Pathological study of implanted dacron grafts in surgery of thoracic aortic aneurysms

We studied woven dacron grafts that had been implanted in 5 patients of thoracic aortic aneurysms. In addition to usual stains, immunocytochemical analysis was performed using monoclonal antibodies to the muscle actin (HHF35) and to the macrophage (HAM56). In the graft of 5 and 24 days implantation, thin thrombi containing red cells and fibrin covered the luminal surface in some places, and macrophages came into the thrombi. In the grafts of 12 and 38 months implantation, intimal hyperplasia of 0.2-1.0 mm thickness was seen at the anastomotic segments with the accumulation of smooth muscle cells. Except for the anastomotic segments, connective tissue matrix with collagen fibers covered the luminal surface, and in some hollows of the graft crimps, old and fresh thombi were seen in layers. Organizing thrombi of 1.0 mm thickness attached where the branched graft was anastomosed to the main graft. Anastomotic intimal hyperplasia in the graft of 148 month implantation was 0.4-1.0 mm in thickness and 5-10 mm in length, and aside from the intimal hyperplasia, an endothelial lining did not cover the luminal surface of the graft. In the thoracic aorta, woven dacron graft implantation did not cause a critical stenosis with the intimal hyperplasia. The mural thrombi formed at the branched graft, however, threatened to result in graft occlusion or embolization.     

Ileocecal tuberculosis as a cause of lower gastrointestinal hemorrhage in lupus erythematosus

BACKGROUND AND AIMS OF THE STUDY: The use of living, untreated autologous pericardium for patch repair in the left ventricular outflow tract was considered attractive in children. METHODS: Ventricular septal defect (VSD) closure with an untreated autologous pericardial patch was performed in 102 children of mean age 13.4 months (range: 1 to 73 months). Postoperative transthoracic Doppler echocardiography was performed in all children at a mean of nine weeks (range: one day to 50 weeks) after surgery. One pericardial patch, which was explanted at autopsy two months after surgery, was studied microscopically. RESULTS: At short-term follow up, no or only minor residual VSD was found in 97 patients, moderate VSD in two and severe VSD in one patient. One patient was reoperated for residual VSD and an aneurysmic patch first diagnosed seven days after surgery. Two more patients showed ballooning of the patch without VSD after five and seven days respectively. All aneurysmic patches were attributed to intraoperative patch oversizing. Patch integrity was confirmed in all other patients. No inflammatory or degenerative changes were observed at microscopy, rather a remodeling response had caused the patch to thicken, indicating an adaptation of the living tissue. CONCLUSIONS: The untreated autologous pericardial patch has shown to be a safe alternative for VSD closure, provided that the patch is properly sized.     

Corneal opacification occurring after phacoemulsification and phacofragmentation

Four patients developed progressive corneal opacification five to eight months after ultrasonic cataract extraction. Transmission electron microscopy was performed in all patients. Scanning electron microscopy, performed in only one patient, showed radiating folds of Descemet's membrane with pits on its posterior surface as well as focal traumatic disruption probably caused by probe contact. Bullous keratopathy was present in one patient. Two other patients had folds of Descemet's membrane and a thin retrocorneal fibrous layer. All four tumor specimens showed secondary epithelial and stromal changes. The common denominator was the total or partial absence of endothelium or marked alterations of its remnants.     

Implantation of a reinforced polytetrafluoroethylene vascular graft for treatment of obstructions of the teat and mammary gland cisternae in cattle

