The effect of prolonged clamping and vascular stasis on the patency of arterial and venous microanastomoses

This study was designed to investigate the influence of the volume irradiated on the probability of ureteral complications and to provide data for volume modeling. One hundred thirty-four purpose-bred beagle dogs received single intraoperative doses of 6 MeV electrons ranging from 12 to 54 Gy to three lengths of ureter: 2, 4 or 8 cm. The response was evaluated by excretory urography. The ED50 was 21.9 Gy (95% CI 13.3-30 Gy) for 8 cm 3 years after treatment. The estimated ED50's were greater than 43 Gy for 4 cm and 85 Gy for 2 cm. Reducing the length of ureter irradiated from 8 cm to 4 cm increased the ED50 for ureteral dilation by at least a factor of 2, while reduction from 8 cm to 2 cm increased the ED50 by at least a factor of 4. The ED50 for renal injury secondary to stenosis was 30.5 Gy (95% CI 17.2-232 Gy) when an 8-cm field was irradiated. There was a significant effect of volume irradiated on the frequency of ureteral stenosis. Reducing the length of ureter included in the treatment field should allow delivery of higher doses to tumors without increased complications.     

On the relationship between knowledge and memory for pictures: evidence from the study of patients with semantic dementia and Alzheimer''s disease

Bladder drainage by the duodenal segment (DS) technique is currently the preferred method of pancreas transplantation (PTX) but is associated with unique complications. Over a 7-year period, 191 diabetic patients underwent 201 whole-organ PTXs with bladder drainage using a 6 to 8 cm length of DS as an exocrine conduit. A retrospective chart review was performed to document all DS morbidity. DS complications occurred in 38 cases (19%). Twelve patients developed DS leaks and required operative repair. DS bleeding was documented in 26 cases, necessitating cystoscopy in 22 patients and open repair in eight patients for significant hematuria. Cytomegalovirus (CMV) duodenitis was diagnosed in seven cases, with four presenting as DS leaks and three with hematuria. Five patients experienced ampullary obstruction early after PTX. Rejection of the DS was confirmed by biopsy in 13 patients, including eight cases of acute and five cases of chronic rejection. Two patients had stone formation from the DS staple line. Enteric conversion was performed in five patients for DS abnormalities (leaks in 2 cases, bleeding in 2, and CMV duodenitis in 1). Among patients with DS complications, patient survival is 84% and pancreas graft survival is 68% after a mean follow-up of 44+/-12 months. Complications related to the DS remain an important source of morbidity but rarely cause death after PTX. In spite of unique side effects, transplantation of the DS remains an acceptable alternative for exocrine drainage after PTX.     

A review of tibial lengthening procedures

Eight patients had tibial lengthening procedures according to Anderson's method. The necessity of early determination of callus formation and bone grafting, if necessary, is emphasized. The potential morbidity in this procedure is great and the parents must be made fully aware of them. As Anderson states, it is a procedure that should be reserved for the child between 8 and 12 years old with a predictable discrepancy between 4 and 15 cm. We believe it is a useful procedure in problems of unequal length of the lower limbs but should not be used whem simpler procedures such as femoral shortening or epiphyseal arrest are indicated.     

Intraepiphyseal resection of the proximal tibia and its impact on lower limb growth

From 1989 through 1996, 10 children affected by high grade bone tumors of the proximal tibia underwent an intraepiphyseal intercalary resection. The residual epiphyseal bone segment measured less than 2 cm in thickness in all cases and reconstruction always was performed using the combination of a vascularized fibular autograft and a massive bone allograft. The proximal epiphyseal osteosynthesis was fixed by small fragment screws. The aim of this study was to report the growth pattern of the residual proximal tibial epiphysis and to evaluate any possible lower limb discrepancy and/or deformity after the end of skeletal maturity. At current followup six patients were available for the final evaluation. Radiographic documentation included computed tomography scan of both knees before surgery, a panoramic radiographic view and a computed tomography scan of both lower limbs after the end of skeletal growth. The length of both femurs and tibias, the size of the tibial plateau and of the opposite distal femur, and any possible deformity of femur or tibia were measured and compared with the preoperative data. No patient had a limb length discrepancy greater than 3.5 cm. In all cases the ipsilateral femur had a valgus deformity of the hip develop. In two patients this deformity was associated with an elongation of the femur, partially compensating for the shortening of the tibia. The tibial plateau close to reconstruction grew less than the contralateral one (range 2%-8%) but maintained its normal relationship with the distal femur. None of these patients reported any restriction in recreational activities. They could walk, run, and jump. Their functional result according the International Society of Limb Salvage functional grading system was satisfactory in all cases.     

