LTP, NMDA, genes and learning

PURPOSE: To describe the results of strabismus surgery on three patients with chronic progressive external ophthalmoplegia, a group of rare disorders characterized by ptosis and slowly progressive ophthalmoparesis that has been shown to result from defects in mitochondrial DNA. METHODS: Strabismus surgery using the adjustable suture technique was performed in three patients with strabismus and chronic progressive external ophthalmoplegia confirmed by clinical, biochemical, histopathologic, and genetic criteria. All three patients had mitochondrial DNA deletions. Two patients were exotropic; one patient was esotropic. RESULTS: Rectus muscle recessions were initially unsuccessful in correcting strabismus in one patient, although a subsequent procedure employing rectus muscle resections was successful in alleviating a significant head turn and improved ocular alignment. In the two other patients, a single procedure consisting of rectus muscle recessions combined with large rectus muscle resections successfully achieved good postoperative alignment. The amount of surgery performed in these three patients exceeded that predicted in standard strabismus tables. CONCLUSIONS: The myopathic process that results in chronic progressive external ophthalmoplegia renders rectus muscle recessions less effective compared with resections for correcting the associated strabismus seen in these patients. Rectus muscle resections therefore should be an integral procedure in the surgical management of the strabismus associated with chronic progressive external ophthalmoplegia.     

Indications and outcomes of strabismus repair in visually mature patients

OBJECTIVE: To identify and examine the indications, outcomes and potential risks of strabismus surgery in visually mature patients. DESIGN: Case series. SETTING: University-based referral practice in Edmonton. PATIENTS: A total of 222 patients (115 females and 107 males) aged 9 to 69 (mean 29) years who underwent strabismus surgery for various types of strabismus (as grouped by original diagnosis). All patients were followed for at least 6 weeks postoperatively. OUTCOME MEASURES: Previous surgery and deviation in prism dioptres (delta) (distance and near), sensory status (measured by the Titmus stereotest at near) and the presence of symptoms (diplopia, abnormal head posture or asthenopia), recorded preoperatively, 6 weeks postoperatively and at the last postoperative visit. RESULTS: The patients were followed for an average of 14 months postoperatively. At the last postoperative visit 187 patients (84%) were aligned to within 15 delta of orthotropia. Overall, 116 patients (52%) demonstrated some degree of stereopsis postoperatively, compared with 78 (35%) preoperatively. A total of 116 patients (52%) had symptoms preoperatively, including diplopia, abnormal head posture or asthenopia; 88 (76%) of the 116 had complete resolution of their symptoms. Six patients (4%) without diplopia preoperatively were found to have this symptom postoperatively. CONCLUSIONS: The findings suggest that most visually mature patients under-going strabismus surgery can expect functional benefits, including improvement of alignment, preservation and occasionally restoration of sensory fusion, and elimination of diplopia, abnormal head posture and asthenopia.     

Bicycle helmet use among American children, 1994

The authors tested preoperatively and postoperatively for binocularity in a series of 29 adults who underwent surgery for long-standing concomitant strabismus. The authors used Bagolini lenses, troposcope and Worth's lights as the tests for binocularity. The patients in whom the postoperative deviation was greater than 10 prism diopters from orthotropia were excluded. Binocularity was not find at any patient before surgery. The authors made a finding of binocularity after strabismus surgery in 14% of patients, in spite of satisfactory parallel ocular alignment in 52% of patients. The results of development of binocularity after strabismus surgery in adults were not as good in this series as the other authors found.     

Effects of external orbital radiotherapy on the oculomotor muscle in Graves disease

