Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites

OBJECTIVE: We describe our protocol for performing decompression radiologic gastrostomy and gastrojejunostomy in patients with ascites and small-bowel obstruction. We also assess the technical success rate, the complications, and the morbidity and mortality in 45 patients who underwent radiologic gastrostomy. MATERIALS AND METHODS: Forty-five consecutive patients with ascites associated with metastatic ovarian cancer underwent a radiologic gastrostomy or gastrojejunostomy with gastropexy. Six patients underwent gastrostomy, and 39 patients underwent gastrojejunostomy. Locking catheters were placed using the Seldinger technique after gastropexy in all patients. Paracentesis was performed before gastrostomy or gastrojejunostomy. Additional serial paracenteses were performed after the procedure when reaccumulation of ascites close to the site of gastropexy was detected on follow-up sonography. RESULTS: Forty-five procedures were attempted. The technical success rate was 97.8%. The complication rate was 15.6%. Three major complications (6.7%) and four minor complications (8.9%) occurred. One procedure-related death (2.2%) occurred 16 days after gastrojejunostomy. CONCLUSION: Radiologic gastrostomy and gastrojejunostomy can be performed safely in patients with ascites if the patients undergo paracentesis first and if the reaccumulation of ascites is prevented after tube placement. In patients with ascites, gastropexy plays an important role in preventing pericatheter leakage. Ascites and peritoneal carcinomatosis should not be considered contraindications for radiologic gastrostomy or gastrojejunostomy.     

A method for radiologic-assisted gastrostomy when percutaneous endoscopic gastrostomy is contraindicated

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has been established as a faster and safer procedure than open surgical gastrostomy. It cannot be done, however, for many patients with partially obstructing pharyngeal or esophageal carcinoma, previous gastrectomy, upper abdominal surgery, or bowel distension from distal obstruction. PATIENTS AND METHODS: We attempted percutaneous radiologic-assisted gastrostomy (RAG) in 231 patients referred for gastrostomy, 38 of whom had a relative contraindication for PEG. The procedure involves passing, under radiologic guidance, an orogastric inflation tube that contains a snare. We used a 5-inch long, 18-gauge needle to transabdominally insert a wire into the stomach, avoiding loops of bowel visualized by air contrast. Retrieving the transabdominal wire by snare allowed retrograde passage of the gastrostomy tube as done in standard PEG. RESULTS: The procedure was successful in 230 of 231 cases, including 37 of the 38 patients with contraindications. We could not gain gastric access in 1 patient with a 75% gastrectomy. Overall, 6 patients developed complications and 1 died. There was no procedure-related morbidity or mortality in the patients with contraindications to PEG who underwent successful RAG. Subsequent laparotomy indicated tube passage through the liver in 2 of these cases and small bowel mesentery in 1 case without clinical problems. We performed a percutaneous jejunostomy in the efferent limb of the gastrojejunostomy in 1 patient with a previous gastrectomy. CONCLUSION: The snare technique is simpler and faster than the usual radiologic gastropexy technique, and safer than an endoscopic procedure. It has become our procedure of choice for gaining gastric access.     

Role of provocation poliomyelitis in vaccine-associated poliomyelitis

BACKGROUND: Laparoscopic gastrostomy as an alternative to open gastrostomy was introduced with various technical variants 5 years ago. However, long-term results of these new methods are still lacking. METHODS: From 4/1993 to 2/1996, laparoscopic gastrostomies were performed on 42 patients (50.9 +/- 15.6 [24-71] years) with esophageal stenosis in locally advanced hypopharyngeal (17 patients) or oropharyngeal (nine patients) carcinoma, incurable esophageal carcinoma (13 patients) and cerebral dyspagia (three patients). Operating time was 38 +/- 11 min [15-65 min]. Procedure-related mortality was 0%. Major complications occurred in 2/42 (4.7%) patients; minor complications were found in 4/42 (9.4%) patients. During a total usage time of 427 months, 14 stoma infections occurred (0.11 infections/100 days). CONCLUSION: Laparoscopic gastrostomy allows a safe, fast, and cheap reestablishment of enteral nutrition. The procedure is minimally invasive and can also be performed under local anesthesia. It has become our method of choice in patients with malignant, nonresectable subtotal stenosis of the hypopharynx or esophagus.     