Aorto-coronary bypass

OBJECTIVES: Saphenous grafts used for coronary artery bypass are classically dissected via a continuous incision of the leg, the thigh or both. Recently, a new video-surgery technique has been introduced in an attempt to reduce the trauma of saphenous vein dissection. The aim of this work was to evaluate the possible benefits of this new technique compared with classical dissection. PATIENTS AND METHODS: Sixty patients requiring coronary artery bypass grafts were included in this study and randomly divided into two groups. In group I (30 patients) the saphenous vein was dissected according to the classical technique. The video-surgery technique was used for the other 30 patients in group II. The two groups were not significantly different for mean age, sex ratio, or history of diabetes or lower limb arteriopathy. The same number of bypasses was performed in both groups (2.6 +/- 0.7). Outcome was compared for: dissection related complications (hematomas, infections), length of the skin incision over the length of the dissected vein, duration of the dissection procedure, and post-operative pain. RESULTS: A leg incision was used in 28 cases out of 30 cases in both groups. The length of the saphenous vein dissected was 27.6 cm in group I and 21.8 cm in group II. The length of the skin incision was 27 cm in group I and only 4.7 cm in the video-surgery group II, giving an incision/vein ratio of 97% and 21% respectively. Operative time was however 37.9 min for group I and 48.5 min for group II. There was no significant difference between the groups for hematoma formation or infection but the patients in the video-surgery group experienced less post-operative pain. CONCLUSION: Besides an improvement in the esthetic result, video-surgery dissection of the saphenous vein reduces post-operative pain at the cost of a slightly longer operative procedure.     

Registration of MR and SPECT without using external fiducial markers

The aim of our work is to present, test and validate an automated registration method used for matching brain SPECT scans with corresponding MR scans. The method was applied on a data set consisting of ten brain IDEX SPECT scans and ten T1- and T2-weighted MR scans of the same subjects. Of two subjects a CT scan was also made. (Semi-) automated algorithms were used to extract the brain from the MR, CT and SPECT images. Next, a surface registration technique called chamfer matching was used to match the segmented brains. A perturbation study was performed to determine the sensitivity of the matching results to the choice of the starting values. Furthermore, the SPECT segmentation threshold was varied to study its effect on the resulting parameters and a comparison between the use of MR T1- and T2-weighted images was made. Finally, the two sets of CT scans were used to estimate the accuracy by matching MR to CT and comparing the MR-SPECT match to the SPECT-CT match. The perturbation study showed that for initial perturbations up to 6 cm the algorithm fails in less than 4% of the cases. A variation of the SPECT segmentation threshold over a realistic range (25%) caused an average variation in the optimal match of 0.28 cm vector length. When T2 is used instead of T1 the stability of the algorithm is comparable but the results are less realistic due the large deformations. Finally, a comparison of the direct SPECT-MR match and the indirect match with CT as intermediate yields a discrepancy of 0.4 cm vector length. We conclude that the accuracy of our automatic matching algorithm for SPECT and MR, in which no external markers were used, is comparable to the accuracies reported in the literature for non-automatic methods or methods based on external markers. The proposed method is efficient and insensitive to small variations in SPECT segmentation.     

The laparoscopic sterilization of women

The optimal time for sterilization is 24-36 hours after childbirth or during the 8th week in the postpartum period. The surgical methods of sterilization of the ovarian ducts are simple, harmless, effective, reversible, economical, and voluntary. These considerations also apply to endoscopic methods. For the occlusion of ovarian ducts, electrical current (monopolar and bipolar) and mechanical means (Yoon ring, Hulka and Filshie clips) are used. Unipolar coagulation of the ovarian ducts is another method of surgical sterilization done by laparoscopy. The area of coagulation occupies about 1.5 cm. The length of bipolar coagulation is 10 times larger than the unipolar coagulation site. Patients can be released 4 hours or the next day after the operation. The frequency of complications with bipolar coagulation is low: burning occurs in 0.04-0.1% of cases and bleeding from the mesosalpinx in 0.16-0.5%. The incidence of pregnancy after the operation amounts to 0.1-0.4%. Mechanical methods of sterilization are also reliable, although they are not suitable for all women. For young women who may still want children it is uniquely expedient to employ the Hulka or Filshie clips. In the rest of the cases the Yoon ring can be used, which was first used in the US in 1972 and became popular subsequently. The rate of complications is rare with its use (0.12-3.75%), and pregnancy occurs in 0.08-0.4% of cases. The incidence of complications with the use of clips amounts to 0-0.71%, the pregnancy rate is 0-0.59%, and the possibility of reversal is 80-100%. This method is ideal for young women who do not want to use other contraceptives and who want to have more children.     

