Management of postoperative stroke after carotid endarterectomy

Major postoperative stroke after carotid endarterectomy is often due to carotid thrombosis, and prompt thrombectomy can reverse the neurologic deficit. We advise reoperation providing the stroke occurs within several hours of carotid endarterectomy, preferably when the patient is in the recovery room, and reoperation can be done immediately. We do not delay reoperation for angiography. Reoperation has not been beneficial for strokes that occur later in the patient's course or when there has been a severe preoperative neurologic deficit. Patients with a mild postoperative stroke, especially if the stroke represents worsening of a preoperative deficit, will often improve without intervention.     

Cause and noninvasive detection of restenosis after carotid endarterectomy

The incidence of significant restenosis after carotid endarterectomy was studied with ocular pneumoplethysmography. Of 105 operations, symptomatic restenosis occurred in 4.8 percent and asymptomatic restenosis in 6.6 percent. No preoperative factors were identified to be associated with subsequent recurrence. However, technical problems with the end-point of the endarterectomy were associated with restenosis. Half of the restenoses occurred in the first 6 months of operation. The results focus on the need for special attention to the technical management of end-point problems and the need for early noninvasive follow-up to detect a substantial proportion of early restenoses.     

Stroke after carotid endarterectomy: risk as predicted by preoperative computerized tomography

In patients undergoing carotid endarterectomy, the role of preoperative computerized tomographic head scanning in predicting the risk of postoperative neurologic deficit was determined by a retrospective evaluation of a select group of 107 consecutive patients with preoperative scans. Patients with infarction determined preoperatively by computerized tomography were found to be at a significantly higher risk for postoperative neurologic deficit than patients with a normal preoperative computerized tomographic scan. History and physical examination alone detected only 66 percent of the infarctions found with preoperative computerized tomographic scanning in these patients. Because the incidence of infarction revealed computerized tomography in patients with symptoms of a reversible ischemic neurologic deficit was 22 percent, we have proposed a new definition of reversible ischemic neurologic deficit to include the necessary finding of a normal computerized tomographic scan. Patients who presented with transient ischemic attack and the unexpected finding of a subclinical infarction on the preoperative scan were at the same significantly higher risk for postoperative stroke and a permanent neurologic deficit. Computerized tomographic scanning of potential carotid endarterectomy patients is of benefit not only to rule out other sources of neurologic symptoms, but also to predict more accurately the risk of postoperative neurologic deficit.     

Incidence of recurrent or residual stenosis after carotid endarterectomy

The incidences of recurrent and residual stenosis after carotid endarterectomy have been controversial. Duplex scanning has recently provided an accurate noninvasive method of quantifying areas of arterial narrowing, and this technique was used in 122 postendarterectomy vessels from 71 men and 35 women with a mean age of 65.2 years. The average time interval between operation and scanning was 26.3 months (range 1 month to 11.76 years). Postoperative examination of the internal carotid artery revealed no stenosis in 78 vessels, less than 50 percent area reduction in 17 vessels, 50 to 75 percent stenosis in 11 vessels, more than 75 percent area reduction in 9 vessels, and total occlusion in 7 vessels. Thus, 22 percent of the vessels (27 of 122) had total occlusion or more than 50 percent area reduction after carotid endarterectomy. This is a higher rate of recurrent stenosis than was diagnosed by oculoplethysmography, where 7 of 52 vessels (13 percent) had a positive oculoplethysmogram after operation. These data show that the reported incidence of residual or recurrent stenosis after carotid endarterectomy is heavily dependent on the testing method used. Duplex scanning documents a 22 percent frequency of residual or recurrent stenosis, a figure higher than has been reported with less sensitive tests.     

Review of colorectal cancer in patients under age 40 years

Brooke Army Medical Center Tumor Registry records from 1947 through 1980 were reviewed. One hundred forty of 819 patients with colorectal cancer were aged 40 or less. The 5 year survival rate was 35 percent and the 10 year survival rate 32 percent. The predominant presenting symptoms were bleeding, pain and change of bowel habits. The median duration of symptoms was 3 months. There were no Dukes' A patients. The 5 and 10 year survival rates in 19 Dukes' B patients were 67 percent. Thirty-three Dukes' C patients had 5 and 10 year survival rates of 37 and 30 percent, respectively. In 42 Dukes' D patients, however, there were no 5 year survivors, and the mean length of survival was only 10 months. Our findings support previous surveys which have concluded that stage at the time of diagnosis, rather than symptoms, duration or patient age, is the most accurate prognostic factor.     

