Morphologic quantitation of pseudointima and effects of antiplatelet drugs on vascular prostheses in goats

The natural process of endothelialization, pseudointimal formation, and connective tissue incorporation of the expanded PTFE grafts in the goat was documented through histologic examination of specimens harvested at 2, 4, 6, and 8 weeks. The goats demonstrated a progressive increase in pseudointimal pannus ingrowth from the anastomoses at a rate of 11.3 mm over a 12 week period. Histologic changes according to time of vascular graft incorporation in the goat model were found to be comparable to those of the dog, pig, and calf models reported in the literature. Platelet-inhibiting drugs, aspirin, dipyridamole, nifedipine, and ibuprofen were administered to goats after replacement of their infrarenal aorta with 5 cm of 8 mm diameter expanded PTFE grafts. The effects of the drugs on graft endothelialization and anastomotic pseudointimal formation was compared with those in the untreated control group after 12 weeks. Aspirin and dipyridamole had no detrimental effect on the healing process compared with the untreated control group. Studies with nifedipine and ibuprofen did not demonstrate a decrease in pseudointimal hyperplasia. Antiplatelet treatment resulted in no significant change in the rate of endothelialization of expanded PTFE grafts.     

Quantitative effects of antiplatelet therapy on healing of the endarterectomized canine aorta

This study was designed to quantitatively evaluate the effects of an antiplatelet agent, ibuprofen, on mural thrombus formation and pseudointimal development in the endarterectomized canine aorta. A 3 cm segment of abdominal aorta was endarterectomized in 18 dogs. Nine dogs served as controls and nine dogs were treated with ibuprofen (12.5 mg/kg) given intravenously 1 hour preoperatively and orally (7.5 mg/kg) three times a day in the postoperative period. Three dogs were killed from each group at 7, 14, and 21 days. Healing of the endarterectomized aortic segment was assessed by means of computerassisted surface morphometry, light microscopy, and both scanning and transmission electron microscopy. One week postoperatively, the thrombus-free surface in the treated dogs was 75 percent, compared with 20 percent in control animals; at 2 weeks 97 percent, compared with 38 percent and at 3 weeks 98 percent, compared with 38 percent (p < 0.01 for each group). The thickness of the pseudointima was 9 percent of the aortic wall thickness in treated dogs compared with 60 percent in control animals 1 week postoperatively (p < 0.001); at 2 weeks 24 percent in treated animals and 64 percent in control animals (p < 0.001); and at 3 weeks 31 percent in treated animals and 55 percent in control animals (p < 0.05). Partial reendothelialization was observed 1 week postoperatively and complete reendothelialization at 3 weeks in both the control and treated animals. These data suggest that administration of preoperative and maintenance therapy with ibuprofen significantly reduces mural thrombus formation and pseudointimal thickness in the endarterectomized canine aorta.     

Splenectomy in high-risk primary renal transplant recipients

One hundred sixty-five high-risk patients who were either 50 years of age or older or had diabetes mellitus, or both underwent primary renal transplantation. One hundred eight had splenectomy and 57 did not. Graft and patient survival were analyzed in regard to whether splenectomy had been performed at all and whether it had been performed 30 days or more before transplantation, less than 30 days before, or at the time of transplantation. Also, the influence of age, diabetes, blood transfusions, blood type, donor type, HLA mismatch, pretransplantation dialysis, and percentage of performed antibodies were analyzed, as were complications and causes of death. Differences in patient survival were not significant in any one of these categories, although survival in the splenectomized group was generally better. The incidence of infection and sepsis was comparable in both groups and was responsible for death in 34 percent of the patients who underwent splenectomy compared with 22 percent of those who did not (no significant difference). Splenectomy improved cadaver donor renal allograft survival (p = 0.001) in the diabetic patients (p = 0.015) and in those 50 years of age or older (p = 0.026) but it did not improve survival in those who received living related donor kidneys. No significant differences were detectable in regard to the timing of splenectomy. The effect of splenectomy was significant in the patients who had not received transfusions (p = 0.003). It also improved survival in the transfused patients. Splenectomy in high-risk diabetic patients and patients 50 years of age or older does not seem to be associated with increased mortality.     

Recurrent and metastatic cystosarcoma phyllodes

During a 30 year period (1950 to 1980), 42 patients with cystosarcoma phyllodes were seen at the Mayo Clinic. Ten patients (24 percent) had recurrence of metastasis. The malignant or metastatic potential could not be identified or predicted by histologically evaluating tumor contour, stromal atypia, or mitotic activity. Spread was chiefly by a hematogenous route, and no patient with metastasis survived. Five of the 10 patients died from their disease 2 to 7 years after treatment. Simple mastectomy appears to be the surgical treatment of choice.     