Palliative bronchial deobstruction with kinetic radiotherapy in non-small cell lung cancer

The palliative treatment of lung atelectasis can significantly improve the quality of life in the patients who are unsuitable for cure. The authors present a new transcutaneous radiotherapy technique for treating this complication of lung cancer. After conventional and CT localization, a treatment is scheduled featuring a small (3-5 cm wide and 4-6 cm long) single 180 degrees arc beam giving 14 Gy to the 90% isodose line in two daily fractions. The treatment is repeated 3 weeks later (dosage: 28 Gy). The mean dosage to the ICRU reference point was 34 Gy; the min., max. and mean dosages to the planning target volume were 31, and 35 Gy, respectively, in 4 fractions over a 3-week period. Lesions were localized best by positioning the distal end of a fiberoscope close to the tumor and by checking its position under fluoroscopic guidance, on two orthogonal projections, immediately after every treatment session. Nine patients with histologically-proven non-small cell lung cancer were treated. They relapsed after surgery and/or full-course radiotherapy. Lung reventilation, demonstrated with fiberbronchoscopy and on chest films, was observed in 8/9 patients, in 1 of them lasting for about 40 days. In the extant 7/8 cases, it lasted longer (range: 60-180 days). Of the latter patients, 5 are alive and 2 died 60 and 86 days after treatment, with no atelectasis. The treatment was very well tolerated and severe symptoms were relieved with no complications.     

Combination of diathermy and argon plasma coagulation in treatment of cicatricial esophageal stenoses

Scar stenoses of the esophagus are caused by peptic reflux or following surgery of the upper gastrointestinal tract. Short scar cicatricial stenoses are difficult to treat and have a high recurrence rate. Pneumatic dilatations show a short term success. We treated 5 patients with a short scar esophageal stenosis after esophagogastrostomy (n = 3) and after esophagojejunostomy (n = 2). The main symptom was dysphagia. X-ray shows the length of the stenosis (max. 1.5 cm). The stenosis was cutted by diathermy in a starshape. In all 5 cases it was possible to achieve the wide lumen. There were no complications. The combination of diathermy and argon-plasma-coagulation is a safe method, rare of complications in the treatment of short scar stenosis of the esophagus.     

Leg function after radiotherapy for Ewing's sarcoma

Twenty-nine patients with Ewing's sarcoma of the lower extremity who survived for two or more years following therapy (5000 rad locally and systemic chemotherapy) were studied to assess functional status of the affected leg. Twenty-two of twenty-nine were alive and were reexamined; the deceased patients were evaluated by record review. Twenty-two of the twenty-nine had serial radiographs, which were reviewed to assess growth change induced by radiation. The living patients were divided on the basis of clinical examination into four functional groups with Group I comprising patients with minor functional limitations and leg length discrepancy 1.5 cm or less. Group II patients had moderate functional limitations with 2.5-cm leg-length discrepancy or less. Group III patients had severe functional limitations with up to 4-cm leg length discrepancy. Group IV patients had severe complications, sufficient enough to warrant amputation. Thirteen of twenty-two patients were classified as functional Group I, five as Group II, three as Group III, and one as Group IV. Radiographic changes in growing bone did not correlate with functional results. Although a femoral fracture and an age less than 16 years at diagnosis were found to be less favorable prognostic factors for the functional treatment result, these results show that neither femoral location nor young age justify primary amputation for Ewing's sarcoma of the lower leg extremity.     

Monte Carlo calculation of single-beam dose profiles used in a gamma knife treatment planning system

The accuracy of single-beam dose profiles used in the algorithm of the Gamma Knife treatment planning system (Leksell GammaPlan) is verified. EGS4 Monte Carlo calculation was employed to calculate the dose distributions of single-beams in a spherical water phantom with diameter 160 mm. The beams were directed to the center of the phantom. Collimators of 4, 8, 14, and 18 mm sizes were studied. The single-beam dose profiles provided by Elekta (Manufacturer of Leksell Gamma Knife) were excellently consistent with the results of Monte Carlo for the 4, 14, and 18 mm collimators. The maximum discrepancy was less than 3% at all radial distances. For the 8 mm collimator, the maximum discrepancy was 8% in the relative dose in the radial distance range from 4.3 mm to 5.2 mm. Excellent agreement in dose profiles along x, y, and z axes for all collimator helmets by summing over all 201 sources was observed between the cases using the default single-beam dose profiles and the calculated Monte Carlo results, except for the 8 mm collimator helmet along z axis. Such difference may however be too small to give a clinical significance.     

