastric stromal tumors are heterogeneous and poorly understood. Investigators have studied these tumors by histologic and immunocytochemical characteristics, but interlaboratory variations have impeded clinical application of these techniques. Although many gastric stromal tumors can be categorized as benign or malignant with some certainty, occasional instances may present great difficulty in this distinction. Uncertainty about malignant potential and the biologic factors of the lesion will therefore generally suggest excision with a 1 to 2 centimeter margin for diagnosis and definitive therapy of these tumors. Subsequent prognosis will be dictated primarily by tumor size, histologic factors and mitotic index. Gastric stromal tumors in young women should suggest the possibility of Carney's triad. Functional extra-adrenal paragangliomas and pulmonary chondromas should be sought preoperatively. The paraganglioma should be managed first and the gastric lesion then addressed. Distal gastrectomy of at least 50 percent would seem to represent a reasonable resection limit. Identification of the specific cellular biologic factors of these lesions will be necessary to accurately classify particular tumors, gauge prognosis and individualize their management.


Anatomical bases of the pediculated pisiform transplant and the intercarpal fusion by Graner in Kienböck's disease.

Anatomic characteristics of the lunate, the pisiform and the capitate were compared in order to support the use of a pisiform transplant or the intercarpal fusion by Graner in advanced stages of Kienböck's disease. Fifty lunate and pisiform bone pairs and 20 wrist specimens served for morphological and functional investigations. In view of the present results, the pisiform, after a rotation of 90 degrees, should be implanted in the lunate box with its longitudinal diameter oriented to the dorsopalmar plane. Despite the small pisiform volume, maintainance of carpal height is assured by its relatively large dorsopalmar diameter. The rotated position permits use of existing soft tissue structures and improves the conditions of force transmission. Measurements comparing the radii of curvature of the original lunate and the substitute pisiform surfaces show a good correspondence proximally and a reduction of the articular congruity distally, due to the flatness of the pisiform surface. The palmar convexity of the pisiform adapts better to the distal radius facet than the capitate head, which replaces the lunate in Graner's surgical procedure.


Anatomical basis of the anterior cervical spine approach: topographic study of the nerve structure.

The results of the surgical anterior approach to the cervical spine are marked in a number of cases by dysphagia and dysphonia, especially when the approach is extensive or performed at the upper cervical spine. 35 cadaver dissections were performed to define the topography of the nerve structures during operative exposure at various vertebral levels: superior and recurrent laryngeal nerves, hypoglossal nerve and its superior root of the ansa cervicalis. The authors suggest some technical improvements, for each stage of surgical dissection.


Anatomical bases of percutaneous surgery for calculi in horseshoe kidney.

Horseshoe kidney is a renal fusion which combines three anatomic abnormalities: ectopia, malrotation and vascular changes. These anomalies can be recognised separately to varying degrees in unfused kidneys. Necessary modifications of the standard technique for percutaneous nephrolithotomy (PNL) are directly deducible from analysis of the anatomic data of the imaging of horseshoe kidneys. We report our experience with 5 patients (7 kidneys) who underwent PNL for calculi in horseshoe kidneys. The percutaneous approach was performed under ultrasound and fluoroscopic monitoring. In situ disintegration by ultrasonic lithotripsy and nephrostomy drainage were necessary in all cases. Modifications of the standard PNL procedure are related to the anatomic changes. The lower abdominal position of a horseshoe kidney necessitates upper or middle calyceal puncture, while the malrotation necessitates a more posterior puncture. Monitoring of the puncture needle by fluoroscopy as it is advanced postero-anteriorly is more difficult and the risk of the surgeon's hand entering the radiation path is increased. The renal pelvis is deep and a long endoscope may be required. Aberrant segmental vessels may create potential hazards. The majority of problems in location can be avoided by use of an ultrasonically guided needle. Percutaneous nephrolithotomy is the treatment of choice for calculi in horseshoe kidneys for the following reasons: the high incidence of recurrent lithiasis in horseshoe kidney and the complexity of repeated surgical approaches diminish the acceptable results of open surgery; difficulties in focussing on the calculi and drainage problems militate against the success of extracorporeal shock wave lithotripsy (ESWL); PNL has a good success rate and the least morbidity.


Arterial supply of the acetabulum in the fetus: application to periacetabular surgery in childhood.

The need to perform triple osteotomies of the pelvis passing very close to the articular surface leads to the isolation of bony fragments whose vascularisation may be precarious. To assess the risks of such surgery, we undertook an anatomic study of the vascularisation of the acetabulum in the fetus. 53 specimens were injected to study the vessels to the acetabulum and their distribution within the osteocartilaginous specimen. The acetabular a., a branch of the obturator a., gives a central pedicle distributed to the acetabular fossa, the triradiate cartilage and ending in the three primary bony components. The superior gluteal, inferior gluteal, internal pudendal and obturator aa. form a periacetabular vascular circle. The abundant vascularity of the acetabulum makes massive necrosis improbable in the child. However, there is a zone of precarious anastomosis at the anterior portion of the acetabulum.


Fetal development of the pyloric muscle.

