bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of tracheal obstruction from thyroid diseases
Authors: Cady Blake
Published: May 2005

Tracheal or laryngeal obstruction in thyroid disease is such a severe, though uncommon, threat that constant awareness of its occurrence and prevention should be the hallmark of the experienced thyroid surgeon. A high index of suspicion, thoughtful analysis of cases, willingness to accept that such a complication does not reflect on the surgeon's competence, and prophylactic elective use of tracheostomy in patients at high risk will afford safety to the patient and peace of mind to the surgeon.
Early postoperative angiographic control of the warren procedure in 40 patients
Authors: Saubier E. C. , Partensky C. , Gouillat C.
Published: May 2005

Between December 1975 and December 1980, a total of 43 patients with portal hypertension due to intrahepatic block underwent the Warren procedure for distal splenorenal anastomosis. Forty of them were submitted to celiomesenteric arteriography between the 10th and 90th postoperative days to assess the efficacy of the procedure and to estimate its effects on the portal flow to the liver. On the late venous phase of the celiac angiogram, the patency of the shunt was demonstrated in 37 patients (92.5%), along with a consistent reduction of splenic volume; there was a clear flattening of esophageal varices at esophagoscopy. The shunt was not patent in the other 3 patients (7.5%), all of whom had anatomic venous abnormalities (diameter of the splenic vein smaller than 10 mm and/or abnormal renal vein). Two of these patients rebled soon after the operation, while the third subject underwent a prophylactic renoportal shunt.

The effects of the procedure on the mesentericoportal flow were studied on the late phase of the superior mesenteric arteriogram. Venous flow to the liver was unaltered in 28 patients, substantially reduced by a latent partial portal thrombosis in 10 (25%), and totally suppressed in 2. Of these 2 complete portal thromboses, one resulted in early recurrent bleeding, while the other has remained asymptomatic. In spite of the portogastric disconnection, reverse flow in large veins from the portal vein to the cardial varices was observed in 14 patients (35%). Thus, after the Warren procedure, esophageal varices are efficiently decompressed by a patent shunt but portal flow is not always preserved.
Bronchobiliary fistula due to stones in the biliary tree: Report of two cases
Authors: Wei W. I. , Choi T. K. , Wong John , Ong G. B.
Published: May 2005

Two patients with bronchobiliary fistula are reported. Each had a history of biliary disease with operations done prior to the onset of bilioptysis. Obstruction of the biliary tree by stones was the etiology in both cases. The diagnosis was made by detection of bile in the sputum. The definitive treatment consisted of removal of the obstructing stones and excision of the fistula. If emergency surgery is required because of sepsis, external drainage of the abscess and T‐tube drainage should be performed first, followed by definitive procedure after recovery.
The continent colostomy
Authors: Schmidt E.
Published: May 2005

Histological and electron microscopic studies, perfusion manometry, and electromyography document the suitability of using intestinal smooth muscle to construct a sphincteroplasty. Postoperative results, surgical experience, and enterostomal therapy over the past 4 years are discussed. Of 509 patients, 231 underwent surgery in the Surgery Department of Würzburg University Hospital, Würzburg, West Germany, Postoperative functional results are so favorable and complications so few, that the author unreservedly recommends the use of smooth muscle for the creation of a sphincteroplasty, e.g., a continent colostomy.
Postoperative adaptation of the small intestine
Authors: Bristol James B. , Williamson Robin C. N.
Published: May 2005

For nearly 100 years, the small intestine has been known to compensate for partial tissue loss. For only some 20 years has the phenomenon been studied in any depth, and a small proportion of these investigations has been undertaken in humans. Experimental and clinical data show that enteric mucosal hyperplasia in the remaining small bowel after enteric resection or bypass is accompanied by cytokinetic and functional adaptation. In general, the degree of adaptation depends on 3 factors: the amount of tissue excised or excluded, the particular enteric segment involved, and the presence or absence of a normal luminal stream. Thus, massive enterectomy can overwhelm the adaptive capacity of the gut, loss of jejunum is better tolerated than loss of terminal ileum, and total parenteral nutrition will abolish the compensatory response. The mechanisms that govern adaptive change are complex and interrelated. They involve both luminal agents (food, alimentary secretions) and humoral influences, of which enteroglucagon appears to be the most important. Wherever possible, small bowel operations should take account of adaptive phenomena in order to minimize metabolic and nutritional sequelae.
Massive enterectomy: Indications and management
Authors: Hill Graham L.
Published: May 2005