PURPOSE: Orbital radiotherapy is recognised to be effective in the treatment of acute Graves' disease. The effect on the oculomotor muscles is still controversial. MATERIAL AND METHODS: To assess this effect, we conducted a prospective study on 15 patients with acute Graves' ophthalmopathy. Patients were investigated before radiotherapy, 3 months later and at long term (mean = 2 years). To study the extent of the ophthalmopathy we chose the following criteria: class IV in the NOSPECS classification system, amplitude of gaze, measurement of the thickness of oculomotor muscles (CT-scan). RESULTS: Improvement of the amplitude of gaze and reduction of the thickness of oculomotor muscles were not statistically significant. The oculomotor disorder was unchanged 3 months after radiotherapy. After a long term follow up (mean: 2 years), only 5 patients, among those who complained of diplopia before radiotherapy, had to be operated, especially large deviations. CONCLUSION: Orbital radiotherapy does not appear as a direct treatment for oculomotor disorder in active thyroid related ophthalmopathy, however favorable indirect effects may be effective due to reduction of inflammation. As it is a harmless treatment, orbital radiotherapy may be proposed as primary treatment in active thyroid related ophthalmopathy.     

Avoiding complicated shunt systems by open fenestration of symptomatic fourth ventricular cysts associated with hydrocephalus

BACKGROUND: The effect of thyroid orbitopathy on intraocular pressure (IOP) remains controversial. We carried out a study to determine the effect of orbital decompression surgery on the IOP in patients with advanced thyroid orbitopathy. METHODS: The records of 12 consecutive patients (22 eyes) who underwent decompression surgery for severe thyroid orbitopathy between 1985 and 1996 were reviewed. All patients were maintained on essentially the same medications before and after surgery. The IOP readings, obtained by means of applanation tonometry in primary gaze, from the pre- and postoperative visits were recorded, and the net change was calculated. RESULTS: The mean preoperative and postoperative IOP values were 19.8 mm Hg and 16.8 mm Hg respectively, a significant difference (p = 0.008). Seven of eight eyes with an IOP of 21 mm Hg or greater preoperatively had a postoperative IOP less than 21 mm Hg; these eyes showed a mean decrease in IOP of 5.6 mm Hg. The degree of preoperative IOP elevation was found to be a strong predictor of the amount of IOP lowering after surgery (p = 0.014). INTERPRETATION: Our results support the concept that orbital congestion associated with thyroid orbitopathy produces an increase in IOP by elevation of episcleral venous pressure (EVP) and that orbital decompression may reduce the IOP by decreasing EVP. Decompression surgery may obviate the need for more aggressive management of glaucoma in patients with severe thyroid orbitopathy.     

Behavior of soluble intercellular adhesion molecule-1 and endothelial-leukocyte adhesion molecule-1 concentrations in patients with Graves' disease with or without ophthalmopathy and in patients with toxic adenoma

Expression of intercellular adhesion molecule-1 (ICAM-1) and endothelial-leukocyte adhesion molecule-1 (ELAM-1) on endothelium can be considered a critical early step for leukocyte migration from blood to tissues during inflammatory processes. Increased circulating soluble ICAM-1 (sICAM-1) levels have been found in sera from patients with Graves' disease (GD) with or without ophthalmopathy. Serum soluble ELAM-1 (sELAM-1) levels have not been measured in these patients. The aim of this study was to clarify the behavior of sICAM-1 and sELAM-1 levels in patients with hyperthyroidism due to GD with or with or without ophthalmopathy and in hyperthyroid patients with toxic thyroid adenoma. We studied sICAM-1 and sELAM-1 levels in 130 subjects (age 23-54 yr), grouped as follows: group 1, 30 untreated hyperthyroid GD patients (21 females and 9 males) with active ophthalmopathy; group 2, 26 euthyroid GD patients (16 females and 10 males) with active ophthalmopathy; group 3, 33 hyperthyroid GD patients (22 females and 11 males) without ophthalmopathy; group 4, 11 untreated hyperthyroid patients (7 females and 4 males) with single toxic adenoma; and a control group of 30 healthy subjects (21 females and 9 males). sICAM-1 and sELAM-1 concentrations were measured by a sandwich enzyme linked immunosorbent assay (ELISA) method. Groups 1, 2, and 3 (P < 0.001 for all 3 groups) but not group 4 showed increased sICAM-1 levels compared with the control group. However, groups 1 and 2 (P < 0.001 for both) showed higher values of sICAM-1 than group 3, and group 1 showed higher sICAM-1 levels than group 2 (P < 0.002). Groups 1 and 2 (P < 0.001 for both) but not groups 3 and 4 showed sELAM-1 levels significantly higher than the control group and positively correlated to the severity score of Graves' ophthalmopathy (GO) (P < 0.002 for group 1 and < 0.01 for group 2). Our results confirm that increased sICAM levels in GD patients with or without ophthalmopathy (with higher levels in patients with GO) but not in hyperthyroid nonautoimmune patients may be the consequence of orbital and thyroid inflammation, and they also suggest that sICAM concentrations could reflect the degree of inflammatory activity. Increased sELAM-1 concentrations only, in patients with ophthalmopathy with or without hyperthyroidism significantly correlated to severity score of GO, suggest the measurement of sELAM-1 levels as a specific marker of endothelium activation in GO.     

