Reoperation for recurrent metastatic brain tumors

Results of reoperation in 48 patients who developed recurrent brain metastases between January 1984 and April 1993 are presented. Median time from first craniotomy to diagnosis of recurrence (time to recurrence) was 6.7 months. Median Karnofsky performance scale (KPS) score prior to reoperation was 80. Recurrence was local in 30 patients, distant in 16 patients, and both local and distant in two patients. Median survival time after reoperation was 11.5 months. There were no operative mortalities. Multivariate analysis revealed that presence of systemic disease (p = 0.008), KPS scores less than or equal to 70 (p = 0.008), time to recurrence of less than 4 months (p = 0.008), age greater than or equal to 40 years (p = 0.51), and primary tumor type of breast or melanoma (p = 0.028) negatively affected patient survival time. These five factors were used to develop a grading system (Grades I-IV). Patients categorized in Grade I had a 5-year survival rate of 57%, whereas the median survival time of patients in Grades II, III, and IV was 13.4, 6.8, and 3.4 months, respectively (p < 0.0001). Overall, 26 patients developed a second recurrence after reoperation. Seventeen patients underwent a second reoperation, whereas nine did not. Patients undergoing a second reoperation survived a median of 8.6 additional months versus 2.8 months for those who did not (p < 0.0001). This study concludes that reoperation for recurrent brain metastasis can prolong survival and improve quality of life. A second reoperation can also increase survival. Five factors influence survival: status of systemic disease, KPS score, time to recurrence, age, and type of primary tumor. The grading system using these five factors correlates with survival time. Reoperation should be approached with caution in Grade IV patients because of their poor prognosis.     

Reoperation rates for recurrent ovarian endometriomas after surgical excision

Maxaquine is a fluoroquinolone agent that is effective against Mycobacterium tuberculosis (MBT). The drug was tested for effects on MBT growth in the infected lung tissue in relation to its concentration and exposure time. The bactericidal effect was found to be achieved no earlier than 72 hours of its administration. The minimum bactericidal concentration of maxaquine was 2 micrograms/ml.     

Gadolinium-enhanced MR angiography of visceral arteries in patients with suspected chronic mesenteric ischemia

The purpose of this study was to evaluate accuracy of dynamic gadolinium-enhanced MR angiography (MRA) of the celiac, superior, and inferior mesenteric arteries in patients with suspected mesenteric ischemia compared with catheter angiography or surgery. Sixty-five patients with suspected mesenteric ischemia underwent three-dimensional spoiled gradient-recalled acquisition in the steady state (GRASS) gadolinium-enhanced MRA. Correlative studies were performed on 14 patients, catheter angiography alone was performed on 12 patients, and surgery alone was performed on two patients. Six patients had mesenteric ischemia. In all patients, the celiac artery (CA) and superior mesenteric artery (SMA) were seen well enough to evaluate; however, the inferior mesenteric artery (IMA) could be evaluated in only 9 of the 14 patients. MRA showed severe stenosis (> 75%) or occlusion of the celiac axis in seven patients, of the SMA in six patients, and of the IMA in four patients. The overall sensitivity and specificity were 100% and 95%, respectively, compared with catheter angiography and surgery. The two errors were caused by overgrading the severity of IMA disease. Three-dimensional gadolinium-enhanced MRA can accurately demonstrate the origins of the CA and SMA and is useful in evaluation of patients with suspected mesenteric ischemia.     

Reoperation for recurrent coronary artery disease: results of 200 consecutive cases

OBJECTIVE: To quantify first-pass enhancement of cervix carcinoma using fast dynamic MRI. To assess the accuracy of dynamic contrast-enhanced colour-coded MRI for determining tumour invasion into surrounding pelvic tissues. METHODS: Gadolinium enhanced dynamic MRI at one image every 2 s was performed in 47 patients with cervical carcinoma and five controls. First-pass contrast enhancement of cervix carcinoma and surrounding pelvic tissues was quantified. Automated colour-coded images were constructed using the dynamic parameters slope, amplitude and timing of enhancement. Of 47 patients, 28 underwent surgery and colour coded images were correlated with histological findings. RESULTS: First-pass contrast enhancement imaging of cervix carcinoma required a temporal resolution of dynamic MRI of one image every 3-4 s. Cervix carcinoma first-pass was more rapid and intense than that of other pelvic tissues (P<0.001) with the exception of normal myometrium (P>0.05). Binary colour coding, however, was not reliable for tumour delineation or for accurate assessment of tumour invasion into the parametria or the bladder wall. Overestimation of the extent of tumour invasion occurred in 15, 16 and nine out of 28 patients, respectively, using amplitude, slope and timing of enhancement as parameters. CONCLUSION: Dynamic contrast-enhanced colour-coded MRI of cervix carcinoma has limited value for assessing the extent of tumour spread and tumour staging.     

Central neuronal changes in recurrent visceral pain

Repeated colics from urinary calculosis produce referred muscle hyperalgesia whose extent is proportional to the number of colics. The pathophysiology of this hyperalgesia was investigated in electrophysiological studies (spinal cord recordings) on an animal model of artificial ureteral calculosis. Stone-implanted rats show both visceral pain episodes and muscle hyperalgesia of the ipsilateral lumbar musculature; the extent of hyperalgesia is a function of the number of episodes. In the dorsal horn of stone-rats compared to controls the following were found: a) significantly higher percentages of neurons driven by stimulation of the hyperalgesic muscle, of spontaneously active cells with muscle input and of neurons with muscle input with a low mechanical threshold of activation, and b) a significantly higher frequency of background activity of spontaneously active cells with muscle input. These findings were proportional in extent to the number of visceral episodes presented by the rats before recordings; in cases of an extremely high number (> 50), several neurons also displayed abnormal activity, i.e. permanent short rhythmic bursts. These changes reflect a state of central sensitization and are probably due to the abnormal inflow from the affected ureter which facilitates the central effect of muscular input, thus accounting for the referred hyperalgesia. The degree of sensitization appears to be a function of the repetition of the visceral afferent barrage.     

Reoperation for valvular heart diseases

To elucidate the limitation of mitral valve reconstruction, 53 mitral disease patients (Mitral stenosis: 29, Mitral regurgitation: 24) undergoing reoperation late after valve reconstruction were studied, taking account of valvular lesions at initial operation. Reoperation rate after open mitral commissurotomy for mitral stenosis was higher in the patients with valvular regurgitation at initial operation than in those with severe subvalvular lesions or calcified valve. Reoperation rate for mitral regurgitation after mitral valvuloplasty was higher in the patients with stenotic fibrous degeneration or dilated annulus at initial operation than in those with torn chorda. Thus, these findings suggest that combined lesion of stenosis and regurgitation at initial operation may affect the reoperation rate in patients undergoing mitral valve reconstruction for either mitral stenosis or mitral regurgitation. Different approaches to the mitral valve through the left atrium and various techniques of the atriotomy have been practiced according to the need for a particular patients. The left atrium and the mitral valve can be exposed through median sternotomy followed by biatrial atriotomy or transplant approach. A correct approach and good exposure plays a key role in the success of redo surgical procedure for mitral valve disease.     

Reoperation for carpal tunnel syndrome

Although primary carpal tunnel release is usually successful, reoperation is needed in up to 3% of patients. Common indications of reoperation are previous incomplete surgery and postoperative fibrosis. Although most patients improve after reoperation, persistent systems are likely and failure is more frequent than after primary carpal tunnel surgery. Risk factors for failure following reoperation include the presence of an active Worker's Compensation claim, pain in the ulnar nerve distribution, and the absence of abnormality on preoperative EMG.     

Reoperation for failed prosthetic replacement used for limb salvage

Patients with segmental bone and joint replacement prostheses because of tumors increasingly need revision surgery because of their long term survival. Between 1970 and 1990, 208 custom prosthetic replacements were performed for limb salvage in patients with tumors. Reoperations were required in 52 patients. The mean time to reoperation was 37 months. The reoperation procedures included 35 prosthetic revisions, 11 amputations, four arthrodeses, one vascularized fibular graft, and one open reduction and internal fixation of a fracture with supplemental bone graft. Functional assessment using the new Musculoskeletal Tumor Society scoring system was available for the 36 living patients, and their mean rating was 63% (18.9) at 12 years' mean followup. Of the 35 patients who received a new prosthesis, 12 (33%) patients needed a third operation at mean followup of 68 months. The probability of prosthetic survival in the group of 35 patients needing revision to the same or another prosthesis was 79% at 5 years and 65% at 10 years. The chance and frequency of needing reoperation increased as patients survived longer. Reoperations for tumor recurrence or infection usually resulted in amputation. Reoperation for failed initial segmental bone and joint prosthetic replacement is feasible and effective and can be done without jeopardizing subsequent patient and implant survival or without significantly affecting functional results compared with the values before reoperation.     

Reoperation for prosthetic thrombosis and acute neurologic injury

Torsions of the spermatic cord occurring from the intrauterine period to the end of the first year of life are termed perinatal. These are divided into prenatal and postnatal torsions, depending on their occurrence in the intrauterine or postuterine period. From January 1984 to January 1996, 6 cases were identified at our institution, involving 4 prenatal and 2 postnatal extravaginal torsions of the spermatic cord. These cases are reviewed with regard to optimal therapeutic approaches for the treatment of both the affected gonad as well as the contralateral one, and whether the event occurred prenatally or postnatally. The authors also propose several clinical indications useful for obstetricians, pediatricians, urologists and nurses.     

