Thyroid hemangioma

A case is presented of a fifty-six year old man with a thyroid hemangioma presenting as a neck mass with tracheal deviation and unilateral vocal cord paralysis. A standard thyroid scan yielded equivocal findings. The diagnosis was determined preoperatively by the use of a ^99mtechnetium angiogram that disclosed the vascular nature of the lesion. Subsequent arteriography demonstrated the main arterial supply of the mass to be from both inferior thyroid arteries. Operative removal of the mass was accomplished through a standard transverse cervical incision. Pathologic study revealed that the vascular tumor involved both the surrounding normal thyroid parenchyma and also a microfollicular adenoma. This case points out the value of utilizing all available diagnostic means in atypical cases of thyroid disease.     

Mechanical effectiveness of closed peritoneal irrigation in peritonitis

Peritonitis was produced in rabbits using a human fecal suspension. Catheters for multiple peritoneal lavage then were inserted and continuous irrigation was performed. Contrast material was injected on day 1, 2, or 3 to evaluate the mechanical effectiveness of irrigation. Radiologic studies revealed that contrast material penetrated most or all six regions in all animals. The addition of heparin to the irrigant did not alter the number of regions irrigated. It has been concluded the peritoneal irrigation effectively irrigates most of the peritoneal cavity for up to 3 days.     

Late sequelae of deep venous thrombosis. Diagnostic and therapeutic considerations

The efficacy of heparin, sodium warfarin, and elastic stockings in preventing the late leg sequelae of deep venous thrombosis was evaluated by reexamining 15 patients with previous acute deep venous thrombosis so treated. All 5 patients with iliocommon femoral disease and only 5 of 10 patients with distal disease had evidence of postphlebitic syndrome. Venous Doppler and strain gauge plethysmography confirmed these clinical findings. The most striking and consistent laboratory abnormalities were in the patients with proximal disease. Treatment of acute deep venous thrombosis by traditional means does not prevent the clinical and laboratory late leg sequelae. In light of these findings, serious investigation of new therapeutic modalities is strongly suggested.     

Hemodynamics of sequential grafts

Sequential femoropopliteal-tibial grafts have been advocated as a promising treatment for use in patients with severe ischemia of the distal lower extremity. Proponents hypothesize better patency rates due to documented increases in proximal graft flow with the sequential technique. We hypothesized that the effect of the sequential graft was to create competitive collateral flow and that distal graft flow would not be increased with the addition of a sequential anastomosis. Seven adult dogs with chronic occlusions were studied with angiography and underwent sequential iliofemoral bypass grafting. Proximal and distal flows were measured with and without the sequential anastomosis open to flow. Proximal graft flows increased significantly whereas distal flows decreased significantly in all dogs with an open sequential anastomosis. The study suggests that there may be limitations to the use of sequential bypass grafts.     

Unexpected parathyroid disease discovered at thyroidectomy in irradiated patients

Eight of 23 patients undergoing total thyroidectomy for radiation-associated nodular thyroid disease were found to have unsuspected parathyroid hyperplasia or adenoma at operation. The total serum calcium level was normal preoperatively in each patient. Serum ionized calcium and parathyroid hormone levels were measured in five patients preoperatively and were normal in each case. These pathologic findings in normocalcemic patients may represent a preclinical form of hyperparathyroidism, which would be further evidence linking radiation to the pathogenesis of hyperparathyroidism. The parathyroid glands should be evaluated both preoperatively and at operation in all patients who have a history of radiation and require thyroidectomy.     

Serum neuron-specific enolase: a serum marker for nonfunctioning pancreatic islet cell carcinoma

The isoenzyme, neuron-specific enolase (NSE) was evaluated as a serum marker for nonfunctioning pancreatic islet cell carcinoma. Serum NSE was measured by radioimmunoassay in 6 patients with islet cell cancer and in 22 healthy adults. Mean serum NSE in control subjects was 5 ng/ml (range 3.2 to 8.4 ng/ml). Three of six patients had clearly elevated serum NSE with values that ranged from 22 to 44 ng/ml. One patient had an equivocally elevated serum NSE of 9.2 ng/ml while receiving chemotherapy. When relapse occurred, the NSE level increased to 44 ng/ml. One of two patients with normal serum NSE had undergone radical pancreatectomy and had no evidence of disease when studied. Elevated serum NSE returned to normal limits after removal of all gross tumor in the only patient from whom a preoperative measurement was obtained. Results of this preliminary study suggest that serum NSE levels can aid in the diagnosis and monitoring of the course of nonfunctining islet cell carcinoma.     

Systemic lymphoblastic response to antithymocyte globulin in renal allograft recipients: an initial report.

Three renal transplant recipients developed marked, multiple lymph node enlargement during or soon after intensive horse antihuman thymocyte globulin (ATG) therapy.This lymphoproliferative disorder is morphologically indistinguishable from malignant lymphoma of histiocytic type but is clinically different since rapid regression occurred without antitumor therapy. The disease exhibited a benign clinical course.     

The National Trauma Data Bank story for emergency department thoracotomy: How old is too old?

Background

The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy.

