Corono-radicular amputation of mandibular molars: indication, technic and prosthetic utilization. Apropos of a clinical case

Lesions to the radicular bifurcation generally entail the removal of the tooth in question. This leads to the need to create a prosthetic bridge to compensate for the absence of the extracted tooth. This solution is not readily accepted by the patient who wishes to avoid involving other teeth. In these cases rhizectomy and the execution of an inlay on an adjacent tooth may satisfy the patient and resolve the clinical symptoms. The authors report a case of rhizectomy and prosthetic reconstruction of a tooth using inlay.     

Mechanism of action, clinical indication and results of treatment of botulinum toxin

Botulinum toxin, the most potent of the neurotoxins, produces paralysis by blocking presynaptic release of the neurotransmitter (acetylcholine) at the neuromuscular junction, with reversible chemical denervation of the muscle fibre, thereby inducing partial paralysis and atrophy. Because chemical denervation is reversible, botulinum toxin has temporary effects, the muscle being progressively reinnervated by nerve sproutings. Type A botulinum toxin (Bix-A) is available under two dosage forms: Botox and Dysport. Although the initial clinical indication was strabismus, subsequent studies have demonstrated the efficacy of Btx-A, mainly in dystonia, hemifacial spasm and spasticity. However, botulinum toxin has been successfully used in various other clinical indications. In regard to spasticity associated with cerebral palsy, Btx-A is a promising treatment requiring a multidisciplinary approach. Btx-A injections lead to effective reduction of muscle hyperactivity with minor side-effects. They are painless, even though electromyographic guidance may be required for the injection of deep muscles. However, the production of antibodies to Btx-A may compromise the effect of long-term treatment.     

Initial clinical results of LINAC-based stereotactic radiosurgery and stereotactic radiotherapy for pituitary adenomas

PURPOSE: To retrospectively evaluate the initial clinical results of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) for pituitary adenomas with regard to tumor and hormonal control and adverse effects of the treatment. SUBJECTS AND METHODS: Forty-eight patients with pituitary adenoma who underwent SRS or SRT between September 1989 and September 1995 were analyzed. Of these, 18 received SRS and 30 received SRT. The median tumor volumes were 1.9 cm3 for SRS and 5.7 cm3 for SRT. Eleven of the SRS and 18 of the SRT patients were hormonally active at the time of the initial diagnosis. Four of the SRS and none of the SRT patients had a history of prior radiation therapy. Both SRS and SRT were performed using a dedicated stereotactic 6-MV linear accelerator (LINAC). The dose and normalization used for the SRS varied from 1000 cGy at 85% of the isodose line to 1500 cGy at 65% of the isodose line. For SRT patients, a total dose of 4500 cGy at 90% or 95% of the isodose line was delivered in 25 fractions of 180 cGy daily doses. RESULTS: Disease control-The three year tumor control rate was 91.1% (100% for SRS and 85.3% for SRT). Normalization of the hormonal abnormality was achieved in 47% of the 48 patients (33% for SRS and 54% for SRT). The average time required for normalization was 8.5 months for SRS and 18 months for SRT. Adverse effects-The 3-year rate of freedom from central nervous system adverse effects was 89.7% (72.2% for SRS and 100% for SRT). Three patients who received SRS for a tumor in the cavernous sinus developed a ring enhancement in the temporal lobe as shown by follow-up magnetic resonance imaging. Two of these cases were irreversible and were considered to be radiation necrosis. None of the 48 patients developed new neurocognitive or visual disorders attributable to the irradiation. The incidence of endocrinological adverse effects were similar in the two groups, resulting in 3-year rates of freedom from newly initiated hormonal replacement of 78.4% (77.1% for SRS and 79.9% for SRT). CONCLUSION: Considering the relatively high incidence of morbidity observed in the SRS group, we recommend SRT as the primary method of radiation therapy for pituitary tumors. When treating a lesion in the cavernous sinus with SRS, special attention should be paid to dose distribution in the adjacent brain parenchyma. Longer follow-up is necessary before drawing any conclusions about the advantages of these techniques over conventional external beam radiation therapy.     

