Ruptured aneurysm of sinus of Valsalva. Long-term postoperative follow-up

Ruptured sinus Valsalva aneurysm was repaired in 13 patients (mean age c. 33 years). Dyspnea, chest pain, fatigue and palpitation were the most common symptoms and systodiastolic murmur, cardiomegaly and pulmonary congestion the most pertinent clinical findings. The pulmonary-to-systemic flow ratio averaged c. 2.5. Associated cardiac anomalies were ventricular septal defect, aortic or mitral regurgitation, aortic coarctation or subvalvular stenosis, tetralogy of Fallot (altogether 8 cases). The origin of the fistula was the noncoronary, right coronary or left coronary sinus (5, 4 and 3 cases) or was not identifiable (1 case). Rupture occurred into the right atrium (6 cases), right ventricle (6) or pulmonary artery (1 case). Repair was undertaken through aortotomy (6 cases), right ventriculotomy (2) or right atriotomy (1) or through aortotomy + right ventriculotomy or atriotomy (4). In one case aortic valve replacement was performed. All survived the operation. Follow-up averaged 9.6 years. Recurrent fistulation, though with small shunt, was found in two cases. Combined two-dimensional and Doppler echocardiography revealed minor cardiac abnormalities in most patients, particularly aortic regurgitation. All the patients were in NYHA function class I or II.     

Long-term follow-up of meningiomas of the cavernous sinus after surgical treatment alone

OBJECT: The authors report on the long-term outcome in 100 consecutive patients with meningiomas arising from the cavernous sinus (CS) with compressive extension outside the CS. The treatment in all cases was surgery alone without adjuvant radiosurgery or radiotherapy. The aim of this study was to evaluate the percentage of patients in whom surgery alone was able to produce long-term tumor control. METHODS: All 100 patients harbored meningiomas with supra- and/or laterocavernous extension, and 27 had petroclival extension. Surgery was performed via frontopterionotemporal craniotomy associated with orbital and/or zygomatic osteotomy in 97 patients. Proximal control of the internal carotid artery at the foramen lacerum was undertaken in 65 patients; the paraclinoid carotid segment was exposed extradurally at the space made by the anterior clinoidectomy in 81 patients. For the petroclival tumor extension, a second-stage surgery was performed via a presigmoid-retrolabyrinthine or retrosigmoid approach in 13 and 14 patients, respectively. RESULTS: The mortality rate was 5% and two patients had severe hemiplegic or aphasic sequelae. The creation or aggravation of disorders in vision, ocular motility, or trigeminal function occurred in 19, 29, and 24% of patients respectively, with a significantly higher rate of complications when resection was performed inside the CS (p < 0.05). Gross-total removal of both the extra- and intracavernous portions was achieved in 12 patients (Group 1), removal of the extracavernous portions with only a partial resection of the intracavernous portion in 28 patients (Group 2), and removal only of the extracavernous portions was performed in 60 patients (Group 3). The follow-up period ranged from 3 to 20 years (mean 8.3 years). There was no tumor recurrence in Group 1. In the 83 surviving patients in Groups 2 and 3 combined, the tumor remnant did not regrow in 72 patients (86.7%); regrowth was noted in 11 (13.3%). CONCLUSIONS: The results suggest that there is no significant oncological benefit in performing surgery within the CS. Because entering the CS entails a significantly higher risk of complications, radiosurgical treatment should be reserved for remnants with secondary growth and clinical manifestations.     

Treatment of carotid-cavernous fistulas by cavernous sinus occlusion.

The author reports the occlusion of 33 carotid-cavernous fistulas in 31 patients using thrombogenic techniques. In one patient the carotid artery had been occluded previously, in one it was occluded deliberately, and with 31 fistulas it was preserved. There was no mortality and virtually no morbidity.     

