Contralateral limb and patient survival after leg amputation

Fifty-three patients who required amputation for ischemic disease of the legs were evaluated actuarially. The incidence of subsequent contralateral amputation and the length of patient survival were found to be nearly identical to incidence rates reported during the 1960s. The diffuse end-stage nature of the atherosclerotic process which led to the initial amputation in both time periods accounted for the similarity. Operative mortality decreased from more than 10 percent to 1.5 percent, presumably because of improved cardiovascular support and early rehabilitation.     

Role of subtotal colectomy in the treatment of incapacitating constipation

Nine patients from a community surgical practice have been presented who underwent subtotal colectomy with ileal lower sigmoid anastomosis for the treatment of chronic incapacitating idiopathic constipation. Emphasis was placed on carefully selecting patients for this procedure. The results in this small series have been promising. Long-term follow-up is necessary to determine whether the patients will continue to do well. A review of the literature regarding the surgical treatment of constipation has indicated that subtotal colectomy is the most successful form of treatment in select patients. More studies are needed, specifically in the area of radiopaque markers and anorectal manometry, to determine whether or to what extent these procedures can help select patients who might benefit from this procedure.     

Subtotal colectomy with primary anastomosis without diversion in the treatment of obstructing carcinoma of the left colon

A small series of patients with obstruction from an adenocarcinoma of the left colon is presented. The recommended treatment in selected cases is subtotal colectomy with primary anastomosis without diversion. The morbidity and mortality in this small series was minimal compared with those reported in a much larger series of similar cases treated by bowel decompression with or without concomitant resection of the lesion. Further follow-up of this series is needed. However, this procedure should be considered seriously in selected patients with obstructing carcinoma of the left colon.     

Pitfalls in the diagnosis of abdominal aortic aneurysm

The lethal progression of expanding aneurysms may present as a confusing clinical picture. Four cases are reported in which the diagnosis was masked and treatment delayed by symptoms thought to be related mainly to inguinal hernias. It is concluded that there is a subset of patients with aneurysmal progression in whom symptoms are related mainly to the groin. Exhaustive diagnostic methods will detect this condition when the aneurysm is not palpable. The ability to recognize these unique symptoms and signs in elderly men presenting with enlarging inguinal hernias and neuropathy is essential. Biologic and biochemical relations between inguinal hernias and aneurysms may exist.     

A neuromuscular basis for the development of right inguinal hernia after appendectomy

Abdominal muscular contractions may have a protective influence against the development of indirect inguinal hernia. A portion of the transversus abdominus muscles acts on the internal inguinal rings and produces a closure mechanism during voluntary abdominal muscular activity. It follows, therefore, that injury or inactivation of this mechanism may be an etiologic factor in the development of indirect inguinal hernia. One cause of injury to this mechanism is denervation and regional muscle paralysis occurring during a surgical procedure. Electromyographic findings support the hypothesis that paralysis of inferior fibers of the transversus abdominus muscle occurred after appendectomy, and may have been important in the development of an inguinal hernia.     

Percutaneous transluminal angioplasty. Results and surgical implications

This retrospective study of 91 percutaneous transluminal angioplasties in 80 patients showed an overall patency rate by life-table analysis of 46 percent with a follow-up period of 36 months. Success rates were significantly reduced by predilatation ankle-brachial ratios less than 0.45, by diabetes, by pain at rest or necrosis, and somewhat, by older age. The overall success rate for iliac dilatation was significantly better (58 percent) than that in the femopopliteal segments (18 percent). Although percutaneous angioplasty was performed on many patients thought to be high surgical risks, the complication rate was low, and complications that required surgical intervention were rare (4 percent). Angioplasty was used as an adjunct to vascular surgery in several ways. An attempt to dilate a Dacron graft-femoral artery anastomosis was unsuccessful, and one of two dilatations distal to a femoropopliteal bypass was successful. However, the combination of an iliac angioplasty with outflow femoropopliteal or femorofemoral bypass produced a long-term patency rate of over 85 percent, significantly better than that achieved with iliac dilatation alone. Percutaneous transluminal angioplasty is both an alternative and an adjunct which should be considered by vascular surgeons for their patients.     