OBJECTIVE: To evaluate use of an artificial vascular graft as treatment for obstructions of the teat and mammary gland cisternae in lactating cattle. DESIGN: Prospective clinical study. ANIMALS: 14 lactating dairy cows. PROCEDURE: After physical examination that included palpation, ultrasonography, evaluation of milk flow, and California mastitis test, each cow underwent surgical excision of obstructive tissue and implantation of a reinforced polytetrafluoroethylene vascular graft. Milk drained passively for 10 to 14 days after surgery. Follow-up evaluation was performed by telephone questionnaire of owners 1, 6, and 12 months after surgery regarding somatic cell count, time needed to milk affected quarter, compared with that of the contralateral quarter, and frequency of mastitis. After the subsequent nonlactation period and calving, milk flow was tested, using a quarter milking machine, and ultrasonographic examination of the affected teat was performed. RESULTS: Milk could be obtained from affected quarters from all cows 14 days after surgery, from 13 (93%) cows 1 month after surgery, from 10 (71%) cows 6 months after surgery, and from 3 (21%) cows 12 months after surgery, but milk flow in these 3 cows was considerably reduced. This technique failed because of collapse of the implant (4 cows), chronic mastitis (1), migration of the implant (4), and ingrowth of obstructive tissue between the distal aspect of the implant and the ridges of mucous membrane that radiate from the internal orifice of the streak canal (4), or a combination of these. CLINICAL IMPLICATIONS: Implantation of this vascular graft is a useful technique to restore teat patency for 6 months. A longer period of passive drainage of milk appears necessary for sufficient ingrowth of the graft. Lesions that extend to the distal most aspect of the teat cistern have a poor prognosis, because this area cannot be sufficiently overlapped by the graft.     

Gastric function after pylorus-preserving duodenectomy in dogs

BACKGROUND/AIMS: The purpose of this study was to delineate the alterations in gastric physiology after pylorus-preserving duodenectomy (PPD). METHODOLOGY: The duodenum was transected 2 cm distal to the pyloric ring in five dogs. A patch graft around the papilla of Vater was preserved. Reconstruction was completed using an end-to-end duodenojejunostomy, anastomosis of the patch graft to the jejunum, and cholecystojejunostomy, in that order. Gastric acid analysis, serum gastrin and secretin concentrations, and gastric emptying were investigated before and one and three months after surgery. RESULTS: The postoperative mean basal and maximal acid outputs were not significantly increased. Fasting serum gastrin concentrations remained unchanged. The fasting serum secretin concentrations one month after surgery increased significantly as compared to the controls. There were no significant differences in meal-stimulated gastrin or secretin responses or gastric emptying after surgery. CONCLUSIONS: The acid output and gut hormone release after PPD were maintained at preoperative levels. Preservation of the duodenal bulb is postulated to be responsible for the maintenance of near-normal gastric physiology.     

Aneurysm of a subclavian-vertebral artery saphenous vein bypass graft: case report

OBJECTIVE AND IMPORTANCE: Although an autogenous saphenous vein is frequently used as a bypass graft, an aneurysm of a venous graft is a rare complication, especially in the case of cerebrovascular revascularization. We report a case of a successfully treated aneurysmal change in a venous graft after short vein bypass grafting. CLINICAL PRESENTATION: A 60-year-old man underwent a left subclavian-to-vertebral artery bypass operation with an interposed saphenous vein graft because of severe stenosis of the vertebral artery bilaterally. Angiograms of the left subclavian artery, obtained 4 months later, showed good patency of the graft without any dilation or stenosis. One year after the bypass surgery, the patient became aware of a pulsating mass in the left supraclavicular region, which was regarded as the grafted vein itself. A giant aneurysm of the vein graft, which developed at the nonanastomotic site, was shown in the angiogram 4 years later. INTERVENTION: The aneurysm was resected, and patch grafting of the orifice of the aneurysmal neck covered with an artificial vessel as a reinforcement was performed. CONCLUSION: The aneurysm seemed to have developed in a curved segment because of hemodynamic stress.     

