Magnetic resonance of the brain: the optimal screening technique

Magnetic resonance (MR) images and computed tomograms of 25 patients with head trauma were compared. MR proved to be superior in many ways for demonstrating extracerebral as well as intracerebral traumatic lesions. Isodense subdural hematomas, which present a diagnostic dilemma on CT images were clearly seen on MR, regardless of their varying CT densities. In a case of epidural hematoma, the dura mater was shown directly as nearly devoid of signal on MR. Direct coronal images provided excellent visualization of extracerebral collections along the peritentorial space and subtemporal area. In a patient with intracerebral hematoma, CT failed to demonstrate residual parenchymal changes in a 3-month follow-up study, but MR clearly depicted the abnormalities. The superiority of MR over CT was also well illustrated in a patient with post-traumatic osteomyelitis of the calvarium.     

Total condylar knee arthroplasty. 16- to 21-year results.

This study presents long term results of arthroplasty with posterior cruciate retention using the Total Condylar Knee implant. From 1976 to 1982, 139 patients had 159 knee arthroplasties using Total Condylar Knee prostheses. Sixty-three patients (72 knees) were available for followup at a minimum of 16 years (range, 16-21 years). The average age of the patients at the time of surgery was 61 years. There were 21 men and 42 women. Patients with 68 knees had osteoarthrosis, three had rheumatoid arthritis and one had posttraumatic arthritis. There were five delayed complications. One patient (one knee) underwent revision surgery and two patients (two knees) declined revision surgery because they were considered to be high surgical risks, as determined by their internists. The average preoperative score was 40.3 points and improved to 88.4 points at followup. Eighty-seven percent of the patients had a score equal to or more than 85 points at last evaluation. Prosthesis survivorship at 20 years was 98.6% for patients who had revision surgery. No femoral components were revised for aseptic loosening. Retention of the posterior cruciate in Total Condylar Knee prosthesis produces results comparable with the results of the original Total Condylar Knee prosthesis with cruciate sacrifice.     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

Anaesthesia for hepatic resection surgery

The first 150 words of the full text of this article appear below. Key points

The liver can regenerate functionally active tissueafter resection.

The commonest indication for hepatic resectionin the UK is for liver metastases from colorectal cancer, forwhich it is the treatment of choice.

There is a potential formajor perioperative blood loss, which is a risk factor for postoperativeliver failure.

Central venous pressure should ideally be <5cm H₂O during resection to minimize bleeding.

Postoperativeliver failure has a high mortality.

  The liver is the only mammalian organ that can regenerate functionallyactive parenchyma after tissue loss. Exploitation of this physiologicalproperty has allowed for the liver resection surgery to develop,and it is now a commonly performed procedure. During the 1970s,perioperative mortality for hepatic resection was quoted around20%, commonly because of uncontrollable bleeding and postoperativeliver failure. Improvements in the understanding of liver anatomy,patient selection, and also surgical and anaesthetic techniqueshave . . . [Full Text of this Article]