Breast reconstruction after mastectomy

The mastectomy patient presenting to the plastic surgeon often relates a profound sense of deformity. The current state of the art in breast reconstruction allows the plastic surgeon to intelligently address this deformity with procedures capable of achieving pleasing aesthetic results. If adequate soft tissue is present, implantation in the submuscular plane has proved satisfactory. However, if soft tissue deficiencies exist, highly acceptable results have been consistently achieved using the latissimus dorsi myocutaneous flap.     

Subclavian artery rupture (an unusual seat-belt injury).

A case of blunt injury to the subclavian artery in the absence of bony injury or dislocation sustained while wearing a seat belt is described. Its rarity and diagnostic pitfalls are discussed. The mechanism of the injury is analysed. The value of angiography is emphazided. It is suggested that, even in the presence of collateral circulation, exploration and repair should be undertaken.     

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.     

Carcinoma of the stomach after gastric operation

Seventeen cases of carcinoma of the stomach occurring late after previous gastric operation are presented. In all instances, patients had undergone gastroenterostomy, with or without gastric resection. Most patients had undergone the initial operation for peptic ulcer disease an average of 18 years before presenting with the tumor. Endoscopic biopsy of the gastroenterostomy and gastric cytologic evaluation offered a high degree of sensitivity and specificity in making the diagnosis. These tumors appeared to originate in the gastric mucosa near the stoma. Survival was poor with both curative and palliative therapy. Alkaline bile reflux, achlorhydria and bacterial colonization are discussed as possible causes. Patients who have undergone partial gastric resection are at increased risk for the development of carcinoma of the stomach remnant. We recommend that any patient in whom new upper gastrointestinal symptoms develop more than 10 hears after partial gastrectomy should undergo endoscopy with biopsy of the gastric mucosa adjacent to the anastomosis.     

Primary surgery for hyperparathyroidism: The lateral approach after preoperative ultrasonographic localization

Increasing experience and improving equipment has made ultrasonography the localizing test of choice before neck exploration for hyperparathyroidism is carried out. A study of 16 patients who were examined with ultrasonography before exploration showed that the sensitivity for finding enlarged parathyroid glands was 80 percent, the specificity 95 percent, and the diagnostic accuracy 91 percent.Our operative technique was altered from the classic midline exploration, with bilateral division of the strap muscles, to a lateral approach on the basis of our experience with a high-risk patient who had undergone unilateral exploration under local anesthesia after successful ultrasonographic localization. We found the results with the lateral approach to be equivalent to the results using the midline approach. The lateral approach appeared to be more direct, efficient, and less traumatic than the classic midline approach. This technique is well suited for parathyroid exploration with local anesthesia in high-risk patients who have multiple system failure.     

Surgical and nonsurgical treatment of total carotid artery occlusion

The natural history of totally occluded internal and common carotid arteries was studied in 102 patients (109 arteries) with a 97 percent follow-up (mean 39.7 months.) Symptomatic occlusions occurred in 72.6 percent of the patients, the reconstructed group (46 patients) having a greater number of symptomatic vessels than the nonreconstructed group (63 patients) (p less than 0.05). Contralateral disease was encountered in 46 percent. Initial mortality was 5 percent. Twenty patients (19.6 percent) were dead at the time of follow-up. Half of these deaths were from strokes and three fourths from atherosclerotic causes. Persisting neurologic symptoms were present in 14 percent of the patients and new events occurred in 5 percent. Fifteen percent of initially asymptomatic vessels were symptomatic at last follow-up. Twenty-one percent of the symptomatic occluded vessels were symptomatic on follow-up, 16 percent being in the reconstructed group and 26 percent in the nonreconstructed group.     

