Pediatric annular pancreas: twenty years' experience

Characterization of pediatric annular pancreas is provided by this analysis of 24 cases (22 neonates, 1 infant, 1 child). Salient observations include: (1) Presentation is affected by the degree of duodenal obstruction at birth and by coexistent anomalies. (2) Polyhydramnios usually accompanies complete high intestinal obstruction by annular pancreas. (3) Primary biliary interruption was not encountered and jaundice was not unusually prevalent. (4) There is a high incidence of associated anomalies. (5) Duodenal bypass by duodenoenterostomy was employed with excellent results.     

Radical hysterectomy with pelvic lymphadenectomy in patients with carcinoma of the uterine cervix--3 years' experience

INTRODUCTION: Almost all patients with invasive cervical carcinoma can be treated with either primary irradiation therapy or primary surgery. Some patients are appropriately treated with the combination of irradiation and surgery. Chemotherapy is not effective as primary treatment of invasive cervical cancer but may be used as additional therapy and when the disease is recurrent or persistent. There are some important advantages of primary extensive surgery over irradiation. The findings at operation and that from the careful pathologic examination of surgical specimens can be very helpful in selection of patients for supplementary postoperation irradiation therapy or chemotherapy, or both [1-6]. AIM OF THE STUDY: The aim of the study was to compare pretreatment clinical evaluations with surgical and postsurgical pathohistological findings. METHODS: Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. The patients were treated at the Department of Obstetrics and Gynaecology of the Clinical Centre of Serbia in Belgrade, between 1993 and 1995. Cervical cancer was detected by clinical examination, colposcopic and cytologic (Pap smear) findings, colposcopically directed biopsy or conisation and pathological findings, sonography, chest radiography, blood and urine analyses. In some cases we had to make other examinations (cystography, cystoscopy, intravenous pyelography, sygmoidoscopy, rectoscopy, CT scanning and magnetic resonance). The surgical treatment of invasive carcinoma of the cervix was limited to those patients in whom the disease was confined to the cervix or vaginal fornix (stage Ia, stage Ib or stage IIa), and who were in high surgical risk. RESULTS: Over a three year period (1993-1995) there were 251 patients with invasive cervical cancer, treated by primary surgery (radical hysterectomy and bilateral pelvic lymphadenectomy sec. Werthein-Meigs), average age 42 years. Most of the patients demonstrated invasive cervical cancer, clinically classified in Ib st. (81.67%). Some characteristics of pathologic findings, such as parametric width, number of removed lymph nodes, percentage of lymph nodes metastases and correlation with clinical stage of invasive cervical cancer, histologic grade of cervical cancer with lymph node metastasis, pathologic findings after surgical treatment, correlation between clinical and surgical staging, were already presented in tables. DISCUSSION: In the last decades the incidence of invasive cervical cancer and death rate have been decreased. Progress in reducing mortality is primarily attributed to the introduction of cervical cancer screening as part of regular gynaecologic examinations. Regular testing with Papanicolaou (Pap) smear and colposcopy have an important role in this problem [1]. Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. We found that the clinical diagnosis of disease extent was correct in 67.7% of patients who underwent extensive surgery for early invasive cervical cancer. Sensitivity of clinical findings was 75.8% and positive predictive value was 86.2%. Lymph node metastasis was detected in 17% patients. Brodman at al. [14] found that clinical examinations, including CT scanning and magnetic resonance, were correct in only 62.5% of cases. It is very difficult to detect parametric involvement and lymph node metastasis by clinical examinations. Irradiation therapy was used in the postoperative period as additional treatment of extensive hysterectomy and bilateral pelvic lymphadenectomy in 89.7% of patients. CONCLUSION: The findings at operation and that from the careful pathologic examination of surgical specimens are absolutely irreplaceable and important in grading invasive cervical cancer and selection of patients for supplementary postoperate irradiation therapy.     

