Showing papers in "Canadian Journal of Surgery in 1981"

Steroid-induced osteonecrosis: a review

Abstract: Between 1963 and 1980 cortisone-induced osteonecrosis has been seen in 122 patients at the Royal Victoria Hospital, Montreal. Of these, 68 had had renal homotransplants; the others suffered from a variety of conditions. The femoral head was most commonly affected; the humeral head, distal femur, proximal tibia, talus and capitellum were also involved. There were two patterns of involvement, similar in all locations. The more common is subchondral osteolysis, which may heal without operation. The other is similar to osteochondritis dissecans and requires operation. Alteration in fat metabolism is the most likely cause of the condition. Vascular occlusion and bone death may result from an increase in fat cell size or from fat embolization. Treatment should be conservative as often as possible, but gratifying results have been obtained in those patients requiring surgical procedures.

Idiopathic necrosis of the femoral head: pathogenesis and treatment.

Abstract: The classic features of idiopathic femoral head necrosis - increased roentgenologic density, the subchondral crescent-fracture and distortion of the femoral head - are now known to be late manifestations of the disease. The early changes have been studied prospectively in 34 patients receiving corticosteroids in high dosage and 11 patients with femoral head necrosis attributed to alcohol abuse. In five patients with unilateral femoral head necrosis, intraosseous pressure studies and core biopsy were carried out on the apparently unaffected side. The earliest pathologic changes were a relative increase in cancellous bone fat at the expense of myeloid tissue, swelling and necrosis of the fat cells, and variable areas of cell death in the trabeculae. All of these were fairly widespread throughout the proximal femur. Intraosseous pressures were raised, suggesting the presence of venous stasis. Fat cell size was measured in undistorted femoral heads with osteonecrosis and in a comparable series with osteoarthritis. There was a significant (P less than 0.001) increase in fat cell size and a virtual absence of sinusoids in histologic sections from those with osteonecrosis. It is posited that idiopathic osteonecrosis results from the following sequence: fatty accumulation and replacement of myeloid tissue, followed by compression of vascular sinusoids, venous stasis, ischemia, fat necrosis and then bone necrosis. The earliest stages in this chain of events are clinically asymptomatic and produce no radiologic abnormality. The results of treatment by core decompression in 22 hips are discussed. This is an effective prophylactic measure in all early cases and it has a place even in the management of more advanced cases, especially if the patient is considered too young for hip arthroplasty.

Pathogenetic considerations in ischemic necrosis of bone.

Abstract: Many factors must be considered in the pathogenesis of ischemic necrosis of bone. Etiologic considerations deal with the heterogeneous disease categories that are associated with bone necrosis; these may affect bone circulation either directly or indirectly on either the arterial or the venous side. Moreover, the compartmental nature of bone makes it vulnerable to the direct effects of pathologic processes on the cellular elements of the intraosseous extravascular compartment. Once ischemia has been initiated, whether directly through influence on the circulatory tree or indirectly by the elevation of bone marrow pressure, the effects of ischemia are likely to be further potentiated because of the compartmental nature of bone blood flow. Once a critical level of ischemia is surpassed, it is possible that the condition becomes self perpetuating through increased bone marrow pressure leading to further ischemia. Interruption of this cycle by core decompression can be successful if extensive tissue death has not already occurred at the time of the intervention.

Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula.

Abstract: A 24-year-old man severely injured in a motor vehicle accident was found to have, on the right side, a pneumothorax, extrapleural hematoma, acromioclavicular dislocation and fracture of the first three ribs and of the transverse processes of C7 and T1. Through a right thoracotomy, transection of the right main stem bronchus and a laceration of the left main stem bronchus were discovered. These were repaired. Twenty days after admission, posterior dislocation of the clavicle at the sternum was noted. A diagnosis of tracheoesophageal fistula was made on the 32nd day but the symptoms had been sternoclavicular and acromioclavicular dislocations. At autopsy the medial end of the clavicle was found to be torn from its articular discand and locked behind the manubrium. The fistula was behind the posterior capsule between the carina and esophagus. The authors conclude that continued pressure from the displaced clavicle may have led to delayed necrosis of the esophagus and that reduction of the dislocated clavicle might have saved the patient's life.