The fetal development of the pyloric muscle was studied in five human embryos (crown-rump length 5 to 31 mm) and in ten fetuses aged 3 to 9 months. Samples of pyloric muscle were obtained during operation for pyloric stenosis in two infants aged six weeks. Anatomo-radiologic, morphologic and immunohistochemical studies were made on this material, from which it emerged that the pylorus is identifiable by means of specific markers from the 40th day. Its two-layered muscular structure is described in detail. The mechanism of sphincteric function is reviewed. This study assumes clinical importance in the context of the etiopathogenesis of hypertrophic stenosis of the pylorus.


Induced and genetic mouse middle ear ossicular malformations: a model for human malformative ossicular diseases and a tool for clarifying their normal ontogenesis.

Oral administration of 13-cis retinoic acid (RA) to pregnant mice on the 9th gestation day provokes important malformations of the middle ear ossicles, associated with a general kind of craniofacial dysmorphogenesis evoking the human mandibulofacial dysostosis. The malleus, incus and stapes are affected. The malleus exhibits a handle separated from its head and keeping a persistant relationship with the tubotympanic recess. The stapes makes no contact with the otic capsule. The malformation pattern is visible early as shown by the appearance of an abnormally curved Meckel's cartilage at day 12, followed by the development of atypically shaped ossicular anlagen. The mouse "far" (first arch malformation) mutation is responsible for minor ossicular abnormalities which disrupts the normal relationships between the stapes, Reichert's cartilage and stapedial muscle. The administration of RA to pregnant mice and the comparison with a genetically induced malformation (the mutation far) provides some interesting information about the postulated mechanisms of human middle ear dysmorphogenesis, as well as precious data about the features of normal ossicular primordia formation. The comparison of these features with human middle ear abnormalities as revealed by medical imaging sheds light on human malformation patterns and provides a better understanding of normal and abnormal radiologic ossicular aspects.


Relationship between the development of diaphragma sellae and the morphology of the sella turcica and its content.

The impaired formation of the diaphragma sellae may lead to the development of the empty-sella syndrome. This structure, when fully formed, is a protective barrier against the pulsating action that the cerebrospinal fluid exerts on the sellar content. There are anatomical features which support this belief, but they also suggest that the development of the diaphragma sellae is a factor which determines the morphology of the sella turcica and its contents. Those human specimens which do not have diaphragma sellae or in which it is only partially developed, are characterized by a smaller hypophysis, always located at the inferior and/or posterior half of the sella, with a larger sellar volume and frequently greater fragility of its bony walls. These findings, although rare (5% of the cases), are indirect signs of the important role which the diaphragma sellae plays in the sellar region.


Three-dimensional reconstruction of the hip muscles on the basis of magnetic resonance images.

MRI in combination with three-dimensional reconstruction is pre-eminently suitable for the study of the human musculoskeletal system in vivo in an accurate and detailed way. MRI provides the possibility of studying superficial as well as deep muscles under tension in the living state. Bones, muscles, tendons and adipose tissue are clearly visible. Parts can also be distinguished within a muscle. After reconstruction of the 2-D images the geometry of the muscles and muscle parts can be visualized from different angles. This leads to a deeper understanding of the biomechanics and functional anatomy of the musculoskeletal system of the human body. In this paper the morphology of the muscles around the hip was studied in three subjects in vivo on the basis of three-dimensional (3-D) reconstructions of two-dimensional (2-D) MR images.


Analysis of length and surface area of each segment of the large intestine according to age, sex and physique.

Length, diameter and surface area of each of 6 segments of the large intestine were determined and calculated in 920 Japanese patients who underwent barium enema. Of the length and surface area measurements obtained, those of the transverse colon were the largest, followed by those of the sigmoid colon. The diameter of the ascending colon was the largest, while those of the descending colon and sigmoid colon were the smallest. There were various sex differences in size of the large intestine. Length and surface area of the entire large intestine in males were shorter and smaller respectively than those in females. Lengths of the cecum, ascending colon, transverse colon and rectum in males were shorter than those in females. Diameters of the descending colon, sigmoid colon and rectum in males were larger than those in females. Total surface areas of the ascending colon and transverse colon in males were smaller than those in females, while total surface areas of the descending colon, sigmoid colon and rectum in males were larger than those in females. Length of the entire large intestine tended to be increased with age. Length and surface area of the entire large intestine tended to be increased with an increase in physical dimensions in females.


Trans-uterine venography. Normal anatomy and pathologic appearances.

From a series of 110 trans-uterine venographies, the authors present the normal radiological anatomy of the uterine venous vascularization and of its efferent venous drainage. They also present the most frequent variations from normal and examples of the pathologies encountered.


Biometry of the infrarenal inferior vena cava measured by computed tomography. Clinical applications.

In a previous study based upon the cavography of 100 patients, we determined that the average diameter of the infrarenal inferior v. cava (IIVC) was 21.3 mm (range 10-31 mm) at its end [1]. We discuss the value of different methods to measure IIVC, and particularly computed tomography (CT) scans reviewed in our department. It showed that the largest diameter of IIVC was not in a frontal plane and the width observed in a cavography was in fact the projection of a transverse diameter on the film. The real diameter of the IIVC is larger than that showed by cavography. This present study shows the results of measurements of the IIVC obtained from 50 consecutive CT scans. The average transverse diameter is 24.26 mm (range 14-33.3). The average anteroposterior diameter is 13.4 mm (range 5-22) and the average angle alpha between the transverse diameter and the frontal plane is 30 degrees 45' (range 12 degrees-55 degrees). We discuss the different methods of measurement of IIVC and we conclude that at present, CT scan is one of the most reliable methods to measure the real diameter of IIVC.