Total pancreatectomy for ductal adenocarcinoma of the pancreas. Mayo Clinic experience

This review reveals that, once again, surgical therapy of ductal adenocarcinoma of the pancreas has been thwarted, probably by the inherent biologic aggressiveness of this particular malignancy. The operative mortality rate (greater than 10 percent) coupled with the 5 year survival rate of 2.3 percent is eloquent testimony to this. Multicentric disease occurred in one third of the patients, whereas extrapancreatic spread was found in half of the resected specimens. At 1 year, the only statistically favorable determinants were multicentricity and female sex. The main bonus of total pancreatectomy appears to be the elimination of pancreatojejunal anastomosis with its lethal complications.     

Cholecystostomy for noninflammatory disease

Cholecystostomy in patients with noninflammatory disease of the biliary tract has rarely been evaluated. Our experience with 124 patients suggests that, in addition to being helpful in inflammatory conditions, cholecystostomy is helpful in performing cholangiography, in removing stones and in decompressing an otherwise obstructed biliary tree. The mortality associated with this procedure is minimal, and the morbidity is 4.5 percent.     

Mechanisms of rectal continence. Lessons from the ileoanal procedure

To clarify mechanisms of rectal continence, we evaluated 34 patients who had straight or J-pouch ileoanal anastomosis. This evaluation included pressures, anal inhibitory reflex, neorectal capacity, neorectal compliance, and the ability to discriminate stool from gas. Both groups of patients had satisfactory anal sphincter resting pressures and neorectal capacities, and all could discriminate stool from gas despite the absence of any rectal mucosa. We conclude that normal rectal mucosa is not necessary to be able to discriminate stool from gas; a long rectal muscular cuff is not necessary for rectal sensation; essentially normal sphincter function is preserved, and this procedure does not normally fail because of inadequate sphincter function or the absence of the anal inhibitory reflex; and in the presence of normal sphincter function, continence is not dependent on the presence of normal mucosa or the anal inhibitory reflex but correlates with reservoir capacity and compliance as well as with the frequency and strength of intrinsic bowel contractions.     

Hypothyroidism after thyroidectomy for Graves' disease

In 100 patients who underwent subtotal thyroidectomy for Graves' disease in 1970 through 1975, postoperative hypothyroidism developed in 75 patients an average of 4.6 months after operation. One patient had permanent hypocalcemia. Unilateral vocal cord function was abnormal postoperatively in three patients. Thyroidectomy for Graves' disease is used at our institution much less frequently than in the past and its use is being restricted to a younger population. The low recurrence rates of thyrotoxicosis (1 percent) was obtained at the expense of a high rate of postoperative hypothyroidism.     

Primary hyperparathyroidism and nonmedullary thyroid cancer

Of 2,058 patients who had surgically proven primary hyperparathyroidism at the Mayo Clinic from 1965 through 1979, 51 or 2.5 percent had associated nonmedullary thyroid carcinoma. A history of radiation exposure to the head and neck was obtained in 14 of 43 patients questioned. Thyroid disease consisted of grade 1 papillary adenocarcinoma in 48 cases and pure follicular adenocarcinoma in 3 cases. The parathyroid disease included 41 single adenomas and 5 cases of parathyroid hyperplasia; 5 patients had 2 adenomas. At follow-up, none of the patients had evidence of metastatic thyroid carcinoma. Ten patients were receiving calcium or vitamin D supplementation for protracted hypocalcemia presumably due to the increased insult to the parathyroids from combined bilateral thyroidectomy and parathyroidectomy. More conservative thyroidectomy, along with parathyroid autotransplantation when indicated, will provide definitive treatment of the thyroid cancer and at the same time minimize the risk of postoperative hypoparathyroidism.     

Toxic megacolon: Ultimate fate of patients after successful medical management

The clinical course and ultimate outcome in 38 patients with toxic megacolon who were successfully treated nonoperatively has been reviewed. Thirty-two patients had ulcerative colitis and 6 had Crohn's disease. Follow-up was complete and ranged from 3 to 22 years (average 13 years). Eleven of 38 patients (29 percent) eventually suffered second episode of fulminant acute colitis or recurrent toxic megacolon. Ultimately, a total of 18 patients (47 percent) underwent colon resection, which was performed on an emergency or urgent basis in 15 patients. A modified Visick classification was employed to assess the long-term results of medical therapy in the entire group, in patients showing improvement within 48 or 72 hours, in patients 30 years or younger, in patients whose initial presentation of inflammatory bowel disease was toxic megacolon, and in patients with ulcerative colitis as opposed to Crohn's disease. The results were equally poor for all subgroups, and they have strengthened our opinion that medical management of toxic megacolon should be regarded almost exclusively as preparation for imminent surgery.     