Long-term follow-up of patients with Grave's disease treated by subtotal thyroidectomy

This long-term follow-up study of 83 patients with Grave's disease who were treated by subtotal thyroidectomy reemphasizes the fact that postoperative hypothyroidism occurs primarily in the first postoperative year (27 percent of the study patients). In addition, there was no evidence of progressive increase in the incidence of hypothyroidism in subsequent years. Patients treated with radioactive iodine have a reported incidence of hypothyroidism of 70 percent 10 years postoperatively [4]. The 6 percent incidence of recurrent hyperthyroidism is much less than a reported incidence of 90 percent in patients treated with long-term antithyroid drugs [7]. Subtotal thyroidectomy continues to be an excellent method of treatment for patients with Grave's disease and compared favorably with both radioactive iodine and long-term antithyroid drugs.     

Long-term follow-up of patients with hydronephrosis treated by Anderson-Hynes pyeloplasty.

A series of 21 patients with hydronephrosis (mean age 37 years) underwent an Anderson-Hynes pyeloplasty; a nephrostomy catheter was not used routinely. One patient developed urinary leakage post-operatively but this ceased following insertion of a ureteric catheter. Assessment was carried out after a mean observation time of 85 months. Clinical examination, laboratory investigations, urography and renography were performed pre-operatively and at follow-up. There was no evidence of stones or stenosis in the pelvis. Patients operated upon before the age of 30 years showed improved renal function. All patients had symptoms pre-operatively but only one had symptoms post-operatively. It was concluded that the results of surgical intervention in hydronephrosis are excellent, especially in patients aged less than 30 years.     

Radiosurgical treatment of cavernous sinus meningiomas: experience with 122 treated patients

OBJECTIVE: To evaluate the efficacy of gamma knife (GK) radiosurgery, in terms of neurological improvement and tumor growth control (TGC), for a large series of patients with cavernous sinus meningiomas. METHODS: Between February 1993 and January 2002, 156 patients with cavernous sinus meningiomas (35 male and 121 female patients; mean age, 56.1 yr) were treated with GK radiosurgery in our department. GK radiosurgery was used as a first-choice treatment for 75 of 156 patients and as postoperative adjuvant therapy for 81 of 156 patients (all with Grade I meningiomas). Eligibility criteria for radiosurgery were as follows: symptomatic meningiomas and/or documented tumor progression on magnetic resonance imaging scans, conditions of high operative risk, patient refusal of microsurgery or reoperation, tumor volume of <20 cm(3), and location no less than 2 mm from the optic pathways. RESULTS: Follow-up data for at least 12 months were available for 122 patients (median follow-up period, 48.9 mo). Clinical conditions were improved or stable for 118 of 122 patients (97%). Neurological recovery was observed for 78.5% of patients treated with GK radiosurgery alone and for 60.5% of patients treated with adjuvant therapy (P < 0.05). Adequate TGC was documented for 119 of 122 tumors (97.5%), with shrinkage/disappearance in 75 of 122 cases (61.5%) and no variation in volume in 44 of 122 cases (36%); the overall actuarial progression-free survival rate at 5 years was 96.5%. Tumor size regression was observed for 80% of patients with follow-up periods of more than 30 months, compared with 43.5% of patients with follow-up periods of less than 30 months (P < 0.0002). Radiosurgical sequelae were transient in 4 of 122 cases (3.0%) and permanent in 1 case (1%). CONCLUSION: For the follow-up periods in our series (median, >4 yr), GK radiosurgery seems to be both safe (permanent morbidity rate, 1%) and effective (97% neurological improvement/stability, 97.5% overall TGC, and 96.5% actuarial TGC at 5 yr). GK radiosurgery might be considered a first-choice treatment for selected patients with cavernous sinus meningiomas.     