Mechanisms of transplantation immunity.

In summary, this chapter describes the biology and genetics of the major and minor histocompatibility antigens and the nature of in vitro and in vivo immune responses to them and to tissue-specific antigens. It reviews the nature and action of immune response genes. It gives an account of how tolerance to histocompatibility antigens was originally defined and the prospects of intervention aimed at establishing tolerance to these and tissue-specific antigens in adult animals, including man.


Transcranial Doppler sonography in carotid-cavernous fistulas: analysis of five cases.

Transcranial doppler sonography was performed transorbitally in five patients clinically diagnosed as unilateral carotid-cavernous fistula. Dural arteriovenous malformation related-shunts were detected in all the patients. In the normal eyes, the only doppler signals observed at an insonation depth of 45 to 55 mm were those of the ophthalmic artery. In the affected eyes, abnormal doppler signals with relatively higher flow velocity and lower resistance were observed. In three of the cases, these abnormal signals showed a flow directed anteriorly or away from the cavernous sinus, consistent with changes in the ophthalmic veins caused by the presence of the shunts. In two cases, however, the observed flows were directed posteriorly, the normal direction of these veins. The possible explanations for this discrepancy are discussed in relation with angiographic findings. The use of transcranial doppler might provide a better understanding about hemodynamic changes in carotid cavernous fistulas.


Mesial temporal subdural electrode as a substitute for depth electrode.

As a substitute for depth electrodes, mesial temporal subdural electrodes were devised. This electrode has a slender trapezoid shape and is easily introduced to the inner uppermost portion of the parahippocampal gyrus. Our results have shown that mesial temporal electrodes can detect not only interictal spikes but also subclinical and clinical seizure discharges from the mesiolimbic structures, and they have excellent capability for lateralization of the mesial temporal epileptic focus. If mesial temporal subdural strips are used in combination with lateral temporal subdural grids, comprehensive understanding of the focus distribution throughout the temporal lobes will be possible without using depth electrodes.


Multimodality treatment of deep periventricular cerebral arteriovenous malformations.

The surgical treatment of arteriovenous malformations (AVMs) located in deep periventricular regions such as the basal ganglia is associated with marked morbidity and mortality. Approaches through critical brain regions afford limited exposure of the lesions, while surgical dissection is sometimes complicated by acute severe brain swelling and/or hemorrhage in the surrounding tissues. In our approach to deep AVMs, our regimen has evolved from direct staged microsurgical excision under routine fentanyl-N2O-relaxant anesthesia (first four patients) to the use of elective high-dose barbiturate anesthesia (subsequent 12 patients). In the first group of four patients, 11 operations were performed. Two patients improved, one of whom returned to normal neurologically. There were three episodes of acute brain swelling and/or hemorrhage. One patient died as a result, and another deteriorated. In the second group of 12 patients, all but two lesions were completely excised. Among the 10 patients in whom the AVM was completely excised, seven improved, six of whom achieved a good to excellent outcome, with two regaining full neurologic function. Three patients worsened (one as the result of acute brain swelling and/or hemorrhage). There was no death in this group. Only one incidence of acute brain swelling and/or hemorrhage occurred in 26 operations. Even though the number of patients is too small in the first group for meaningful statistical comparison, our intraoperative observations and postoperative results suggest that our evolved multimodality regimen, such as staged excision and the use of elective high-dose barbiturates, was likely to have contributed to the improved treatment results of these formidable lesions.


Hemifacial spasm due to tumor, aneurysm, or arteriovenous malformation.

The authors report eight cases of so-called symptomatic hemifacial spasm. They had gross pathological lesions such as a tumor (one epidermoid, one neurinoma, and two meningiomas), vascular malformation (one medullary venous malformation and two arteriovenous malformations), and aneurysm. In all four cases with a tumor, no artery compressed the facial nerve at the root exit zone. In three of the four cases, the hemifacial spasm disappeared after removal of the tumor in contact with the facial nerve. Compression or encasement of the facial nerve by the tumor was the pathogenesis of the hemifacial spasm in these three cases. The remaining case with tumor (tentorial meningioma) did not have a mass or vessel that directly compressed the facial nerve at the root exit zone. However, the hemifacial spasm disappeared after the removal of the tumor. In a case with a medullary venous malformation with arterial component, an engorged draining vein compressed the root exit zone of the facial nerve. In the remaining three vascular cases--two cases of arteriovenous malformation and a case of saccular aneurysm--enlarged feeding arteries and an aneurysm directly compressed the root exit zone of the facial nerve. Not only arterial or venous but also mass compression can cause hemifacial spasm in some symptomatic cases. Surgical decompression of the facial nerve from the causative organic lesion is the primary choice of treatment.


Vertebral hemangioma causing spinal cord compression during pregnancy.

