Redo surgery for carotid artery stenosis: when and how?

PURPOSE: We analyzed operations performed at our institution retrospectively for recurrent carotid artery stenosis to assess the indication for surgery. We also assessed the techniques used for these operations. PATIENTS AND METHODS: From January 1992 to December 1998 1210 carotid endarterectomies were performed. Forty two (3.4%) of these were for recurrent stenosis. A new vein patch was implanted in 27 cases, PTFE patches were used in nine cases. In six cases an interposition with the great saphenous vein was performed. RESULTS: The mean interval between primary and secondary procedure was 60. 2months (3months to 23yr). Twenty five of our 41 patients had had ipsilateral neurologic symptoms before redo surgery, the remainder were free of symptoms. The grade of stenosis was over 90% in 22 cases, between 75 and 90% in 11 cases and below 75% in nine cases, two cases had aneurysmatic lesions. None of the patients died in the 30day observation period. One patient had a stroke with a permanent neurological deficit. In two cases postoperative bleeding occurred requiring reexploration. Two patients developed hypoglossal neurapraxia and in four patients the recurrent laryngeal nerve was injured. One patient had an apneic episode in the recovery room. CONCLUSION: The reported incidence of recurrent carotid artery stenosis surgery ranges from 3 to 36% and our incidence is at the lower end of this range. The surgical results of reoperating are acceptable with a low incidence of complications.     

Symptomatische Afibrinogenämie

Zusammenfassung Es wird über ein Kind mit rezidivierenden Sinusthrombosen berichtet, das beim ersten Klinikaufenthalt eine Afibrinogenämie durch Defibrinierung mit begleitender Fibrinolyse aufwies.Die Schwierigkeiten und die Bedeutung der Differentialdiagnose des pathologischen Mechanismus werden eingehend diskutiert.Das Krankheitsbild wird als Manifestation des Sanarelli-Phänomens gedeutet.Die Untersuchungen wurden mit Unterstützung der Blood Research Foundation, Washington D. C., durchgeführt.     

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE: To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting. STUDY DESIGN: Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. METHODS: Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. RESULTS: All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements. CONCLUSIONS: The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.     

Radiotherapy for postmastectomy local-regional recurrent breast cancer

From 1980 to 1989, 70 women with postmastectomy local-regional recurrent breast cancer and no clinical or radiographic evidence of distant metastasis were treated with radiotherapy with or without systemic therapy. The interval from mastectomy to local-regional recurrence ranged from 5 to 240 months (median, 34 months). The chest wall alone was involved in 37 patients, the supraclavicular area in 12 patients, the internal mammary node area in 3 patients, the infraclavicular area in 2, and the axilla in 1. Fifteen patients had multiple areas of involvement. The complete response rate was 87%. Further local-regional recurrence developed in at least 21 patients, and distant metastasis developed in at least 41 patients. Twenty-five patients (36%) survived at least 5 years and 15 patients (21%) survived at least 10 years. An initial negative node status and long disease-free interval from mastectomy to recurrence were associated with an improved postrecurrence survival. Patients with local-regional recurrence postmastectomy who do not have clinical or radiographic evidence of distant metastasis should be treated aggressively with radiotherapy with or without systemic therapy. Distant metastasis will develop in most such patients, but the majority will remain free of further local-regional recurrence.     

A randomized study of very accelerated radiotherapy with and without amifostine in head and neck squamous cell carcinoma

Purpose: The aim of this study was to assess whether amifostine could minimize acute mucositis induced by a very accelerated irradiation regimen in patients with advanced head and neck squamous cell carcinoma (HNSCC).

Methods and Materials: Between May 1996 and February 1998, 26 patients with an inoperable nonmetastatic Stage IV HNSCC were entered in this study. The treatment consisted of very accelerated radiotherapy given 64 Gy in 3.5 weeks. The patients were randomized to receive or not 150 mg/m², amifostine (Ethyol, U.S. Bioscience) 15–30 min prior to each radiation session.

Results: Of the 13 patients who received amifostine, definitive interruption of amifostine occurred in 5 cases (38%), due to tolerance problems (vomiting, liver enzyme elevation, generalized erythema). The distribution of Grade 4 mucositis (WHO) was 1 case versus 8 cases, with and without amifostine, respectively. The mean duration of “at least Grade 3” mucositis (WHO) was 25.1 days versus 49.2 days with and without amifostine (p = 0.03). In the amifostine group, 11/13 of the patients required a feeding tube (nasogastric tube or medical gastrostomy), because of acute mucositis, whereas in the control group a feeding tube was necessary in all cases. The mean duration of the use of this feeding tube was 1 month versus 2.5 months with and without amifostine respectively (p < 0.01). Local-regional control was not different between both arms with a median follow-up of 15 months.

Conclusion: Despite the limited number of patients, this pilot randomized study suggests that amifostine was able to markedly reduce the severity and duration of mucositis induced by very accelerated radiotherapy. However, the tolerance of this twice daily amifostine schedule was relatively poor.     

Current and potential therapeutic uses of lanthanide radioisotopes

In the last 25 years, diagnostic nuclear medicine has come to depend on the versatile chemistry of a single radioisotope, technetium-99m (Tc-99m). Different chelating molecules can be used to guide Tc-99m through various physiological pathways in the body to gain information about disease states. No single radioisotope similarly dominates therapeutic applications. In the field of radioisotope therapy, much discussion and debate have focused on what radioisotope might be "ideal" for treatment of malignant tumors. The ideal may not be a single radioisotope, but rather the class of very closely related radiolanthanides and lanthanide-like radioisotopes. These radioisotopes possess strikingly similar chemistries and thus all may be conjugated to biomolecules using a single chelate, the DOTA moiety (and its chemical analogs). They also provide a wide range of physical characteristics, such as half-lives and beta energies, that can be chosen to match the biological properties of the conjugated biomolecule and the malignant tumor. Thus, the radiolanthanide-DOTA bioconjugate model provides a set of physically diverse, but chemically very similar, therapeutic radiopharmaceutical agents, the individual members of which can be tailored to treat specific types of cancers.     

New Technique for the Use of a Precision Attachment in the Fabrication of a Cast Crown/Core and Post Unit: Procedures and Case Report

A case report of a prefabricated cast post system, Flexi-Cast, is presented. This tech-nique provides maximium retention of the post in the root and crown to a core by incorporation of a prefabricated split-shank threaded post with an attachment sleeve. Clinically this appears to be a simple predictable technique for the fabrication of a crown/core as a single unit.