Long-term follow-up of patients with hyperparathyroidism treated by transcatheter staining with contrast agent

Primary hyperparathyroidism is generally treated by primary neck exploration. Particularly in patients with hyperparathyroidism caused by adenoma, cervical exploration is generally curative, and extensive preoperative localization studies are unnecessary. If, after thorough primary cervical exploration, no adenoma is identified or at least four parathyroid glands are not confirmed and the patient's hypercalcemia persists, radiologic localization studies are indicated prior to a repeat operation. Persistent hypercalcemia in defined as the failure of calcium levels to return to normal soon after parathyroid exploration; recurrent hyperparathyroidism is defined as hypercalcemia that follows 6 months of low or normal serum calcium levels. Persistent or recurrent hypercalcemia not controlled by a primary cervical exploration may be due to an ectopic parathyroid adenoma, either outside the usual anatomic sites in the neck or in the mediastinum. Techniques used for localization of these ectopic adenomas include sonography, computed tomography scanning, venous sampling, digital angiography, and selective arteriography. Of these techniques, selective arteriography not only has been precise but also offers the possibility of therapy. A small group of patients who underwent embolization of ectopic parathyroid adenomas through the angiographic catheter was reviewed 6 years ago with the cautious suggestion that this technique, under highly specialized indications, might offer a percutaneous treatment of hyperparathyroidism in selected patients. Since the time of the preliminary report, radiologic techniques have been modified, indications for patient selection have been refined, and experience with this method of managing persistent hyperparathyroidism has increased. It is the purpose of this report to summarize this experience with long-term follow-up of those patients treated by transcatheter staining.     

Long-term follow-up of partial caval occlusion by clip

A series of 55 patients with partial caval occlusion by a smooth clip is presented with a follow-up period of 5 to 12 years. The clip provided continuing protection from fatal emboli. Persistent new postoperative leg swelling was present in 18 percent of patients but was generally well controlled with elastic stockings. In two patients with previous thromboembolism a postphlebitic syndrome proved troublesome. The quality of life led by patients was high and was enhanced by their knowledge of permanent protection against lethal embolism.     

Long-term follow-up of 5 patients with intracranial germinoma initially treated by chemotherapy alone

Summary Background. High rates of overall- and event-free survival have been reported in patients with intracranial germinoma treated by radiotherapy. We report the long-term results after treatment initially with chemotherapy, but without radiation. Patients and method. Five patients with an intracranial germinoma were treated with 2 cycles of etoposide and cisplatin, without radiotherapy. All achieved complete remission; 3 suffered recurrence within 2 years and were again treated with 2 cycles of etoposide and cisplatin followed by radiotherapy. Results. At long-term follow-up, each of the 5 patients was in complete remission without further recurrence. Each patient with a neurohypophyseal germinoma who presented with endocrinopathy had initially recovered endocrinological function. Conclusion. In a patient with a germinoma chemotherapy, and restriction of radiation to those with recurrence may allow restoration of hypophyseal function damaged by the intracranial germinoma without compromising long term survivial.     

Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release

BACKGROUND: Although long-term follow-up studies have shown favorable results, in terms of foot function, after treatment of idiopathic clubfoot with serial manipulations and casts, we know of no long-term follow-up studies of patients in whom clubfoot was treated with an extensive surgical soft-tissue release. METHODS: Forty-five patients (seventy-three feet) in whom idiopathic clubfoot was treated with either a posterior release and plantar fasciotomy (eight patients) or an extensive combined posterior, medial, and lateral release (thirty-seven patients) were followed for a mean of thirty years. Patients were evaluated with detailed examination of the lower extremities, a radiographic evaluation that included grading of osteoarthritis, and three independent quality-of-life questionnaires, including the Short Form-36 Medical Outcomes Study. RESULTS: At the time of follow-up, the majority of patients in both treatment groups had significant limitation of foot function, which was consistent across the three independent quality-of-life questionnaires. No significant difference between groups was noted with regard to the results of the quality-of-life measures, the range of motion of the ankle or the position of the heel, or the radiographic findings. Six patients who had been treated with only one surgical procedure had better ranges of motion of the ankle and subtalar joints (p < 0.004) than those who had had multiple surgical procedures. CONCLUSIONS: Many patients with clubfoot treated with an extensive soft-tissue release have poor long-term foot function. We found a correlation between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft-tissue releases can result in a stiff, painful, and arthritic foot and significantly impaired quality of life.     