Gastric dilatation volvulus. Surgical prevention

Definitive surgical management of gastric dilatation volvulus involves gastric repositioning, gastric resection when indicated and surgical formation of a permanent adhesion to prevent recurrence of the problem. Derotation and gastropexy procedures are recommended as soon as the patient is a reasonable anesthetic risk. Splenectomy and pyloric outlet procedures are of questionable value in preventing recurrence in the majority of cases. In North America, most veterinary surgeons perform right-sided antral gastropexy as a means of preventing recurrence. The technical advantages and disadvantages and experimental and clinical results of several techniques, including the tube gastrostomy, incisional gastropexy, circumcostal gastropexy, and belt-loop gastropexy, are discussed.     

Aspiration pneumonia following surgically placed feeding tubes

BACKGROUND: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. PATIENTS AND METHODS: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. RESULTS: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). CONCLUSIONS: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.     

Use of buccal mucosal flaps for the correction of congenital soft palate defects in three dogs

BACKGROUND: We evaluated the clinical efficacy of visceral angioplasty in the treatment of chronic mesenteric ischemia. METHODS: Over a 14-year period, we performed percutaneous transluminal angioplasty of 41 occlusive diseases of visceral arteries founded by angiography in 23 patients with chronic mesenteric ischemia. All but one (fibrodysplasic) stenoses were atherosclerotic, and 13 were localized in the ostial tract. Clinical follow-up was evaluated at 2, 6, 12, 24, and 36 months (mean follow-up = 27 months). RESULTS: Angioplasty demonstrated a residual stenosis of 30% or less in 37 procedures, for a technical success rate of 90%. Seventeen of 20 patients had symptom remission after the first treatment, for a short-term clinical success of 77%; two patients needed a reangioplasty after 2 months, and one was referred for aortomesenteric bypass. During a mean follow-up of 27 months (range = 2-36), the clinical success was 88%; 2/15 patients underwent successful repeat angioplasty at 24 and 36 months, for a 100% secondary long-term clinical success. Only two minor complications were encountered. CONCLUSION: Although surgical results are undoubtedly positive, visceral angioplasty is justified in relation to both the high surgical mortality and the low incidence of complications arising from visceral angioplasty.     

Comparison between the polypeptide profile of halophilic bacteria and salt tolerant plants

The endoscopic placement of percutaneous gastrostomy tubes has been an accepted technique for several years but has traditionally been performed by gastroenterologists and general surgeons. Fluoroscopically guided tube placement is now performed by radiologists. Head and neck surgeons have been slow to adopt the responsibility for placing percutaneous gastrostomy tubes despite the fact that most are proficient in both rigid and flexible esophagoscopy and trained in the Seldinger technique. We report on 41 percutaneous endoscopic gastrostomies performed in 39 patients by the Head and Neck Service at Stanford Medical Center between July 1, 1992, and August 30, 1995. There were 28 (71.8%) male and 11 (28.2%) female patients. Eleven (28.2%) procedures were performed in patients at the time of major head and neck resections. Another seven (17.9%) patients underwent percutaneous gastrostomy tube placement at the time of their initial staging panendoscopy before receiving chemotherapy and radiation. Fifteen (38.5%) procedures were performed for severe postsurgical dysphagia. Six (15.4%) patients had neurologic dysfunction, and this procedure was often performed in conjunction with tracheostomy. There were no major complications. Two patients had to undergo intraoperative tube replacement at 7 months and 18 months for chronic infection and tube damage, respectively. The only other complication was local irritation at the surgical site, which occurred in 2 (5.1%) patients. Our experience with percutaneous gastrostomy tube placement confirms that this is a procedure that can be safely performed by head and neck surgeons and should be part of otolaryngology-head and neck surgery training. The ability to provide comprehensive care of head and neck cancer patients as well as a means of supplemental feeding in conjunction with performing tracheostomy in neurologically impaired patients will no doubt improve the service that our specialty can provide.     

