Breast masses in young women

Based on our review we conclude the following concerning breast masses in young women under 30 years of age: (1) Breast masses are nearly always benign. (2) Mammograms are not helpful in most patients. (3) Needle aspiration or needle biopsy is rarely indicated. (4) Excisional biopsy should be performed through a circumareolar or other cosmetic incision. (5) Preparation for frozen section and mastectomy is not indicated. (6) The breast should be reconstructed in layers without drains. (7) Further manifestations of benign disease can be expected in 15 percent of the cases.     

Postoperative necrotizing fasciitis of the abdominal wall

Postoperative necrotizing fasciitis of the abdominal wall is usually caused by peritonitis in patients who have undergone multiple procedures for complications of emergency laparotomy. Better patient survival may be achieved by the following method: thorough peritoneal exploration to drain abscesses, excision of necrotic fascia, temporary Marlex placement, and delayed closure of the wound with skin flaps.     

Advanced hidradenitis suppurativa: Review of surgical treatment in 23 patients

Hidradenitis suppurativa remains a poorly understood disease involving the apocrine sweat glands. Management of 23 patients with the advanced form of the disease has been reviewed. Local therapy and incision and drainage all have an unacceptable rate of recurrence. From our experience, we recommend wide and deep excision of the area involved combined with individualized closure.     

The deleterious effects of high dose cimetidine in acute thermal injury

Pharmacological doses of cimetidine have been reported to reduce oedema formation in murine burn models. Sprague-Dawley rats subjected to a 30 per cent full-thickness burn were treated with cimetidine (200 mg/kg) pre and post burn. Untreated, burned animals and sham-burned animals were also studied. No beneficial effects of cimetidine were demonstrated. Cimitidine increased the water content in lung, stomach and eschar of burned animals. No differences were seen in serum or urine electrolytes, or extrarenal water loss. Cimetidine did reduce serum hyperosmolality seen in unresuscitated burned animals. Multiple doses of cimetidine following thermal injury were associated with a significant increment in mortality rate.     

Primary malignant retroperitoneal tumors: Current management

Our experience with 16 retroperitoneal tumors seen over a 13 year period has been reported. Patients presented with either an abdominal mass or abdominal pain associated with a large retroperitoneal tumor. Delineation of the tumor is best accomplished with computerized tomography and venacavography. Exploration and resection is possible in most patients. Postoperative radiotherapy and chemotherapy are recommended in most patients. Local recurrence frequently occurs and should be diagnosed early and resected aggressively if found.     

Evaluation of the effectiveness of postoperative radiation therapy for the control of local disease

Although we agree that postoperative irradiation does improve the local and regional control, our findings indicate that the rate of control, especially local control, is somewhat less than 90 percent. Our data reveal a recurrence rate of 32.7 percent in advanced, stage III and IV, squamous cell carcinomas in the head and neck treated by surgery and post-operative irradiation; this rate may be even greater with longer follow-up. We recommend that surgeons avoid “close” surgical margins (less than 5 mm) when resecting primary cancers and not rely too heavily on radiation therapy to control residual subclinical disease. It appears that continued study is needed to establish the true efficacy of irradiation in the control of subclinical disease, and that local recurrence must be differentiated from regional recurrence when reporting these results.     

Melanoma today does not require radical surgery

From this study we conclude that melanoma has a more favorable outcome today than 20 years ago, 2 cm margins around the tumor achieve acceptable survival and local recurrence rates, primary closure is preferred when possible, elective regional node dissection is of questionable value, and further trials are warranted to determine optimal therapy for intermediate thickness melanoma.     

Acute perforations of the sigmoid colon secondary to diverticulitis.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.     

Reappraisal of intravenous procaine as a short-acting anesthetic adjuvant

Our data in 74 patients demonstrate that procaine hydrochloride is a safe anesthetic adjuvant in doses of 1 mg/kg/min even when total doses are 5 to 7 g. Blood pressure, heart rate, electrocardiographic variables, and blood gases were not adversely affected. Patients had no nausea or untoward postanesthesia symptoms. Emergence from anesthesia was rapid, within less than 15 minutes in all patients, and most were fully awake before leaving the operating room. In two patients in whom blood levels were studied the drug disappeared within 40 minutes. Procaine is inexpensive, $1.16 for 10 g, and it is not a known liver or kidney toxin. Until studies on cardiovascular dynamics and analgesic effects as in whom a low plasma cholinesterase activity is present or suspected. The clinical appraisal in 56 patients indicates its usefulness in suppressing premature venticular contractions and cough reflexes during endoscopic procedures in the respiratory tract. Procaine can be used to advantage in supplementing general anesthesia in outpatient surgery because of its brief action. For these reasons, the drug merits further study.     

A Prospective Randomized Study of Membrane versus Bubble Oxygenators in Children

We studied 60 children, 2 weeks to 10 years old, prospectively by randomly assigning them to a SciMed membrane oxygenator or Harvey bubble oxygenator. Variables of cardiopulmonary bypass (CPB) were closely controlled: prime, circuit configuration, flow rate, and blood gases. Blood variables measured at eight intervals before, during, and after operation were as follows: seven plasma proteins, free hemoglobin, formed elements, and clotting functions. Preoperatively and postoperatively, we evaluated brain function (psychological testing), renal function (creatinine clearance), and pulmonary function (compliance changes and postoperative shunt fraction). Postoperative blood loss, fever, and length of hospitalization were also evaluated. We compared 302 variables by computer program.No difference (p > 0.05) between the two groups was found in any variable related to CPB or organ function (pulmonary, renal, or cerebral) or in hematological variables except free hemoglobin. After 5 and 60 minutes of CPB and the next day, it was significantly lower (p < 0.05) in the group with a membrane oxygenator. Safety, cost, and convenience, not physiology, should be the major factors in considering membrane versus bubble oxygenators for cardiac operations in children.     

Permanent pacing through a persistent left superior vena cava: an approach and report of dual-chambered lead placement

The patient with a persistent left superior vena cava who requires permanent pacing presents difficulties if no right superior vena cava is present or if it is encountered unexpectedly at pacemaker implantation. A case is presented that illustrates potential problems and suggests a general approach to this situation. Successful transvenous universal pacemaker insertion through a persistent left superior vena cava is reported.