Breast cancer in association with lobular carcinoma in situ. Clinicopathologic review and treatment recommendation

A 6 year follow-up study of 80 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 percent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (T2 and greater).     

Tracheo-innominate artery fistula

Two additional cases of tracheo-innominate artery fistula are presented. One patient survived after prompt surgical management. The emphasis is placed on prevention. However, when post-tracheostomy or post-tracheal resection is complicated by bleeding, the diagnosis of tracheo-innominate artery fistula must be considered. Only appropriate and immediate surgical intervention will save the patient.     

Compression sclerotherapy: preparation, technique, complications, and results

Compression sclerotherapy is not surgery-free, is not a cure, and rarely produces a "Hollywood leg". Repetitive injections are necessary for cosmetic control. The use of injection-compression for large thigh varicosities associated with saphenofemoral incompetency led to an inordinately high recurrence rate in this study, despite good initial results. By increasing the number of injections at the first session, 75 percent of the limbs were treated in a single session. The reinjection rate to maintain control was approximately 5 percent per year over the 7 year follow-up period. Compression sclerotherapy is an effective method of controlling venous perforators. Patients with bursting pain, severe signs of stasis, or ulceration are ideal candidates. It is particularly applicable to patients who are elderly, obese, or at high risk for other reasons and is a very useful tool in the management of venous disease. It is also very well accepted by patients. The technique should be more widely taught and practiced in North America.     

Hyperparathyroidism: A review

Hypercalcemia with and without clinical manifestation appears to be diagnosed with increasing frequency. If hypercalcemia persists with no other obvious reason, hyperparathyroidism can be suspected with a high degree of certainty. Surgical treatment requires confidence, patience and a thorough knowledge of the embryologic peculiarities and anatomic variations of these glands. In 88 percent of our 71 patients, a solitary benign parathyroid adenoma was diagnosed by light microscopy. Parathyroid four-gland hyperplasia was found in 5.6 percent of the patients and multiple adenoma in 3 percent. The cause of hypercalcemia was not found in 3 percent. All patients treated with parathyroidectomy responded well, with calcium levels returning to normal. Our results confirm that this conservative approach to parathyroidectomy without multiple gland biopsy is the better and more acceptable method of dealing with hyperparathyroidism. Multiple gland dissection biopsy, chest exploration and parathyroid implantation are necessary only in very difficult cases.     

Impacted common bile duct stones

The impacted common bile duct stone can be managed either surgically or radiologically using methods such as percutaneous basket extraction or endoscopic papillotomy. At operation, if an impacted common bile duct stone cannot be removed by the usual methods, duodenotomy and sphincteroplasty are indicated. If the patient's condition is good, sphincteroplasty should not be avoided in the belief that other means of stone removal are superior. However, if the patient's condition is not ideal, sphincteroplasty should be deferred in favor of delayed removal by percutaneous or endoscopic techniques. In patients without percutaneous access to the biliary tree, endoscopic papillotomy can be effective in removing impacted stones, or at least in relieving the obstruction and allowing improvement in the patient's condition before surgical intervention is attempted.     

Experience with 130 polytetrafluoroethylene grafts

One hundred thirty operations utilizing polytetrafluoroethylene (Gore-Tex) grafts were analyzed after follow-up of 1 to 3 years. The results of femoropopliteal below-knee and femorotibial grafts were disappointing. The polytetrafluoroethylene graft is versatile and allows crossing of the knee joint. It will maintain patency into a poor outflow tract and has a low complication rate. Thrombectomy can be accomplished easily and late. The main disadvantage appears to be neointimal hyperplasia, most obvious when the graft is inserted into small vessels. Sudden occlusion is not uncommon.The polytetrafluoroethylene graft is still a second choice to vein. Its use as a composite graft with vein to small vessels deserves further examination.     

Fibroblast inhibition: a new and treatable cause of prosthetic graft failure

We have encountered two patients who had repeated false aneurysms, seromas, and unseated grafts which presented about 18 months after aortobifemoral grafting. An inhibitor of fibroblast growth was detected in each patient's serum by in vitro dilution tests. Normal ingrowth of fibrous tissue resumed after plasmapheresis, leaving the patients clinically stable for up to 3 1/2 years after treatment. Criteria for the diagnosis of fibroblast inhibition are an unseated prosthesis which simulates infection, no bacterial growth on carefully studied cultures, and inhibition of fibroblast growth by the patient's serum in vitro. The diagnosis should be entertained in the differential diagnosis of graft infection when an unseated graft is encountered in association with a late seroma or false aneurysm. Plasmapheresis removed the inhibitor. Fibroblast inhibition has not been reported previously.     

Vein graft stenosis: Characteristics and effect of treatment

One hundred seventy-three femoropopliteal vein grafts were followed carefully for a minimum of 4 years. Twenty percent developed stenosis in the graft or associated with an anastomosis, usually within 2 years. Appropriate secondary operations were effective in increasing 5 year patency by an estimated 16 percent. Thirteen thrombosed vein grafts treated by early thrombectomy and revision gave poor results. Strict follow-up is recommended. Urgent operation is advocated for tight stenosis to avoid the consequences of graft thrombosis.     