Balloon dilatation in acute myocardial infarct in routine clinical practice: results of the register of the Working Society of Leading Cardiologic Hospital Physicians in 4,625 patients

Balloon angioplasty as the treatment of first choice in the setting of an acute myocardial infarction (AMI) is gaining widespread acceptance because of favourable results from specialised centres concerning high patency rates and low mortality. This study reports the results of angioplasty for AMI at large community hospitals during 1992-1995. 4625 procedures were performed at 68 centres of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhaus?rzte (ALKK). The age of the patients was 60.8 +/- 11.3 years, with 75.1% men. The infarct related artery was the left anterior descendent in 43%, the right coronary artery in 37%, the circumflex artery in 16%, a bypass graft in 2.3% and the left main stem in 1.4% of patients. The success rate (residual stenosis < 50%) of the intervention was 86%. There was a wide range of procedures per centre, with a median of 40 AMI angioplasties per year and centre. The amount of angioplasties for AMI in relation to all angioplasties performed during this period rose from 5.2% in 1992 to 5.9% in 1995 (p = 0.01). Local complications at the puncture site occurred in 3.2%, with the need for a surgical intervention in 1.1% of patients. In 273 (5.9%) of the patients a second angioplasty was performed during the hospital stay. Aortocoronary bypass surgery was performed in 3% of the patients. Hospital mortality was 9.5% (438/4625 patients). The mortality rate remained constant during the years investigated (1992: 10.6%; 1993: 8.6%; 1994: 9.7%; 1995: 9.8%; p = ns). Higher mortality was observed in older patients, patients with multiple vessel disease, the left anterior descending artery or a bypass graft as infarct related artery as well as in patients with failed reperfusion (residual stenoses > 50%). Hospitals with a case load of more than 40 angioplasties for AMI per year showed a lower mortality as compared to the others. In clinical practice at large community hospitals results of angioplasty for AMI concerning mortality, complications and technical success rate are comparable to those of highly specialised centres. The absolute numbers of angioplasties for AMI increased constantly over the years.     

Spontaneous germ cell apoptosis in humans: evidence for ethnic differences in the susceptibility of germ cells to programmed cell death

Since the first clinical studies regarding sealing of arterial puncture sites with collagen with the use of the vascular hemostatic device (VHD) and the hemostatic puncture closing device (HPCD) in the early 1990s were performed, no analysis summarizing the published patients has been reported. Therefore we performed a Medline search of data as far back as 1990 and included abstracts presented at the major scientific meetings in the United States (American Heart Association, American College of Cardiology), Europe (European Society of Cardiology), and Germany (German Society of Cardiology). A total of 6007 patients were found to have been enrolled in studies with VHD (4448 patients) or with HPCD (1559 patients). Parameters analyzed in this review were hemostasis success rates and local complications. To assess the impact of the sealing devices on local complications, studies without control groups were excluded. The hemostasis success rates immediately after deployment seemed to be higher for HPCD, but at 2' to 5' after sheath removal, they were in the same range for VHD and HPCD. In controlled studies minor local complications occurred at a rate of 7.6% in the VHD group and in 6.7% of the HPCD group. Because the control group in the HPCD studies showed a considerably higher rate of minor complications than the VHD group (11.7% vs 5.7%), the reduction in minor complications was statistically significant for HPCD, whereas VHD did not reduce minor local complications. Major local complications were reported in 3.8% of the VHD group but in only 1.8% of the HPCD group. The increase of major local complications was statistically significant with VHD (control, 1.7%) but not with HPCD (control, 1.4%). Our analysis shows that some differences between collagen devices may exist, but neither device has been proven to reduce major local complications.     

Examination of contact lens surfaces by Atomic Force Microscope (AFM)

BACKGROUND: Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux. METHODS: Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV). RESULTS: There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not. CONCLUSIONS: Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.     

Response rate accuracy in oncology trials: reasons for interobserver variability. Groupe Fran?ais d'Immunothérapie of the Fédération Nationale des Centres de Lutte Contre le Cancer

PURPOSE: We evaluated the impact of an evaluation committee (EC) on patients' overall response status in a large multicenter trial in oncology. We identified reasons for disagreements between investigators and the EC. MATERIALS AND METHODS: The Cancer Renal Cytokine (CRECY) study was a French multicenter trial that tested cytokine therapy in 489 patients with metastatic renal cell carcinoma. Objective response (OR) evaluation included medical imaging and was studied according to international guidelines. A blinded peer review of all responders and litigious cases was performed by an EC. RESULTS: Major disagreements occurred in 40% and minor disagreements in 10.5% of the reviewed files. The number of significant tumor responses was reduced by 23.2% after review by the EC. Reasons for disagreements included errors in tumor measurements, errors in selection of measurable targets, intercurrent diseases, and radiologic technical problems. These reasons for disagreements are analyzed and discussed. CONCLUSION: We conclude that all therapeutic trial results should be reviewed by peer analysis of all presumed responders by an EC. International guidelines for response evaluation should be updated by including more reliable methods of measurements and definition of minimal imaging procedures.     

Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients

BACKGROUND: Recent reports of decreased morbidity and mortality following palliative surgery for patients with irresectable pancreatic head carcinoma prompted a review of the results in 126 patients (median age 64 (range 39-90) years) who had undergone palliative biliary and gastric bypass surgery. METHODS: The indication for surgical palliation was the finding of an irresectable tumour at laparotomy (n = 44), failure of endoscopic treatment (n = 43), clinical symptoms of gastric outlet obstruction (n = 28) and miscellaneous (n = 11). Biliary and gastric bypass was performed in 118 patients, biliary bypass alone in six and gastrojejunostomy alone in two. The indication for gastrojejunostomy was symptoms in 28 patients (23 per cent) and prophylaxis in 92 patients (77 per cent). RESULTS: Postoperative local complications occurred in 17 per cent of patients, general complications in 10 per cent and delayed gastric emptying in 14 per cent of patients. The 30-day mortality rate was 1 per cent and overall hospital mortality rate 2 per cent. Median hospital stay was 17 (range 5-80) days. Median overall postoperative survival was 190 (range 14-830) days. Late obstructive gastrointestinal symptoms occurred in 14 patients (11 per cent) after a median of 141 (range 21-356) days. CONCLUSION: Roux-en-Y hepaticojejunostomy combined with gastrojejunostomy offers effective palliation for irresectable pancreatic head cancer and can be performed with low mortality and acceptable morbidity rates.     

Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways

OBJECTIVES: The purpose of this study was to compare success rates, procedure and fluoroscopy times and complications for the transseptal and retrograde aortic approaches in a consecutive series of patients undergoing catheter ablation of left free wall accessory pathways. BACKGROUND: Radiofrequency catheter ablation of left-sided accessory pathways can be performed either by a retrograde, transaortic approach or by means of a transseptal puncture. METHODS: A total of 106 patients (mean age 33 years, range 4 to 79) underwent attempted catheter ablation of a single left-sided accessory pathway by either the retrograde or the transseptal approach, or both. In the first 65 patients, the retrograde aortic approach was the preferred initial method. In the most recent 51 patients, we first attempted the transseptal approach whenever a physician trained in the technique was available. Ultimately, 102 (96.2%) of 106 patients had successful ablation. RESULTS: Of 89 retrograde procedures, 85% resulted in elimination of accessory pathway conduction. Four retrograde procedures performed after failure of the transseptal approach were successful. Of the 13 patients with a failed retrograde procedure, 11 later underwent ablation using the transseptal approach. Twenty-six (85%) of 33 transseptal procedures were successful. All four patients with unsuccessful initial transseptal attempts were successfully treated with the retrograde method during the same session in the electrophysiology laboratory. Ten of 11 transseptal procedures after unsuccessful retrograde procedures were successful. Crossover from the retrograde to the transseptal approach was performed during a separate session in 9 of these 11. There was no difference in total procedure time (220 +/- 12.8 vs. 205 +/- 12.5 min) (mean +/- SEM) or fluoroscopy time (44.1 +/- 4.4 vs. 44.7 +/- 5.1 min) between the retrograde and transseptal methods. Ablation time was longer for the retrograde method (69.2 +/- 10.5 vs. 43.4 +/- 9.3 min) (p < 0.01). Of patients > or = 65 or < or = 16 years old, technical factors requiring crossover to the other technique or complications occurred in 7 (42%) of 17 patients undergoing the retrograde and 1 (11%) of 9 patients undergoing the transseptal approach (p < 0.01). The overall rate of complications was the same for both (6.7% for retrograde and 6.1% for transseptal). The most serious complication involved dissection of the left coronary artery with myocardial infarction during a retrograde procedure. CONCLUSIONS: The retrograde and transseptal approaches are complementary; if one method fails, the other should be attempted, yielding an overall success rate close to 100%. Because patients undergo heparinization immediately after the arterial system is entered during a retrograde procedure, failure of that approach requires crossover to the transseptal method during a separate session or reversal of heparin; if the transseptal method is tried first, crossover to the retrograde approach can be accomplished easily during the same session. To avoid complications related to access, the transseptal method should be the first used in children, the elderly and those with arterial disease or hypertrophic ventricles.     

