Carcinosarcoma of the lung with gastrointestinal metastasis. Case report.

An unusual case of carcinosarcoma of the lung with metastasis to the gastrointestinal tract causing intussusception is presented. The clinical, radiologic and histopathologic features are reviewed with reference to relevant literature.     

Subcapital fractures of the femur. Re-operations with internal fixation.

Over a period of 5 years, 55 re-operations with internal fixation were performed on 51 patients. The re-operations constituted 9.2 per cent of all operations employing internal fixation for subcapital fractures of the femur during that period. The indications for re-nailing were penetration of the nail through the femoral head, or slipping of the nail, with or without dislocation of the fracture. Only 26 per cent of the re-nailed fractures healed. Seventy-three per cent showed avascular necrosis and 61 per cent non-union.     

Fistulas of the gastrointestinal tract. Experience with eighty-one cases.

Eighty-one cases of gastrointestinal fistulas are reported. Sixty-seven of these fistulas occurred postoperatively, all of them external, and fourteen occurred spontaneously, all but one internal. Fifty-two patients were treated conservatively and twenty-nine underwent operation, with an overall mortality rate of 23.4 per cent. It is noted that the presence of severe intraperitoneal infection and a high location of the fistula were associated with an unfavorable prognosis, with mortality rates of 31.4 per cent and 48 per cent, respectively.     

Experience with the intraprostatic spiral.

Thirty-six patients have been followed up after insertion of an indwelling intraurethral device for prostatic obstruction. Follow-up exceeded 1 year in some cases. The main problem was dislocation of the spiral not only in the early stages but also after several months. Endoscopic assessment of the obstruction seems important during the pre-operative investigations. The ideal indication is prostatic obstruction in patients who are unsuitable for surgery and who need relief of acute retention for a limited time only. In selected patients the prostatic spiral has a place in the treatment of obstructive prostatism.     

Fracture of the penis with laceration of the urethra.

Two patients are described with severe injury to the penis sustained during sexual intercourse. The literature is reviewed. A conservative approach to management with suprapubic urinary diversion led to acceptable results.     

Experience with the ileal ureter.

The isolated ileal loop often provides a satisfactory solution to the problem of extensive ureteric defects. Our experience in 18 cases of diseased ureters partially or totally replaced by isolated ileal loops is presented. The indications for the operation and important operative and preoperative details are discussed. The operation presents a definite method for renal conservation in many cases in which nephrectomy would otherwise have been unavoidable.     

Calcium transport through the luminal membrane of the distal tubule. I. Interrelationship with sodium.

Calcium (Ca2+) transport by isolated luminal membranes from rabbit renal distal tubule has been characterized. Ca2+ uptake by these membrane vesicles exhibited saturation kinetics. In the absence of sodium (Na+) in the incubation medium, a low affinity system was observed with a KmCa2+ of 2.83 +/- 0.64 mM and Vmax of 3.03 +/- 0.48 pmol/microgram/10 sec. A second type of kinetics was also detected with a high affinity and a low velocity (KmCa2+ 0.04 +/- 0.01 mM, Vmax 1.18 +/- 0.22 pmol/micrograms/10 sec). The luminal membranes from proximal tubules showed a single system with a KmCa2+ of 0.49 +/- 0.20 mM and Vmax of 1.26 +/- 0.17 pmol/micrograms/10 sec. The presence of Na+ sharply decreased Ca2+ uptake by the high affinity system of the membranes from distal tubules, increasing the KmCa2+ to 0.07 mM +/- 0.01 (P less than 0.01) and decreasing the Vmax to 0.27 pmol/microgram/10 sec (P less than 0.005). This effect of Na+ was concentration-dependent, with a half-maximal effect at 38 mM Na+ and a Hill coefficient of 0.9. In contrast, Na+ had no effect on Ca2+ transport through the luminal membranes of proximal tubules nor on the low affinity system of the distal tubule. The composition of the intravascular medium also influenced Ca2+ uptake by the membranes from distal tubules. Compared to mannitol, trans-Na+ or K+ significantly reduced Ca2+ transport. Finally, cis-K+ induced an increase in this transport. As found with Na+, the effect of K+ was concentration-dependent, with a Hill coefficient of 0.42.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experience with the extracardiac conduit.

A review is made of all Mayo Clinic cases wherein 468 patients have received 516 extracardiac conduits in the repair of congenital heart defects. All patients had complex defects, which are classified in 10 basic diagnostic categories. The early mortality rate (which ranged from 4% to 49%, according to diagnostic group) averaged 25%, improving with experience. The postoperative complication rate was 70%. In 1% of operations, compression of the conduit was encountered at chest closure. The conduits placed in 333 patients contained a porcine valve. The conduit diameter averaged 22 mm. At completion of the operation, the mean gradient across the conduit was 22.8 mm Hg. At late study this mean gradient remained at 26 mm Hg in patients who had received the currently employed porcine-valved conduit. The average ratio of intraoperative postrepair ventricular (RV/LV) systolic pressures was 0.68. It was lower among the group who were to survive but was not ov prognostic value in individual cases. Among patients who survived the postoperative period, the late mortality rate (based on a mean of 3.6 years' follow-up) averaged 3.5% per year. Of the long-term survivors, 18% have required reoperation, primarily for replacement of calcified aortic homograft conduits used in the earlier part of the experience. Only 0.8% of porcine-valved conduits have required reoperation. Unrestricted life-styles were possible for 90% of survivors.     

Esophagogastrostomy with the EEA stapler.

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeon's error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.     

Isolation-perfusion of the liver with 5-fluorouracil.

Isolation-perfusion of the liver was performed in ten pigs using 5-fluorouracil administered in the perfusion circuit at doses of 100, 250, 500, and 1000 mg/kg body weight. Perfusion was performed for 60 minutes at normothermic (37 C) or hyperthermic (41 C) temperatures. One animal died shortly after perfusion. Incomplete isolation of the hepatic vasculature in two animals resulted in significant drug leakage into the systemic circulation with resulting hematologic toxicity. Perfusion with 5-fluorouracil at 1000 mg/kg produced hepatic necrosis. Perfusion with 5-fluorouracil at doses of 100, 250, or 500 mg/kg produced no hepatic toxicity except for transient elevations of hepatic enzymes and resulted in no systemic drug toxicity. Levels of 5-fluorouracil tolerated by the liver in the isolation-perfusion system were more than 1000-fold greater than the maximum drug levels achievable by routine systemic, intra-arterial, or intraperitoneal administration.     

Conservative treatment of breast cancer with the QU.A.RT. technique

Data are presented from a randomized, prospective clinical trial comparing the Halsted radical mastectomy with quadrantectomy, axillary node dissection, and breast radiotherapy (QU.A.RT.). From 1973 to 1980, a total of 701 patients with tumors <2 cm and clinically negative axillary nodes were accessed; the mean time on study is 8 years. No significant differences were apparent in local/regional recurrence, relapse-free survival, or survival. Two percent of the patients in either group developed a local recurrence, and an additional 2% demonstrated a regional treatment failure. Relapse-free survival at 8 years was 79% in the mastectomy group and 80% in patients treated with the quadrantectomy regimen; the proportion of patients surviving was 82.5% and 85%, respectively. In histologically node-positive patients, there appeared to be prolonged survival for women treated with quadrantectomy (82% versus 70%), although this difference was not statistically significant. It is concluded that for patients meeting the eligibility criteria of this study, there is no demonstrable disadvantage for the use of quadrantectomy, axillary node dissection, and radiotherapy to the ipsilateral breast.

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Resumen Se presentan los resultados de un ensayo clínico prospectivo y al azar en el cual se comparó la mastectomía radical de tipo Halsted con la cuadrantectomía con disección axilar más radioterapia. Setecientos un pacientes con tumores < 2 cm y ganglios axilares clínicamente negativos fueron introducidos al estudio entre 1973 y 1980; el tiempo promedio de observación es de 8 años. No se encuentran diferencias aparentes en cuanto a recurrencia loco-regional, supervivencia libre de recurrencia o supervivencia global. Dos por ciento de las pacientes en cada grupo desarrollaron recurrencia local y 2% adicionales demostraron falla regional del tratamiento. La supervivencia libre de recurrencia a los 8 años fue de 79% en el grupo con mastectomía y de 80% en las pacientes tratadas con el regimen de cuadrantectomía; la proporción de pacientes sobrevivientes fue de 82.5% y 85% respectivamente. En las pacientes con ganglios histológicamente positivos parece que existiera una prolongación de la supervivencia en las mujeres manejadas con cuadrantectomía, 82% vs 70%, aunque esta diferencia no es estadísticamente significativa. Nuestra conclusión es que para las pacientes que llenen los criterios de elegibilidad del presente estudio no existe desventaja demostrable con el uso de la cuadrantectomía con disección axilar y radioterapia para el seno ipsilateral.

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Résumé Les résultats d'une étude clinique prospective randomisée concernant d'une part la mastectomie type Halsted et d'autre part la quadrantectomie associée au curage axillaire et à l'irradiation du sein sont rappôrtés. De 1973 à 1980, 701 malades qui présentaient une tumeur < à 2 cm et sans adénopathie axillaire ont fait l'objet de cette étude s'étendant sur une période moyenne de 8 ans. Aucune différence dans les résultats obtenus n'a été observée en ce qui concerne la récidive localrégionale, la survie sans récidive et la survie globale. Dans chacun des deux groupes 2% des malades ont présenté une récidive locale et 2% ont enregistré un échec du traitement régional. Le taux de survie sans récidive à 8 ans a été de 79% chez les malades qui ont subi une mastectomie et de 80% chez celles qui ont été traitées par une quadrantectomie, le taux de survie étant respectivement de 82,5 et 85%.En cas d'envahissement ganglionnaire affirmé par l'examen histologique, la survie a été de 82% après exérèse du quadrant tumoral et de 70% appès mastectomie, cette différence numérique n'étant pas statistiquement significative. Ces faits permettent d'affirmer que la quadrantectomie complétée par le curage axillaire et l'irradiation du sein ou siégeait la tumeur ne présente aucun désavantage dès lors que l'indication de ce traitement est portée à bon escient.

     

Dorsal dislocation of the D.I.P. joint with fracture of the volar base of the distal phalanx

Between 1978 and 1985, we treated 12 cases of dorsally displaced fracture-dislocation of the I.P. joint of the thumb or of the D.I.P. joint of the finger, with a volar bony fragment. All were treated surgically, active exercise being started three to five weeks later. At the last follow-up, averaging 6.4 years (range 4.3-10 years) after operation, none of the joints was painful but the range of motion was somewhat limited.