EEA stapling for control of acute variceal hemorrhage. Technique and indications

Considerable enthusiasm has recently appeared for the application of the fairly simple technique of EEA stapling (transection and reanastomosis) of the distal portion of the esophagus in patients with esophageal variceal hemorrhage. Technical aspects and practical considerations in the application of this technique have been discussed herein. We have found that the indications for this technique are extremely limited.     

Resection of primary solid hepatic tumors

Experience with surgical management of 60 solid hepatic tumors was analyzed with respect to the size and type of lesion, extent of resection, operative risk, postoperative complications and survival after resection. The present study concerns 46 primary hepatic malignancies and 14 benign lesions. Lesions varied in size from 5 to 29 cm (average 13). The extent of resection required for removal was related to both the size and location of lesions. Twelve trisegmentectomies, 33 hemihepatectomies and 15 major segmentectomies were done. There were three postoperative hospital deaths, two of which were related to extensions of tumor that precluded safe resection. Postoperative complications necessitated hospital convalescence for more than 21 days in 9 of the 57 surviving patients; the hospital stay of the remaining patients averaged 12 days. The 10, 5 and 3 year survival rates of patients who had resection of malignant lesions were 33, 36 and 65 percent, respectively. We conclude that aggressive treatment of primary hepatic malignancy is justified by acceptable operative risk and significant palliation or improved survival.     

Parotoidectomy: Points of technique for brief and safe operation

Parotidectomy is, in the experience of some surgeons, a very long and cumbersome procedure. If followed in detail, the technique that has been presented makes it possible to perform the procedure safely and in a relatively short period of time.     

Adrenal surgery: Trends during the seventies

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.     

Subcutaneous mastectomy in the treatment of breast disease

Subcutaneous mastectomy should be performed only for certain well-outlined indications. Preoperative discussion should emphasize that the procedure is not prophylactic for breast cancer, that significant complications are a possibility, and that conclusive data as to diminution of risk are not yet available. Resection of breast tissue including the tail of the breast, should be carefully carried out, deliberately leaving only a small remnant under the areola for preservation of blood supply. Implants should be placed submuscularly leaving all residual breast tissue readily palpable to the examining finger. Continued follow-up procedures and self-examination are to be stressed.     

Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie's syndrome). Report of 22 cases and review of the literature

This report has described a series of 22 patients who underwent colonoscopic decompression for acute pseudoobstruction of the colon and summarizes those cases previously reported in the literature. Twenty of the 22 patients (91 percent) were successfully treated by decompression initially. Fifteen patients (68 percent) were cured with the initial procedure, and 4 patients (18 percent) experienced recurrence. Overall, in 17 patients (77 percent), the pseudoobstruction resolved completely with colonoscopic decompression. Three patients (14 percent) underwent operation because of cecal dilatation refractory to colonoscopic decompression, and in one patient (4.5 percent), the colonic dilatation resolved spontaneously after a failed colonoscopy. Complications resulted in the death of one patient (4.5 percent). Our data are similar to those in the literature and indicate that colonoscopic decompression is a safe and efficacious first line of treatment for acute pseudoobstruction of the colon.     

Patient acceptance of mastectomy for cancer

Of 300 women who had mastectomy for breast carcinoma, 278 (93 percent) responded to a questionnaire about how well they accepted loss of a breast. Of those responding, 73 percent stated that they had no appreciable adverse reaction to the extent of the operation. Twenty patients (7 percent) cited major work, social or sexual problems resulting from mastectomy. Among the 20, sexual problems —cited by 85 percent—predominated. Four (1 percent) of the 278 patients expressed major dissatisfaction with the cosmetic result of an external prosthesis. Two of these patients and four others had surgical reconstruction of the breast, which was satisfactory in five.     

Randomized prospective evaluation of the EEA stapler for colorectal anastomoses

A randomized, prospective study should be done to evaluate any new procedure or instrument. Our experience with the end-to-end anastomosis (EEA) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional hand-sewn technique. This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis. There appears to be little difference in the security of a hand-sewn anastomosis compared with that of stapled anastomosis. Postoperative complications appear similar. With the stapler, however, there is an increased risk of intraoperative complications that are not apparent with the traditional hand-sewn technique. These include rectal tears and anastomotic defects. It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis.