Showing papers in "Annals of Surgery in 1981"

Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury.

Abstract: A bilayer artificial skin composed of a temporary Silastic epidermis and a porous collagen-chondroitn 6-sulfate fibrillar dermis, which is not removed, has been used to physiologically close up to 60% of the body surface following prompt excision of burn wounds in ten patients whose total burn size covered 50--95% body surface area (BSA). Following grafting, the dermal portion is populated with fibroblasts and vessels from the wound bed. The anatomic structure of the artificial dermis resembles normal dermis and serves as a template for the synthesis of new connective tissue and the formation of a "neodermis," while it is slowly biodegraded. This artificial skin has physiologically closed excised burn wounds for periods of time up to 46 days before the Silastic epidermis was removed. At the time of election when donor sites are ready for reharvesting, the Silastic epidermis is removed from the vascularized artificial dermis and replaced with 0.004 autoepidermal graft in sheet or meshed form. Clinical and histologic experience in a relatively short follow-up period (2--16 months) indicates that "neodermis" retains some of the anatomic characteristics and behavior of normal dermis, thus promising improvement in the functional and cosmetic results, as well as providing physiologic function as a skin substitute. The artificial skin is easily sterilized and stored at room temperature, capable of large scale production, and immediately available for grafting, indicating its potential for easy and relatively economic use in the burn patient.

Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period.

Abstract: This report is concerned with the factors influencing survival in 920 consecutive patients submitted to operation for infrarenal abdominal aortic aneurysm during the past 25 years. Rupture had occurred in 60 patients (6.5%) and survival was 77%, which did not vary during the period of study. Of the 860 patients (93.5%) treated for nonrupture, 819 (95%) survived operation. The mortality rate in this group varied from 18%, in the earlier period to 1.43% , in recent years. Risk factors including heart disease, hypertension, and advanced age accounted for 95% of the deaths that occurred within 30 days however, the mortality rate in patients with these problems decreased from 19.2% to 1.9% during the period of study although the average number of patients treated each year with these risk factors increased tenfold. Improvements in operative techniques and experience were responsible for decreasing mortality up to about 1971. Subsequent decrease in mortality was due to improvements in anesthesia, monitoring, and other supportive measures during operation and the early recovery period. Complete survival information was obtained in 816 (99.6%) patients, 191 of whom had been treated for periods over 15 years. Factors influencing long-term survival were associated disease and age at time of operation. Survival in percentage in patients without associated heart disease of hypertension for 5, 10, and 15 years was 84, 49, and 21; with heart disease, it was 54, 34, and 17. The median age of patients in the series was 65.5 years and survival at above intervals according to quartile was less than or equal to 60; 71, 53, and 24; 60 less than age less than or equal to 71; 66, 38, and 18; less greater than 71; 43, 13, and 11.

Surgical management of intussusception in the adult.

Abstract: Controversy concerning the appropriate surgical management of intussusception in the adult prompted review of the Mayo Clinic's experience with this uncommon entity. During the last 23 years, 48 patients had documented intussusception: 24 instances of intussusception originating in the small intestine and 24 instances of intussusception originating in the colon. Two-thirds of the colonic intussusceptions were associated with primary carcinoma of the colon. Only one-third of the intussusceptions of the small intestine were harbingers of malignancy, and 70% of these lesions were metastatic. Because of these findings, we advocate resection of intussusceptions of the colon without initial surgical reduction, in order to minimize the operative manipulation of a potential malignancy. In the patient with intussusception of the small intestine, an associated primary malignancy is uncommon. Initial reduction, followed by limited surgical resection, is the preferred treatment. Surgical resection without reduction is favored only when an underlying primary malignancy is clinically suspected.

Principles of surgical treatment for carcinoma of the esophagus: analysis of lymph node involvement

Abstract: Extensive lymph node dissections in the posterior mediastinum and abdomen were performed during resections of esophageal carcinomas. Analysis of lymph nodes demonstrated a widespread distribution of positive lymph nodes regardless of the location of the tumor. The distribution of positive lymph nodes was noticed in the area between the superior mediastinum and the celiac region. The studies were also made on the distribution of positive lymph nodes in the superior gastric region, particularly in the region of the lesser curvature of the stomach. The following principles should be followed when carcinoma of the esophagus is surgically treated. 1) Lymph node dissection of the whole length of the posterior mediastinum, superior gastric region, and celiac region must be performed. 2) Total thoracic and abdominal esophagectomy with resection of the proximal lesser curvature and cardia, including the first to fourth branches, and preferably the fifth branch of the left gastric artery, is mandatory in order to remove possible lymphatic and intramural spread of tumors. 3) Satisfactory esophageal replacement in one stage must follow. Of the Toranomon Hospital, 210 underwent resections and reconstructions, for a resectability rate of 59.3%. The operative mortality rate was 1.4% and the overall five-year survival rate was 34.6%.

Secondary femoropopliteal reconstruction.

Abstract: Retrospective analysis of the authors' experience with 109 primary femoropopliteal bypass vein grafts that failed allows description of three distinct modes of failure Within 30 days of surgery, failure resulted primarily from technical or judgmental errors The development of stenotic lesions within the vein graft caused a second group of failures during the first year after bypass The third group most commonly failed due to progression of peripheral atherosclerosis a year or more following original bypass No correlation was found, however, between the mode of failure and results of secondary femoropopliteal-tibial reconstruction, which yielded an overall 50% five-year cumulative limb salvage rate The results indicate that this salvage rate can be anticipated regardless of the number of secondary operations required The highest long-term patency rate was achieved when frequent postoperative follow-up examinations allowed recognition of graft failure prior to total occlusion Under such circumstances a simple vein patch of stenotic lesions yielded an 85% five-year graft patency Following actual thrombosis, however, the highest five-year patency rate was achieved when reconstruction was performed using a new vein graft; saphenous vein and arm vein were equally effective When prosthetic material was used, no secondary graft remained patent beyond three years Finally, when a proximal or distal portion of the original vein graft proved adequate in caliber following thrombectomy, it could be successfully incorporated in a secondary reconstruction with the expectation of a 50% five-year limb salvage rate No statistically significant difference was found in salvage rates among each of the patient groups representing the three common modes of graft failure This finding, coupled with an acceptable 25% operative mortality rate, provides justification for an aggressive approach toward secondary femoropopliteal reconstruction

A multifactorial analysis of melanoma: III. Prognostic factors in melanoma patients with lymph node metastases (stage II)

Abstract: Twelve prognostic features of melanoma were examined in a series of 185 patients with nodal metastases (Stage II), who underwent surgical treatment at our institution during the past 20 years. Forty-four per cent of the patients presented with synchronous nodal metastases (substage IIA), 44% of the patients had delayed nodal metastases (substage IIB), and 12% of the patients had nodal metastases from an unknown primary site (substage IIC). The patients with IIB (delayed) metastases had a better overall survival rate than patients with IIA (synchronous) metastases, when calculated from the time of diagnosis. These differences could be explained on the basis of tumor burden at the time of initial diagnosis (microscopic for IIB patients versus macroscopic for IIA patients). Once nodal metastases became evident in IIB patients, their survival rates were the same as for substage IIA patients, when calculated from the onset of nodal metastases. The survival rates for both subgroups was 28% at five years and 15% for ten years. Substage IIC patients (unknown 1 degrees site) had better five-year survival rates (39%), but the sample size was small and the differences were not statistically significant. A multifactorial analysis was used to identify the dominant prognostic variables from among 12 clinical and pathologic parameters. Only two factors were found to independently influence survival rates: 1) the number of metastatic nodes (p = 0.005), and the presence or absence of ulceration (p = 0.0019). Additional factors considered that had either indirect or no influence on survival rates (p > 0.10) were: anatomic location, age, sex, remission duration, substage of disease, tumor thickness, level of invasion, pigmentation, and lymphocyte infiltration. All combinations of nodal metastases were analyzed from survival differences. The combination that showed the greatest differences was one versus two to four versus more than four nodes. Their five-year survival rates were 58%, 27% and 10%, respectively (p < 0.001). Ulceration of the primary cutaneous melanoma was associated with a <15% five-year survival rate, while nonulcerative melanomas had a 30% five-year survival rate (p < 0.001). The combination of ulceration and multiple metastatic nodes had a profound adverse effect on survival rates. While tumor thickness was the most important factor in predicting the risk of nodal metastases in Stage I patients (p < 10(-8)), it had no predictive value on the patient's clinical course once nodal metastases had occurred (p = 0.507). The number of metastatic nodes and the presence of ulceration are important factors to account for when comparing surgical results, and when analyzing the efficacy of adjunctive systemic treatments.

Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications.

Abstract: The acute replacement of full-thickness abdominal wall has been facilitated by polypropylene mesh (Marlex) (PPM), allowing debridement of nonviable tissue and restoration of abdominal wall integrity without tension. However, no substantial long-term follow-up has been reported on the definitive wound coverage after the use of PPM in open wounds. Since 1976, we have placed PPM in 31 patients; 25 for infectious complication, three for massive bowel distension preventing abdominal closure, and three for shotgun wounds with extensive tissue loss. In 29 of 31 patients, the mesh was placed in heavily contaminated wounds; extensive fasciitis was present in 23 patients and 21 had intra-abdominal abscesses. Following mesh placement, 23 reoperations were required for continuing complications. No patients eviscerated, despite these multiple procedures. Polypropylene mesh was highly effective in restoring abdominal wall continuity. Despite advantages when PPM was used, significant long-term problems developed. Seven patients died from their primary illness in the postoperative period. Nine wounds were closed by granulation and subsequent split-thickness skin grafts. All nine developed mesh extrusion and/or enteric fistulae. Nine wounds healed by secondary intention, six developed enteric fistulae or continuing mesh extrusion. Full-thickness flap coverage after granulation provided the best means of wound closure. Polypropylene mesh had significant early advantages for providing abdominal wall integrity even in the presence of severe infection. However, long-term problems were common when wounds were closed to skin grafts or secondary intention. If the mesh cannot be completely removed, strong consideration should be given to myocutaneous flaps for coverage after the primary illness has resolved.

Mathematic coupling of data: a common source of error.

Abstract: The relationship between two variables may be mathematically coupled if either one or both variables are derived and/or calculated, and this can lead to erroneous results and invalid conclusions. The purpose of this report is to identify four types of mathematic coupling of data. Type 1 coupling involves directional changes in two variables which are mathematically coupled. Type 2 coupling is the functional relationship between two calculated variables which have one or more common component variables. Type 3, the most common type of mathematic coupling, is direct algebraic coupling between two variables, when one or more of the variables is derived and/or calculated. Type 4 is indirect coupling or physiologic coupling. The common problem in each type of mathematic coupling is that one variable either directly or indirectly contains the whole or components of the second variable. Statistical techniques, when properly applied to the relationship between the two variables, further obscure the underlying mathematic coupling, and tend to support the erroneous results. Recognition of mathematic coupling is imperative for correct data analysis and accurate interpretation.

Bacterial adherence to surgical sutures. a possible factor in suture induced infection

Abstract: Surgical sutures are known to potentiate the development of wound infection. The purpose of this study was to investigate whether the capability of bacteria to adhere to various types of sutures has a significant effect on their ability to cause infections. Bacterial adherence to sutures was quantitatively measured using radiolabeled bacteria. In vitro adherence assays revealed remarkable variations in the affinity of bacteria to the various sutures: nylon bound the least bacteria while bacterial adherence to braided sutures (silk, Ti-cron, Dexon) was five to eight folds higher. The degree of infection obtained in mice in the presence of different sutures nicely correlated with their adherence properties. The different removal rate of adherent bacteria (glutaraldehyde-fixed) from various sutures by the tissue factors in mice supports the hypothesis that bacterial adherence to suture materials plays a significant role in the induction of surgical infection. Our observation points out at the need for careful suture selection in contaminated wounds. The adherence properties of sutures should be considered in any future surgical suture design.

Nonfunctioning islet cell tumors.

Abstract: In nonfunctioning islet cell tumors of the pancreas, hormone production is not clinically evident. This type of tumor constituted 15% of all islet cell tumors seen at the Mayo Clinic from 1960 through 1978. Although identical to functioning islet cell tumors embryologically and histologically, the nonfunctioning tumors differ in presentation, location, size, and rate of malignancy. At admission to the hospital, patients often have pain or jaundice due to a large, solid, solitary lesion that occurs most commonly in the head of the pancreas. Extended survival is not excluded by the high malignancy rate (92%) of these slow-growing tumors. The survival rates at three and five years were 60% and 44%, respectively, even though most patients had metastatic disease at the time of exploration.

Operative and nonoperative management of esophageal perforations.

Abstract: During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).

Prognostic factors in bile duct carcinoma: analysis of 96 cases.

Abstract: A computerized analysis of prognostic variables was performed in 96 proven cases of extrahepatic bile duct carcinoma treated over a 24-year period at UCLA. Forty-nine percent of the lesions were in the upper third of the bile ducts and 47% of these were resected, for an operative mortality rate of 23% and a maximum survival rate of 4.5 years. Palliative procedures in this region were associated with a 16% mortality rate and maximum survival rate of three years. The patients whose lesions were in the middle third suffered no operative mortality rate for resection or palliation and had a 12% five-year survival rate, with the longest survivor lasting 11 years. In the lower third lesions, 67% were resected by Whipple's procedures, for an 8% mortality rate and a five-year survival rate of 28% extending to nine years. Resection of these difficult carcinomas offers the best hope of survival but must be weighed against the high operative mortality risk in those lesions located in the hilar region.

Pancreatic duct drainage in 100 patients with chronic pancreatitis.

Abstract: Although the development of islet cell autotransplantation has focused attention on extended resections of the pancreas, drainage of a dilated pancreatic duct remains an effective means of relieving intractable pain of chronic pancreatitis. Between 1954 and 1980, 98 men and two women with chronic pancreatitis were treated for pain with ductal drainage. All patients had a history of chronic alcoholism. Pancreatic calculi were found in 68 patients. Operative procedures include: seven caudal pancreaticojejunostomies, 42 longitudinal pancreaticojejunostomies, and 54 side-to-side pancreaticojejunostomies. Two caudal pancreaticojejunostomies were converted to longitudinal pancreaticojejunostomies, and one longitudinal pancreaticojejunostomy required revision. The operative mortality rate was 4%. Follow-up studies, lasting up to 24 years, were conducted for all but seven patients. Eighty per cent of these patients have had substantial improvement or complete resolution of their pain. Diabetes, as evidence by an elevated fasting blood sugar level, was present prior to operation in 30% of the patients, and developed after operation in 14%. Only nine of 21 insulin-dependent diabetics in this series did not require insulin prior to pancreaticojejunostomy. Pancreatic enzyme replacement was needed for control of steatorrhea in 18 patients. Four patients with continued pain underwent total or near total pancreatectomies. Three of these patients died of uncontrolled diabetes. Only one patient with a drainage procedure alone has died of uncontrolled diabetes. In patients with dilated pancreatic ducts, pancreaticojejunostomy is a safe, reliable means of providing pain relief, with minimal loss of endocrine and exocrine function.

Gallstone Pancreatitis: Biliary Tract Pathology in Relation to Time of Operation

Abstract: During a 29-month trial, 65 patients with acute gallstone pancreatitis were randomly selected for biliary tract explorations either within 73 hours of admission (36 patients) or at three months following remission with nonoperative measures (29 patients, with five others awaiting elective operation). The details of surgery were identical, i.e., cholecystectomy, transduodenal sphincteroplasty, and pancreatic duct septotomy. Major bile ducts were cleared of stones by Fogarty catheter passage up the sphincteroplasty. At early operation, pancreatitis was in the acute edematous form in 29 patients, necrotizing in six, and hemorrhagic in one. Acute inflammatory changes were also noticed in three patients who underwent late operation. The locations of the gallstones in patients undergoing early versus delayed operations were, respectively: 97% and 100% in gallbladder, 75% and 28% within common or hepatic ducts (p < 0.02), and 31% and 0% free in duodenum (p < 0.01). The distal choledochus and ampulla were inflamed in 89% of the patients who underwent early operations, but in merely 17% operated upon electively (p < 0.01). Concomitant acute cholecystitis was present in 31% of the patients if surgery was performed during the initial admission, but in only 3% of the patients at delayed operation (p < 0.05). Most striking was the sudden "gush" of pancreatic juice when the ampullary sphincter was first stretched or cut during sphincteroplasty at early operation. Precipitous falls in serum amylase levels then followed over the next 24 hours. No significant differences were noticed in the mortality rate (one death after early operation, two after a delayed procedure), major morbidity rate (in four and three patients, respectively), or in duration of the initial hospitalization period (early operation: 13.5 days, delayed operation: 16.7 days). However, a second admission to the hospital for the delayed operation (12.1 days) was avoided by early operation. These data support the concept that biliary pancreatitis is probably initiated by gallstone passage through, or lodgement at, the ampulla of Vater. The resultant ampullary edema with or without gallstone impaction appears to be the anatomic cause for major pancreatic duct obstruction and the consequent pancreatitis. Early and appropriate surgical relief of the biliary tract pathology via a transduodenal sphincteroplasty can obviate the need for a second admission to the hospital without increasing, significantly, the attendant morbidity and mortality rates.

Axillary micro- and macrometastases in breast cancer: prognostic significance of tumor size.

Abstract: Recurrence and survival data at 10 years were examined for 147 women with single axillary lymph node metastases found in a modified radical or standard radical mastectomy. The cases were identified through a review of all patients with primary operable breast cancer treated at Memorial Hospital from 1964 to 1970. The patients were stratified into groups according to size of the primary tumor and of the metastatic deposit (micro less than or equal to 2 mm; macro greater than 2 mm) as well as level of the positive node. In the entire series, there was a significantly poorer prognosis among those patients with single macrometastases (30/77 patients; 39% recurrence rate) when compared with those having micrometastases (17/70 patients: 24% recurrence rate). A major prognostic difference emerged after stratification by tumor size. Within the first six years of the follow-up period, T1 patients with negative nodes and those with single micrometastases had similar survival curves, significantly better than those with macrometastases. However, at 12 years, the survival rats of those patients with either a micro- or macrometastases was nearly identical, and significantly worse than for those patients with negative lymph nodes. On the other hand, among women with primary tumors 2.1-5.0 cm (T2), patients with negative lymph nodes or single micrometastases had survival curves that did not differ significantly throughout the course of the follow-up period. Both had an outcome significantly better than observed for patients with macrometastases. These findings have important implications for our understanding of the clinical behaviour of breast cancer and for the stratification of patients entered into randomized treatment trials.

Management of acute full-thickness losses of the abdominal wall.

Abstract: Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.

Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures.

Abstract: In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583 or 86% of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at five years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at five years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at five years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at two years. Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.

Predictors of recurrence in stage I (T1N0M0) breast carcinoma.

Abstract: A ten-year follow-up study of 382 women with Stage I (T1N0M0) breast carcinoma revealed recurrence and/or death due to cancer in 16% of the patients. Among 134 patients (35%) with a primary tumor 1.0 cm or less in diameter (Group A), 7% had recurrences and 5% died of breast carcinoma. Recurrences were observed in 21% of the 248 women with a tumor 1.1-2.0 cm in diameter (Group B), and 15% died of disease. These differences in recurrence and mortality rates were statistically significant. All recurrences were due to infiltrating duct or lobular carcinoma which accounted for 91% of the 382 carcinomas. Most strongly linked to recurrence was the finding of tumor emboli in lymphatics of the breast. This was found in 23 Group B patients and ten of them (43%) died of disease. No recurrences were observed among the seven Group A patients with lymphatic emboli. Other features associated with a significantly increased risk of recurrence were poorly differentiated carcinoma, marked lymphoid reaction to tumor, and menarche before age 12 years or after age 14 years. No combination of variables proved to identify a subset of patients with an especially increased or low risk of recurrence. Stage I patients with lymphatic tumor emboli in the breast surrounding a carcinoma 1.1-2.0 cm in diameter have a sufficient risk for recurrence to warrant consideration of adjuvant systemic therapy. A very low risk of recurrence was observed for the following: any tumor 1.0 cm or smaller; and tubular, medullary or colloid carcinoma up to 2.0 cm.

Malignant melanoma. Prognostic significance of "microscopic satellites" in the reticular dermis and subcutaneous fat.

Abstract: A review of the microscope slides of the primary tumors for 596 patients with clinical Stage I melanoma revealed that primary lesions displayed two distinct patterns of invasion: 1) single cell invasion with direct extension of the main body of tumor into the reticular dermis or subcutaneous fat, and 2) invasion with "microscope satellites" (ie discrete tumor nests greater than 005 mm in diameter, that were separated from the main body of the tumor by normal reticular dermal collagen or subcutaneous fat) The five-year disease free survival rate for 95 patients with "microscopic satellites" was 36% +/- 6% This is in contrast to a five-year disease free survival rate of 89% +/- 2% for 501 patients without these satellites (p = 43 x 10(-29), generalized Wilcoxon test) "Microscopic satellites" (present vs absent) was comparable to histologic ulceration in its additive prognostic effect of tumor thickness (Breslow)

Surgical Management of Congenital Coronary Artery Fistulas

Abstract: Congenital fistulas are the most common of the coronary arterial malformations and with the widespread use of selective coronary arteriography are being recognized with increasing frequency. Twenty-eight patients with congenital coronary fistulas have been evaluated at the Duke University Medical Center between 1960 and 1981. An additional 258 patients have previously been reported in the literature, making a total of 286 available for review. The right coronary artery is most commonly involved, and the fistulous communication is most often to the right ventricle, right atrium or pulmonary artery. Slightly more than half of the patients with coronary fistulas are symptomatic at the time the diagnosis is made. Surgical correction is strongly recommended to prevent the development of congestive heart failure, angina, subacute bacterial endocarditis, myocardial infarction, and pulmonary hypertension, as well as coronary aneurysm formation, with subsequent rupture or embolization. There were no operative or late deaths in the patients who underwent operations. Moreover, there have been no recurrent fistulas during a mean follow-up period of ten years. The risks of operative correction appear to be considerably less than the potential for development of serious and potentially fatal complications, even in asymptomatic patients.

Central venous catheterization for parenteral nutrition.

Abstract: To define the risks associated with central venous catheterization for total parenteral nutrition (TPN) 3291 patient days of this therapy, delivered by an established nutrition support team, were evaluated. One hundred and seventy-five catheters placed in 104 patients were reviewed over an 18 month period. Positive cultures were reported on 11 cannulae for a 6.4% incidence of colonization; five catheters (2.8%) were considered septic. Pleural or mediastinal complications of subclavian or internal jugular venipuncture occurred in eight patients (4.8%). Misdirection of the catheter tip occurred in 11.5% of insertions. Five patients (4.8%) had clinically apparent thrombosis in the superior vena cava, innominate and/or subclavian veins during hospitalization; four others had evidence of thrombosis at autopsy examination, giving an incidence of 8.7% in the entire series. No death directly resulted from the use of this therapy. Compliance with a rigid protocol by an experienced team can allow safe and effective use of central venous catheters and parenteral nutrition therapy.

Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (Doppler and fluorescein) compared with standard clinical judgment.

Abstract: Two adjuvant techniques for the intraoperative assessment of small intestinal viability were compared with standard clinical judgment in a prospective, controlled study of 71 ischemic bowel segments in 28 consecutive patients operated on for acute intestinal ischemic disease. Each segment was independently assessed 15 minutes after surgical correction of the underlying lesion by: 1) standard clinical judgment; 2) Doppler-detected pulsatile mural blood flow; and 3) fluorescein ultraviolet fluorescence pattern. Viability endpoint for each segment was determined objectively by patient follow-up or "blinded" microscopic evaluation of histologically unequivocal resection specimens using criteria established by previous animal studies. Seventeen histologically equivocal specimens were excluded from the final results. Standard clinical judgment proved moderately accurate overall (89%) but would have led to a relatively high rate (46%) of unnecessary bowel resection. The Doppler technique did not increase accuracy in any category of evaluation. The fluorescein fluorescent pattern was correct in all 54 determinant bowel segments, and proved more sensitive specific, predictive, and significantly more accurate overall than either standard clinical judgment or the Doppler method. This controlled study suggests that the fluorescein technique is the method of choice for the prediction of small intestinal recovery following ischemic injury.