Experimental biliary reconstruction with a Dacron graft which preserves the function of papilla Vater

Roux-en-Y cholangiojejunostomy has been widely accepted as a method of biliary reconstruction after resection of the bile duct, however complications such as cholestasis, cholangitis and peptic ulcer attributable to the loss of papillary functions are frequently encountered after this procedure. In this point of view, the author experimentally studied biliobiliary anastomosis with a Dacron vascular graft to preserve normal bile passage through the duodenal papilla. End-to-end choledocho-graft-choledochostomy with a Dacron vascular graft coated with collagen (Hemashield) was carried out in 10 pigs. Out of them three died of complications during the 13th to 26th the POD, and seven were sacrificed 6 weeks after the operation. Two weeks after biliary grafting (n = 3) the grafts were surrounded by thin fibrous tissue and microscopically collagen fibers infiltrating into pores of the graft were noted, however after 6 weeks the grafts were spontaneously detached from the bile duct and floated in bile. The covered fibrous tissue was remained and the anastomotic site was replaced with soft granulation tissue, where infiltration of inflammatory cells were microscopically noted. Caliber of the anastomotic site was not smaller and but for slight elevation of total bile acid level blood biochemistry did not show cholestasis and cholangitis. The papillary function was manometrically well maintained. A Dacron graft shielded by collagen seemed to be inadequate material as a permanent bile duct graft, however granulation tissue after spontaneous removal of the graft may be covered with biliary epithelium, and may heal maintaining normal papillary function.     

A case of subacute necrotizing fasciitis

We report a 48-year-old woman who developed necrotizing groin fasciitis with insidious onset. Before she visited us, she had been unsuccessfully treated with several kinds of antibiotics by other doctors for one month, because of a small ulcer covered by blackish necrotic tissue. She was referred to us because of high fever, an ulcer on the left labium majus, and a cellulitis-like lesion with severe pain on the lower abdomen. Methicillin-resistant Staphylococcus aureus (MRSA), Streptococcus intermedius, and Bacteroides uniformis were isolated from the wound. After aggressive debridement on the eighth day after admission of the whole indurated area and the fascia of the underlying muscle, healthy granulation tissue covered the defect, and the wound was finally closed with a skin graft Long-term administration of antibiotics along with insufficient and delayed surgical treatment were considered to have caused the full development of this disease.     

Local arthroscopic bone grafting of a juxta-articular glenoid bone cyst

This report describes a rare, juxta-articular bone cyst of the posterior glenoid that developed after a fracture of the glenoid in a 38-year-old male. The patient had persistent pain, popping and stiffness of his right shoulder for 3 years, and failed to improve after a nonoperative rehabilitation program. At arthroscopy, the senior author transported an autogenous bone graft from the bare area of the humeral head to fill the glenoid cyst arthroscopically. At second-look arthroscopy approximately 1 year after the index procedure, the bone graft had consolidated within the original cystic defect and the surface was covered with fibrocartilage. The graft harvest site posteriorly on the humeral head had healed with a small amount of scar tissue at the articular margin. Comfortable motion and function were restored.     

Risk of lung cancer among masons in Iceland

AIMS/BACKGROUND: Deep lamellar keratoplasty (DLK) was performed to restore visual acuity in 120 eyes with corneal stromal opacification. DLK is believed to be an effective treatment in eyes in which endothelial cell function had been preserved, and in which there was no epithelial or stromal oedema. The purpose of this study was to evaluate the effectiveness of this treatment. METHODS: The stroma was excised to the extent that only Descemet's membrane remained, at least in the optical zone. Donor corneas of full, or almost full, thickness with Descemet's membrane removed, or which had been lathed to a thickness of 0.4 mm from the endothelial side, were attached by suturing. RESULTS: In 113 eyes which were observed for 6 months or more postoperatively in which average prospective visual acuity was 0.09, average postoperative visual acuity improved to 0.6. Specular microscopy 1 month postoperatively revealed average endothelial cell counts of 2225 (SD 659)/mm2, while 24 months postoperatively this value was 1937 (642)/mm2 (cell loss 13%). Puncturing of Descemet's membrane during surgery occurred in 47 of 120 eyes (39.2%), but after 12 months, there was no difference in visual acuity or number of endothelial cells between these eyes and those in which no puncturing had occurred. CONCLUSIONS: There was no postoperative endothelial rejection reaction with DLK, and restoration of postoperative visual acuity was quite adequate. Compared with penetrating keratoplasty, DLK allows endothelial cell counts to be maintained for a longer period. In addition, results can be expected to be more consistent over the long term with DLK.     