The results of the Ravitch-Sutherland technic for surgical correction in pectus excavatum

The aim of our study was to asses the functional and cosmetic results after performing a modified Ravitch-Sutherland procedure in children presenting with pectus excavatum. A series of 31 children with ages ranging between 5 and 16 years, presenting with pectus excavatum, were operated between 1986-1996 in our service. In 5 cases surgical treatment was required by the presence of respiratory and/or cardiac functional impairment due to the malformation. In the other 23 cases operation was performed mainly for cosmetic reasons. In all cases a modified Ravitch-Sutherland procedure was performed. Modifications consisted in renouncing at the plication of the perichondrium and in associating a diaphragmatic elongation and Bedouelle laparoplasty in all cases. Longitudinal sternotomy was performed in 2 cases with severely impaired ventilatory capacity. Functional and cosmetic results were good in all cases. In 2 cases, in which recurrence of the condition was observed, a second identical procedure was performed, with a good result. The interval between the operation and the moment of long-term evaluation ranged between 3 months and 11 years. We conclude that the modified Ravitch-Sutherland procedure represents an effective method for the treatment of pectus excavatum cases, offering good functional and cosmetic long-term results.     

Precise selective alcoholic Gasserian injection for tic douloureux. Recent advances in technic and results

The Ecker-Perl method of alcoholic trigeminal rhizolysis has proved to be a safe and effective method of treating tic douloureux in a consecutive series of 324 patients over a period of 21 years.     

The results of radiotherapy for ependymomas: the Mayo Clinic experience

It is known that exogenous 11-cis-retinol inhibits the recovery of photosensitivity of bleached rod outer segments (ROS) and 11-cis-retinol exists in the interphotorecepter matrix. We examined the conversion of 11-cis-retinol with bovine ROS. ROS was incubated with 11-cis-retinol under dim red light. Retinoids were extracted from the reaction mixture with hexane and analyzed by HPLC coupled with a fluorescence spectrophotometer. Isomerization of 11-cis-retinol to all-trans-retinol was observed in the presence of ROS. This isomerization was not suppressed by heat treatment and did not have stereospecificity. In addition, we incubated purified rhodopsin and phospholipids extracted from ROS with 11-cis-retinol. Rhodopsin was found to isomerize 11-cis-retinol to all-trans-retinol as well as ROS, but phospholipids did not. In contrast, the phospholipids inhibited the isomerization of 11-cis-retinol to all-trans-retinol by the purified rhodopsin. Commercially available phospholipids, especially phosphatidylserine, also inhibited the isomerization. Our results suggest that rhodopsin has activity for the isomerization of 11-cis-retinol to all-trans-retinol and may play an important role in the detoxification of 11-cis-retinol in the ROS.     

Indications, technic and results following Sedlacek-Kambic-Tucker reconstructive partial resection of the larynx

Substantial evidence of postangioplasty vasoconstriction is available, both at the dilated site and distal to balloon injury, demonstrating its frequent occurrence. It is likely that even mild or moderate vasoconstriction at the site of balloon injury may create flow turbulence, promoting platelet aggregation and contributing to thrombotic vessel closure. The regulation of arterial smooth muscle tone is a complex process and should be distinguished from elastic recoil, which occurs at the site of balloon injury due to passive elastic properties of the artery, generally immediately after balloon deflation. The contribution of a variety of messengers generated by humoral, neurogenic, myogenic, and endothelium-derived factors in this regulatory process has been implicated. The possible mechanisms of post-percutaneous transluminal coronary angioplasty vasoconstriction at the dilated site (local) and in segments of coronary artery beyond the dilated site (distal) are reviewed in this article.     

The results of primary radiotherapy in vaginal carcinoma

The results of two previous and two recent studies of middle-aged males and females are presented to exemplify the clinical importance of lipoprotein(a) (Lp(a)) as a risk factor for atherosclerosis and coronary heart disease. In these studies various conventional and recently suggested risk factors were included and different methods for Lp(a) quantification were used. Lp(a) was a significant risk factor in all four studies. In the recent prospective case-control study, Lp(a) and cholesterol were found to act synergistically and predict primary acute myocardial infarction in Swedish males. A cholesterol level above 6.5 mmol/l increased the risk of acute myocardial infarction if the Lp(a) level was above 200 mg/l. The plasma apo A-I level was a protective factor. In the other recent case-control study, an Lp(a) level above 500 mg/l was a highly significant risk factor in Black and White US women with myocardial infarction or advanced coronary artery disease in addition to low density lipoprotein cholesterol levels above 130 mg/dl. A high apo A-I level was a protective factor. In these studies no other factors tested reached significance in multivariate logistic regression analysis. A hypothetical association between high Lp(a) levels and intracellular infection with Chlamydia pneumoniae is discussed. The results suggest that the Lp(a) level is useful in identifying high-risk individuals. Lowering low density lipoprotein cholesterol below 100 mg/dl (<2.6 mmol/l) seems to be most important in both males and females with high-risk Lp(a) levels.     