Massive enterectomy in adults may be necessary for Crohn's disease in young patients or for intestinal infarction in older patients. Other indications are rare. When less than 3 m of small bowel remain, a number of serious metabolic and nutritional abnormalities occur. When 2 m or less remain, most patients have a limited work capacity as well, and many patients with less than 1 m of small bowel need parenteral nutrition at home on an indefinite basis. Correct management depends on an understanding of the disordered physiological state brought about by the resection and a realization that adaptation may occur. Based on these principles, the management of these patients in the operating room and during their subsequent rehabilitation is discussed.
An epilogue to jejunoileal bypass
Authors: Baddeley R. Michael
Published: May 2005

The advantages of jejunoileal bypass performed for morbid obesity have been well reported, as have its undesirable side effects. Both early and long‐term weight reduction are generally satisfactory. Problems can arise from an increased enteric circulation of bile salts, liver dysfunction, metabolic bone disease, malnutrition and metabolic failure, diarrhea and electrolyte disturbances, enteric colonization and its consequences, and renal calculi and failure. In the author's personal series of 255 patients, 62 have required restoration of intestinal continuity, largely for the complications of bacterial colonization of the blind loop. Half the patients studied (55%) developed increasing hepatic steatosis during the first postoperative year, while 9% developed micronodular cirrhosis. Some degree of osteomalacia occurred in 35% of patients within 5 years of bypass.
Enteric ulceration and its complications
Authors: Thomas W. E. G. , Williamson R. C. N.
Published: May 2005

Ulceration of the small bowel is uncommon and difficult to diagnose. Many patients require operation for the complications of perforation, hemorrhage, and obstruction. There is a wide differential diagnosis, and in a few cases of enteric ulceration (nonspecific, idiopathic) no etiological cause can be defined. Ten unusual cases of complicated small bowel ulceration are presented to illustrate the investigation and management of these obscure conditions.
Tropical diseases of the small bowel
Authors: Archampong E. Q.
Published: May 2005

Typhoid and tuberculosis still account for the bulk of small bowel diseases encountered in surgical practice in most parts of the tropical world. In the emergency setting, these conditions present with perforation or obstruction of the intestine. Against this background must be considered the occasional appearance of conditions that lead to perforation or obstruction in temperate countries, e.g., lymphoma and regional enteritis. Children with infestations with parasites such as ascaris present a puzzling picture with acute abdominal signs. Tropical diseases affecting the small bowel are thus predominantly preventable. Their continued prevalence among causes of an acute abdomen indicates an unrealistic allocation of priorities in the mass control of endemic disease.
Small bowel carcinoid tumors
Authors: Woods H. F. , Bax N. D. S. , Smith J. A. R.
Published: May 2005

During the last 7 years we have managed 48 cases of carcinoid tumor. Of these 15 have been tumors of the small bowel. In this article we describe and discuss the presentation of small bowel carcinoid tumors, the carcinoid syndrome, and its treatment. The content reflects our clinical experience.
Small intestinal lymphoma
Authors: Cooper B. T. , Read A. E.
Published: May 2005

This paper reviews small intestinal lymphoma. Although a major emphasis is placed on primary small intestinal lymphoma of the “Western” type, the important topic of lymphoma in celiac disease is discussed. Our own recent experience of 7 patients with lymphoma in celiac disease is presented. The lymphoma of immunoproliferative small intestinal disease (“Mediterranean” lymphoma) and the associated α‐chain disease are also reviewed, with emphasis on the differences from the “Western” type of primary small intestinal lymphoma.
Roux‐en‐Y
Authors: Kirk R. M.
Published: May 2005

In Roux's modification of gastroenterostomy, the bowel is transected at the duodenojejunal junction. The proximal jejunum is united to the stomach. The duodenum is joined, end‐to‐side, into the jejunum at a distance from the gastrojejunostomy. Jejunal peristalsis is unidirectional, and contents entering its proximal end are removed and passed distally since jejunum is a transmitting—not a capacitance—part of the intestine. The loop can be used to drain away contents and also acts as a one‐way valve, preventing reflux. A single segment of intestine can be extended much farther than an intact loop, while retaining an adequate blood supply. Originally used to prevent intragastric bile reflux, the technique has been exploited to allow esophagojejunal anastomosis and drainage of the biliary and pancreatic ducts. The ability of a Roux‐en‐Y loop of jejunum to remove and pass on contents makes it a valuable means of draining cysts and fistulas. Preparing a Roux‐en‐Y segment demands careful preliminary assessment of the vascular supply to the upper jejunum since the pattern is inconstant. The technique of dividing the arterial and venous arcades to increase the reach of the jejunal segment is described, together with some of the more frequently used modifications of Roux's method.
Conservative operations for Crohn's disease of the small bowel
Authors: Alexander‐Williams John , Haynes Ian G.
Published: May 2005