Hemangiomas of bone are extremely common vascular tumors that are most commonly discovered as incidental findings in the vertebral column. Infrequently, these benign lesions may cause local or radicular pain and neurologic deficits, from myeloradiculopathy to paralysis. This report describes the occurrence of a symptomatic vertebral hemangioma during pregnancy, in order to illustrate current methods for diagnosis and treatment of these lesions when associated with spinal cord compression. The possible mechanisms by which they may become symptomatic during pregnancy are reviewed.


Neurinoma of the third, fourth, and sixth cranial nerves: a survey and report of a new fourth nerve case.

A rare case of trochlear nerve neurinoma is described. Including this case, the number of reported intracranial tumors arising from the sheaths of the third, fourth, and sixth cranial nerves is 38. By site and relationship to the nerve segment, they fall into three groups: cisternal, cisternocavernous, and cavernous. In cisternal tumors of the third and sixth nerves, paresis of the nerve hosting the tumor is the unique nerve deficit; by contrast, in those of the fourth nerve, paresis of the trochlear nerve can be absent and that of the third nerve present. In the latter tumors, a peculiar ataxic hemiparesis syndrome is produced by midbrain compression. Cisternocavernous neurinomas often cause symptoms of intracranial hypertension, while cavernous neurinomas bring about two clinical features: paresis of one or more nerves of the cavernous sinus and a clinicoradiological orbital apex syndrome. At surgery, generally cisternal neurinomas are totally removed and the nerve source of the tumor identified; in cisternocavernous and cavernous neurinomas, total removal of tumor and identification of the parent nerve have been reported in only half of the cases. In the majority of parasellar neurinomas, clinical differences can be found between those arising from the nerves governing eye movement and those arising from the gasserian ganglion.


Repositioning of the tortuous vertebrobasilar artery for trigeminal neuralgia: a technical note.

A patient with trigeminal neuralgia caused by a tortuous vertebrobasilar artery is reported. To obtain safe and certain neurovascular decompression of the trigeminal nerve, the tortuous vertebrobasilar artery was repositioned by pulling it toward the dura mater of the clivus using a synthetic vascular slip. The authors describe the technique of repositioning of the tortuous vertebrobasilar artery and its usefulness.


Implications for the pathogenesis of aneurysm formation: metastatic choriocarcinoma with spontaneous splenic rupture. Case report and a review.

We report a case of ruptured intracranial aneurysm from metastatic choriocarcinoma in a patient presenting with intracerebral hemorrhage. Operative evacuation of the hematoma with clipping of a distal right middle cerebral artery aneurysm was performed. Postoperatively, the patient developed hypovolemic shock from spontaneous splenic rupture. Histopathologic examination of the cerebral aneurysm showed choriocarcinoma invading the vessel wall. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral or subarachnoid hemorrhage in women of child-bearing age.


Cavernous angioma of the posterior fossa dura mimicking a meningioma: case report and review of literature.

A cavernous angioma of the posterior fossa dura was discovered incidentally on neuroimaging studies. The clinical and pathologic features of this lesion are described. Although it has been reported to arise in the posterior fossa and the tentorium cerebelli, we present the first case of such a malformation arising from the dura of the posterior fossa.


Benign meningioma with a short latency period following irradiation.

Meningiomas have been reported following radiation of the head, usually with a long latent interval between exposure and the diagnosis of the new tumor. We report a benign meningioma resected approximately 3 1/2 years after radiation therapy for a glioma, which represents an unusually short latent interval between radiation and new tumor growth.


The association of cervical spondylosis and multiple sclerosis.

The diagnostic and therapeutic considerations produced by the coexistence of cervical spondylosis and multiple sclerosis are complex. We have encountered six patients, affected by both multiple sclerosis and cervical spondylosis, in whom neurosurgical procedures were performed. The diagnosis of multiple sclerosis was confirmed by a combination of clinical, neuroimmunologic, electrophysiologic, and neuroradiologic findings. The diagnosis of spondylosis with spinal cord compromise was confirmed by myelography and computed tomographic scan in all cases, and by magnetic resonance imaging in four. Surgery was followed by lasting clinical improvement in two patients, transient improvement in one, and no change in the other three. Our experience confirms that multiple sclerosis and cervical spondylosis can coexist and suggests that this coexistence may result in an interaction that compounds the deleterious effect on the nervous system. Diagnostic evaluations of patients, particularly young patients, with symptoms of cervical spondylosis should include consideration of the possible coexistence of multiple sclerosis. The evaluation of a patient with known multiple sclerosis who develops new signs of cervical spinal cord dysfunction should always include spinal neuroimaging studies. When progression of symptoms coincides with documented progression of anatomic compression, surgical intervention can yield good results.


Use of propofol (Diprivan) for awake craniotomies: technical note.

We describe the use of propofol (Diprivan) to provide patient comfort during the initial stages of awake craniotomies.


Meningioma in a neonate: case report.

A 10-day-old female with a parasagittal meningioma presenting as a subcutaneous tumor is reported. Meningiomas within the 1st month of life are rare. The clinical and pathological characteristics of congenital meningioma are reviewed.


Cerebral berry aneurysms in identical twins: a case report.

A pair of identical twins in whom cerebral berry aneurysms were found is reported. One presented with epilepsy, and the aneurysm was discovered incidentally. The other presented with a spontaneous bleed, which was fatal.