Cystosarcoma phylloides in adolescent female patients

Nine cases of cystosarcoma phylloides in adolescent female patients are reported along with an additional 35 cases collected from the literature. Analysis of these 44 cases revealed 37 (84.1 percent) benign lesions, 6 (13.6 percent) malignant tumors, and 1 borderline lesion. Excision was the most common operative procedure and was performed in 35 patients. Nine patients underwent mastectomy. There were three recurrent lesions (one benign and two malignant) for a recurrence rate of 6.8 percent. Wide excision was successful in the treatment of recurrent lesions. On the basis of these data, excision is the preferred initial therapy of cystosarcoma phylloides in the adolescent patient regardless of the histologic classification of the lesion. Malignant cystosarcoma is more likely to recur than a benign lesion but a recurrence can be managed with reexcision. Sacrifice of the adolescent breast at the initial procedure is strongly discouraged.     

Consistent, effective technique for muscle and nerve biopsy.

Muscle and nerve biopsy provides information of increasing importance in the management of neuromuscular disorders. A simplified technique is presented that yields a specimen which equals and often surpasses in quality specimens obtained by more complex methods that require specially designed clamps and forceps.     

Blunt injuries to the carotid and vertebral arteries

A small series of patients with blunt injury to either a carotid or vertebral artery is presented. In three patients the injury was recognized relatively promptly. Two underwent surgery and one was observed with reasonably good results. In two patients the injury was unrecognized, resulting in death in one patient and in a severe, fixed, long-term neurologic deficit in the other. It appears likely that reconstruction may be the treatment of choice in any patient with angiographically proven injury unless coma or severe dense hemiplegia is present.     

Uncommon cause of a right upper quadrant abdominal mass in the newborn: Acute cholecystitis

What appears to be the first reported case of an otherwise-asymptomatic newborn with a mass in the right upper quadrant of the abdomen and no signs of biliary disease is presented. At exploration, acute acalculous cholecystitis was found, probably secondary to cystic duct obstruction.     

Incidence of recurrent stenosis after carotid endarterectomy determined by digital subtraction angiography

The results of recent reports of nonselected patients studied by noninvasive techniques suggest there is a 10 to 36 percent rate of restenosis within the first 1 to 2 years after carotid endarterectomy. In the present study of nonselected patients examined by intravenous digital subtraction angiography, only 6.7 percent of operated vessels had recurrent stenosis with a 50 percent or greater decrease in vessel diameter at a mean of 28.5 months postoperatively. These data, when compared with the results of most noninvasive studies, suggest that many of the early lesions regress after 1 to 2 years, as suggested by Zierler et al [8] or that there is a true difference in the rates of restenosis between centers, possibly due to subtle differences in surgical technique or patient risk factors, or both. A symptomatic recurrence rate of only 2.7 percen and a 6.7 percent overall rate of hemodynamically significant recurrent stenosis support the conclusions from earlier and larger series that carotid endarterectomy is a highly effective and durable operation. Although it is important that research centers continue to study the natural history of carotid artherosclerosis and serial changes after carotid endarterectomy, these results suggest that for routine clinical follow-up, frequent and expensive periodic tests to detect recurrent stenosis may not be warranted.     

Bile acid composition and esophagitis after total gastrectomy

Ten patients who had undergone total or subtotal gastrectomy for carcinoma 1 to 8 years earlier were evaluated in terms of subjective symptoms, endoscopy and the presence of bile in esophagojejunal aspirates obtained by direct aspiration during endoscopy. The concentrations of individual bile acids were determined by means of gas chromatography. Six of the patients had macroscopic esophagitis and all of them also had bile in their aspirate. The remaining four patients with normal esophageal mucosa did not have positive specimens. Neither did the total bile acid concentration nor any of the individual bile acids, regardless of whether they were free or conjugated, correlate with the severity of symptoms or the degree of endoscopic esophagitis. Esophagitis healed in all three patients who underwent conversion of loop esophagojejunostomy to a long Roux-Y reconstruction.     