Noninvasive diagnosis of internal carotid artery occlusion

In summary, internal carotid artery occlusion can be reliably diagnosed by noninvasive techniques, particularly when complementary studies such as B-mode imaging, oculopneumoplethysmography and Doppler frequency spectral analysis are used in combination. Our data suggest that it may also be possible to distinguish acute thrombosis from chronic occlusion by real-time ultrasonography, although further evaluation is necessary. Additional clinically important information about the ipsilateral external carotid artery and the contralateral internal carotid artery is also obtained with this combination of noninvasive studies. Finally, although internal carotid artery occlusion remains a therapeutic challenge to the clinician, its noninvasive diagnosis may be of great help in planning early therapy and in determining arteriographic needs.     

Gastric lymphoma: A clinicopathologic reappraisal

Histologic material from 42 cases diagnosed as gastric lymphoma at Hartford Hospital was reviewed, confirming the diagnosis in 37. Three cases of pseudolymphoma were found. The incidence of gastric lymphoma has increased steadily over the past 50 years: 35 percent of cases occurred during the past decade. Most patients with gastric lymphoma are in the seventh or eighth decade of life. Resection offered the best chance for long-term survival, either alone or with radiation therapy. Nodal status was correlated with length of survival: 60 percent of patients with negative nodes survived 5 years or more. Cases were classified according to the Rappaport classification and the Working Formulation of Non-Hodgkin's Lymphomas. The formulation was more useful than the Rappaport classification in assessing prognosis in various types of lymphoma and better reflects our current understanding of neoplasms of the lymphoid system.     

Parathyroid cysts

Fourteen new cases of parathyroid cyst are presented. Two distinct groups were identified: functioning and nonfunctioning. Patients with functioning cysts presented with hypercalcemia, tended to be men and were older. Patients with nonfunctioning cysts were all women, had normocalcemia and all presented with neck masses. Ultrasonography proved useful while radionuclide thyroid scans were often misleading. In the functioning group removal of parathyroid cysts resulted in postoperative normocalcemia in all cases. In the nonfunctioning cysts thyroid lobectomy was performed in five of six instances. Parathyroid cysts usually contain clear or serous fluid and are surrounded by a well-delineated plane of dissection. We believe that preoperative aspiration of cystic neck masses and consideration of the diagnosis of parathyroid cysts may avoid needless thyroid lobectomy.     

Carcinoid tumors of the colon. A study of 72 patients

Since carcinoid tumors rarely originate in the colon (excluding those that arise in the appendix and rectum), there are few large clinical series describing these neoplasms. Seventy-two patients with colonic carcinoids treated over a 40 year period have been reviewed. The peak incidence was in the seventh decade and females outnumbered males 2:1. Virtually all patients were symptomatic, usually complaining of abdominal pain. The symptom duration averaged 3.6 months. Thirty-eight percent of patients had masses in the right lower quadrant and 16 percent, hemoccult-positive stools. Three patients had a documented elevation of the urinary 5-HIAA level. Nearly 70 percent of the lesions were situated in the right segment of the colon. Barium enemas usually detected the neoplasms. Most patients had colon resections and five had resection of adjacent organs. Forty-four percent of the lesions had spread to regional sites and 38 percent to distant points. Most lesions were bulky. The operative mortality was 19 percent overall. Chemotherapy and radiotherapy did not appear to provide good palliation. Synchronous or metachronous neoplasms developed in 30 patients, especially in the colon, during the period of follow-up. The crude survival rates were 58, 51, 25 and 10 percent at 1, 2, 5, and 10 years, respectively.     

Effect of drug-induced platelet dysfunction on surgical bleeding

Two hundred patients scheduled to undergo a variety of surgical and gynecologic procedures were studied to determine whether increased surgical bleeding occurred in those who had drug-induced platelet dysfunction. Twelve of 55 patients (22 percent) who had a positive drug history and abnormal platelet aggregation were judged to have excessive bleeding at surgery or postoperatively, compared with 7 of 97 patients (7 percent) with a negative drug history and normal platelet aggregation (p < 0.02). The data suggest that drug-induced qualitative platelet dysfunction predisposes to excessive surgical bleeding.     

Acute pancreatitis of biliary origin: Is urgent operation necessary?