Reoperation after gastroesophageal reflux surgery

In a group of 19 patients reoperated after a primary operation on account of gastrooesophageal reflux the authors demonstrate that the reason for reoperation can be either a relapse of the reflux or also other complaints (most frequently dysphagia). The selection of a suitable operation is strictly individual. Cases of a short oesophagus are most difficult to resolve. The decisive factor is a correct surgical approach-laparotomy or thoracotomy.     

Attempt at the classification of chronic and recurrent headaches

The authors describe a proposal of classification of chronic and recurrent headaches based on criteria different from those used as yet. The initial criterion of headache classification was its extent and location: 1) diffuse, 2) partial, 3) posterior, b) anterior, 3)localized. Another element is: 1) unequivical or 2) non-unequivical clinical pattern. Definite clinical entities, probable aetiological factors, or possible pathological mechanisms are referred to definite extent and localization, and unequivocal or non-unequivocal clinical patterns.     

Good results of endoscopic paranasal sinus surgery for chronic or recurrent sinusitis and for nasal polyps

Endoscopic sinus surgery is being applied increasingly for chronic or recurrent sinusitis and nasal polyps. We investigated the results, which we classified as subjective results (i.e. the opinion of the patient) and objective results (i.e. the result as seen with nasal endoscopy). The subjective result was 'good' in 85% of 92 patients with chronic or recurrent sinusitis, the objective result in 77% of the treated sides, with a median follow-up of 46 months. In 90 patients with nasal polyps the percentages were 90% and 65% respectively, with a follow-up of 24 months. In 63% of 30 patients with chronic obstructive lung disease and nasal polyps the pulmonary function increased postoperatively (FEV1). In 4.2% of 1235 operated sides in 593 patients local complications were seen. These were mainly minor complications. Only in 0.3% serious complications as a orbital hematoma or a CSF leak were seen. Endoscopic sinus surgery has good results and little morbidity.     

The role of laparoscopy in chronic and recurrent abdominal pain

BACKGROUND: This study was designed to determine the efficacy of laparoscopy on patients with a history of recurrent and chronic abdominal pain longer than 3 months, of unknown origin. METHODS: From September 1990 to May 1994, we performed 66 laparoscopic treatments on 59 patients. The assessment of life quality ensured the disability score, the McGill pain questionnaire, and the visual analogue pain scale, which were completed preoperatively, then on the day of discharge, and finally at a mean period follow-up of 75.3 weeks. Laparoscopy provided diagnosis on 53 of 59 patients (89.8%). RESULTS: All 66 attempted laparoscopic procedures were completed successfully, no conversion to laparotomy was necessary, and no postoperative complication occurred. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) still suffer from pain at the time of the follow-up. CONCLUSIONS: The pain assessment and disability score was statistically significant postoperatively and at the time of the follow-up in relation to the preoperative score.     

Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis

In this study, we describe the importance of the whole-body bone scan in diagnosing the multifocality of chronic recurrent multifocal osteomyelitis (CRMO) and in distinguishing it from unifocal acute hematogenous osteomyelitis. MATERIALS: The medical records and two-phase, whole-body bone scans of 14 patients (mean age 10.5 yr) with the diagnosis of CRMO, were retrospectively reviewed. The diagnosis of CRMO was based on bone biopsy in 9 patients and clinical course/laboratory findings in 5. Bone scans were evaluated for geographic and anatomic locations of their lesions. Correlative radiographs of areas of abnormal uptake were performed to assess the radiographic appearance of the lesions. RESULTS: The presentation of the disease was localized to one painful, tender and swollen periarticular site 86% of the time. The number of lesions detected by bone scan varied from 1-18 (mean 6). Most lesions were metaphyseal, proximal or distal tibial lesions. Purely sclerotic or mixed (sclerosis and lysis) lesions were found on radiographs. Bilateral lesions were seen in 64% of patients. Biopsies were negative for organisms in all patients and exhibited subacute or chronic histologic changes in most instances. Complications of chronic hyperemia included marked overgrowth (5), diffuse demineralization (1), angular deformity (1) and length discrepancy (1). CONCLUSION: The identification of the multifocal configuration of the disease process by two-phase (soft-tissue and delayed) whole-body bone scintigraphy results in appropriate diagnosis and therapy of CRMO. Additional sites for possible bone biopsy become apparent for exclusion of other diagnoses. Supportive (nonsteroidal, anti-inflammatory medication) instead of antimicrobial therapy can be initiated with significant cost savings.