Lack of correlation between activated clotting time and plasma heparin during cardiopulmonary bypass.

Abstract: The activated clotting time (ACT) with a Hemochron system for determining heparin requirements during cardiopulmonary bypass surgery, (CPB) accompanied by hemodilution and hypothermia was evaluated using plasma heparin levels as a standard. In 28 patients who were administered a standard heparin regimen (300 units/kg prebypass, 8000 units in the pump prime and 100 units/kg hourly during CPB) mean prebypass plasma heparin was 4 units/ml, and ACT was 493 seconds. During CPB mean plasma heparin decreased significantly (p < 0.001) to 3.1 units/ml, whereas mean ACT increased significantly (p < 0.001) to 674 seconds. The mean protamine requirement predicted from ACT was significantly higher (43%) than predicted from plasma heparin levels or actual protamine administered. The ACT neither accurately reflected plasma heparin during CPB nor predicted protamine requirements. The fixed-dose regimen employed, however, prevented both intraoperative thrombosis, assessed clinically in all patients, and clotting on six arterial line filters, as determined by scanning EM, despite wide variations in ACT and plasma heparin levels during surgery.

Diagnosis of thrombosis by catheter phlebography after prolonged central venous catheterization.

Abstract: Sixty central venous catheterizations in 53 patients were prospectively studied with respect to phlebographic findings after prolonged parenteral nutrition. Phlebography was performed by a special technique on completion of the intravenous therapy. Under fluoroscopic control, the central venous catheter was slowly removed, while simultaneously contrast medium was continuously injected through it. Two types of thrombosis were demonstrated--sleeve thrombosis, on 25 occasions (42%), and mural veno-occlusive thrombosis, on five occasions (8%). On removal of the catheter the sleeve thrombosis peeled off the catheter and in several cases it was noticed that parts of the sleeve thrombus or the entire sleeve became detached and were carried away with the blood flow. Although the sleeve thrombus seldom gave rise to any symptoms, this type of thrombosis is of great importance in view of the risk of pulmonary embolism, especially in connection with removal of the catheter. With use of the described phlebographic technique thrombi of this type can be visualized.

Use of Demineralized Allogeneic Bone Implants for the Correction of Maxillocraniofacial Deformities

Abstract: Two major problems in maxillocraniofacial surgery are the limited amount of fresh autogenous bone, the standard material for bone grafting, and the resorption of the grafted bone. Experimental studies with demineralized, devitalized bone matrix have shown induction of endochondral ossification. Fifty-five demineralized allogeneic implants have been used in 44 patients over the past two years for a variety of congenital (n = 37) and acquired (n = 7) defects. The allogeneic bone was obtained from cadavers, prepared as powders, chips or blocks, and was demineralized. After having been sterilized by irradiation, they were used to augment contour, fill defects, or construct bone within soft tissue. Of implanted sites that could be evaluated by physical examination, 31 of 31 were solid by three months. By radiographic examination three of 19 were healed by three months, and an additional 11 were positive by six months. Induced bone was seen in four of four biopsy specimens. Infection occurred in four of 44 patients (9%), comparable with conventional grafts. Implant resorption occurred in four instances. Allogeneic demineralized implants offer several advantages over conventional bone grafting, such as avoidance of a harvesting operation, ease of manipulation, and potentially unlimited material in banked form. In addition, healing by induced osteogenesis may bypass the resorption seen with healing of mineral-containing grafts.

Carotid artery disease following external cervical irradiation.

Abstract: A retrospective study of 910 patients surviving at least five years after cervical irradiation for Hodgkin's disease, non-Hodgkin's lymphoma, or primary head an neck neoplasms showed the incidence of stroke following cervical irradiation was 63 of 910 patients (6.3%) during a mean period of observation of nine years. This represents a trend toward an increased risk for this population observed over the same period of time (p = 0.39). A prospective study of 118 similar patients currently living five years after cervical radiotherapy was performed to determine the incidence of carotid artery disease occurring as a consequence of neck irradiation. Abnormal carotid phonangiograms (CPA) were found in 25% of the patients and abnormal oculoplethysmographs (OPG) were found in 17%. These studies represent significant carotid lesions that are not expected in such a population. It is concluded that the carotid stenoses demonstrated are most likely a consequence of prior irradiation. Patients that are five-year survivors of cervical irradiation should have noninvasive vascular laboratory studies performed as part of their routine follow-up examinations in order to detect these carotid lesions while they are occult.