Thymic carcinoma. Five distinctive histological variants

Five histologically distinct variants of thymic carcinoma are described: mixed small cell undifferentiated squamous cell carcinoma (three cases), basaloid carcinoma (two cases), mucoepidermoid carcinoma (one case), clear cell carcinoma (one case), and sarcomatoid carcinoma (one case). While forming a heterogeneous group, these tumors bear the common features of an anterior mediastinal location and lack of evidence of a primary tumor elsewhere, marking them as primary thymic neoplasms. All except the sarcomatoid variant are morphologically related to similar malignant neoplasms of other organs. These tumors should be recognized as morphological variants of primary thymic carcinoma and demonstrate the ability of thymic epithelium to differentiate toward a variety of different cell types.     

Vascular trauma. Review of 10 years' experience

The records of 82 patients with vascular trauma, treated at the Departments of General Surgery of the Sahlgren's Hospital, G?teborg, between 1969-1978 were revised. Nine patients were female and 73 male. The most common type of trauma was stab wounds. The overall mortality was 10.9%, all being patients with major vascular trauma and/or multiple injuries. Fourteen cases were due to iatrogenic lesions. Of the remaining 68 patients, minor vessels were traumatized in 40 cases, and treated with ligation. In 28 patients some kind of reconstructive procedure was attempted, 23 of these patients survived. All reconstructive procedures in surviving patients were successful. In comparison with international experience, vascular trauma in Sweden seems to be very uncommon.     

Carpal bone titanium implant arthroplasty. 10 years' experience

In 1984, in an effort to address the silicone wear particle problem, titanium implants were developed for the scaphoid, lunate, and trapeziometacarpal joint. The design of these implants closely resembled their silicone counterparts, though some modifications were made to accommodate the properties of unalloyed titanium and enhance their stability. Carpal bone implants act as articulating spacers to help maintain the relationship of adjacent carpal bones after local resection procedures. Their use allows carpal stabilization procedures and provides functional mobility with good strength and pain relief. Their surgical application began in 1985. The 10-year clinical experience seems very promising to date.     

Biopsy of the accessory salivary glands. 5 years' experience

Biopsy of the minor salivary glands has become a routine examination ordered by physicians working in a wide range of disciplines in order to search for or eliminate the diagnosis of Gougerot Sj?gren's disease or another systemic disease. We emphasize the need to use this examinations as a part of a complete work-up of the buccal cavity and the salivary glands. We reviewed our experience with 1,500 biopsies. The glands biopsied were normal in 56% of the cases and led to the diagnosis of Gougerot Sj?gren's disease in 24%, chronic sialadenitis in 10% and diverse trophic problems in 5%. The clinical stage of Gougerot Sj?gren's disease is usually proposed according to the Chisholm classification which we propose to compare with the Chomette classification. Finally, we described the technique of minor salivary gland biopsy.     

Intracranial surgery for cerebral artery aneurysms. Five years' experience

During the previous five years, there were 133 cases of intracranial surgery for cerebral artery aneurysms. For patients with aneurysms in the anterior circulation and in good preoperative condition, the surgical morbidity was 28% and the mortality was 19%. A depressed sensorium preoperatively, an age of 50 years or above, and an interval of less than 15 days from rupture to surgery were associated with markedly increased mortality. The results of this series, which do not compare favorably with those from foreign referral centers, are partially the result of disproportionate numbers of patients in those poor-risk groups. The possible advantages of regionalization are, nevertheless, apparent. Further comparative studies should be conducted on an interinstitutional basis.     