Percutaneous transluminal renal artery angioplasty using the coaxial technique. Ten years of experience from 591 procedures in 419 patients

PURPOSE: To evaluate the angiographic and clinical results of all percutaneous transluminal renal angioplasties (PTRAs) performed at one centre in Norway since the introduction of the method. Most of the PTRAs were performed with the coaxial technique (guiding-catheter-assisted angioplasty). MATERIAL AND METHODS: In 419 patients, 595 PTRAs of 552 stenoses were performed from 1982 to 1993. The cases included 295 patients with arteriosclerotic vascular disease (AVD), 49 with fibromuscular dysplasia (FMD), and 74 transplantation patients (TX). Angiographic and clinical follow-up were undertaken. RESULTS: Initial angiographic success was obtained in 92% of the patients and another 3% improved. The rates of immediate success were 92%, 98% and 84% for AVD, FMD and TX respectively. The corresponding rates for primary patency were 57%, 67% and 54%, and for secondary patency (after 1 to 6 angioplasties) 77%, 93% and 64%. Lower long-term results were obtained for: recanalized vessels; long lesions; bifurcation stenoses; stenoses in patients with abdominal aortic aneurysm; smaller vessels; and segmental branches in native and TX kidneys. Of 252 patients with hypertension, 8% were cured and another 58% improved. Of 215 patients with reduced renal function, 38% were normalized or improved and 42% unchanged. Major complications including 2 deaths were seen in 2.9% of the procedures and other complications in 4.7%. CONCLUSION: PTRA with a guiding catheter can be performed in most patients with a high success rate and a low complication rate. This study points to two major problems with PTRA: the high restenosis rate and the low response to treatment of hypertension. The careful selection of patients for PTRA is important for increasing the success rate, and follow-up to detect restenosis is mandatory.     

Evaluation of percutaneous endoscopic gastrostomy in a university hospital

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) has become a commonly performed procedure to provide nutritional support for chronically ill patients. The aim of this study was to review the safety and results of PEG in a teaching hospital. METHODOLOGY: A retrospective review of 44 patients who underwent PEG procedure. The indication was long-term enteral feeding in patients who were unable to maintain adequate nutrition by mouth with an otherwise functioning gut. The most common primary diagnosis was cerebrovascular accident (17 patients). All patients were unable to swallow. RESULTS: There were six (13.6%) minor complications, and two mortalities from peritonitis (4.5%). The most common complication was gastrostomy site infection, which did not require exchange of the feeding tube. CONCLUSIONS: PEG is a useful means of providing nutrition in patients unable to swallow without the necessity for laparotomy and general anesthesia. This method provides an adequate avenue for enteral alimentation in selected patients and is relatively safe. Careful attention to the technique of insertion is important to prevent leakage or bowel perforation.     

Endoscopic sphincterotomy for lithotripsy (EST-L) of bile duct stones

We performed EST-L for 555 patients with choledocholithiasis between 1981 and 1992. With the aid of conventional occlusion balloons and dormia-type baskets, calculi < or = 1.5 cm was extracted with relative ease. In patients with larger stone (> 1.5 cm), the mechanical lithotripter, extracorporeal shock wave lithotripsy (ESWL) and electrohydrolic lithotripsy were used for the lithotripsy. The overall success rate was 95%. Important early and late complications from these procedures occurred in 6.9% and 9.1% of all cases respectively. This result reveal that EST-L is safe and effective therapeutic procedures for choledocholithiasis. We would recommend EST-L is adopted as an initial measure to remove common bile duct stones.     

Results of peripheral endovascular procedures in the operating room

PURPOSE: This study presents the results of closed (percutaneous) and open endovascular procedures performed exclusively by vascular surgeons in the operating room and compares them with results from combined series from the literature, including primarily closed procedures in radiology or cardiology facilities. METHODS: Retrospective review of 607 consecutive peripheral arterial and venous angioplasties, stents, thrombolytic cases, and inferior vena caval filters in 446 patients was analyzed for immediate success rate, complication rate, and 1-year life table patency rate. RESULTS: The incidence of initial technical success was: aorta, 89%; iliac artery, 91%; superficial femoral artery, 90%; popliteal artery, 91%; tibial arteries, 79%; arm arteries and veins, 86%; renal arteries, 100%; IVC filters, 98%; and iliofemoral veins, 100%. The 1-year primary patency rates, including technical failures, were 70.3% in 113 femoropopliteal procedures and 83.7% in 194 iliac arteries. Advantages to the use of the operating room included: (1) simultaneous angioplasty during a bypass operation for abnormalities proximal or distal to the graft, (2) correction of lesions first discovered during thrombectomy, and (3) optimum patient monitoring and sedation in the operating room. CONCLUSIONS: Endovascular procedures performed by vascular surgeons in the operating room lead to results comparable with procedures performed in nonsurgical interventional suites, and the use of the operating room has advantages.     