Radical excision of the small bowel and affected lymph nodes was originally advocated for Crohn's disease of the small bowel. Subsequently, intestinal bypass became popular, either in continuity or by exclusion of the diseased segment. Bypass in turn was superseded by limited resection, which remains the procedure of choice in most patients. Recognition that Crohn's disease is both panintestinal in nature and incapable of surgical cure has led to increasingly conservative operations aimed solely at overcoming the complications of the disease. Balloon catheters have been used to assess luminal stenosis in 20 patients and to undertake dilatation of strictures between 20 and 25 mm in diameter. Tighter strictures have been treated by strictureplasty. In 3 years, 37 patients have had 43 operations and 106 strictureplasties. Rates for anastomotic leakage episodes of pain and fever and overt wound infection have all been below 10%. Six patients have required reoperation, usually for strictures elsewhere.
The continent ileostomy (Kock's pouch) versus the restorative proctocolectomy (pelvic pouch)
Authors: Hultén Leif
Published: May 2005

The Kock continent ileostomy and the ileoanal anastomosis with a pelvic ileal reservoir are each alternatives to conventional ileostomy in patients undergoing proctocolectomy for ulcerative colitis and polyposis coli. Problems associated with construction of the nipple valve have been the chief factor limiting the popularity of continent ileostomy, but these can be minimized by strict attention to technique. The cumulative revision rate for nipple valve dysfunction over a 7‐year period has been below 30%, and continence can usually be restored by reoperation. A successful pelvic reservoir procedure maintains both the normal defecation pathway and satisfactory continence, although rectal sensation is impaired; pelvic sepsis is the major postoperative risk (15–20%). Both types of operation are associated with nonspecific inflammation of the reservoir (“pouchitis”) in some 20% of patients. The pelvic pouch procedure is likely to become the chief method for preserving fecal continence after proctocolectomy, but the Kock pouch should be considered for inappropriate or unsuccessful cases.
Prognostic value of nuclear DNA content in medullary thyroid carcinoma
Authors: Bäckdahl Martin , Tallroth Eva , Auer Gert , Forsslund Gun , Granberg Per ‐Ola , Lundell Göran , Löwhagen Torsten
Published: May 2005

The prognostic value of nuclear DNA content in medullary thyroid carcinoma was studied in 36 patients. Eleven patients are still living 13–35 years after diagnosis. Twenty‐five patients died of medullary thyroid carcinoma between 10 months and 23 years following diagnosis. DNA measurements in morphologically identified single tumor cells were performed either on fine‐needle aspiration biopsy material or on histologic sections from the primary tumor. Metastases or local recurrences were also examined in 18 cases. In the survivors, the majority of tumors exhibited cells with DNA amounts approximating the normal diploid value, whereas the tumors of the nonsurvivors had significantly higher DNA values. The primary tumors and their metastases or local recurrences exhibited in all cases essentially similar DNA content. The data suggest that DNA measurements in medullary thyroid carcinoma contribute valuable prognostic information that adds to standard clinical and morphological parameters.
Secretory disturbance in hyperplastic parathyroid nodules of uremic hyperparathyroidism: Implication for parathyroid autotransplantation
Authors: Wallfelt Chris H. , Larsson Rolf , Gylfe Erik , Ljunghall Sverker , Rastad Jonas , Åkerström Göran
Published: May 2005