The hemodynamics and anatomy of the circle of Willis. The technic and clinical value of selective MR angiography

This study evaluates the usefulness of MR angiography in analysing the individual collateral flow dynamics and anatomy of the circle of Willis in 56 patients with high-grade extracranial carotid stenosis or occlusion. Selective MRA of the carotid or vertebrobasilar area was performed by means of presaturation up to the brain-supplying arteries at the level of the middle neck (angled presaturation slabs). Results obtained with selective and non-selective MRA in 56 consecutive patients were compared with the findings at transcranial Doppler ultrasonography and arterial angiography. Ischaemic cerebral infarctions were classified by computerized tomography and correlated with the results of collateral flow analysis: Sensitivity of selective MRA in detecting intracranial collateral flow via anterior or posterior communicating artery was 96 and 97%, respectively; sensitivity in depicting extracranial transorbital flow was lower (71%). Non-selective MRA was 100% sensitive in detecting a non-filling of the horizontal (A1) segment of the anterior cerebral artery and in identifying an origin of the posterior cerebral artery from the intracranial carotid artery. Slow flow infarctions occurred more frequently in patients with transorbital and posterior-to-anterior collateral flow than in patients with collateral flow via anterior communicating artery.     

Multivariate analysis results of radiotherapy for laryngeal cancer

We assess the impact of radiotherapy in the treatment of laryngeal cancer and evaluate the value of the standard dose (linear quadratic plus time model) and other variables to predict tumor control and survival. Between 1972 and 1989, 80 patients with laryngeal cancer received comprehensive radiotherapy. Patients with stage I laryngeal glottic cancer (T1-N0-M0) were excluded from this study. Mean follow-up was 15 months (range 4 to 181). The mean age was 64.8 years (range 40 to 92). Standard dose varied from 32.65 to 81.81 Gy (mean 66.78). The 5-year overall survival and tumor-specific survival rates were 44.9 +/- 5.8% and 51.4 +/- 5.9%, respectively. Five-year local control and locoregional control rates were 66.4 +/- 5.7% and 61.9 +/- 5.8%, respectively. Multivariate analysis showed that local control was significantly predicted by T stage (p = .032), but not by standard dose (p = .906). Independently significant factors predicting tumor-specific survival included stage (p = .006), site (p = .019), and age (p = .001). Local control and survival were significantly predicted by the TNM-staging classification. The standard dose did not predict local recurrence or survival.     

The clinical management and results of surgery for acute cholecystitis

Malnutrition, a common problem in cancer patients, adversely affects survival and quality of life. It results from several factors that alter nutritional intake and cause massive metabolic disturbances. Anticancer therapies may compound the malnutrition. Optimal nutrition improves therapeutic modalities and the clinical course and outcome. Oral nutrition should be used whenever possible; in patients unable to ingest adequate amounts orally, enteral and parenteral feedings are safe and effective.     

Pilonidal sinus: long term results of excision and closure technic. Review of the literature

The Authors report their experience in the surgical management of pilonidal sinus with modified Leichtling technique. Long term results of various treatments proposed in the past are analyzed: it is not possible to identify a satisfactory procedure for the treatment of pilonidal sinus. Ideal treatment should avoid hospital admission and general anaesthesia, assure a short time of healing, a reduced number of complications, a low risk of recurrence and a minimal time off from work. Authors' variations to the original technique show good results for non recurrent pilonidal sinus and a lower number of failed primary healing. Recurrences are probably related to the patient anatomical status which may be modified only by flattening natal cleft or surgically changing follicles orientation of presacral skin, together with a meticulous hygiene and shaving of the presacral healing area as well as a dietary regimen for obese patients.     

Bone grafting the piriform aperture deformity in isolated cleft lip patients: indication, technique, and results