Intracerebral injury following thermocoagulation of the trigeminal ganglion.

An unusual postoperative complication of percutaneous thermocoagulation of the gasserian ganglion is reported. Computed tomography and magnetic resonance imaging of the brain disclosed an intracerebral lesion following the surgical procedure. Some rare abnormalities of the skull base could increase the risk of such complications. A meticulous surgical technique with fluoroscopic and neurophysiological control is mandatory in any percutaneous procedure on the trigeminal ganglion.


Growth of a giant aneurysm following complete thrombosis by detachable balloon occlusion.

A giant basilar artery aneurysm demonstrating growth and causing neurological deterioration even after complete detachable balloon occlusion is reported. Autopsy revealed total thrombosis of the aneurysm and a hemiconcentric, onion skin-like, laminated structure. Numerous vascular channels and multiple fresh intramural hemorrhages were noted within the outer margin of the aneurysmal wall. Repeated intramural hemorrhages appeared to have been responsible for the aneurysmal laminated structure and contributed to progressive aneurysmal growth. This case demonstrates that the growth of some giant aneurysms is not dependent upon the continuity with the parent artery, and progressive enlargement cannot always be prevented by balloon occlusion.


Acute intramedullary spinal cord abscess: case report.

We report the first case of an acute pyogenic intramedullary cervical spinal cord abscess, brain abscesses and meningitis due to an unusual anerobe, Bacteroides disiens. The importance of spinal magnetic resonance imaging for establishing the diagnosis is emphasized.


A case of double-compartment hydrocephalus presenting with opisthotonus.

Double-compartment hydrocephalus, a rare shunt complication, is caused by occlusion of the aqueduct and the fourth ventricular outlets after shunting of the lateral ventricles. Dilation of the fourth ventricle causes brain-stem dysfunction and cerebellar signs. A case of double-compartment hydrocephalus presenting with opisthotonus is presented, and the relevant literature is reviewed.


Intraventricular craniopharyngioma: report of two cases and review of the literature.

Two unusual cases of purely intraventricular craniopharyngioma are presented. Both patients complained of headache as a sign of increasing intracranial pressure, but neither other neurological deficits nor hormonal disorders were present. Magnetic resonance images showed a mass lesion located within the third ventricle. Surgery confirmed that these two tumors were completely confined within the third ventricle, and histologically they proved to be squamous papillary craniopharyngiomas. Review of the literature demonstrates that craniopharyngiomas at this location have many common features and would appear to form a distinct entity.


Serial development of 'de novo' aneurysms after carotid ligation: case report.

A case demonstrating the serial development of "de novo" aneurysms following common carotid ligation is presented. Persistence of the hemodynamic changes caused by carotid ligation, proven by ophthalmodynamometry performed twenty-five years later, might be the underlying basis for the serial formation of de novo aneurysms. The need for a program of routine neuroradiological follow-up in patients undergoing carotid ligation is discussed.


Multiple spinal neurinomas presenting visual disturbance as the initial symptom: case report.

A case of multiple spinal neurinomas with visual disturbance is reported. A 63-year-old man was admitted with a complaint of progressive visual disturbance due to papilledema without spinal symptoms and signs. The neuroimaging studies demonstrated communicating hydrocephalus and two mass lesions in the cauda equina. Both tumors were found to be neurinomas. Intracranial hypertension secondary to spinal tumors is unusual, and multiple spinal neurinomas are rare. In the patient without spinal symptoms and signs, it is difficult to make a diagnosis of spinal tumor. Importance of checking for a spinal cord lesion by magnetic resonance imaging in such a case is stressed.


Endometrial carcinoma in patients aged 75 years or older: outcome and complications after postoperative radiotherapy or radiotherapy alone.

A retrospective analysis is reported of 89 patients at least 75 years old (median age 79 years) treated with irradiation for endometrial carcinoma between 1972 and 1989, the median follow-up being 39 months. In 66 patients radiotherapy was given postoperatively and in one case preoperatively, 22 patients were treated with radiotherapy alone: intravaginal insertions exclusively in 22 patients (median dose 60 Gy to the mucosa) and combined with external radiotherapy in 53 patients (median external target dose 45 Gy; three or four fields, all treated daily, 1.8 to 2.0 Gy per fraction, five fractions per week; 30 Gy to the vaginal mucosa with low-dose rate). A few patients were treated with external radiotherapy or intrauterine insertions only. 65% of the patients treated with radiotherapy alone and 34% of the patients receiving postoperative radiotherapy had FIGO stage II or III disease. Five-year actuarial overall survival and disease-free survival for all patients with adenocarcinomas treated with curative intent was 47.5% and 57.2%, respectively. In 48 patients with surgical stages I and II, treated with postoperative adjuvant radiotherapy, overall actuarial survival is 58.2% and disease-free survived 65.5% at five years. After postoperative vaginal insertions only, no vaginal recurrence occurred. With combined external and intravaginal radiotherapy in surgical stage I and II, 4/36 patients (11%) showed a recurrence in the vagina only, the abdominal and pelvic recurrence rate being 8.3%. Grade 3 to 4 late toxicity was observed in 6/53 patients (11.3%) treated with external and intravaginal radiotherapy. However, in patients receiving external radiotherapy less than 45 Gy and intravaginal radiotherapy 30 to 40 Gy, as is standard postoperative adjuvant treatment today, only one grade 3 late toxicity was observed in 17 patients (5.9%). We conclude, that treatment of elderly patients with adenocarcinoma of the uterus should follow the same pattern as in younger patients, the acute side-effects and late toxicity of radiotherapy being similar.