Guided tissue regeneration for the treatment of intraosseous defects using a biabsorbable membrane. A controlled clinical study

The aim of this controlled, clinical study was to evaluate guided tissue regeneration using a bioabsorbable membrane in periodontal intraosseous defects. Forty patients, each contributing one defect > or =4 mm in depth participated. The control group (18 individuals) received conventional flap therapy, while the test group (22 individuals) was treated using the bioabsorbable membrane, Guidor. Clinical assessments were made by one examiner, blinded with respect to treatment group, at baseline, 6 and 12 months following surgery. Baseline probing pocket depths of 7.7+/-1.4 mm in the membrane group and 7.6+/-1.9 mm in the control group were measured. Twelve month results showed a significant clinical attachment level gain in both control (1.1+/-1.8 mm), and membrane group (1.3+/-2.1 mm). Probing pocket depth reduction of 2.6+/-1.9 mm and 2.7+/-1.9 mm was observed in the respective groups. Bone sounding showed a non-significant gain of 0.4+/-1.8 mm and 0.6+/-1.4 mm at membrane and control sites, respectively. Radiographic evaluation confirmed these results. There were no significant differences found between treatment groups for any of the tested variables. Smoking had a negative effect on healing in both groups. In conclusion, clinical and radiographic results indicate that guided tissue regeneration using a bioabsorbable membrane at intraosseous defects did not predictably achieve greater clinical attachment level gain nor bone gain when compared to conventional flap therapy.     

Friedrich Daniel von Recklinghausen. Biography and significance of his osteopathologic work after more than 100 years

A new technique for post-infarction ventricular septal defect is accomplished by suturing a single patch to healthy endocardium excluding the infarcted area from the high left ventricular pressure. We have used this infarction exclusion technique for 3 cases since 1994. Three patients developed cardiogenic shock before operation and were managed initially with an intra-aortic balloon pump. All patients were urgently operated using this technique, at the same time, CABG operation was performed in 2 cases from the finding of preoperative coronary angiography. All of the patients survived. The first patient had a residual shunt (L-R; 30%), which spontaneously resolved in one month after the operation. In this method, a two-dimensional plane patch has to be sutured to healthy endocardium like a three-dimensional dome. Consequently the edge of the patch has wrinkles, which cause a residual shunt easily at the suture line. So from the second case, previously prepared circular conic patch, which had been made from a plane circular patch, was sutured to the left ventricular endocardium. At the suture line, this conic patch was well fitted to the endocardium, and the patients had no residual shunt. Though this method has the advantage to retain left ventricular function and volume, the technique must be improved to prevent residual shunt after operation.     

The molecular weights of plasma and intestinal kallikreins in rats

Three centimeters of the urethra were replaced by lyophilized homograft veins in nine male dogs. The dogs were followed for up to 6 months with periodic urethrograms. The grafted lyophilized veins served as a guide for the ingrowing transitional cell epithelium. The graft caused very little tissue reaction and hardly any formation of fibrous tissue. The urethra was covered by transitional cell epithelium after 4 to 8 weeks, and eight of the nine dogs showed no signs of obstruction during the follow-up period.     

c-Fos dimerization with c-Jun represses c-Jun enhancement of androgen receptor transactivation

We assessed the possible association between an aggressive intercondylar notchplasty and histopathologic, radiographic, and gait changes to the knee. Three groups of six adult greyhounds were observed for 6 months. Group I dogs had a sham operation. Group II dogs had a 4-mm notchplasty of the lateral femoral condyle where it articulates with the lateral tibial spine. Group III dogs had a 7- to 8-mm notchplasty of the lateral femoral condyle to simulate the long-term effects of an overly aggressive notchplasty. Force plate gait analyses were not significantly different for any dogs at 3 and 6 months. Histopathologic studies (hematoxylin and eosin and safranin O stains) revealed notchplasty area remodeling with a thin layer of lamellar bone covered by fibrous connective tissue. Both Group II and III dogs had significant loss of lateral femoral condyle and trochlear groove articular surface proteoglycans. The radiographic notch width index remained unchanged throughout the study for Group I; the indexes increased immediately after surgery in Groups II and III because of the notchplasty, but after 6 months these values returned to near-preoperative measurements. An aggressive intercondylar notchplasty caused articular cartilage histopathologic changes at 6 months consistent with those found in knees with early degenerative arthritis. Significant refilling of a non-impinged notchplasty occurred by 6 months after surgery. Our results raise concern about the effects of aggressive intercondylar notch widening in humans.     

