Traumatic incarceration of the jejunum between two lumbar vertebrae.

An unusual case of traumatic herniation of the upper jejunum into the lumbar spine is presented. A suggested mechanism of injury is discussed.     

Preliminary study of the upper limb with the use of ultrasound transmission imaging

A biologically safe, noninvasive method for visualizing bone and soft tissue relationships has been developed recently. Termed the ultrasonic transmission imaging system, its advantages include visualization of soft tissues in real time while motion is underway. The image can be correlated to standard x-ray films, but since no ionizing radiation is involved, repeated risk-free visualization of extremities for either diagnostic assessment or biomechanical studies is permitted. Resolution of 1 mm and a depth of field of 8 mm are adequate for visualization of neurovascular bundles, tendons, ligaments, bones, and joints. The image can be digitized and stored for later analysis on computer graphic systems. Pilot studies have correlated the ultrasonic anatomy of normal and abnormal living and cadaver hands with known anatomic structures. The benefits to biomechanical analysis include the ability to visualize and accurately measure in a noninvasive manner the in vivo changes of position of tendons and other structures during movement. These initial efforts indicate the growing diagnostic and analytic capabilities of this instrument.     

A dynamic myocutaneous flap for hand reconstruction

Relocation of functional units by neurovascular pedicle transfer is firmly established in reconstructive hand surgery. Transfer of muscle and overlying skin, the myocutaneous flap, to provide skin cover is equally established. The dynamic myocutaneous flap is an extension of these concepts. Injection studies confirmed that the abductor digiti quinti muscle and its overlying hypothenar skin could be transferred on its neurovascular bundle. This dynamic myocutaneous flap was used to reconstruct both skin cover and functional opposition following resection of an arteriovenous malformation involving the thumb. Other clinical applications would include reconstruction of thenar skin and muscle lost secondary to electrical burns, avulsion, or tumor resection.     

Late right heart reconstruction following repair of tetralogy of Fallot.

Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.     

Clinicopathologic score predicting lymph node metastasis in T1 gastric cancer

Background

Although gastrectomy with adequate regional nodal examination is considered the standard of care for invasive gastric adenocarcinoma, endoscopic resection has been adopted increasingly in select patients with T1 gastric cancer. The objective of this study was to identify preoperative predictors of lymph node metastasis in patients in the United States with T1 gastric cancer.

Percutaneous transvenous endomyocardial biopsy in human heart recipients. Experience with a new technique

Sixty-seven cardiac biopsy procedures have been performed in 17 cardiac transplant recipients at Stanford University Medical Center. Six other patients were biopsied as part of their assessment prior to transplantation. Biopsies were performed percutaneously through a sheath inserted into the right internal jugular vein. Two instruments were used, a Konno-Sakakibara bioptome and a new catheter biopsy forceps of our own design. Biopsies of the endomyocardium sufficient for examination by light and electron microscopy were obtained on all but one occasion. There were no deaths and no serious complications.Serial biopsies performed in the first two months after transplantation were used to diagnose and aid the management of acute rejection episodes. Biopsies on long-term survivors permitted the recognition of late acute rejection episodes and provided a new assessment of the myocardium following cardiac transplantation.Percutaneous transvenous endomyocardial biopsy is simple and safe to perform and is an important new aid in the management of patients following cardiac transplantation.     

Compartment syndromes of the forearm: early recognition using tissue pressure measurements.

A compartment syndrome of the forearm can be a devastating injury if not relieved promptly by early fasciotomy. Of five patients who developed compartment syndromes, compartment pressures were measured in four and found to average 69 mm Hg. Tissue pressure measurements provided early objective evidence of the presence of the compartment syndrome and contributed significantly to the ultimate functional recovery. We would advise repeating the measurement for pressures in excess of 30 mm Hg in the upper extremity, and fasciotomy for pressures in excess of 40 mm Hg when accompanied by any neurovascular compromise.     

Clinical experience with a porcine aortic valve xenograft for mitral valve replacement

Between March, 1971, and July, 1973, 103 patients underwent mitral valve replacement with a glutaraldehyde-preserved porcine aortic valve mounted on a flexible polypropylene, Dacron-covered stent. Overall operative survival was 95.1%. Actuarial analysis of late postoperative results indicates 92% survival through 2 years, with functional improvement in nearly all patients. The rate of systemic thromboembolism has been approximately 1.7% per patient-year without anticoagulants. No valve failure has occurred. We conclude that this xenograft prosthesis provides a technically and functionally satisfactory valve substitute, the durability of which appears to significantly exceed that of previously available tissue valves for mitral replacement.     

Simplified operative method for heart and lung transplantation

An operative method was developed to facilitate heart and lung transplantation. Four consecutive operations in small cynomolgus monkeys (average 4.7 kg) are described in which central cannulation and cardiopulmonary bypass were employed. The major modification from previous reports is the use of a retained portion of the right atrium for a single inflow anastomosis. Preservation of the donor sinoatrial node assures normal sinus rhythm postoperatively. The method obviates potential caval stenosis, and would facilitate the operation in man where the intrathoracic component of the inferior vena cava is short.     

Simultaneous Correction of Aortic Coarctation and Partial Anomalous Pulmonary Venous Return

A 23-year-old asymptomatic woman with aortic coarctation and anomalous drainage of the right inferior and left pulmonary veins underwent correction. Coarctation repair was followed by anastomosis of the anomalous vertical vein to the left atrium under femoral-femoral bypass. A left thoracotomy offered excellent exposure for simultaneous repair of this unusual combination of vascular anomalies.     

Patient-related risk factors as predictors of results following isolated mitral valve replacement

Results following isolated mitral valve replacement in 897 consecutive patients over a twelve-year period were analyzed with regard to the influence of various preoperative patient-related risk factors. Actuarial data analysis allowed definition of major preoperative, etiological, clinical, and hemodynamic correlates to both perioperative and long-term postoperative patient survival. Patient age below 60 years, preoperative New York Heart Association Functional Class of III or less, cardiac index greater than 2.0, and left ventricular end-diastolic pressure of less than 12 mm Hg were all highly significant correlates of improved perioperative as well as long-term patient survival. Patients whose predominant functional lesion was mitral insufficiency had only a 53% five-year survival (187 of 352 patients) following mitral valve replacement as opposed to 70% (521 of 745 patients) for those who had mixed or stenotic mitral lesions. Primary ischemic mitral dysfunction was associated with only 31% five-year survival (17 of 54 patients) after mitral valve replacement in contrast to 69% (480 of 695 patients) for patients with rheumatic mitral lesions. The presence of occlusive coronary artery disease coexisting with, but not the primary cause of, mitral dysfunction was associated with decreased perioperative and late postoperative survival. Results support both earlier operative intervention and wider use of associated procedures, ie, coronary bypass grafting, with mitral valve replacement. Recognition of major preoperative patient-related risk factors should enhance survival following this procedure.     

Double-Patch Technique for Correction of Complete Atrioventricular Canal

This technique involves the use of a crescent-shaped Teflon patch to close the ventricular septal defect and resuspend the septal components of the atrioventricular valves. A pericardial patch is used to close the atrial septal defect. Exposure is excellent and allows accurate leaflet rearrangement.