The Risk of Sepsis in the Asplenic Adult

Abstract: The risk of postsplenectomy sepsis in children is well established. The risk of sepsis following splenectomy in the adult remains unknown. This study provides data on this important subject. All adults (ages 16--91) who underwent splenectomies in three hospitals of the Louisiana State University Medical Center between 1965 and 1975 were identified. There were 298 patients included in the study. Postsplenectomy information was collected on 256 patients. The mean period of observation was 45 months (960 patient years). There were seven deaths from fulminant sepsis (incidence rate: 2.7%). Data were collected on 250 patients who had either a gastrectomy or cholecystectomy without splenectomy. The mean period of observation was 61 months (1270 patient years). There were no deaths due to fulminant sepsis (p less than 0.05). When postsplenectomy sepsis was compared with the risk of sepsis in the population at large (0.001%), the difference is significant (p less than 0.001). In the subgroup of 69 patients with hematologic or malignant disease, there were three deaths from sepsis (4.3%). In 187 patients with no underlying diseases, four patients developed sepsis, which is an incidence of 2.2% (p less than 0.05 when compared with the population at large and control group). The risk of sepsis appears to be greater in patients with chronic disease, but has no relationship to age. These data speak for the conservation of splenic tissue when possible.

Release of cholecystokinin in man: correlation of blood levels with gallbladder contraction.

Abstract: Although it is generally assumed that release of cholecystokinin (CCK) is the chief mechanism by which a fatty meal causes contraction of the gallbladder, measured release of CCK and gallbladder contraction have never been correlated. We have achieved this correlation in eight adult male volunteers, by means of a specific radioimmunoassay for CCK and by ultrasonographic imaging of the gallbladder. This study validates our CCK radioimmunoassay and correlates measured concentrations of CCK with changes in gallbladder size measured by ultrasonographic examination. Basal concentrations of CCK (82.6 +/- 10.4 pg/ml) rose significantly to a maximum of 411.1 +/- 79.9 pg/ml at 16 minutes after intraduodenal instillation of medium-chain triglyceride (Lipomul). Mean basal volume of the gallbladder was 34.6 cm3; maximum reduction of gallbladder volume (to one-third of original) was achieved at 18 minutes. Elevated CCK concentrations began to fall toward basal, and the gallbladder began to refill at 25 minutes. Results obtained after oral ingestion of Lipomul provide similar results. Linear regression analysis demonstrated excellent correlation between concentrations of CCK and gallbladder size during both contraction and relaxation phases. Future study of this correlation may be useful in patients with manifest dysfunction of the gallbladder, as well as in individuals known to be at risk of gallbladder disease.

Fatal myocardial infarction following carotid endarterectomy: three hundred thirty-five patients followed 6-11 years after operation.

Abstract: Routine coronary angiography has been recommended to all patients undergoing carotid endarterectomy at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization as a staged or combined procedure in conjunction with carotid endarterectomy in an attempt to reduce the incidence of fatal myocardial infarction during the postoperative period, and during the late follow-up interval. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 95% of 335 consecutive patients who underwent carotid endarterectomy between 1969 and 1973. Fatal myocardial infarction accounted for 60% of early deaths within 30 days of operation and occurred in 1.8% of the entire series. Among the patients who survived operation, the five-year mortality rate was 27%, and the 11-year mortality rate was 48%. Myocardial infarction caused 37% of the deaths that occurred within five years after operation and 38% of the deaths that have occurred within 11 years. Differences in the incidence of fatal myocardial infarction within five years after operation between a group of 116 patients who had no clinical evidence of CAD and a group of 209 patients suspected to have CAD attained statistical significance (p less than 0.1) despite the fact that 67 patients suspected to have CAD eventually underwent myocardial revascularization. Improvement in actuarial survival (p less than 0.05) and reduction in the late mortality rate (p less than 0.01) were statistically significant for the subset of patients with suspected CAD who had aortocoronary bypass graft procedures.