Abnormal drainage of the biliary tree after relief of long-standing extrahepatic biliary obstruction

To assess the progress of pathologic changes of the biliary tree and particularly their role on biliary drainage after the relief of long-standing extrahepatic biliary obstruction, 100 patients with postcholecystectomy choledocholithiasis who underwent choledochoduodenostomy as a supplementary procedure to choledochotomy were assessed by use of barium meal follow-through studies at different postoperative intervals. Patients were divided into two groups (50 patients each). Group A included patients over 50 years of age with a history of symptoms for more than 10 years. The additional criterion used for these patients was the finding of a common bile duct dilatation greater than 3 cm. In contrast, Group B included patients under the age of 50 years with a comparatively shorter history of symptoms (that is, less than 10 years) and with a common bile duct dilatation less than 3 cm. Results revealed that a major proportion of patients in the first group had no effective decompression of their ductal systems and that there existed a feature of biliary stasis associated with a higher incidence of both bile infection and pathologic changes of the biliary tree.     

Pancreatic enzyme levels in bile of patients with extrahepatic biliary tract disease.

A total of ninety three patients with biliary tract disease were studied to determine the concentration of the pancreatic enzymes, amylase and lipase, in bile obtained from the gallbladder and/or common bile duct. Of seventy gallbladder bile samples, amylase levels were higher than actual or predicted serum levels in 87 per cent, while bile lipase were higher than serum lipase values in 66 per cent. Bile obtained from the common bile duct had enzyme concentrations which fluctuated from values similar to those in serum to remarkably high levels. This suggests that pancreatic enzymes enter the biliary system through a common terminal ampulla which is known to exist in 60 to 90 per cent of human subjects. The premise is advanced that pancreatic enzymes may initiate inflammatory changes in the gallbladder and could play a role in gallstone formation by altering the constituents which maintain cholesterol in a soluble state. Biliary reflux of pancreatic enzymes could play a role in the pathogenesis of some cases of cholecystitis can cholelithiasis.     

Technical considerations in elderly renal allograft recipients

Atherosclerosis in renal allograft recipients necessitated modification of vascular anastomoses in 62 per cent of patients older than forty years in contrast with 10 per cent in younger patients. Three forms of vascular disease occurred: atherosclerotic occlusion, tortuosity of vessels, and disruption of plaques by vascular clamps. Successful modifications of the procedure and avoidance of ischemie graft injury are described including relocation of the transplanted ureter.     

Vena cava interruption after pulmonary embolectomy.

Interruption of the inferior vena cava for thromboembolism is occasionally apppropriate following either pulmonary embolectomy or other cardiac operation performed through a median sternotomy. Experience has shown that simple extension of the sternotomy incision to the umbilicus is a quick and practical means of obtaining good exposure for caval interruption.     

Bacterial contamination of the biliary tree after choledochostomy

Secondary exogenous contamination of bile after choledochostomy could be an important cause of long-term morbidity if infection persists after removal of the T tube. Surprisingly, documentation of the frequency of conversion of sterile to infected bile after choledochostomy has rarely been recorded. Patients undergoing exploration and T-tube drainage of the common bile duct between July 1966 and January 1975, in whom intraoperative and postoperative cultures of bile were available, were studied. Postoperative cultures were obtained from five to forty days after operation. Of ninety-five patients available for study, contamination developed postoperatively in previously sterile bile in 44 per cent. The common duct bile contained bacteria at operation in 42 per cent and remained sterile throughout in 14 per cent. The most common secondary contaminants were klebsiella group and Escherichia coli. The fate of the contaminating organisms in a biliary tree without anatomic abnormalities is unknown. Two cases are presented which suggest that persistent infection may linger in the biliary tree for many years and give rise to pigment calculi. Since bacterial cannot be eradicated so long as a foreign body remains in the common duct and because such bacteria may cause symptoms even in an anatomically normal biliary tree, we suggest that a closed system of biliary drainage be employed and that appropriate antibiotic therapy be instituted for seven to ten days after removal of the T tubes.     

Surgery to achieve dynamic motor balance in adult acquired spastic hemiplegia: a preliminary report

Reconstructive surgery of the upper limb was performed in an attempt to restore dynamic motor balance in 55 patients with adult-acquired spastic hemiplegia. An eight-level grading system was developed to determine the level of functional capacity. Because this system proved useful in predicting the results of surgery, it was utilized for operative planning. A two-level increase in functional grade was necessary for patients to obtain a meaningful increase in function. The average improvement after surgery was 2.10 functional levels. A two-level increase was achieved in 73.2% of the patients. No patient decreased in grade, and only one remained unchanged. In selected patients with upper limb spasticity, a predictable improvement in functional capacity can be obtained with dynamic motor balancing surgery.     

Neural control of blood flow in gastric mucosa.

The innervation of the small vessels in the fundic mucosa of the rat and the effects of vagotomy on this innervation were studied ultrastructurally. The capillaries and arterioles, but not the venules, were found to receive direct innervation. Vagotomy causes degeneration of the nerve endings that innervate these vessels, confirming their vagal origin. This finding, and the fact that some morphologic changes in the capillaries were observed after vagotomy, provides morphologic evidence for the neural control of blood flow in the rodent gastric mucosa.     

Surgical technic for the resection of internal carotid aneurysms using an internal shunt

A technic for reconstruction of the internal carotid artery after resection of carotid aneurysms is presented. Reconstruction is performed over an internal shunt using a vein or Dacron patch. Total interruption of cerebral circulation is usually less than three minutes. The technic is described in detail. Oculoplethysmographic and phonoangiographic follow-up studies demonstrate normal carotid flow.