Control of smooth muscle cell proliferation by psoralen photochemotherapy

PURPOSE: Restenosis after balloon angioplasty or the intimal hyperplasia occurring at distal anastomoses of bypass grafts severely limits the long-term therapy for peripheral vascular disease. The aim of this study was to evaluate the application of psoralen photochemotherapy with ultraviolet A (UVA)-activated 8-methoxypsoralen (8-MOP) to suppress smooth muscle cell (SMC) proliferation in vitro by the formation of 8-MOP-DNA monoadducts and interstrand cross-links to inhibit DNA synthesis. METHODS: Bovine aorta SMC (2 x 10(4)/cm2) were treated with 8-MOP (0 to 1000 ng/ml) for 30 minutes, followed by UVA (2 joule/cm2) to determine the dose of 8-MOP and UVA that inhibits SMC proliferation. RESULTS: The results show that 8-MOP in the range 30 to 1000 ng/ml in combination with 2 joule/cm2 UVA inhibited SMC proliferation by 40% to 60% 3 days after treatment. In time course studies the growth of SMC treated with 100 ng/ml 8-MOP and 2 joule/cm2 UVA were monitored over 5 days, and this regimen was found to be cytostatic. SMC viability was confirmed by trypan blue exclusion. CONCLUSIONS: Our studies suggest that 8-MOP/UVA photochemotherapy may represent a novel approach to the control of localized SMC proliferation.     

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

Percutaneous bile duct drainage; experiences with a new type of endoprosthesis]

Self expandable stents were placed percutaneously in 105 patients with malignant biliary obstruction. Stent diameter was 1 cm; length, 3.5-10.5 cm. Of the 60 patients with common bile duct obstruction, 50 died 0.2-12 months (median 3 months) after stent insertion. Two patients developed recurrent jaundice and cholangitis after 6 and 12 months, respectively. One patient underwent reintervention. Ten patients, one after a successful reintervention, were alive without jaundice 1-8 months (median 5 months) after stent placement. Of the 45 patients with hilar lesions, 26 died 0.7-18 months (median 5 months) after stent placement, five of them with signs of cholangitis. Nineteen are alive 1-21 months (median 7 months) afterwards. Reinterventions were carried out in 13 patients (29%). The most common cause of stent malfunction was tumour overgrowth. Stent-related complications were seen in three patients.     

An unusual parotid gland in the tent-building bat, Uroderma bilobatum: possible correlation of interspecific ultrastructural differences with differences in salivary pH and buffering capacity

PURPOSE: To determine the utility and accuracy of helical CT angiography (CTA) in the evaluation of carotid artery stenosis. METHODS: A comparison of CTA and conventional arteriogram was performed in 53 patients undergoing evaluation for carotid artery stenosis. Ninety-six carotid systems were evaluable. CTA stenosis was determined by the percent of area reduction seen on axial images through the level of greatest narrowing. MIP images were used to identify the point of maximal stenosis and to visualize overall vascular anatomy. The percent diameter stenosis was measured on conventional arteriograms using strict North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. RESULTS: Significant correlation was found between CTA and arteriography (NASCET method R=0.87, ECST method R=0.87, p < 0.001). Using NASCET >60% as an indicator for disease, CTA had a sensitivity of 87%, specificity of 90%, accuracy of 89%, negative predictive value of 88%, and positive predictive value of 89%. CTA identified plaque characteristics such as ulcerations (8), occlusion (10), fatty plaques (22), calcifications (48), and fibrosis (2). CTA underestimated 2 cases of short segment stenoses because of volume averaging, but this discrepancy was detected by duplex scan. No complications or renal dysfunction occurred with CTA; 1 patient became symptomatic during arteriography, necessitating termination of the procedure. CONCLUSION: CTA is a safe, non-invasive technique that precisely measures carotid artery area reduction and highly correlates to conventional arteriography. With this new technology, the current standards for carotid artery imaging may need to be reevaluated, and the precise role for helical CTA more clearly defined.     