Modified Buie amputation for extensive hemorrhoidal disease

Radical anal surgery of the type described for complicated hemorrhoidal and mucosal prolapse has good to excellent anatomic and functional results in 90 per cent of patients. This has been demonstrated in a group of 100 consecutive patients followed for an average of more than two years.     

Complications of surgery for morbid obesity

From experience with 261 jejonoileal bypass operations performed by one surgeon with the assistance of an interested endocrinologist, many problems have been encountered and many apparently solved. However, there are still some unexplained complications requiring further study, and there must be a continuous follow-up of the patients for some years before the operation can be a completely acceptable treatment for morbid obesity.     

Profundoplasty: Expectations and ominous signs

Computer analysis of angiographic data on 50 limbs in which profundoplasty was performed is reviewed. Patients with profundus stenosis and graftable findings on arteriography or with an open popliteal artery had favorable results. Four ominous signs are described: open profundus inflow, competing superficial femoral, poor thigh collateral and poor calf visualization. In the presence of one ominous sign, a success rate of 50 percent can be expected. The presence of two ominous signs is a contraindication for profundoplasty.     

Long-term parenteral nutrition with arteriovenous fistula

Sixteen arteriovenous fistulas were created for parenteral nutrition. The complications included stenosis at the site of needling or at the site of vascular anastomosis. Two infections occurred from the surgical creation of a fistula. There were no infections related to fluid infusion. The advantage of the technique is simplicity of fluid administration and the absence of dressings and catheters between infusions.     

Management of small bowel fistulas

Fifty-two patients with fistulas that arose from the small intestine were encountered in the 6 year span between 1975 and 1981. The mortality rate in this group was 38 percent, the average hospital stay was 95 days, and 47 patients were receiving total parenteral nutrition for an average of 56 days. Intraabdominal sepsis and peritonitis forced early reoperation in eight patients in whom exteriorization of the fistula as an ileostomy and mucous fistula and reconstruction after a long interval, was a more successful means of management than were attempts at immediate resection and anastomosis. Nineteen of 44 patients (43 percent) had spontaneous closure while receiving parenteral nutrition without oral feeding. The average time span to spontaneous closure of the fistula was 25 days. Delayed reoperation was carried out after a long interval in patients without spontaneous closure. There was a high rate of success with resection of the fistula and primary anastomosis.     

Review of conservative surgery in early breast cancer. British Columbia experience

Conservation mastectomy in combination with radiotherapy is becoming an accepted treatment for early breast cancer. No absolute guidelines exist as to appropriate patient selection or correct surgical technique, but certain unifying trends can be ascertained from the current literature. The purpose of this study was to review the literature and to identify areas of incongruence between present management of patients in British Columbia and suggestions in the current literature. One hundred patients were reviewed. Twenty-six percent of them did not receive preoperative mammograms, and tumor stage was inappropriate in 9 percent. Thirteen percent had excisional biopsies only. A quarter of the patients had tumor resection through unfavorably placed incisions. Eight percent did not have estrogen receptor determination. Thirty-nine percent of the pathology reports made no comment as to adequacy of resection margins. It is hoped that these areas that, with proper attention, can improve cosmetic results and decrease the incidence of local tumor recurrence.     

Management of the obese kidney transplant candidate

Obesity is an increasingly common condition that can exclude end stage renal disease patients from consideration of kidney transplantation. The optimal management of obese transplant candidates is uncertain, especially the use of pharmacologic therapies or bariatric surgery. We review the rationale to consider transplantation in obese patients, the impact of obesity on access to kidney transplantation, the evidence for obese patients to lose weight loss prior to kidney transplantation, peri-operative management considerations and specific weight loss strategies prior to transplantation. We also propose an algorithm for pre-transplant management of obese transplant candidates that takes into consideration the patient's peri-operative risk, the anticipated time to transplantation and the risk of delayed graft function. Finally, we suggest a number of areas in need of further research as well as health policy considerations to improve the care of obese kidney transplant candidates.     

Laparoscopy in general surgery.

In the last seven years laparoscopy has become increasingly popular in North America. The procedure has been mainly embraced by the gynecologist. Other specialities have been relatively slow in recognizing its value. Laparoscopy has wide applications in general surgery. It is a useful tool in blunt abdominal trauma and often prevents laparotomy. In patients with acute abdominal conditions, when findings are atypical, uncertainty in diagnosis may be resolved by laparoscopy. In patients with malignant disease it permits assessment of the extent of the lesion and enables accurate selection of the mode of therapy. Numerous procedures per laparoscopy, including biopsies, division of adhesions, cholangiography and collection of samples for bacteriologic studies, may be carried out simultaneously. Complication associated with the procedure are few but may be severe. These can be avoided by careful adherence to proper technic.