Studies into the mechanism of reversal of experimental acute hepatic failure by hepatocyte transplantation. 1.

Abstract: The authors reported previously that single cell suspensions of syngeneic, allogeneic and xenogeneic hepatocytes can significantly improve survival in a rat model of acute hepatic failure induced by D-galactosamine. This report explores the mechanism by which hepatocyte transplantation reverses the toxin-induced hepatic necrosis. Radioautographic studies indicated that intraperitoneally administered hepatocytes labelled with tritiated thymidine did not repopulate the injured recipient liver. Hepatocytes irradiated with 10 000 rad (i.e., the cells were nonreplicating) also resulted in a significant (P less than 0.001) increase in animal survival when given to rats treated with D-galactosamine. Experiments with subcellular fractions of hepatocytes demonstrated that an intact cell was not required and that a heat stable "factor" (or factors) present in the cytosol fraction, which is not insulin or glucagon, is responsible for the increase in survival observed. This factor appears to increase the rate of endogenous regeneration of the injured recipient liver.

Appendicitis: a historical review.

Abstract: The author traces the history of appendicitis through the successive stages of its evolution--from the early anatomic descriptions of the appendix by Leonardo da Vinci and Vesalius to Louyer-Villermay's recognition of the fatal course that appendiceal inflammation may take; through the confusion of typhlitis and perityphlitis, until Reginald Fitz at the end of the last century classified its pathology and the disease appendicitis was born. The author has described the efforts of the early surgeons as they grew to understand the symptomatology of appendicitis and to realize that only by early operation could the tragic outcome of delay be averted. Credit is given to those whose contributions have advanced the frontiers of surgery-- Lawson Tait was the first to diagnose and remove a diseased appendix in 1880 in England and Abraham Groves the first on the North American continent, in 1883, in Ontario. Within a decade, the early surgical treatment of appendicitis became established. The writings of men like Charles McBurney and John B. Murphy are shown to be as pertinent today as they were at the turn of the century.

Is it important to preserve the chordae tendinae and papillary muscles during mitral valve replacement

Abstract: To evaluate the importance of preserving chordae tendinae and papillary muscles to left ventricular function after mitral valve replacement, 12 dogs had Carpentier-Edwards or Bjork-Shiley mitral valves inserted. Cardiopulmonary bypass, systemic hypothermia at 25 degrees C and cold cardioplegia were used. The period of anoxic arrest was 30 minutes. In six dogs, mitral valve replacement was performed after complete excision of the mitral valve. In the other six dogs the anterior leaflet was partially excised but all chordae tendinae and papillary muscles were left intact. Hemodynamic measurements, including left ventricular function following volume loading, were made preoperatively and postoperatively. Left ventricular angiograms were obtained postoperatively in all dogs. Preoperatively there was no significant difference in the left ventricular function curves in the two groups, but postoperatively the curves showed significant differences. In the group with preserved chordae tendinae, left ventricular function improved with volume loading to a left ventricular end-diastolic pressure of 20 mm Hg while in the group with divided chordae tendinae, function improved more slowly and ceased to improve after loading to an end-diastolic pressure of 15 mm Hg. The mean left ventricular ejection fraction following mitral valve replacement with preserved papillary muscles was 0.62 +/- 0.01 and with divided papillary muscles was 0.45 +/- 0.05 (P less than 0.05). The authors conclude that it is important to preserve chordae tendinae and papillary muscles when carrying out mitral valve replacement.

Electrical burns; pathophysiology and complications.