Infrequent association: massive inguinoscrotal bladder hernia, multiple scrotal lithiasis, and bilateral obstructive uropathy]

BACKGROUND AND AIMS OF THE STUDY: Surgical treatment of functional tricuspid regurgitation associated with advanced valvular disease remains controversial, mainly due to the difficulty in choosing between valve replacement or reconstructive surgery. Failure to correct tricuspid regurgitation during valvular surgery carries a poor prognosis, as reoperation may represent a significant risk to the patient. Thus correct tricuspid valve surgery is vital to achieve improved early and long-term clinical results. METHODS: A total of 142 patients underwent concomitant tricuspid annuloplasty with mitral valve replacement and their clinical outcome was assessed. RESULTS: Overall hospital mortality rate was 11.3%. Seven patients died during follow up. The overall actuarial survival rate for 10 years was 74.1 +/- 14.2%. Postoperatively, 75.8% of the patients had no residual tricuspid insufficiency, while 24.2% had first- or second-degree tricuspid insufficiency and were treated medically. All patients were in NHYA functional class I or II postoperatively. CONCLUSION: Clinically, it is important to assess the severity of functional tricuspid insufficiency before and/or during the operation. Bicuspidalization annuloplasty for functional tricuspid insufficiency has provided good results, with a low incidence of reoperation and significant clinical improvement. The technique could be used in most patients with functional tricuspid regurgitation.     

The long-term use of botulinum toxin for adult strabismus

PURPOSE: To characterize patients choosing repeated botulinum toxin injection as a treatment for their strabismus, and assess their demand for it over time (up to 8 years). METHOD: Patients who had undergone at least eight injections were identified and their clinical records analyzed for diagnosis, demographic details, and demand for toxin injections with time. To establish any predictive variables, the details for these cases were compared with those of matched controls who had undergone fewer injections. Lastly, a questionnaire was mailed to research patients' views as to the indications and preferences for regular toxin injection as a method of treatment. RESULTS: Ninety-five patients were identified (34 men, 61 women; median age 37 years), of whom 35 had consecutive exotropia and 16 had secondary exotropia. Other diagnoses represented were residual and primary deviations, restrictive exotropias, and oscillopsias. A trend of fewer injections over the attendance period was seen, and the only complication observed was upper lid ptosis in 1% of injections. Cases exhibited similar demographic composition to matched controls, but were more likely to have consecutive exotropia or secondary esotropia as a diagnosis. Univariate analysis showed evidence (p < 0.001) of an association between the number of previous operations and the odds of being a case. No evidence was found that cases and controls lived at differing distances from our hospital. The questionnaire found that 71% of patients stated appearance as the prime reason for seeking treatment, and 37% stated simplicity of toxin therapy as their reason for reattendance. Twenty-six percent of the patients were disillusioned with the results of previous surgery and preferred toxin therapy as a means of controlling their symptoms. CONCLUSION: Botulinum toxin injection is an appropriate long-term treatment for some strabismus patients who choose not to undergo further surgery. A trend toward fewer injections with time was observed, and no adverse effects were associated with long-term treatment.     