Effects of prophylactic antibiotics on wound infection after elective colon and rectal surgery: 1960 to 1980

Wound infection continues to be a common complication of elective colon and rectal surgery. During the period from 1960 to 1980, 42 prospective, controlled prophylactic antibiotic trials were undertaken which addressed this problem. In this report we have analyzed these trials and compared them to all noncontrolled, prospective wound infection surveys and a representative sample of the retrospective surveys of the same period. From this analysis several conclusions have become apparent: (1) wound infection remains a common complication for which prophylactic antibiotics are generally effective, (2) the most effective agents are those with activity against anaerobic bacteria, (3) orally administered nonabsorbable antibiotics have little effect on reducing wound infection following these procedures, and (4) the optimal antibiotic regimen is yet to be found. The data do suggest, however, the more preferred regimens currently available as well as those worthy of further investigation.     

Routine use of a shunt for carotid endarterectomy

A temporary inlying shunt used during carotid endarterectomy is the ideal method of cerebral protection. The data presented suggest that if meticulous technique is used, the potential complications of a shunt may be avoided and excellent clinical results expected. When a shunt is used properly, carotid endarterectomy may be performed in a teaching situation with a high degree of safety.     

Distal splenorenal shunt: Hemodynamic advantage over total shunt and influence on clinical status,hepatic function and hypersplenism

Clinical status, hepatic function and hypersplenism were investigated in 20 patients who underwent distal splenorenal shunt between January 1970 and June 1978. The operative mortality rate was 5 percent, and encephalopathy of varying degrees affected 30 percent of the patients. There was no recurrence of bleeding, and the 3 to 5 year actuarial survival rate was 78 percent. Hypersplenism was significantly ameliorated in 17 patients (p < 0.01). Serum glutamic oxalacetic and pyruvic transaminase significantly improved postoperatively and bilirubin significantly worsened, whereas other tests of liver function remained unchanged. Our results confirm the efficacy of this procedure in controlling recurrence of bleeding from esophageal varices. Moreover, severe hypersplenism is not an absolute contraindication to the shunt, which is preferable to total shunts since hepatopetal flow is preserved, thus avoiding early hepatic decompensation as demonstrated by the substantial stabilization of the liver function tests in the short run.     

Ultrasonographic screening for evaluation and follow-up of carotid artery ulceration

Routine ultrasonographic screening and examination of patients with and without specific symptoms of carotid artery disease now provides greater understanding of the natural history of the disease. In one year, 194 ulcers were detected, classified, and followed. No initially asymptomatic ulcer shallower than 2 mm later became asymptomatic, and it is concluded that a trial of antiplatelet therapy in these patients would be inconclusive. More than a third of the initially asymptomatic ulcers from 2 to less than 4 mm in depth gave rise to lateralizing symptoms that required surgery, The effects of antiplatelet therapy in this vulnerable population could be readily followed by ultrasonographic monitoring. All patients with ulcers 4 mm or more in depth were initially symptomatic and so required surgery.     

Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.     

Mechanical arm with a universal clamp for intraoperative self-retaining holding of retractors and other equipment

A unique arm is described that attaches to the operating table and has a universal clamp. The arm will hold any retractor or other instrument in exactly the position and with exactly the pressure required. Suggestions for its use are given.     

Surgical management of total carotid artery occlusion: An update

Fourteen operations were performed in 13 patients with total carotid artery occlusion. All patients had symptoms ranging in duration from a few hours to several months. Flow was reestablished in 10 of the 14 arteries operated on, a success rate of 74 percent. Complications included one operative death and one permanent neurologic deficit. An aggressive approach to the surgical management of patients with total carotid artery occlusion is recommended.     

A misdiagnosis of carotid pseudoaneurysm

We report a case of blunt injury of the neck associated with the use of an imported plastic rock-guard designed for use in motorcycle scrambling. The injury may have important implications for the future use of this particular guard.     

Analysis of terrorist injuries treated at Craigavon Area Hospital, Northern Ireland, 1972-1980

As a result of terrorist incidents, 482 patients were seen at a district hospital between September 1972 and December 1980. Details of 339 bomb victims and 115 gunshot victims were available for analysis. Most patients in both categories suffered injuries not affecting vital structures and there was an admission rate of 42 per cent for bomb victims and 81 per cent for gunshot victims. Five patients died in hospital as a result of explosions, and 12 of gunshot wounds. The majority of patients (72 per cent) were seen outside normal working hours (9.00 am-5.00 pm). Initial emergency treatment was carried out at Craigavon Area Hospital and ultimately 41 cases were transferred for either security or medical reasons.