Experimental study of tracheal allotransplantation with cryopreserved grafts

OBJECTIVE: Tracheal reconstruction is necessary in patients with extensive tracheal stenosis caused by neoplasm, trauma, and congenital disease. We investigated the possibility of tracheal allotransplantation with cryopreserved grafts in a canine model. METHODS: A seven-ring section of thoracic trachea was removed in 19 adult mongrel dogs. In group A (n = 4), a five-ring tracheal autograft was implanted. In group B (n = 6), a five-ring allograft was implanted without immunosuppression. In group C (n = 9), a five-ring cryopreserved tracheal allograft was implanted without immunosuppression. Omentopexy wrapping around the grafts and both anastomotic sites was used in all animals. RESULTS: All grafts survived without any evidence of atrophy or stenosis in group A. All animals in group B died of severe airway obstruction within 1 month, and postmortem examination of these grafts showed epithelial defect and necrotic tracheal cartilage in the scar tissue. In group C, no animals died of asphyxia caused by severe stenosis of the grafts. The graft epithelium was no longer present 20 days after transplantation, and the graft was covered with regenerated epithelium within about 60 days after the operation. CONCLUSION: These findings show that cryopreserved tracheal allografts can be transplanted by means of omentopexy without immunosuppression and that cryopreservation may reduce tracheal allogenicity.     

Pulmonary hypertension. Response of vasoactive peptides to a nonionic contrast medium in patients undergoing pulmonary angiography

A 46-years-old male was admitted to our hospital because of productive cough and infiltrates on the chest roentogenogram. The patient had a history of left upper bullectomy ten years prior to the admission. The CT scan of the chest on admission showed infiltrats with cavitation in the left apex and multiple bullae in almost whole lung. Microscopical examination of smears of sputum and bronchoalveolar lavage fluid revealed acid-fast bacilli. They were identified as Mycobacterium szulgai by DNA-DNA hybridization method. The patient was treated with isoniazid, streptomycin and rifampicin. After treatment for about a month, the culture of sputum converted to negative for M. szulgai. After about three months hospitalization, the infiltrates decreased and the cavity wall became thin, and no recurrence sign has been observed after the discharge. There are a few case reports of pulmonary infection due to M. szulgai associated with bullous disease of the lung in Japan.     

Salvage of femoropedal bypass graft complicated by interval gangrene and vein graft blowout using a flow-through radial forearm fasciocutaneous free flap

We report the case of a 71-year-old man who had interval gangrene of his calf with subsequent vein graft blowout 3 months after undergoing a femoral-to-dorsalis pedis saphenous vein bypass grafting procedure. To provide wound coverage, restore vascular continuity, and preserve functional ambulation, a flow-through radial forearm fasciocutaneous free flap was interposed between cut ends of the bypass graft. Venous drainage of the flap was from the cephalic vein to the popliteal vein. At 1 month after the operation, the patient had complete wound healing and began to ambulate. At 11 months an asymptomatic high-grade stenosis in the distal radial artery segment of the reconstruction was successfully treated with percutaneous angioplasty. After 22 months of follow-up there have been no further complications, and the patient continues to have full, functional ambulation. The radial forearm flow-through free flap allows single-stage restoration of bypass graft continuity and coverage of extensive, complex tissue defects. This technique represents a novel approach to this difficult problem and provides a viable alternative to major limb amputation.     