PURPOSE: This study was undertaken to determine the effect of a bone graft in the piriform aperture on the nasal deformity and orthodontic treatment of the cleft side teeth in isolated cleft lip patients. PATIENTS AND METHODS: All primary cleft lip repair was done 3 months after birth. Nine patients, four female and five male, with a mean age of 12.5 years (range, 8.2 to 24.8 years) and with a repaired cleft lip, were bone grafted between 1992 and 1996. The mean postoperative period was 2 years (range, 1 to 4 years). An iliac crest bone graft was placed in the piriform aperture deformity on the side of the cleft lip. The improvement in the nasal symmetry and angulation of the cleft side teeth were evaluated. The eight growing cleft lip patients (mean age, 11 years; range, 9 to 13 years) were compared with a control group of eight healthy growing children (mean age, 11 years; range, 9 to 13 years). The improvement of nasal symmetry was measured by the formula of the lobule portion of the columella index preoperatively and postoperatively. RESULTS: The mean lobule portion of the columella index preoperatively was 41.8% (SD, 4.4%; SE of Mean, 1.5%) and postoperatively was 44.2% (SD, 4.9%; SE of Mean, 1.6%) (P > .006, t-test for paired samples). The angulation of the cleft side teeth was improved by orthodontic treatment. CONCLUSION: Bone grafting the piriform aperture deformity results in a stable result and improves nasal symmetry and the angulation of the cleft side teeth.     

The Array multifocal lens--functional principle and clinical results

BACKGROUND: Common refractive bifocal IOLs feature 2 or 3 spherical zones with different refraction; the design of the Array multifocal IOL consists of 5 concentric zones, each of them providing a progressive near addition with multiple foci by means of an aspherical surface. METHODS: As a part of a prospective study, distance and near visual acuity, contrast sensitivity, glare and depth of field were examined in 15 patients with the Array lens and a monofocal control group 12 months after implantation. Subjective assessment of the optical quality was performed by detailed asking for optical symptoms. Results were retrospectively compared with the one year follow-up of 15 patients with diffractive bifocal IOLs. RESULTS: No difference was found for best corrected far and near visual acuity and sensitivity for high contrasts. Glare and sensitivity for low contrasts of the monofocal IOL was significantly superior to both multifocal models. Array IOL and diffractive IOL achieved a near acuity of Nieden 2-1 with only distance correction; defocus curves revealed an increase in the depth of field, but with a superiority of the Array lens in intermediate imaging. Optical symptoms as halos were much more frequent in patients with the diffractive IOL than in the Array group. CONCLUSIONS: Functional results of the Array multifocal IOL seem to be comparable to those of the diffractive bifocal IOL, but with the advantage of an improved intermediate imaging and a reduction of optical side effects.     

Extracapsular axillary node extension in patients receiving adjuvant systemic therapy: an indication for radiotherapy?

PURPOSE: This is a retrospective review into the patterns of failure of 82 patients with Stage II or III breast cancer who had extracapsular extension (ECE) of axillary nodal metastases and who received systemic chemotherapy or hormonal therapy without loco-regional radiation. METHODS AND MATERIALS: The clinical records of patients with axillary node positive (T1-T3, N1, 2) Stage II or III breast cancer seen at the London Regional Cancer Centre between 1980-1989 were reviewed. Patients were identified who underwent segmental mastectomy with axillary node dissection or modified radical mastectomy and received adjuvant chemotherapy or tamoxifen but did not undergo loco-regional radiation. Eighty-two patients within this group had pathologic evidence of extracapsular axillary node extension (ECE). For 45 of these patients the extension was extensive, and for the remaining 37 it was microscopic. This ECE-positive group was compared to a subgroup of 172 patients who did not have pathologic evidence of extracapsular axillary node extension but had metastatic carcinoma confined within the nodal capsule. RESULTS: Median age of the 82 ECE-positive patients was 56 years. Twenty-five patients had had a segmental mastectomy, the remainder a modified radical mastectomy. Median actuarial survival was 60 months, with a median disease-free and loco-regional failure-free survival of 38 months. Seventy-eight percent of these patients developed a recurrence, which was loco-regional in 60% (21% local, 21% regional, 2% local and regional, and 16% loco-regional and metastatic). There was a 36% recurrence rate in intact breast, 14% the chest wall following modified radical mastectomy, 7% relapsed in the axilla, 12% in supraclavicular nodes, and 1% in the internal mammary nodes. A comparison of the 82 ECE-positive patients with a group of 172 ECE-negative patients determined that there was a statistically significant difference between the two groups in terms of survival (overall and disease-free) and loco-regional recurrence. Univariate analysis of the entire 254 node-positive patient group revealed extracapsular nodal extension (ECE) to be a prognostically significant factor for actuarial and disease-free survival as well as for loco-regional failure, but ECE did not remain an independently prognostic factor after multivariate analysis. Segmental mastectomy, positive resection margins, and ER negative status increased the risk of loco-regional recurrence within the ECE-positive group. CONCLUSIONS: Extracapsular axillary node extension is a prognostically significant factor for actuarial survival, disease-free survival, and loco-regional failure but not independent of other adverse prognostic factors. It is a marker for increased loco-regional recurrence associated with doubling of breast, chest wall, and supraclavicular recurrence rates. The risk of axillary relapse in patients who have had an adequate level I and II axillary dissection but demonstrate extracapsular extension is low (7%). We recommend breast/chest wall and supraclavicular radiation for all patients with pathologic evidence of such extranodal extension who have had a level I and II axillary dissection regardless of the number of positive axillary nodes. Axillary irradiation should be considered for patients who have had only an axillary sampling or level I axillary dissection.     