Separation of several free polyamines and their acetylated derivatives by ion-pair reversed-phase high performance liquid chromatography

BACKGROUND: Convergence excess esotropia (EC) can be an additional component in all forms of strabismus. The most favourable prognosis is found in those cases where EC is associated with microtropia or bifoveal fusion, due to a better binocular potential. METHODS: 50 non selected cases were entered into the study and divided into two groups (Group A: EC with microtropia; Group B: EC with bifoveal fusion). All the patients were followed at the Lausanne Strabismus Unit and all cases underwent a bilateral medial rectus posterior fixation (Cüppers' Faden operation) placed at 13 mm from the original insertion. RESULTS: In Group A, the average reduction of angle of strabismus was 25 delta for near fixation, 20 delta in Group B. In both groups, the average decrease in angle for distance fixation was 6 delta. In Group A, 75% of cases gained some binocularity post-operatively, not only for distance but also for near fixation. In Group B, all the patients showed a normal response on the Lang stereotest post-operatively. CONCLUSIONS: In both groups of this study, a bilateral medial rectus retroequatorial myopexy was a satisfactory alternative for those patients who refused to wear bifocal glasses.     

Thyroid surgery in children and teenagers

From 1961 to 1976 62 patients under age 20 underwent thyroidectomy for various thyroid disorders. Twenty-four thyroid lobectomies and eight subtotal or near-total thyroidectomies were performed for benign nodular goiter. Eight near-total thyroidectomies and two thyroid lobectomies were performed for carcinoma. Two patients also had a radical neck dissection. Twenty patients with hyperthyroidism underwent near-total thyroidectomy. Postoperative complications occurred in six patients-all with hyperthyroidism. Operative mortality was zero. Two indications for thyroidectomy in our series were nodular goiter (to rule out carcinoma), and hyperthyroidism (that was not well-controlled medically or where surgery was chosen as primary therapy). In patients with nodular goiters that required surgery, a minimal complication rate occurred. By contrast, surgery for hyperthyroidism was associated with a high postoperative complication rate, six of 20 patients or 30%, which must be anticipated by the surgeon.     

Seqalert--a daily sequence alertness server for the EMBL and SWISSPROT databases

OBJECTIVE: Fine-needle aspiration biopsy (FNAB) is the preferred diagnostic study for evaluating thyroid nodules. Despite its accuracy, many patients undergo thyroidectomy for benign nodules. This study was undertaken to identify risk factors that might increase the specificity of FNAB. METHODS: Medical records of 422 patients who underwent thyroid surgery between 1986 and 1996 were reviewed. All patients had FNAB prior to surgery. RESULTS: Of the 422 patients, 36% had benign cytology, 46% had indeterminate cytology, and 13% had cancer. In the indeterminate group, 29% of patients had cancer at surgery. Of patients with papillary cytology, 84% had malignancies. Five percent of FNABs were nondiagnostic. Neither age, gender, nor tumor size was associated with increased specificity of FNAB. CONCLUSION: There is no subpopulation of patients with indeterminate FNAB cytology at increased risk of having well-differentiated thyroid cancer.     

Evidence of iodine storage within thyroid stroma after iodine treatment: imaging by secondary ion mass spectometry (SIMS) microscopy in goitrous tissue

We measured the 127I distribution within tyroid tissue to find out where intrathyroid iodine was deposited during iodine treatment in eight Tunisian female patients (aged 33-58 yr) with endemic euthyroid goiter. Before surgery, five patients were treated during 6 months either by Lugol's solution (group 1: three patients) or by Lugol's and L-thyroxine (group 2: two patients). All patients remained euthyroid during the course of the treatment, which supplied 3.8 mg/day iodine. Three other patients did not receive Lugol's solution (control group). Secondary ion mass spectrometry microscopy was used to map 127-I quantitatively on thyroid sections. Specimens obtained at thyroid surgery were divided macroscopically into nodular and extranodular tissue and chemically fixed to preserve organified iodine. The iodine profile of patients in group 1 did not differ from that in group 2: large amounts of iodine were localized in thyroid follicles and stroma of both nodular and extranodular tissues. In the control group, iodine within stroma was found only in the extranodular tissue. Despite the limited number of patients studied, these data suggest that stromal iodine might represent a storage compartment in times of large iodine supply.     