Chiari截骨术治疗成人髋发育不良的远期随访

目的:对成人髋发育不良行Chiari截骨术进行远期随访,评估该治疗方法的有效性.方法:对接受Chiari截骨术治疗的病人,分别测定其术前和术后JOA评分、中心边缘角和Sharp角、术后截骨远端内移率和截骨平面的高度,并对影响结果的因素进行相关性分析.结果:平均随访时间为12.8年,病人38例,共45侧髋,其中男3例,女35例,手术时平均年龄为38.5岁.45侧髋中,有17例髋关节骨性关节炎得到明显改善,占37.7%;有13侧髋关节骨性关节炎无明显变化,占28.9%;有15侧髋关节骨性关节炎病变继续恶化,占33.3%.术前JOA平均为59.9分,术后83.8分.术后疗效为优占37.0%,良占34.2%,一般占15.5%,差占13.3%.术前平均中心边缘角-11.5°,术后为24.6°.术前平均Sharp角为54.4°,术后平均为43.3°.平均截骨角度为7.51°,股骨头顶点至截骨平面的距离平均为8.17mm.截骨远端内移率平均值为33.6%.结论:经过10年以上的随访表明,Chiari截骨术能使成人髋发育不良的疼痛症状得到缓解,一部分病人骨性关节炎的过程得到有效的遏制.     

Internal carotid artery occlusion for cavernous segment aneurysm

We review our recent experience with occlusion of the cervical internal carotid artery (ICA) in 15 patients with symptomatic aneurysms of the cavernous segment. All the patients were women and ranged in age from 38 to 74 years. Ten patients sought treatment initially for ophthalmoplegia, 9 for retro-orbital pain, 8 for facial paresthesia, and 3 for loss of vision. Two patients had symptoms of transient ocular or brain ischemia. The diameter of the aneurysm was greater than 3 cm in 10 patients. Ten patients underwent gradual occlusion of the ICA by Selverstone clamp under anticoagulation and monitoring of neurological status. One patient underwent ligation of a severely stenotic ICA under general anesthesia and electroencephalographic monitoring. Four patients underwent trapping of the aneurysm (after attempts at direct obliteration) under electroencephalographic and cerebral blood flow monitoring. Two patients with incompetent circle of Willis collaterals underwent prophylactic superficial temporal artery to middle cerebral artery bypass surgery prior to ICA occlusion. There was no postoperative clinical change in 9 patients. Ophthalmoplegia improved in 2 patients, and facial pain improved in 3. Three patients developed new extraocular muscle palsies within hours of ICA occlusion; these resolved in all patients by 1 week postoperatively. No change in aneurysm size was documented by serial postoperative computed tomographic or magnetic resonance imaging scans. After a follow-up of 5 to 6 years (range, 6 months-9 years), 11 patients have remained neurologically stable. Two patients experienced delayed transient worsening of visual or facial symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term follow-up study of 93 patients with TIA

Long-term outcome and recurrence rate were discussed in 96 patients of TIA out of 792 of cerebral ischemic disease who were admitted to our hospital during the past 11 years. They all had had attacks in the territory of internal carotid artery. Ninety-three patients could be interviewed finally. They included 63 males and 30 females and the age ranged from 36 to 88 years with an average of 60.5 years. The follow-up period ranged from 4 months to 8 years and 10 months with an average of 3 years and 1 month. Cerebral angiography was performed in 88 patients of them and revealed 16 patients of internal carotid artery stenosis, 12 patients of middle cerebral artery stenosis, 19 patients of severe cerebral arteriosclerosis and 41 patients of normal findings. CT scan was performed in 88 patients and showed abnormal findings in 12 patients. Eleven patients of them had lacunar infarction. Twenty-four patients of arterial stenosis (14 patients of internal carotid artery stenosis and 10 patients of middle cerebral artery stenosis) had surgical treatment of STA-MCA anastomosis (the superficial temporal artery-the middle cerebral artery) and carotid endarterectomy because they were considered to be cause of TIA. The other 69 patients were treated conservatively mainly with antiplatelet therapy. Four of 24 surgical treated patients developed another attack of cerebral ischemia thereafter, 2 patients had TIA of the contra-lateral hemisphere, one had cerebral infarction in the territory of posterior cerebral artery and the rest had lacunar infarction in the contra-lateral basal ganglia.(ABSTRACT TRUNCATED AT 250 WORDS)     