Abstract: The authors review the pathophysiology and complications of electrical injuries. Such injuries can be categorized into direct electrical injuries, arc burns and flame burns. Each has a distinct appearance and prognosis. Nine patients with electrical injuries were admitted to the Toronto General Hospital over the 5-year period 1973 to 1978. All were men and the average age was 33 years. Five patients required amputation. In one patient a convulsive disorder developed 3 weeks after injury. One patient demonstrated peripheral nerve injury with complete axonal lesions of the right median and ulnar nerves; there was progressive full return of nerve function over 12 months. Direct electrical injury to nerves is usually transient and return of function can be expected unless there has been a concomitant thermal or mechanical injury.

False-negative mammograms in patients with breast cancer

Abstract: Because of reports that negative mammographic findings have resulted in a delay of treatment in patients with breast cancer, the authors reviewed their experience with mammography in 160 patients, admitted to the Sir Mortimer B. Davis-Jewish General Hospital in Montreal over a 28-month period, who had histologically verified carcinoma of the breast. Of these patients 153 had clinically palpable masses and 7 had occult carcinomas. The mammogram was considered to be positive for carcinoma in 112 (73.2%) and negative in 41 (26.8%). In 44 patients under the age of 50 years the mammogram was positive in 26 (59.1%) and negative in 18 (40.9%), a significant difference (P less than 0.05). There was no significant difference between the findings of mammograms read by the hospital radiologists and those read by community radiologists. This study confirms the findings of others that mammography is not a reliable technique for evaluating the clinically suspicious breast lesion and must not be used as a substitute for biopsy of such lesions.

Surgical treatment of Wolff--Parkinson--White syndrome.

Abstract: Since 1972, 32 patients with Wolff-Parkinson-White syndrome (WPW) have been treated surgically. Nine patients presented with valvular lesions associated with WPW. Malignant ventricular arrhythmia secondary to atrial fibrillation (AF) was present in 14, and reciprocating supraventricular tachycardia in 18.

Revision of total knee replacement.

Abstract: In the London and Toronto areas between 1969 and 1978, 597 patients had 661 cemented knee replacements. Eighty-nine (13.5%) prostheses failed; 73 of them were revised. Nineteen (2.9%) failed primarily because of infection. The revised replacements were examined and rated using a modification of the British rating system. The overall results of revision were excellent or good in 30% and fair or poor in 52%. Fusion was attempted in two patients after revision. In 16 patients with failed replacements that were not revised, fusion was attempted in 9; 4 of the 16 patients had amputation. The results of failure in knee replacement surgery are similar to those of hip replacement, but are helped considerably by lower patient expectation.

Intra-aortic balloon counterpulsation in septic shock.

Abstract: Mortality in patients in septic shock remains high (50% to 80%) despite available treatment. In a 76-year-old women with hypodynamic septic shock intra-aortic balloon counterpulsation (IABC) successfully improved the hemodynamic status to the point at which the patient could maintain adequate cardiac output without assistance. The pertinent literature on experimental and clinical shock in which mechanical assistance devices were used, is reviewed. From the few clinical reports available it appears that IABC may be life-saving in those patients with hypodynamic septic shock who deteriorate despite the administration of antibiotics, steroids and vasopressors. Its value in hyperdynamic shock remains doubtful. Since the mortality associated with septic shock has not decreased despite modern management, there is justification in searching for new modalities of treatment, and the use of IABC seems most appropriate and promising.

Bilateral persistent sciatic artery with bilateral aneurysms: case report and review of the literature. ?

Abstract: Persistent sciatic artery is a rare anomaly, only 33 cases having been reported to date. A 34th case is described in this report., The patient, a 45-year-old man, had bilaterally persistent sciatic arteries with bilateral aneurysms and acute ischemia due to distal embolization. The literature regarding the embryology, incidence and the problems of diagnosis and management of this rare condition is reviewed. The authors emphasize that in cases of aneurysm formation if the sciatic nerve adheres to the aneurysm no attempt should be made to excise the aneurysmal sac.

Bronchogenic cyst presenting as a supraclavicular mass.