Heart pacemaker with lithium batteries. 2 years' clinical experience

102 lithium-powered cardiac pacemakers manufactured by Cardiac Pacemakers Inc. (CPI 301 UD, 101 UA and 501 UD) were implanted in 94 patients. During the observation time (25 months) the following complications were registered: 2 pulse generator failures, 4 failures of the demand-function, anodic muscle-twitching in 2 patients, 2 erosions of the pacemaker-pocket and 1 hematoma of the pocket. 5 pulse generators were exchanged without malfunction of the pacemaker. In 4 patients reinterventions on the electrode had, to be performed. 4 deaths occurred, none of them related to malfunction of the pacemaker. 2 lithium-powered pacemakers were explanted in other hospitals, for reasons not known to us and 1 patient left the German Federal Republic. 83 patients are under control with well working lithium-powered pacemakers.     

Thymic carcinoma which developed in a thymic cyst

The first human infection caused by Ascotricha chartarum of the maxillary sinus is described. The patient, a 35-year-old woman, developed a hard bony swelling on the right cheek. Her maxillary X-ray showed complete opacity of the right maxillary antrum with a shadow of erosion. C.T. scan revealed a radio opaque mass having vacuolated appearance in the antrum. The debris removed from the antrum contained phaeoid fungal elements. At places, softening of the bone was observed. The mucoperiosteum exhibited acute inflammatory reaction and invasion by the pathogen. The pale brown to subhyaline fungal elements in biopsy tissue grew Ascotricha chartarum, a phaeoid ascomycetous fungus in culture. The patient had a smooth recovery when treated with betadine lavage and itraconazole after surgical intervention.     

Aortic root replacement: twenty years of experience

BACKGROUND: Aortic root replacement is a complex surgical procedure which has undergone major technical modifications with time. In order to assess the early and long-term outcome after aortic root replacement with this procedure, our entire experience of a two decade period was reviewed. METHODS: Between January 1979 and March 1997, 156 aortic root replacement operations were performed. One hundred and twenty five patients (80%) were male and 31 female; their mean age was 50 +/- 16 years. Diagnosis was annuloaortic ectasia in 79 patients, aortic dissection in 51 (acute 22, chronic 29), isolated aortic valve pathology in 24 and aneurysm of sinus of Valsalva in 5. Thirty nine patients had aortic root replacement using the standard "Bentall" technique, 73 using the "modified Bentall" technique, 15 using the Cabrol technique. Biologic substitutes of the aortic root were used in 29 patients (19 autografts, 4 homografts, 6 xenografts). Mean follow-up time was 41 +/- 40 months (range 1 month-18 years). RESULTS: There were 12 (7.6%) hospital deaths. Hospital mortality in elective cases was 5% (7/134) and 22% (5/22) in emergent (p = 0.01). A trend toward reduced early mortality was demonstrated in recent years. Mortality was 5% for the "modified Bentall" group, 3% for the "Biologic root" group, 10% for the "Bentall" group and 20% for the "Cabrol" group. Hospital mortality was significant higher in "Cabrol" group than in "modified Bentall" group (p = 0.04). The overall long-term survival rate was 78 +/- 4% at 5 years, 71 +/- 6% at 10 years and 51 +/- 13% at 15 years. No significant difference in survival rate nor freedom from complications was observed among patient groups. Need for reoperation and valve-related adverse events become prevalent after 10 years of follow-up. CONCLUSION: The decrease in early mortality and the satisfying late results demonstrate that aortic root replacement is a low risk surgical procedure and an effective and durable treatment. The availability of biologic substitutes for the aortic root has allowed the extension of this operation to all patient age group, with results comparable to these obtained with composite grafts.     

Four years' experience with the gravigard in nulliparous women

A study of the Gravigard in nulliparous patients is presented. Experience with the use of the device in 348 other patients is drawn upon for the discussion. The Gravigard is shown to be an acceptable form of contraception for nulliparous females who cannot take oral contraceptives. The failure rate was 2-6 per hundred woman-years (HWY) (corrected 1-3/HWY).     