Immunomodulatory effect of pentoxifylline in Graves ophthalmopathy

In the pathomechanism of the thyroid associated ophthalmopathy (TAO) the inflammatory cytokines produced by infiltrating lymphocytes of the retroorbital tissues are involved. The activated lymphocytes have been shown to secrete a number of cytokines including tumour necrosis factor-alpha, interleukin-1 and interferon-gamma. The widely used immunosuppressive therapies have potential serious side effects. The pentoxifylline (Ptx) is known to have effect on production of cytokines. The aim of this study was to investigate the effect of Ptx on expression of HLA-DR molecules and production of glycosaminoglycan of human retroorbital tissue cultures and potential efficacy in patients with TAO. It was found that pentoxifylline (Ptx) was able to inhibit significantly the HLA-DR expression and glycosaminoglycan synthesis induced by inflammatory cytokines including TNF-alpha, IFN-gamma and IL-1. Ten patients with untreated moderate severe ophthalmopathy (8 female and 2 male) were excluded from steroid treatment due diabetes mellitus and psychiatric disease. Classification of eye changes was made by NOSPECS categories and total eye score. All patients were euthyroid during the study and was no remarkable difference in thyroid function and eye symptoms. Before and during Ptx therapy the laboratory parameters were also determined including glycosaminoglycan. TNF-alpha, anti-TSH-receptor, anti-eye muscle, anti-thyroglobulin and anti-thyroid peroxidase antibodies in the patients'sera. It was found a remarkable improvement in the eye symptoms in eight of ten patients. The levels of glycosaminoglycan (uronic acid) and TNF-alpha gradually decreased in eight patients who considered to be responders. The levels of uronic acid in plasma of the responders were found to be significantly lower after Ptx treatment. Before Ptx therapy the TNF-alpha in the sera was not different remarkably in non-responders and responders. After 4 weeks Ptx treatment the TNF-alpha decreased significantly in responders compared to non-responders (20.9 +/- 4.8 pg/ml v. s. 28.3 +/- 6.1 pg/ml) (p < 0.01). The titre of anti-eye muscle antibodies were found to be lower at the end of observation, however, the anti-thyroid antibodies were not changed remarkably. It was concluded that Ptx in the majority of patients (8/10) has a beneficial effect on inflammatory symptoms of TAO and laboratory parameters and suggested to use as an additive therapy, however, further comparative studies are required for final evaluation of Ptx in the treatment of TAO.     

Aortoiliac surgery in chronic hemodialysed patients

Thirty eight patients on chronic hemodialysis were operated on for treatment of complicated aortoiliac atherosclerosis: 31 had aneurysms and 7 had stenotic or obstructive lesions. The 35 male and three female patients ranged in age from 39 to 78 years (mean: 55.3). The duration of hemodialysis treatment before the operation ranged from one month to 22 years but 80% of the patients were operated on during the first five years following the beginning of maintenance hemodialysis. The surgical repairs consisted of long aorta to femoral artery prosthesis in obstructive lesions and of short prostheses in cases of aneurysms so as not to make more difficult subsequent renal transplantation. All patients were operated on from 6 to 18 hours after a dialysis. Hemodialysis was resumed on the day of surgery in few patients or later according to the level of kalemia. Postoperative mortality rate was 10.5% and morbidity 13.5%. Only seven patients underwent secondary renal transplantation. The long-term survival rate was 43% at five years and 11% at ten years. Late deaths were due to coronary artery disease or to worsening of arterial lesions in the lower limbs.     

How occupational therapists teach older patients to use bathing and dressing devices in rehabilitation

PURPOSE: Brown's syndrome is a form of anatomical strabismus, or retraction syndrome. It is defined by active and passive limitation of upward gaze in adduction in the field of action of the inferior oblique muscle. The etiology of Brown's syndrome remains unknown. The defect lies at the level of the superior oblique's tendonis trajectory via the trochlea. We studied the frequency of clinical signs and results after surgery in patients presenting congenital Brown's syndrome. PATIENTS AND METHODS: Our study involved 18 children. They all underwent complete ophthalmological examination with orthoptic testing, pre and postoperatively. RESULTS: Neither sidedness nor predominance of sex was noted. Compensatory head posture was noted in 7 of 18 cases. Limitation of upward gaze in adduction was a constant finding, with a positive duction test. Eleven cases underwent superior oblique recession. Results of surgery were satisfactory, with resolution of compensatory head posture in over 80% of cases. CONCLUSION: The etiology of congenital Brown's syndrome remains unknown. The different surgical techniques give inconstant results. Operative indication is decided only when in the presence of well defined clinical manifestations: CHP, deviation in primary position with alteration of binocular vision.     