Polyclonal/monoclonal ratio in kidney and bone marrow transplanted patients treated with cyclosporine

OBJECTIVE: To examine the hypothesis that suppression of frequent premature ventricular contractions may be associated with improvement in left ventricular function in patients with presumed idiopathic dilated cardiomyopathy. DESIGN: We conducted a retrospective case study and statistical analysis of the effect of cardiac medical therapy on outcome. MATERIAL AND METHODS: The study population consisted of 14 patients with more than 20,000 premature ventricular contractions in 24 hours recorded by Holter monitoring and associated left ventricular dysfunction (ejection fraction, 40% or less). Clinical characteristics, number of premature ventricular contractions per hour on 24-hour ambulatory Holter monitoring, and ejection fraction based on transthoracic echocardiography were compared before and after cardiac therapeutic intervention. RESULTS: Of the 14 patients, 10 had presumed idiopathic dilated cardiomyopathy, and 4 had ischemic heart disease. Of the overall study group, seven had received additional cardiac medical therapy after the index evaluation, including four patients who had amiodarone therapy. A significant reduction (75% or more from baseline) in premature ventricular contractions after medical therapeutic intervention was observed in five patients at the first follow-up examination. The mean interval to the first follow-up examination was 6 +/- 3 months. Of the five patients, four had significant improvement in clinical functional status and the ejection fraction. The mean ejection fraction of these five patients increased from 27 +/- 10% at baseline to 49 +/- 17% after medical therapy (P = 0.04). CONCLUSION: The suppression of frequent premature ventricular contractions may be associated with improvement of left ventricular function in patients with presumed idiopathic dilated cardiomyopathy.     

The effects of metformin on glycemic control and serum lipids in insulin-treated NIDDM patients with suboptimal metabolic control

The edentulous ridge expansion has been introduced in recent years to reestablish an appropriate alveolar ridge width. This technique consists of the placement of implants in the space formed after the dislocation of the buccal plate in a labial direction. In guided bone regeneration, the quantity of bone regenerated under the membranes has been demonstrated to be directly related to the amount of the space under the membranes. This space can diminish as a result of membrane collapse. To avoid this problem, a new technique of edentulous ridge expansion, which involved the use of a titanium mesh barrier to protect the regenerating tissues and to achieve a rigid fixation of the bone segments, was used in association with autologous bone in 25 patients. At second-stage surgery in all patients, it was possible to see tissue, under the mesh, that had the macroscopic characteristics of mature bone and was superficially covered by a thin soft tissue layer. The microscopic examination showed that all autologous bone particles were embedded in newly formed bone. The use of a rigid mesh can assist bone regeneration in non-space-making defects, since it probably does not interfere with the blood flow to the underlying tissues because of the presence of microholes within the mesh.     

Estrogen differentially modulates nicotine-evoked dopamine release from the striatum of male and female rats

BACKGROUND: Transluminal balloon angioplasty offers advantages to patch angioplasty. We evaluated the primary patency of thrombosed hemodialysis grafts that had undergone balloon angioplasty versus patch angioplasty as a salvage method. METHODS: We reviewed our experience with 22 consecutive intraoperative balloon angioplasties that were done in a 6-months period. The balloons used were noncompliant high pressure balloons. The balloon results were compared with those of 22 patients who had undergone patch angioplasties by the same surgeons. Age, gender, average time between graft insertion and revision, and number of prior revisions were analyzed. The two groups (patch and balloon) had similar ages (57 versus 58 years, respectively), gender distribution (12 women, 11 men versus 11 women and 11 men), average time of revisions before that particular procedure (15 versus 12 months), and average times of revisions before that procedure. RESULTS: Primary patencies of the patch and balloon group were respectively 86% versus 77% at 1 month, 45% versus 40% at 3 months, and 17% versus 28% at 6 months. There was no statistically significant difference between the two groups. Complications were comparable in both groups. CONCLUSION: Balloon angioplasty offers advantages to patch angioplasty, and we have shown similar patency rates. We recommend balloon angioplasty as a comparable method to salvage dialysis access grafts.