Abstract: Bronchogenic cyst is one of the more common congenital pulmonary anomalies. It is related to abnormal budding of the tracheobronchial tree during embryologic development. These lesions may present as a mass in the lung parenchyma in the mediastinum or within or below the diaphragm. An unusual case of bronchogenic cyst presenting as a mass in the supraclavicular fossa of a 24-year-old woman is reported. Treatment of bronchogenic cyst consists of excision of the mass. Recurrence is rare if excision is complete.

Incentive breathing devices and chest physiopathy: a controlled therapy.

Abstract: Intestinal ischemia should be suspected in any patient following aortic surgery who has pain out of keeping with the operation, postoperative diarrhea (with or without bleeding) or an unexplained metabolic acidosis. Ten such cases of intestinal ischemia were identified during a 10-year period at the Toronto General and Toronto Western hospitals. Six occurred following repair of a ruptured abdominal aneurysm, one followed elective aneurysmectomy and three followed elective bypass for occlusive disease. The overall mortality was 70%. Transmural bowel infarction was found in six patients (all died), while four patients had partial-thickness injury (one died, three had late strictures). Potentially preventable factors in each patient, either single or multiple, were identified and are discussed. Emphasis on early diagnosis is stressed, because once transmural necrosis has occurred the prognosis is poor.

Recurrent hiatal hernia: management by thoracoabdominal total fundoplication gastroplasty.

Abstract: Recurrent hiatal hernia presents a difficult diagnostic and therapeutic challenge. The authors present a series of 121 patients in whom recurrent hiatal hernia was investigated by history, radiology, endoscopy and manometry and acid perfusion testing before surgical correction by thoracoabdominal total fundoplication gastroplasty. The preoperative findings were compared with those of 238 patients who had undergone primary repair. Roentgenography was found to be less accurate in the diagnosis of anatomic recurrence than of the original hernia. Manometry and endoscopy increased the diagnostic accuracy of recurrent hernia. The thoracoabdominal approach was used to allow direct vision dissection both above and below the diaphragm. Gastroplasty minimized the risk of anatomic recurrence and allowed reflux control even in patients with an irreducible hiatal hernia. Total fundoplication, added to gastroplasty, is the most effective method of preventing reflux. There were no anatomic recurrences and no evidence of reflux in the 121 patients who had secondary repair. Two patients have required further surgery to modify the total fundoplication gastroplasty. With a 96.7% follow-up, 94.2% of the patients are considered to have excellent results.

Gastrointestinal complications in patients with acute and chronic leukemia.

Abstract: Between July 1, 1972 and June 30, 1977, 541 leukemic patients were admitted to the University Hospital in Edmonton. Eight of 11 patients who underwent emergency operation for complications of leukemia or antileukemic therapy died within 30 days of operation. Six cases are reviewed to illustrate the four basic types of gastrointestinal lesions and complications of leukemia: hemorrhagic and agranulocytic necrosis, leukemic infiltrates and fungal lesions. A fifth type which is a mixture of the four basic types was also noted. As a result of their experience and a review of the literature the authors believe that an aggressive approach, consisting of close monitoring and early laparotomy combined with vigorous supportive therapy, should be used when dealing with suspected gastrointestinal complications in leukemic patients.

Carcinoid in a rectal duplication: a unique pediatric surgical problem.

Abstract: Since 1935 at the Hospital for Sick Children in Toronto, 13 cases of carcinoid have been seen as incidental findings in the appendix, but carcinoids of the rectum have never previously been reported in childhood. The authors report a child with a rectal duplication in which this tumour was found. The rationale for local resection of the duplication with its contained carcinoid is understood in the light of the principles for treatment of intestinal carcinoids in general and carcinoids of the rectum in particular. Two years after operation the child is well without signs of local or systemic recurrence.

Abdominal aortic aneurysm in the elderly.

Abstract: Over a 20-year period, 35 consecutive patients, 78 years of age and older, underwent resection of an abdominal aneurysm. Operation was performed electively in 8 and urgently in 10 patients with intact aneurysms and in 17 patients with ruptured aneurysms. The overall mortality was 46%. The mortality for operation on intact aneurysms was 12.5% for elective resections and 20% for emergency resections. For those with ruptured aneurysms the mortality was 76.4%. The mean survival for the 19 patients who survived operation was 48.6 months. Previous cardiac disease, rupture of the aneurysm and severe blood loss increased the mortality. Age in itself is not a deterrent to resection of an abdominal aneurysm and survival after operation, as determined by life-table analysis, compares favorably with that of the general population.

Coronary artery steal secondary to coronary arteriovenous fistula.

Abstract: Coronary arteriovenous fistula in adults may be associated with angina pectoris. It has been suggested that the cause of the angina is a coronary artery steal of blood into the fistula but this has not been demonstrated. To study its hemodynamics the authors describe two cases of coronary artery fistula. They discuss the use of radionuclide angiography in this setting. The surgical technique is outlined and the use of intraoperative electrocardiographic monitoring is emphasized.

Role of needle aspiration in reducing the number of unnecessary breast biopsies.

Abstract: The accuracy of the results obtained from 2334 open breast biopsies performed during a 9-year period at Mount Sinai Hospital in Toronto are reviewed. With meticulous follow-up and the liberal use of needle aspiration, the senior author (A.A.B.) noted a progressive increase in his malignant to benign ratio, from 18% in 1970 to as high as 56% near the end of the study. In contrast, the overall hospital ratio of malignant to benign breast biopsies obtained over the same decade remained stationary at 25%. A low ratio implies unnecessary hospital admissions and biopsies, all adding to the patient's anxiety. The authors conclude that a currently acceptable malignant to benign ratio is 1 to 3 and that with the use of fine-needle aspiration the number of surgical biopsies can be reduced, minimizing patient anxiety and morbidity, and increasing the efficiency of hospital bed use.

Scapulectomy for soft tissue sarcoma.

Abstract: Between 1961 and 1978, 19 patients with primary soft tissue sarcomas were treated by resection of part or all of the scapula and musculoaponeurotic attachments. Recurrence-free survival was from 2 to 18 years (mean 10.7 years) in all six patients with a histologically low-grade fibrosarcoma and from 2.5 to 9 years (mean 4.9 years) in three of six patients with high-grade tumours. In all 12 patients the margin of resection was satisfactory. In contrast, only two of seven patients with high-grade sarcomas and gross or microscopically involved resection margins were alive 1 year after operation. Long-term salvage or cure of soft tissue sarcomas at this or other sites depends upon the histologic grade of the tumour and the feasibility of an adequately wide monobloc excision. Adjunctive measures to diminish the likelihood of local recurrence and to avoid amputation in marginal situations include intraoperative brachytherapy (with iodine-125 or iridium-192) and supplemental external radiotherapy. Recent experience with intensive multiple-agent chemotherapy indicates an appreciable reduction in the occurrence of systemic metastases from tumours with this potential.

Use of hypertension and electroencephalographic monitoring during carotid endarterectomy.

Abstract: Intraoperative hypertension and continuous electroencephalographic (eeg) monitoring were used during 42 carotid endarterectomies performed on 37 patients from 1970 to 1978. Computer spectral analysis of a majority of the electroencephalograms was also performed. Under supplemented nitrous oxide general anesthesia, elevation of the mean arterial blood pressure to 20% above the individual's preoperative mean blood pressure resulted in reversal to normal of an ischemic EEG pattern in 19% of the patients. The authors discuss the benefit of this technique. they present guidelines for patient selection and analyse the data to help the surgeon decide whether to use shunt during carotid endarterectomy.

Steroid receptors in adjuvant hormonal therapy for breast cancer.

Abstract: Using a computerized mathematical model the authors found that either a small [5%] or large [50%] hormone-dependent reduction in tumour cell population at the beginning of adjuvant chemotherapy for breast cancer greatly increases the probability fo achieving a cure. The fact that even a minor response to hormonal therapy early in the treatment of the tumor is effective underlines the importance of using estrogen receptors to to select potential responders in whom a cure is at least a strong theoretical possibility.

Computerized axial tomography to demonstrate occult fractures of the acetabulum in children.

Abstract: Following hip trauma in children an intra-articular osteocartilaginous fragment may be retained within the hip joint. This fragment may not be visualized by plain films or arthrography. However, computerized tomography clearly demonstrated such fragments in the two children with post-traumatic painful hips reported in this paper.

Primary adenoid cystic carcinoma of the esophagus.

Abstract: Primary adenoid cystic carcinoma or cylindroma of the esophagus is rare, only 22 cases having been reported previously. The histogenesis of this tumour is disputed, but it is believed to arise from the submucosal glands. A 75-year-old man with a cylindroma of the esophagus underwent radical excision of the tumour and has been clinically disease-free and asymptomatic since his operation in February 1979. Despite the poor results of surgery in the small number of patients reported in the literature, this unusual type of adenocarcinoma of the esophagus should be treated like epidermoid carcinoma--by radical excision.

Cosmesis in segmental mastectomy.

Abstract: The controversy about the best treatment for primary breast cancer will be settled only when properly designed clinical trials are completed. Most surgeons would rather await the results of such trials than participate in them. Prominent among the reasons for this view is the belief that an adequate cancer operation can seldom be performed with appropriate cosmetic preservation of the breast and, therefore, the trial of an unproven operation is not justified, because nothing can be gained. The poor cosmetic result is often owing to lack of experience with segmental mastectomy. From experience with 400 patients in the National Surgical Adjuvant Breast Project (NSABP) protocol has emerged an appreciation of the technical points that permit adequately wide local excision with minimal cosmetic loss. The results should stimulate both patients and surgeons to consider appropriate clinical trials for primary breast cancer surgery. This paper considers the causes of cosmetic failure and suggests the means of overcoming them.

Osteitis pubis: an unusual complication of herniorrhaphy.

Abstract: Osteitis pubis is a well known complication of urologic and gynecologic procedures but its association with herniorrhaphy is poorly documented in the literature. A 55-year-old man underwent herniorrhaphy for a direct inguinal hernia, followed in 48 hours by herniorrhaphy for a femoral hernia. One week later he complained of pain in the pubic area and over the ischial tuberosities, had intermittent fever and an elevated erythrocyte sedimentation rate. Roentgenograms showed changes typical of osteitis pubis with widening of the symphysis pubis, loss of definition of the adjacent cortical surfaces and involvement of the ischial tuberosities. There ws no evidence of infection in the urinary tract or elsewhere. The patient was treated with indomethacin and showed clinical and radiologic improvement over the next 6 months. It is possible that in this case two operative interventions involving structures inserting into the pubic bones and performed within a short time of each other exposed this patient to an unusual complication.

Liposarcoma: the Manitoba experience.

Abstract: In a retrospective review all cases of liposarcoma recorded in the province of Manitoba from 1944 to 1978 were studied. There were 104 patients. Follow-up was obtained in all. Sites of tumour were peripheral limb in 45 patients, limb girdle in 15, retroperitoneal area in 23 and trunk and neck in 21. Fifty-seven percent of the patients were men: the disease was most commonly found in patients aged 50 to 69 years. Initial treatment was excision in 96 patients with irradiation in 26 and chemotherapy in 6. The 5- and 10-year survival rates were 60% and 49% respectively. In those who had definitive surgery the prognosis was somewhat better, while radiotherapy had little beneficial effect. Prognosis was also related to the pathologic type; well differentiated and myxoid types had a better prognosis than round cell or pleomorphic tumours. Trunk and peripheral limb tumours were associated with higher survival rates than limb girdle or retroperitoneal neoplasms. At least 37 patients had local recurrences; distant metastases occurred in at least 26, most commonly to the lungs, bones and liver. Unusual cases consisted of a patient with a multicentric tumour involving bones, a young boy with a neck liposarcoma and a woman with a breast liposarcoma.