Low dose flunarizine protects the fetal brain from ischemic injury in sheep

This retrospective long-term study analyzes the clinical function, failures, and radiographic status of 131 Richards Series 2 prostheses in total hip arthroplasties (THAs) performed during 1981 and 1982. After a minimum follow-up period of 11 years, the results were evaluated. Sixty two (54%) patients with 71 THAs were available for follow-up; 44 (38%) patients with 49 THAs had died. Three patients with three THAs were lost to follow-up, and seven patients with eight THAs were unable to participate in the examination due to causes not related to their present hip status. Ten patients underwent revision THA during the observation period. The median hip functional index (HFI) was 8.6 preoperatively and 15.8 at follow-up. Hip functional index correlated to radiographic signs of loosening. With revision as endpoint, the Kaplan-Meier survivorship for all 131 hips was 93% after 10 years and 91% after 12 years. The radiographic examination at follow-up revealed 5 (8%) definite loose cups and 12 (19%) definite loose stems. Including the number of aseptic loosened cups and stems confirmed at revision, aseptic loosening was found in 6% of all cups and 13% of all stems. This radiographic evaluation confirmed that lack of containment of the cup and varus position of the stem were factors influencing the long-term stability of the prostheses, whereas etiology, type of arthritis, and ectopic ossification did not. A fixation and stability score that was modified for cemented prostheses was developed and was of value in detecting the prostheses at risk. The long-term results of the Richards Series 2 THA are acceptable and comparable with other long-term studies on conventional prosthetic designs. Ten percent to 20% revision THAs due to aseptic loosening can be expected. In addition, patients younger than age 60 at surgery and especially men were found to belong to a high-risk group with regard to revision THA. These patients must be evaluated carefully so that revision THA can be performed before the bone bed is destroyed.     

Adolescent abortion and parental notification: evidence for the importance of family functioning on the perceived quality of parental involvement in U.S. families

Hyperthyroidism is common and affects approximately 2% of women and 0.2% of men. The most common cause of hyperthyroidism is Graves' disease, an autoimmune disorder associated with circulating immunoglobulins that bind to and stimulate the thyrotropin (TSH) receptor, resulting in sustained thyroid overactivity. Toxic nodular goitres cause hyperthyroidism due to autonomous hyperfunctioning of localised areas of the thyroid. There are 3 recognised modalities of treatment for hyperthyroidism: antithyroid drugs, surgery and radioiodine. All are effective but no single method offers an absolute cure. Patients with Graves' disease may be prescribed antithyroid drugs over a period of 12 to 18 months with a view to inducing a long term remission. These drugs are also often given for a short period to render the patient euthyroid before definitive therapy with radioiodine or thyroidectomy. However, antithyroid drugs will not 'cure' hyperthyroidism associated with a toxic nodular goitre. The use of radioiodine as a first-line therapy for hyperthyroidism is growing. It is well tolerated, with the only long term sequelae being the risk of developing radioiodine-induced hypothyroidism. Radioiodine can be used in all age groups other than children, although it should also be avoided in pregnancy and during lactation. Pregnancy should be avoided for 4 months following its administration. Radioiodine may cause a deterioration in Graves' ophthalmopathy and corticosteroid cover may reduce the risk of this complication. The treatment of choice for toxic nodular goitre hyperthyroidism is radioiodine. Surgery, either subtotal or near-total thyroidectomy, has limited but specific roles to play in the treatment of hyperthyroidism: this approach is rarely used in patients with Graves' disease unless radioiodine has been refused or there is a large goitre causing symptoms of compression in the neck. The goal of surgery is to cure the underlying pathology while leaving residual thyroid tissue to maintain postoperative euthyroidism.     

Inferior rectus recession--an effective procedure?