In a group of 127 patients with biliary pancreatitis, 60 percent had operation during the same admission after clinical improvement. Only four patients had operation less than 48 hours after admission, and 6 of 25 patients having elective surgery during a later admission had recurrent pancreatitis. Using the delayed approach, the surgeon infrequently finds severe pancreatitis or impacted ampullary stones. Very careful technique in performing common duct exploration is crucial in decreasing morbidity and mortality.     

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.     

Covering stoma for elective anterior resection of the rectum: An outmoded operation?

A prospective multicenter study of the management of large bowel cancer recorded the results in 4,500 patients in whom 2,056 have had an elective colorectal anastomoses. Of these patients, 15.8 percent had a synchronous covering stoma to protect the anastomoses. Although the anastomotic leak rate was high in patients with a stoma, no overall differences were observed in mortality between those patients who had a covering stoma and those patients who did not (7 percent and 6.1 percent, respectively). However, when surgical policies were analyzed, clinically large and statistically significant differences were found. Some surgeons frequently used a covering stoma for low anterior resection whereas others only rarely did so. The differences in anastomotic leak and mortality were 20 percent and 7.8 percent, and 8.4 percent and 3.6 percent, respectively. We conclude that all surgeons should know their own clinical and radiologic anastomotic leak rate. If and when this figure becomes low (less than 5 percent), the covering stomas will become necessary except for the very rare and difficult case.     

Acute acalculous cholecystitis in the critically ill patient

Nine cases of acute acalculous cholecystitis were diagnosed in the surgical intensive care unit at Hartford Hospital during a 2 year period after abdominal, cardiovascular, and traumatic surgery. A tender mass in the right upper quadrant was suggestive but not diagnostic of the condition. Hyperamylasemia was seen in all patients. Ultrasonography is the most useful diagnostic tool; serial studies reveal progressive gallbladder dilatation and edema. Tube cholecystostomy was used in five patients and cholecystectomy in four. Cholecystostomy led to resolution of the inflammatory process in all five patients. Cholecystectomy should be reserved for those patients with extensive gallbladder necrosis. Six of the nine patients in the series died, all from multiple systems failure with concomitant sepsis. Hypotension is probably central to the development of acute acalculous cholecystitis. In the face of elevated intraluminal gallbladder pressure caused by ampullary edema and increased bile viscosity, hypotension may result in mucosal ischemia and necrosis with subsequent bacterial colonization. Acute acalculous cholecystitis represents another organ failure in critically ill patients who are experiencing progressive failure of multiple organ systems. An aggressive approach to the manifestations of organ failure, including acalculous cholecystitis, must be employed.     

Preservation of sight after complete destruction of the eyelids by burning

The destruction of the upper and lower eyelids by burning may present the surgeon with an urgent problem of preparing skin flaps to save the eyes. The outlook will become more serious if the eyes themselves are damaged, but even if the corneas become severely scarred it may be possible to restore sight by the use of a keratoprosthesis. A successful, illustrative case is reported.     

Activity level and employment status after coronary bypass surgery

Questionnaires were sent to 1,100 postoperative coronary patients to evaluate their symptoms, activity level and employment status. Ninety percent considered themselves improved and more active since surgery. Many of the patients were approaching retirement age at the time of surgery, and 20 percent of the group entered retirement postoperatively. Disregarding those who were unemployed or disabled from noncardiac illness before surgery, 82 percent of the patients either retired or returned to work after coronary surgery. From an economic standpoint, the disabled patients who have been able to return to work by virtue of the operation will generate for the economy 34 percent more than the total cost of surgery for all the patients.     

New technique of gastrojejunal anastomosis after partial gastrectomy

The results of a survey of 165 patients who underwent a new technique of gastrojejunal anastomosis after gastrectomy are presented and the technique is described. It consists of jejunal loop division and separate anastomosis of its two limbs to the gastric pouch. Follow-up of 2 to 13 years revealed encouraging results. There is a lower incidence of postgastrectomy complications compared with the standard Polya anastomosis. The factors responsible for the better results are discussed.