Fascia lata paraurethrovesical suspension for the correction of stress urinary incontinence in the woman

Fascia lata paraurethrovesical suspension for the correction of stress urinary incontinence in the female was used 68 times in 66 women. There was an 80 percent overall cure rate (74 percent if allowances are made for potential late failure). This cure rate is not considered good enough to recommend the operation as a primary procedure. The simplicity of the operation and the 75 percent cure rate in failed previous Marshall-Marchetti-Kranz-type procedures commend it as a secondary procedure. Improvement in the cure rate is expected with more experience and refinement of technique.     

Pancreaticojejunostomy. Report of a 25 year experience

Surgical therapy for 88 patients operated on between 1958 and 1982 has been reviewed. Ninety-three operative procedures were performed including pancreaticojejunostomy in 56, pancreaticocystojejunostomy in 12, pancreaticojejunostomy with resection of less than 10 percent of the pancreas in 16, and pancreaticojejunostomy with resection of more than 50 percent of the pancreas in 9. Operative mortality was 7.5 percent and operative morbidity was 25 percent. Overall, 63 percent of the patients had an excellent or good result in the postoperative follow-up period which averaged 4 years. In the nonalcohol-induced pancreatitis group, ductal diameter was a good predictor of postoperative success, whereas in the alcoholic patient population, abstinence from further alcohol intake was a more accurate predictor of the success of pancreatic drainage.     

The St. Jude experience

This paper covers our experience with the use of the St. Jude prosthetic heart valve from November 1979 through August 1983 in 91 patients operated on for aortic and mitral valve replacement. Nonfatal complications included hemorrhagic sequela due to anticoagulation, with an annual rate of 1 percent (1.4 percent per 100 patient years), thromboembolism with an annual rate of 0.8 percent (0.87 percent per 100 patient years), sternal infection 1 percent, operative cardiovascular accident 1 percent, and pericardial tamponade 1 percent.Operative mortality was 1 percent, early mortality (within 30 days) was 3 percent, and late mortality was 3 percent, with a total overall mortality of 7 percent. Excluding two patients who died from noncardiac causes, the overall mortality was 5 percent. The mortality rate per year was 2 percent. The survival rate 3.8 years postoperatively was 89 percent for mitral valve replacement patients and 93 percent for aortic valve replacement patients, for an overall 38 year survival rate of 92 percent. All patients were anticoagulated with warfarin. There were no instances of valve failure, replacement, or serious hemolysis. Eighty-three percent were active or working with a New York heart functional class I.In our experience, the complication rate with the St. Jude valve is as low or lower than that for any other mechanical prosthetic cardiac valve available in the world today.     

Safe management of patients with simultaneously occurring prostatism and abdominal aortic aneurysm

In patients who present with both an abdominal aortic aneurysm and signs or symptoms of urinary obstruction from prostatic hypertrophy, prostatectomy should be performed first if the patient's condition permits. Since bleeding from the site of prostatic resection is rare, the interval between prostatic and subsequent aneurysm operations need not be long. One to 2 weeks after hematuria disappears should be sufficient. If clinical conditions prompt emergency operation for a abdominal aortic aneurysm in a patient with prostatism, blood spectrum antibiotics should be used which include coverage for enterococci. Subsequent prostatectomy should be delayed as long as possible unless the patient cannot void or develops a urinary tract infection that cannot be cleared with appropriate antibiotics. Broad spectrum antibodies during and after prostate surgery, in this instance, are mandatory.     