AIMS: To examine the postoperative stability of inferior rectus recession, with particular reference to the incidence of progressive overcorrection. METHODS: The results of consecutive patients undergoing inferior rectus recession over a 3 year period were reviewed. RESULTS: 21 patients underwent inferior rectus recession, using an adjustable suture technique in all but three cases. In 16 patients additional vertical muscle surgery was performed at the time of the inferior rectus recession. All patients were followed for a minimum of 3 months postoperatively, with a mean follow up of 9.3 months. At the final postoperative visit 11 patients were well aligned, eight were undercorrected, and two were overcorrected. In five of the eight undercorrected cases, the residual deviation was the result of postoperative drift in the direction of the preoperative deviation, following an initially good alignment. Review of the results failed to reveal any factor predictive for this postoperative drift. CONCLUSION: The risk of postoperative overcorrection following inferior rectus recession should be considered, but in this study, undercorrection occurred more frequently than overcorrection. The possible reasons for overcorrection and undercorrection are discussed.     

Open-heart surgery in a growing geriatric population: patient selection and risk factors to be considered

AIMS: This report describes our experience with cardiac surgery in elderly patients and aims to ascertain predictors of poor outcome. PATIENTS: Five hundred and ninety-eight (598) consecutive patients aged 75 years and older underwent cardiac surgery at the Department of Cardiothoracic Surgery, University Hospital of Lund, Sweden, between January 1980 and December 1993. There were 324 men (54%) and 274 women (46%); their age varied between 75 and 91 years (mean age +/- SD, 77.8 +/- 2.6 years). One hundred and twenty-nine patients underwent aortic, mitral or combined valve replacement, 273 patients underwent exclusive coronary revascularization (CABG) alone and 109 underwent a surgical procedure which included valve replacement and concomitant CABG. The remainder (87 patients) underwent other, more complex surgical procedures. RESULTS: The 30-day or in-hospital mortality rate was 5.5% (0.8% for valve replacement, 5.1% for CABG, 5.5% for valve replacement with concomitant CABG, and 12.6% for other procedures). Concomitant severe diseases occurred in 34.9% of the patients. All surviving patients were evaluated during June 1994. None of the patients was lost to follow-up. The 566 long-term survivors have been followed for an average of 23.0 months (median 21; range 1-53 months). Late mortality was 12.0% in the 566 hospital survivors. Only 17 patients experienced late complications (after hospital discharge), as an adverse effect linked to heart surgery.     

Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study

BACKGROUND/AIMS: To clarify whether the pancreatic duct remains patent during long-term follow-up of patients after pancreaticogastrostomy. In a previous study of pancreaticogastrostomy with post-operative follow up for 3 years after surgery, we found that the orifice of the pancreatic duct was difficult to detect in some patients because of swelling of the gastric mucosa. Previous studies have not examined pancreatic duct patency during long-term follow-up. METHODOLOGY: Between July 1985 and August 1989, 20 patients underwent a pylorus-preserving pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy. Five of these patients were followed up post-operatively for more than 9 years to determine the patency of the pancreatic duct. All pancreatic anastomoses were performed by the telescopic method. RESULTS: All 5 patients were female, with a mean age of 65.4 years (range: 54-75). Median post-operative follow-up was 10.8 years (range: 9-12). The indications for surgery were carcinoma of the ampulla of Vater in 4 patients and chronic pancreatitis in 1 patient. Pancreatic duct patency was confirmed in 4 patients by gastroscopy and pancreatography. However, the anastomotic orifice could not be detected in the remaining patient because of complete coverage by the gastric mucosa. In this patient, pancreatic exocrine and endocrine function deteriorated with dilation of the distal pancreatic duct. The patient underwent a second operation involving dissociation of the pancreatico-gastric anastomosis and resection of about 1 cm of the fibrous, proximal portion of the pancreas. Reconstruction was performed with a Roux-en-Y pancreaticojejunostomy and a mucosa-to-mucosa anastomosis. CONCLUSIONS: Although pancreaticogastrostomy has been applied as a safe and straightforward method for reconstruction after pancreaticoduodenectomy, anastomotic stenosis is a potential late complication of this approach.