Pathophysiological characteristics of dispersed parathyroid cells were investigated in vitro with the principal aim of examining dominating hyperplastic parathyroid nodules in uremia. Ten large nodules were macroscopically dissected from the glands of 8 hypercalcemic patients with uremic hyperparathyroidism (HPT). Histologic examination revealed that the remaining parts of these glands were composed of a diffuse or slightly nodular parathyroid hyperplasia. Parathyroid hormone (PTH) concentrations were estimated with a mid‐C regional immunoassay and the calcium indicator quin‐2 was utilized to measure cytoplasmic calcium concentrations (Ca2+i) of the parathyroid cells. Ambient calcium control of PTH release and Ca2+i was significantly more abnormal in cells from the nodules while the less nodular tissue demonstrated a regulation similar to normal bovine parathyroid cells. Since an aberrant secretory regulation of the parathyroid tissue has been shown to greatly influence serum calcium concentrations in HPT, the findings substantiate a functional importance of hyperplastic parathyroid nodules in uremia. The results imply that parathyroid autotransplants should be excised from essentially nonnodular parts of the parathyroid glands since this may reduce the incidence of graft‐dependent recurrences after total parathyroidectomy in uremic HPT.
Secondary thyroidectomy: A twenty‐year experience
Authors: Reeve Tom S. , Delbridge Leigh , Brady Peter , Crummer Patsy , Smyth Christine
Published: May 2005

Secondary thyroidectomy is an operation generally considered to be associated with a significantly increased risk of damage to the recurrent laryngeal nerves and parathyroid glands. During a 20‐year period, to December, 1986, a total of 408 secondary thyroidectomies were performed. The majority (n=227) were for recurrent nodular goiter, followed by reoperations for thyroid cancer (n=151), and operations for secondary thyrotoxicosis (n=30). The incidence of operative recurrent laryngeal palsy was 1.5% over the 20‐year period, while the incidence of permanent hypoparathyroidism fell from 3.5% during the first 15 years to 1.6% over the last 5 years, with a similar fall in the incidence of transient hypocalcemia (8.4% down to 4.8%). The risk of complications can be minimized by careful attention to operative detail, employing the technique of capsular dissection with preservation of the vascular supply to the parathyroid glands while protecting the recurrent laryngeal nerve.
The effect of intravenous magnesium sulphate on parathyroid function in primary hyperparathyroidism
Authors: Gough Ian R. , Balderson Glenda A. , Lloyd H. Martyn , Galligan John , Willgoss Desley , Fryar Barry G.
Published: May 2005

Ten patients with primary hyperparathyroidism caused by enlargement of a single parathyroid gland were studied preoperatively. An intravenous bolus of 4 g magnesium sulphate followed by a continuous infusion of 2 g per hour for 3 hours increased serum magnesium from 0.76 to 2.12 mmol/l (median values,p <0.005). Serum C‐terminal parathyroid hormone (PTH) decreased from 94 to 78 pmol/l (p <0.005), and serum intact PTH from 7.0 to 4.8 pmol/l (p <0.008). The PTH changes preceded decreases in serum total calcium from 2.79 to 2.55 mmol/1 (p <0.01), and serum ionized calcium from 1.52 to 1.45 mol/1 (p <0.007). Urinary calcium excretion increased and urinary phosphate excretion decreased. Serum phosphorus, pH, albumin, creatinine, alkaline phosphatase, and urinary cyclic AMP showed no significant changes. The study showed that an intravenous magnesium sulphate infusion which at least doubled the normal serum magnesium concentration significantly suppressed PTH secretion in patients with primary hyperparathyroidism and subsequently reduced the serum calcium concentration.
Psychiatric morbidity in primary hyperparathyroidism
Authors: Joborn Charlotte , Hetta Jerker , Johansson Henry , Rastad Jonas , Ågren Hans , Åkerström Göran , Ljunghall Sverker
Published: May 2005

This report deals with the psychiatric symptomatology in patients with primary hyperparathyroidism (HPT). In a retrospective search of hospital records, psychiatric symptoms were found in 102 (23%) of 441 patients, 78 of whom had depressive and anxiety states. The presence of psychiatric symptoms was not related to the degree of hypercalcemia. Screening for HPT in 101 old patients hospitalized at a psychogeriatric clinic revealed HPT in 5 (5%) patients. Among 13 patients with organic brain syndrome (e.g., senile dementia) and HPT, 8 patients (with a duration of psychiatric illness of less than 2 years) improved mentally after parathyroid surgery, and could return home or to somatic units. The psychiatric symptomatology was prospectively investigated in 59 consecutive patients with primary HPT (mean serum calcium, 2.89±0.30 mmol/l), using the Comprehensive Psychopathological Rating Scale (CPRS). A majority of the patients had considerable psychiatric symptoms (mean CPRS total score, 13.7±9.1) compared with a healthy control group (mean CPRS total score, 4.4±2.0;p <0.001). The most pronounced psychiatric symptoms among the patients were fatiguability, lassitude, failing memory, concentration difficulties, sadness, and inner tension. Analysis of monoamine metabolites in the cerebrospinal fluid in 48 of the patients revealed subnormal values of 5‐hydroxyindoleaceticacid (5‐HIAA) and homovanillic acid (HVA). At follow‐up, 1–1 1/2 years after parathyroid surgery, there was a marked improvement in mental health in the patients (p <0.001), together with a significant rise in the levels of 5‐HIAA and HVA (p <0.05).