Evaluation of 20 years' experience of enuresis in children

The clinical and urodynamic approach to enuretic children over a period of more than 20 years has allowed the authors to develop a multifactorial pathophysiological concept of this disorder. The main factors involved are psychological, familial, genetic, vesical, due to bladder immaturity, hormonal, due to a defect of nocturnal ADH secretion, hygiene and dietary habits, etc. The sleep factor is predominant in the majority of cases. Although nocturnal enuresis is apparently isolated in many cases, it is often associated with a state of bladder immaturity, sometimes latent during the day, but occurring at night with episodes of detrusor hyperactivity, occurring during various phases of sleep. In practice, the recognition, in children, of these factors, some of which require specific treatments, implies a management combining several of these therapeutic modalities.     

Transmission of the electrocardiogram via telephone. Analysis of 10 years' experience

BACKGROUND: The problem of impaired cardiac rhythm is in recent years in the foreground of the interest of cardiologists. This was influenced not only by the conclusions of the CAST study which changed the therapeutic pattern used for some years but above all the diagnostic pitfalls of impaired rhythm as regards detection and identification. The objective of the present study was to provide evidence of the advantages and usefulness of the method of telephone transmission of the electrocardiogram within the complex of other diagnostic procedures. METHODS AND RESULTS: The group was formed by 251 patients, incl. 186 men and 65 women, average age 51.7 years (range 19-85 years). The transmission of the ECG by phone was implemented by the system TESLAR (VUIS-CVUT) which comprises recording units and a terminal with a graphic outlet. A total of 3,727 electrocardiographic tracings were assembled. During their analysis the arithmetic mean was used as the characteristic of the position of the group or groups on the scale, the error of the mean expressing the ratio of the standard deviation to the number of cases. In nominal variables most frequently percentage expression was used, frequently with a confidence interval obtained from tables. Evidence of the usefulness of the method is the high rate of detected arrhythmias within emergency calls (88.5%), as compared with normal calls (10.6%) where the yield is close to that of Holter monitoring, however, with the advantage of time ad libitum and thus also a higher yield. CONCLUSIONS: The presentation of long-term experience with electrocardiograms by telephone confirms unequivocally the assumption that the method extends existing diagnostic possibilities in short-term, symptomatic, but sporadic arrhythmias, that it makes possible dispensarization of risk patients as well as patients with permanent pacemakers and that it improves the tactics of antiarrhythmic treatment.     

Prepubertal ovarian cyst formation: 5 years' experience

OBJECTIVE: To document the frequency of ovarian cyst formation in the prepubertal female and to report on the clinical implications of these cysts. METHODS: We evaluated cases from a retrospective chart review of prepubertal females with ovarian cysts. RESULTS: Over a 5-year period, 1818 ultrasound studies were completed in prepubertal females, from which 99 patients were identified as having ovarian cysts. The majority (82 of 99, 83%) were small, unilocular cysts averaging 2-3 mm in diameter. The incidence of these small cysts ranged at 2-5% in females between birth and age 8. Large ovarian cysts (ie, greater than 2 cm in diameter) are rare in young girls over age 2, with most occurring within the first year of life. Of the 17 large ovarian cysts, two presented with torsion and both were complex on ultrasound examination. Five (29%) of the large ovarian cysts were treated conservatively and demonstrated regression on follow-up; these were unilocular cysts. Although functioning cysts resulting in precocious pseudopuberty are expected to be rare, we identified five cases (5%) in our series. CONCLUSIONS: Small, unilocular ovarian cysts less than 1 cm in diameter are found in prepubertal females with a frequency of 2-5% and are clinically insignificant. Ovarian cysts greater than 2 cm are rare. Unilocular ovarian cysts less than 5 cm may be followed conservatively with ultrasound surveillance until regression, without a major risk of torsion. Ovarian cysts associated with precocious pseudopuberty are generally larger than 2 cm and may be recurrent.     

Sinus of Valsalva aneurysms: 20 years' experience

BACKGROUND: Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years. PATIENTS AND METHODS: One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement. RESULTS: There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful. CONCLUSION: Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.