Perioperative complications of anterior procedures on the spine

We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.     

Carotid restenosis: operative and endovascular management

PURPOSE: Surgical management of carotid restenosis (CR) after carotid endarterectomy (CEA) has been associated with a higher perioperative complication rate than that of primary CEA. We recently used carotid angioplasty-stenting (CAS) as an alternative to operative management in patients who had undergone CEA within three years, and we retrospectively compared these results with those of operative management of CR and the overall results of CEA. METHODS: CEA was performed on 1065 adult patients (58% symptomatic, 42% asymptomatic), 62% of whom were men (n = 660) and 38% of whom were women (n = 405), from 1989 to 1997. Before our initiation of a program of CAS, 16 operative procedures (1.9% of CEAs) were performed for CR in 14 adult patients (7 women and 7 men). During the last 20 months, CAS was used in the management of 17 CRs (16 patients; 9 women and 7 men). RESULTS: The 30-day stroke morbidity-death rate for all CEAs (n = 1065) was 1.4%; 11 strokes (1. 0%) occurred (4 major strokes with disability and 7 strokes with minor or no disability), and 4 deaths (0.4%) occurred (2 deaths caused by myocardial infarction, 1 caused by intracranial hemorrhage, and 1 caused by stroke). Operative management of CR (n = 16) included patch angioplasty in 12 cases (autologous vein patches in 10 cases and synthetic patches in 2 cases), whereas interposition grafting was used in 4 cases (saphenous vein in 3 instances and synthetic [polytetrafluoroethylene] in one case). No strokes or deaths were observed. One recurrent laryngeal nerve palsy occurred (6.2%). Among the 16 patients undergoing 17 CAS procedures, the technical procedures were accomplished in all patients. No strokes or deaths occurred. No recurrent restenoses (50% or greater) have been identified within or adjacent to the CAS procedures. CONCLUSION: CR caused by myointimal hyperplasia can be managed by operative techniques or CAS with comparable periprocedural complications. Although long-term follow-up will be required to determine the incidence of recurrent restenosis, CAS may become the preferred procedure in these cases. A randomized clinical trial ultimately will be necessary to determine the role of CAS, as compared with that of operative management.     

Topotecan for the treatment of advanced epithelial ovarian cancer: an open-label phase II study in patients treated after prior chemotherapy that contained cisplatin or carboplatin and paclitaxel

PURPOSE: Topotecan, a topoisomerase I inhibitor, was evaluated in a multicenter, phase II study of women with epithelial ovarian carcinoma who relapsed after one or two prior regimens that included platinum and paclitaxel. PATIENTS AND METHODS: Topotecan 1.5 mg/m2 daily was administered as a 30-minute infusion for 5 consecutive days on a 21-day cycle. Eligibility criteria included bidimensionally measurable disease, Eastern Cooperative Oncology Group performance status of 2 or less, and adequate bone marrow, liver, and renal function. Efficacy was assessed by independent radiologic review. RESULTS: One hundred thirty-nine patients were treated; 81% were platinum resistant. Sixty-two patients had received one prior regimen and 77 patients had received two prior regimens. Nine patients were not assessable for response; however, all patients were included in the response analysis. The overall response rate was 13.7%; 12.4% in platinum-resistant and 19.2% in platinum-sensitive patients. Stable disease lasted at least 8 weeks in 27.3% of the patients. The median duration of response and time to progression were 18.1 and 12.1 weeks, respectively. The median survival was 47.0 weeks. Grade 4 neutropenia occurred in 82% of the patients (34% of the courses) and thrombocytopenia in 30% of the patients (9% of the courses). Infectious complications occurred in 6% of the courses. Nonhematologic toxicities were mild. There were no drug-related toxic deaths. CONCLUSION: As a single agent, topotecan has modest activity in women with advanced epithelial ovarian carcinoma who have progressed or not responded after one or two prior regimens with platinum and paclitaxel. Further investigation of combination regimens is indicated in the primary therapy for ovarian cancer based on the mechanism of action and tolerability.