心形吻合术治疗先天性巨结肠的远期效果

目的 总结心形吻合术治疗巨结肠的经验。方法 回顾11年来心形吻合术治疗巨结肠的疗效,技术操作及改进,并发症的发生率和防治。结果 193例手术患者得到随访者152例,早期术后并发症15例,其中尿潴留2例,肠炎10例,吻合口狭窄1例,肠梗阻2例。晚期并发症22例,其中肠梗阻2例,便秘5例,切口疝2例,肠炎6例,7例偶有污粪,无盆腔、腹腔伤口感染、肛门失禁和死亡。结论 心形吻合术能明显减少术后并发症,提高疗效。     

Long-term follow-up of patients with node-negative breast cancer treated only by regional therapy.

BACKGROUND. This study examines the potential impact of intercurrent diseases on survival after adjuvant chemotherapy for node-negative (N0) breast cancer in light of 30-year follow-up results in 136 patients with N0 disease receiving only regional therapy at the University of Texas M.D. Anderson Cancer Center between 1958 and 1960. METHODS. We made a retrospective review of treatment records. RESULTS. Thirty-nine women (28.6%) died of the initial breast cancer, including 12 (22%) of 54 premenopausal women, 15 (43%) of 35 perimenopausal women, and 12 (25%) of 47 postmenopausal women (p less than or equal to 0.09). Six (12%) of 49 patients with T1 disease died of the initial breast cancer versus 27 (38%) of 70 patients with T2 disease and 6 (35%) of 17 patients with T3 disease (p less than or equal to 0.006). Five of 10 women died of metachronous contralateral breast primary lesions. Deaths from other cancers occurred in 11%, 2.8%, and 6.4% of premenopausal, perimenopausal, and postmenopausal women, respectively. Deaths from nonmalignant conditions occurred in 22%, 20%, and 59% of premenopausal, perimenopausal, and postmenopausal women, respectively. Overall survival at 30 years was 35 (26%) of 136 patients. CONCLUSIONS. Given these statistics, if one postulates that adjuvant chemotherapy reduces the death rate from an initial breast cancer by 30% to 77% (estimates based on data from adjuvant chemotherapy trials in patients with N+ or N0 disease), a 5% to 12.9% increase in the 30-year survival would have resulted.     

Symptomatic inferior cavernous sinus artery aneurysm associated with cerebral arteriovenous malformation

A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.     

Long-term follow-up of 166 surgically treated patients with congenital hip dislocation

166 patients with congenital dislocation of the hip, ranging from 10 months to 5 years old, were operated between 1958 and 1971. 140 patients were women (84%) and 26 patients were men (16%). 96 patients had unilateral and 70 patients had bilateral dislocation; that makes a total of 236 dislocated hips. 61 patients with bilateral hip dislocation were operated simultaneously on both hips. All the patients were treated with adductor tenotomy and open reduction through Smith Petersen incision with section or elongation of the psoas tendon. The postoperative immobilization consisted in a period of one month pelvic toecast followed by 2 plaster casts with abduction rod during 3 to 5 months. The postoperatory follow-up ranged from 9 years to 26 years, 2 months; average 14 years, 5 months. The clinical evaluation comprises pain, hip mobility, gait and muscle power. Results: excellent 138 (59%); good 66 (28%); fair 29 (12%); and poor 3 (1%). The radiological evaluation considered: Mose; acetabular femoral head index; Wiberg's CD-angle; cervico-diaphysiary angle and radial quotient. Results: normal 5 (2%); excellent 44 (19%); good 78 (33%); subtotal 54%; fair 90 (38%), and poor 19 (8%). Complications (hips); infections 12 (5%); 3 of them deep ones (1%); residual subluxation 19 (8%); reluxation 1 (0.5%). Isquemic necrosis Grade II of T?nnis 31 (13%); Grade III 2 (1%) and Grade IV 1 (0.5%).