Our findings demonstrate that psychiatric symptoms are present in a majority of patients with primary HPT, that the symptoms are reversed by parathyroid surgery, and that their severity seems not to be related to the degree of hypercalcemia. The results also indicate that HPT is associated with changes in the central nervous system turnover of monoamines, of possible importance for the symptomatology.
Prognostic value of nuclear DNA content in papillary and follicular thyroid cancer
Authors: Hamming Jaap F. , Schelfhout Lodewijk J. D. M. , Cornelisse Cees J. , van de Velde Cornelis J. H. , Goslings Bernard M. , Hermans Jo , Fleuren Gert Jan
Published: May 2005

The relative importance of prognostic factors in papillary and follicular thyroid cancer was studied in 113 patients using Cox's proportional hazards model. Prognostic factors studied were: histology, tumor grade, extrathyroidal growth, nodal involvement, distant métastases at diagnosis, nuclear DNA content, age at diagnosis, and sex. Nuclear DNA content was measured in primary tumors by flow cytometry. Total thyroidectomy and postoperative131I ablation was the standard treatment. The results showed that nuclear DNA content correlated significantly with histologic type and, in papillary cancer, also with tumor grade. The presence of distant metastases at diagnosis was, by far, the most important prognostic factor. In the patient group without distant metastases (n=91), multiploidy (i.e., presence of 2 or more aberrant stemlines) was the only significant prognostic factor for overall survival. With respect to diseasefree survival, multiploidy was second only to the age factor. In the patient group with distant métastases (n=22), all 6 patients with multiploid tumors died compared to 8 (50%) of 16 of those with other ploidy tumors. However, the small number in this group precluded significant results. The present study demonstrates that nuclear DNA content is a prognostic factor in those patients with papillary and follicular thyroid cancer without distant metastases at diagnosis.
Hashimoto's thyroiditis revisited: The association with thyroid cancer remains obscure
Authors: McLeod Michael K. , East Mary E. , Burney Richard E. , Harness Jay K. , Thompson Norman W.
Published: May 2005

Hashimoto's thyroiditis (HT) is an autoimmune disease of the thyroid associated with goiter and hypothyroidism. Although there exists a clear association between HT and lymphomas of the thyroid, the association between HT and thyroid cancer remains unclear. To evaluate this further, we retrospectively reviewed the pathology reports for all thyroidectomy specimens as well as the records of patients admitted to the University of Michigan Medical Center, Ann Arbor, Michigan, U.S.A., over a 10‐yearperiod (1975–1985) with the diagnosis of HT or chronic lymphocytic thyroiditis (CLT). Eight hundred and nine pathologic diagnoses were recorded for 816 thyroidectomy specimens from 793 patients. Furthermore, 180 of 228 patient chart records were available for review. Only 128 patients satisfied our criteria for the diagnosis of HT. HT or CLT were diagnosed in 147 (18.2%) of 809 thyroid specimens. HT occurred concurrently with thyroid cancer in 24% of all cases of HT, whereas, HT occurred concurrently with benign thyroid disease in 71% of all cases of HT in all thyroid specimens. Furthermore, HT was associated with 43 (22%) of 195 cases of thyroid cancer. There were 111 (87%) women and 17 (13%) men of 128 patients whose charts were reviewed. The mean age was 49±14 years. Ninety‐eight (77%) of the patients presented with goiters and 57 (45%) presented with dominant thyroid masses, 38 (67%) of which were solitary nodules. One patient (0.8%) presented with a recurrent laryngeal nerve palsy (RLNP) and 12 (9%) presented with tracheal compression. Only 29 (38.2%) of 76 patients measured had positive antithyroglobulin (ATG) titers, whereas 65 (87%) of 75 patients measured had positive antimicrosomal (AM) titers. Seventy (55%) patients were evaluated with either a technetium or131I thyroid scan. There was a heterogeneous pattern to the scan in 75% of these patients. Niney‐one (71%) patients were initially treated with thyroid suppression. However, 27 (21%) required thyroidectomy for initial management. Ultimately, 60% required thyroidectomy and 37% required none. The major indication for surgical intervention was the presence of a dominant mass in 40 (52%) of 77 patients. Only 17 (13%) patients were found to have thyroid cancer concomitant with HT and 3(2%) had lymphoma with HT. The incidence of minimal (occult) cancer in a study of 100 consecutive autopsies at this institution was 13%. We believe that these data suggest that the association of HT with thyroid cancer is relative, at best. It will be necessary to prospectively follow both a large group of patients with HT and a control group of patients without HT for the incidence of thyroid cancer in each before this issue can be appropriately addressed.
Vitamin D deficiency and hyperparathyroidism with severe bone disease
Authors: Ingemansson Stig G. , Hugosson Claes H. , Woodhouse Nicholas J. Y.
Published: May 2005