A growth control approach to Class II, Division 1 cases during puberty involving the simultaneous application of maxillary growth restriction and mandibular forward induction

A simple method that used headgear and a functional appliance simultaneously was used for the correction of Class II, Division 1 cases with severe denture base discrepancy. The treatment restricted the forward growth of the maxilla and advanced the mandible. The functional appliance, referred to as the mandibular growth advancer (MGA), advances the mandible progressively with a splint, with the objective of remodeling the condyle and the glenoid fossa in the temporomandibular joint. Functional adaptation was achieved as the muscles that are attached to the mandible adjusted to new positions. In the two cases that illustrate this method, the ANB angle decreased and the Ar-B distance increased over a short period to four and six times the mean Japanese growth rate, respectively. After the correction of the denture-base discrepancy, a multibracket fixed appliance was used for dental alignment, and good skeletal, occlusal relationships and profiles were obtained. Treatment of severe denture-base discrepancy in this manner may reduce the skeletal abnormality, decrease the number of extraction cases, and shorten the subsequent multibracket treatment time. And it may reduce the iatrogenic side effects caused by prolonged mechanotherapy with a fixed appliance.     

Foreign bodies in the digestive tract

In the past two years time 128 patients-prisoners, who had swallowed foreign bodies, have been observed. Six anchors and crosses, which had been stuck in the esophagus, were immediately and successfully removed endoscopically. Long rods and crosses (60 cases) situated mostly in the stomach or descending part of the duodenum were operated without any complications. A few weeks delay of operation caused the covered perforation of the alimentary tract wall nearly 20% of cases and one of which died. Ingested small foreign bodies (less than 10 cm in length) are harmless, pass spontaneously through the gastrointestinal tract and don't need any surgical intervention. In a few cases those small foreign bodies perforated the guts, covered outside the digestive tract without any complaints.     

Arthroscopic treatment of anterior ankle impingement

Ankle arthroscopy has recently allowed the elaboration of less invasive techniques for the treatment of anterior impingement. Its indications, advantages, and drawbacks in this application are discussed. Between 1987 and 1994, 133 patients were treated for ankle impingement. Among them, 58 patients, 37 men and 21 women (mean age, 28.5 years), who had failed a trial of conservative treatment were treated by means of tibiotalar arthroscopy. Twenty-seven were athletes engaged in sports with abnormal stressing of the ankle. According to McDermott's radiological classification, there were 15 stage I cases, 23 stage II, 13 stage III, and 7 stage IV. Preoperative evaluation with a modified version of McGuire's scoring system gave 50 cases rated as "poor" (< 60 points) and 8 cases rated as "fair" (60-67 points). Treatment consisted of removal of adhesions, cartilage shaving, and removal of the bone impingement with powered instruments, curettes, or small osteotomes. Follow-up was from 8 to 62 months (mean, 21.5 months). The postoperative McGuire ratings were 37 good, 13 fair, and 8 poor. There were no major complications. Recurrence of impingement was observed in four cases of stage III and IV. The conclusion is drawn that ankle arthroscopy is a sound method for the treatment of anterior impingement. Even in cases with severe joint cartilage impairment, it plays a therapeutic role as a means of postponing a possible arthrodesis.     

Proliferative potential of recurrent intracranial meningiomas as evaluated by labelling indices of BUdR and Ki-67, and tumour doubling time

BACKGROUND: Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications. METHODS: One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 +/- 8 cm versus 40 +/- 14 cm), bypasses done (4.1 +/- 1.1 versus 4.2 +/- 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease). RESULTS: Leg wound complications were significantly (p < or = 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p < or = 0.02) and diabetes (p < or = 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p < or = 0.03). Harvest rate (0.9 +/- 0.4 cm/min versus 1.2 +/- 0.5 cm/min) was slower for group A (p < or = 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients. CONCLUSIONS: In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.     

Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989-1994

Recurrent inguinal hernia represents a great problem in surgery given the frequency of this operation, with a recurrence rate of 0.5-8%. Re-recurrence after repair without implantation of a prosthesis occurs in 1-23% of cases. We analyzed our results of patients with recurrent inguinal hernia, operated according to the method of Stoppa. Between 1989 and July 1994 there were 58 operations upon 55 patients with an average age of 65 years, 79% of whom had unilateral and 21% bilateral hernias. 89% of all patients underwent surgery because of a recurrent inguinal hernia. A Marlex mesh was used in 79% of the case. All patients were followed up (mean 35 months, minimum 12 months). Early complications consisted in one hematoma (1.7%), which had to be drained, as well as one early recurrence (1.7%). No infections were observed. The overall recurrence rate was 12%. However, 60% of all recurrences occurred in the few first years after introduction of this technique at our clinic; with growing number of operations and experience with Stoppa's technique, we obtained a recurrence rate of 6-7% per year. In our opinion, supported by the results of other studies, Stoppa's technique is a successful method in the treatment of recurrent inguinal hernia.