Clinical assessment of tumor clearance during radiotherapy as a prognostic factor of early glottic carcinoma.

From 1967 through 1985, 358 cases of early glottic carcinoma were treated with telecobalt therapy at the Department of Radiology, Osaka University Medical School. Among 278 cases treated with 2 Gy a day, the tumor response of 262 cases at 40, 50 and 60 Gy were evaluated by direct or indirect laryngoscope. The five-year local control rates of these evaluable cases of T1 and T2 glottic carcinoma were 79% and 70%, respectively. The local control rates of T1 glottic carcinoma with tumor clearance and persistence at 40 Gy were 83% (119/143) and 64% (43/67), and those of T2 cases were 86% (18/21) and 58% (18/31), respectively. The local control rates of the cases with tumor clearance and persistence at 40 Gy were same between T1 and T2 cases. The tumor clearance rates of T1 cases were significantly higher than those of T2 cases (p < 0.005). T2 glottic carcinoma had larger tumor volumes and slower tumor regression and resulted in lower control rates compared with T1 glottic carcinoma. The difference in the radiation dose of T1 and T2 glottic carcinoma with the same clearance rate was estimated as 15 Gy using logit analysis.


Ideal dose level in treatment planning optimization.

The biological response of the tumor is expressed in terms of tumor control probability (TCP) and its dependence on the inhomogeneous dose distribution throughout the tumor volume is studied. The ideal dose level to which the prescribed dose must be referred is derived, by employing a formula based on the linear quadratic model. To administer the prescribed dose to the ideal dose level renders the tumor control probability equal to that one corresponding to a uniform irradiation of the tumor. For the normal tissue irradiated a normal tissue complication probability index (NTCPI) is also defined and calculated. The comparison between NTCPIs of competing plans supports the optimization. In general the resulting ideal dose level is lower than the mean dose level, but not necessarily equal to the minimum in the tumor. This result shows the possibility of administering the prescribed dose to a dose level higher than the minimum, maintaining the tumor control probability at a good level and consequently lowering the complications to the normal tissue. The method offers a general support for the choice of the reference dose level and of the better technique. An example of application of the method is shown.


The cytoskeleton and proliferation of melanoma cells under hyperthermal conditions. A correlative double immunolabelling study.

Hyperthermia provides a potent therapeutical tool of cancer treatment, the cell biological effects of which are fairly understood. In the present study we applied hyperthermal shocks of 42 degrees C and 44 degrees C to human melanoma cells under tissue culture conditions. The integrity of the microtubular (mT) system and rate of DNA replication was assessed by indirect immunofluorescence using antibodies to tubulin as an mT marker and to BrdU as an indicator for DNA replication. Through this approach we obtained evidence that heat (44 degrees C for 60 min) exerts a profound damaging effect on the mT system accompanied by a change in the phenotypical appearance of melanoma cells. DNA replication, however, was still in progress in a significant number of heavily afflicted cells. From these data we conclude that a therapeutic regiment combining hyperthermia and mT inhibitors might prove useful in the treatment of human melanomas.


Micronucleus assay prediction and application optimized by cytochalasin B-induced binucleated tumor cells.

Improvement in the predictive assertion of the micronucleus assay was achieved by treating human malignant melanoma cells (Mewo) with cytochalasin B (CB), generating binucleated cells (BNC) representing cells after a single karyokinesis. Optimal cell binucleation was determined by testing several cytochalasin B concentrations and different incubation times. On average, 56% binucleated cells were found after incubation with 2 to 3 micrograms/ml cytochalasin B for 48 h. Cells with at least one micronucleus (Mn) were defined as fraction of cells with micronuclei and describes the degree of damaged cells. We found in binucleated cells 2.2 fold the fraction of cells with micronuclei than in mononucleated cells (MNC), as expected assuming that an induced micronucleus is associated with only one single daughter cell after mitosis. The mean of micronuclei per binucleated cells, however, was enhanced about 2.9 fold in relation to that of micronuclei per mononucleated cells and is related to the nuclear damage per cell. The application of cytochalasin B did not enhance the fraction of damaged cells although the degree of the injury per cell is intensified. A micronuclei promoting or inhibiting effect of the experimental design due to changes in cell proliferation was excluded by cytofluorometric investigations of DNA content and synthesis after cytochalasin B application. A comparison of the modified with the conventional micronucleus assay shows the superiority of the former.


Protection of mouse oesophageal mucosa against gamma rays injury.