Experimental, clinical, and metabolic results of side-to-side portacaval shunt for intractable cirrhotic ascites

BACKGROUND: Intractable ascites, refractory to medical therapy, occurs in approximately 10 percent of patients with ascites from cirrhosis and is almost always fatal. Sinusoidal hypertension resulting from hepatic venous outflow obstruction plays a primary role in the pathogenesis of cirrhotic ascites and provides the rationale for decompression of the liver by side-to-side portacaval shunt in treatment of intractable ascites. This report presents the experimental basis for the use of side-to-side shunt and long-term results of a prospective study in 34 selected patients with intractable cirrhotic ascites. STUDY DESIGN: In the experimental studies, hepatic venous outflow obstruction and massive ascites were produced in dogs by ligation of the hepatic veins, and the effect of portacaval shunts on ascites, thoracic duct lymph flow, and aldosterone secretion were measured. In the clinical study, 34 carefully selected patients with cirrhosis (91 percent alcoholic) and truly intractable ascites (failure of medical therapy for 5 to 24 months) underwent side-to-side portacaval shunt. The effects on ascites, survival, metabolic abnormalities, and quality of life were studied prospectively during follow-up that was longer than 5 years in all but two patients. Quantitative Child's risk classes in percent of patients were A in 0, B in 68, and C in 32. RESULTS: In the experimental studies, side-to-side portacaval shunt permanently relieved severe ascites, reduced the 13-fold increase in thoracic duct lymph flow rate to almost normal, and abolished the aldosterone hypersecretory response to minimal hepatic venous outflow obstruction. End-to-side portacaval shunt was much less effective. In the clinical study, side-to-side portacaval shunt reduced mean portal vein-inferior vena cava pressure gradient from 282 mm saline to 4 mm and permanently relieved all patients of ascites without subsequent requirement of diuretic therapy. Two patients who died of hepatoma, and one who died of heart failure developed terminal ascites. Thirty-day mortality rate was 6 percent, and long-term survival rates at 5, 10, and 15 years were 75 percent, 74 percent, and 73 percent. In metabolic studies, side-to-side shunt produced marked diuresis and natriuresis and abolished hypersecretion of aldosterone. Quality of life was generally improved as a result of a low incidence of recurrent portal-systemic encephalopathy (6 percent), abstinence from alcohol in 91 percent, improvement in liver function in 81 percent, and improvement in Child's risk class. The portacaval anastomosis remained permanently patent in every patient. CONCLUSIONS: Side-to-side portacaval shunt is very effective treatment of intractable ascites from cirrhosis. Our results are attributable to careful selection of patients, an organized system of care, and a program of rigorous, lifelong follow-up that emphasizes abstinence from alcohol and dietary protein restriction.     

The indications and choice of the technic for pancreatic resections

The progress of pancreatic surgery naturally leads to broadening the scope of indications for resection of the gland. Over the period 1970 through 1993, in the Clinic of Abdominal Surgery are performed 99 pancreatic resections for carcinoma of the pancreas (including cancer of papilla Vateri (45), endocrine-active tumor of pancreas (5), benign tumor (1), chronic pancreatitis (4), pseudocysts of the pancreas (4), cancer of an adjacent organ infiltrating the pancreas (36), benign lesions to a neighbouring organ (4). The size of resection depends on a number of factors of which location of the neoplasm and stage of the disease are the leading ones. Operations done: duodenopancreatic resection--47, left side hemipancreatectomy--13, resection of the body region and tail of pancreas--14, and partial resection--19. The choice of operative technique is discussed against the background of the variety of indications for pancreatic resection. Special attention is focused on the operative technique used in pancreatoduodenal resection. The practicability of performing pylorus-preserving intervention, the need of vagotomy and its scope are precisely determined. Also discussed are issues relating to the choice of organ for anastomosis with the pancreas and its protection, as well as the variants of successiveness of anastomoses with the biliary canal, residual pancreas and stomach. Morbidity and mortality rates show a decrease parallel to the surgical experience gained.