Experiences with autotransfusion during abdominal aortic aneurysm resection

In a series of 79 elective and ruptured abdominal aortic aneurysm resections, the autotransfuser manufactured by the Bentley Laboratories was used in 50 patients. These 50 patients, in whom the average amount of autotransfused blood was 1,500 cc, required a smaller number of intra- and postoperative transfusions, maintained satisfactory recovery hematocrit levels and had an essentially unchanged platelet count throughout the first 24 hours. There was no evidence of laboratory or clinical coagulopathy. The autotransfusion equipment was set up and operated by the patients' anesthesiologists without the assistance of a perfusion technician, and proved devoid of air embolism or clotting components.Although there are many patients whose aneurysms are easily removed and grafted and who require a small number of whole blood transfusions, there still remain operative traps and pitfalls in many patients that suggest to us that the autotransfuser is a security system, and thus it is routinely set up in all cases.     

Ruptured abdominal aortic aneurysm. Treatment and review of eighty-seven patients

Between 1954 and 1973 at the Texas Heart Institute, eighty-seven patients underwent operation for resection of ruptured abdominal aortic aneurysms. Included in this series were eighty-one men and six women who ranged in age from forty-four to eighty-four years. Hospital mortality, including intra- and postoperative mortality (within thirty days of operation), was 21 per cent. Mortality for men was 19.8 per cent and for women, 33.3 per cent.The lower mortality indicates that abdominal aortic aneurysms should be excised electively. When rupture does occur, aggressive surgical treatment can produce gratifying results.     

Fifty families with abdominal aortic aneurysms in two or more first-order relatives

Fifty families were collected with clustering of abdominal aortic aneurysms in two or more first-order relatives. If only one gene is responsible for these patterns, it is likely to be autosomal. However, multigene mechanisms cannot be excluded.     

Abnormal mammographic findings. A critical appraisal

We performed a 1 year review of mammographic interpretations and breast biopsy experiences at Madigan Army Medical Center, correlating biopsy results with mammographic interpretations when possible. Fibrocystic mammary dysplasia was reported in two thirds of our patients, with interpretations heavily weighted toward findings of moderate or severe dysplasia. Sixteen percent of our patients had indeterminate or suspicious mammograms, and only 11 percent of the mammograms were read as normal. Of 19 patients who underwent needle-directed biopsy for nonpalpable lesions and suspicious or indeterminate mammograms, two had invasive cancer and one lobular carcinoma in situ. Our data suggest that many patients who have indeterminate mammograms are followed in preference to early biopsy if there is no palpable lesion and no high yield radiologic criteria of malignancy.     

The implanted pump in metastatic colorectal cancer of the liver. Risk versus benefit

Forty patients with colorectal cancer metastatic to the liver were treated with an implanted pump for hepatic artery perfusion. Regional chemotherapy utilized floxuridine with half of patients also receiving monthly cisplatin. Follow-up was 13 to 29 months. Responses to treatment occurred in 19 patients (47 percent) and correlated with survival of more than 1 year. Several factors produced significant reductions in survival: presence of extrahepatic disease, large tumor volume, jaundice, ascites, or both, and elevated liver chemistry values. These prognostic factors should govern patient selection. Toxicity included gastritis, peptic ulcer, disruption of arterial integrity, and severe chemical effects on the hepatic cells, the bile ducts, and the gallbladder. Over half of the patients had serious toxicity. Two died from biliary strictures without autopsy evidence of tumor. Steps to avoid life-threatening toxicity include ligation of all hepatic artery branches to the stomach, prophylactic cholecystectomy, and reduction of chemotherapy at the first sign of toxicity.     

Alternatives in the treatment of abdominal aortic aneurysms

Most patients with abdominal aortic aneurysm can safely undergo aneurysmectomy. In poor-risk patients the mortality rate is greatly increased. A procedure which is a safe alternative for patients who might otherwise be denied an elective procedure is described. However, this technique for the management of abdominal aortic aneurysm is not a substitute for the classic surgical treatment.