The alterations in the oesophageal epithelium were studied in mice after a single whole-body exposure to 7.5 Gy of Co-60 gamma rays in presence or absence of 2-mercaptopropionyl glycine. The epithelium showed an increase in the thickness which reached a maximum on the third day and then decreased gradually up to seventh day after irradiation in the non-drug treated group. In the 2-mercaptopropionyl glycine treated animals the epithelial thickness remained in the normal range except on the day 7 when it was significantly lower than normal. The total cell population registered a steady decline from one to seven days post-irradiation in both groups, but the number of cells was more in the 2-mercaptopropionyl glycine treated group. The number of pycnotic nuclei showed an inverse relationship to the total cell population, it increased continuously up to seven days in both the protected and non-protected groups. However, pycnotic nuclei were significantly lower in the protected group on days 3, 5 and 7 in non-protected group.


Retroperitoneal Castleman's disease.

A case of Castleman's disease localized in the retroperitoneal space is reported. A 29-year-old patient had a mass 15 cm in diameter with radial calcification. After surgical resection, both the patient's anemia and hypergammaglobulinemia disappeared. Castleman's disease should be considered when facing a solid retroperitoneal or mesenteric mass, mainly if anemia and hypergammaglobulinemia are present. Previous reports about this unusual condition are reviewed.


Laparoscopic cholecystectomy during pregnancy in symptomatic patients.

The management of symptomatic biliary tract disease during pregnancy is controversial. Although most patients receive temporizing medical therapy, some authors have advocated a more aggressive surgical approach. We have extended this surgical approach to include laparoscopic cholecystectomy. Five women with pregnancies at 13 to 23 weeks' estimated gestational age underwent laparoscopic cholecystectomy for symptomatic cholelithiasis or acute cholecystitis between March and September 1991. No complications occurred, and the postoperative courses of all patients were unremarkable. Four patients have been delivered of healthy babies, and the fifth patient is still pregnant at the time of this report. Laparoscopic cholecystectomy appears to be a safe treatment for selected patients with symptomatic biliary tract disease during pregnancy. Further study is warranted to determine its proper role in managing this difficult clinical problem.


Granulocyte oxidative activity after thermal injury.

Alterations in granulocyte function after thermal injury have been described. We have serially studied the level of granulocyte cytosolic peroxidase activity in 23 thermally injured patients during the first 6 weeks after injury. The patients' mean age and burn size were 35.1 +/- 15.7 years and 41.6% +/- 16.8% (range, 18% to 88%), respectively. Fourteen patients had concomitant inhalation injury, and the overall mortality rate was 4.3%. Purified granulocytes were obtained from peripheral blood after red cell lysis and Ficoll-Hypaque (Pharmacia Inc., Piscataway, N.J.) gradient separation. Cells were loaded with dichlorofluorescin diacetate, and baseline fluorescence was measured by flow cytometry. After phorbol myristate acetate stimulation, fluorescence was measured again. Cells from unburned normal subjects were used as daily controls. The data are expressed as percent of stimulated control granulocyte fluorescence. Unstimulated patient granulocytes demonstrated a significantly higher baseline activity than did unstimulated controls (22.9% vs 15.4%; p < 0.05). Mean fluorescence from stimulated granulocytes was 114% of the control values (p < 0.05). Granulocytes from thermally injured patients exhibited a baseline increase in cytosolic oxidase activity, suggesting in vivo activation and a greater than normal oxidase activity after in vitro stimulation.


Lymphatic and venous examination of the ulcerated leg: a preliminary report.

It has been widely accepted that deep venous thrombosis and venous incompetence initiate a series of events resulting in various ulcerations. The role of the lymphatic system in the progression of these events has not been extensively studied. Twenty-three patients with nonarterial ulcerations of the legs were examined by phlebography and lymphangiography. All had recurrent ulcerations associated with nonpitting edema, brawny induration, and dermatitis characteristic of the postphlebitic syndrome. Arterial circulation was normal in all patients. Phlebographic abnormalities found were the presence of communicating vein incompetence in all 23 patients, varicose veins in six, and deep venous occlusion in one. Lymphatic abnormalities were also present in all patients. Extravasation in the area of the ulcer was seen in eight patients, dermal backflow in six, tortuosity and irregularity of the channels in four, and retention of contrast agent for more than 24 hours in seven. Significant abnormalities of the lymphatic system exist in patients with leg ulcers caused by the postthrombotic syndrome.


Modified anoabdominal rectal resection and colonic J-pouch anal anastomosis for lower rectal carcinoma: preliminary report.

There has recently been increasing interest in coloanal reconstruction after proctectomy for low rectal carcinoma. We describe here our pilot experience with seven patients undergoing modified anoabdominal resection of the rectum and a colonic J-pouch anal anastomosis. The procedure varied according to the extent of internal anal sphincter (IAS) resection (type a, partial resection of the upper IAS; type b, circumferential resection of the upper IAS; type c, partial preservation of the lower IAS; and type d, total resection of the IAS). None of the patients had incontinence, but preservation of the lower half of the IAS (types a and b) showed functional superiority over more extensive IAS resection (types c and d). Only patients who underwent types c and d resection needed medications to reduce stool frequency. Our results suggest that the lower half of the IAS has a more important role than the upper half in the control of defecation. Total resection of the IAS did not sacrifice continence, but preservation of at least the lower IAS resulted in a better quality of life. Careful patient selection is needed when considering the use of these procedures for tumors in the lowest part of the rectum.


Adrenal scintigraphy of well-differentiated (functioning) adrenocortical carcinomas: potential surgical pitfalls.

Adrenal scintigraphy with 131I-6 beta-iodomethylnorcholesterol (NP-59) has been widely used to evaluate adrenal cortical tumors during the past 20 years. Unilateral visualization on the side of an adrenal tumor has been considered diagnostic of a benign adrenocortical adenoma in the patient with Cushing's syndrome. Bilateral nonvisualization of the adrenal glands in the presence of Cushing's syndrome is considered diagnostic of adrenocortical carcinoma (ACC). ACCs characteristically are unable to incorporate enough NP-59 to be visualized on NP-59 adrenal scintigraphy. Two patients with well-differentiated cortisol-secreting ACCs, in which the primary tumor or subsequent metastases demonstrated intense uptake (visualization) on NP-59 scans are reported here. As a result of these findings on NP-59 adrenal scintigraphy, the lesions were initially misinterpreted to represent benign disease. In each patient the operative approach selected, based on the interpretation of the NP-59 scan, was inappropriate for the management of the respective adrenal neoplasm or its metastasis. A review of the literature reveals 16 other cases of either ACC or their metastases that were visualized with adrenal scintigraphy. Ninety percent of these cases were associated with adrenocortical hormone hypersecretion. It is concluded that in the presence of Cushing's syndrome or another adrenocortical hormone excess state, unilateral visualization of an adrenal tumor on NP-59 scintigraphy cannot be interpreted to represent uniformly benign disease.


Surgery for malignant obstructive jaundice: analysis of mortality.

Surgery on patients with malignant obstructive jaundice carries formidable morbidity and mortality rates. Clinical records of 120 consecutive patients who had a serum total bilirubin levels of 100 mumol/L or greater before exploration were analyzed retrospectively to provide guidelines for better management. Although most patients underwent bilienteric bypass to either the extrahepatic (n = 45) or intrahepatic ductal system (n = 28), resection was possible in 32 (26.7%). Complications developed in 42 patients (35%), among whome 12 (10%) required reexploration and 32 (26.7%) died within the same hospitalization. Identification of risk factors associated with hospital deaths after surgery was conducted on 84 of the 120 (group A) patients randomly selected from the entire study period. Based on multivariate analysis, age greater than 65 years, a raised serum aspartate transaminase value greater than 90 IU, and serum urea level greater than 7 mmol/L before surgery were the risk factors selected from 39 different clinical (n = 6), laboratory (n = 26), and operative (n = 7) parameters studied. The predictive value was validated in the remaining 36 patients (group B), and a high-risk patient population had been isolated. Because both serum urea and aspartate transaminase values correlated significantly with the necessity of urgent exploration, aggressive nonoperative treatment should be used to control the emergency. Alternative therapeutic options or perioperative management should be considered for the selected high-risk patients before definitive surgical biliary decompression.


Spontaneous rupture and functional state of the esophagus.

Esophageal function was investigated after 1 to 8 years in five consecutive patients surviving spontaneous esophageal rupture (Boerhaave's syndrome) and treated by suturation. Only one patient was symptom free and had almost normal esophageal function as judged by manometry, 24-hour pH monitoring, endoscopy, and barium swallow. In the other four patients reflux symptoms and a severe functional disturbance of the esophagus were observed. In four patients the manometry revealed a lack of propulsive peristaltic movements and esophageal muscular incoordination (particularly in the upper part of the esophagus) closely mimicking those seen in the nonspecific esophageal motility disorder. In 24-hour intraesophageal pH monitoring a pathologic gastroesophageal reflux with long-lasting single reflux periods was observed, suggesting poor esophageal clearance. Also endoscopic and histologic signs of reflux esophagitis were seen in the same four patients. In contrast, lower esophageal sphincter pressure was normal in all five survivors. It is concluded that patients with spontaneous esophageal rupture have a severe disturbance of esophageal motility. The concomitant reflux esophagitis may be caused primarily by the esophageal motility disturbance, which may also contribute to the origin of the rupture.


Conventional versus high-porosity polytetrafluoroethylene grafts: clinical evaluation.

In baboons, nonreinforced (unwrapped) 60 microns internodal distance polytetrafluoroethylene grafts form a complete endothelial lining within 2 weeks by capillary ingrowth through the wall. Smooth muscle cells then grow under the endothelium and proliferate to form a complete neointima. To determine if spontaneous endothelialization of these grafts can also occur in humans, 10 above-knee femoropopliteal grafts composed of equal lengths of 60 and 30 microns polytetrafluoroethylene were placed in eight patients. These grafts were reinforced (wrapped) for human use. Because biopsy of the grafts was not possible, endothelialization was assessed noninvasively by 111In-labeled platelet imaging 1 week and 3 months after surgery. There was no difference in indium uptake between 60 and 30 microns segments at either time. Histologic sections were available from 60 microns segments of two patients who underwent operation for graft thrombosis. Capillary ingrowth was seen in these grafts, but it rarely extended more than half the distance from the outside of the graft to the lumen. Smooth muscle cells were not seen on the flow surface, indicating that a neointima had not formed. These findings demonstrate that capillary ingrowth can occur in 60 microns grafts in humans but does not produce an endothelial lining. The failure to endothelialize is perhaps a result of inadequacy of angiogenesis in adult humans or retardation of capillary ingrowth by the reinforcing wrap.