Circulating 25‐hydroxycholecalciferol (25OHD3) levels are low in Saudi Arabia due to a lack of sunlight exposure and a low dietary intake of vitamin D (vit D). Recent studies in animals and man indicate that the half‐life of 25OHD3 is reduced in states of hyperparathyroidism. We, therefore, reviewed the charts of 43 patients with primary hyperparathyroidism (HPT) to establish whether there was coexisting vit D deficiency and osteomalacia. In the 22 patients studied, 25OHD3 levels were below normal in 14 and in the low normal range in 7, and the 1,25‐dihydroxycholecalciferol [1,25(OH)2D3] levels were inappropriately low in 8 of the 9 studied. Three of the 13 patients with classical “parathyroid” bone disease had evidence of osteomalacia with Looser's nodes or rickets.

We conclude that patients with primary HPT are likely to develop vit D deficiency in countries in which 25OHD3, stores are low. In selected cases, preoperative treatment with vit D might diminish subsequent bone hunger.
Monoclonal antiparathyroid antibodies revealing defect expression of a calcium receptor mechanism in hyperparathyroidism
Authors: Juhlin C. , Åkerström G. , Klareskog L. , Gylfe E. , Johansson H. , Larsson R. , Ljunghall S. , Nygren P. , Rastad J.
Published: May 2005

Monoclonal antibodies were generated with a hybridoma technique after immunization of mice with intact human parathyroid cells. Three antibodies of the IgG type reacted in immunohistochemistry and immunofluorescense with parathyroid epithelial cells and proximal tubule cells of the kidney but not with a large number of other human tissues. Adenomatous and hyperplastic parathyroid glands of patients with hyperparathyroidism (HPT) demonstrated a reduced immunohistochemical reactivity with the antibodies as compared to the intense staining of normal human parathyroid tissue. Experiments with dispersed parathyroid cells from the normal and pathological glands showed that 2 of the antibodies blocked the effects of ambient calcium on cytoplasmic calcium and parathyroid hormone release. This indicates that the antibodies interfere with a newly recognized receptor mechanism of parathyroid cells involved in the sensing and gating of calcium and thereby also in the regulation of parathyroid hormone release. A reduced expression of the putative calcium receptor mechanism of abnormal parathyroid cells may, thus, be principally responsible for the hypercalcemia of HPT by causing a decreased sensitivity to extracellular calcium of the parathyroid hormone release from pathological parathyroid glands. The antibodies should improve the parathyroid histological diagnosis by their ability to identify and to distinguish between normal and abnormal parathyroid tissue.
Immunohistochemical study of medullary thyroid carcinoma: Relationship of clinical features to prognostic factors in 36 patients
Authors: Takami Hiroshi , Bessho Takashi , Kameya Toru , Mimura Takashi , Ito Kunihiko , Abe Osahiko , Hosoda Yasuhiro , Shikata Jun‐ichi
Published: May 2005

This study was designed to identify 11 different antigens including calcitonin (CT), calcitonin gene‐related peptide (CGRP), gastrin‐releasing peptide (GRP), and carcinoembryonic antigen (CEA), in the tumors of 36 patients with medullary thyroid carcinoma (MTC) using immunoperoxidase staining techniques. In addition, clinical features of MTC patients were compared with the immunohistochemical findings to establish factors influencing prognosis. MTC was found to contain various products in many patients and CT and CEA were positive in all patients. CGRP and GRP showed positive staining in 96.6% and 82.9% of MTC patients, respectively, suggesting that CGRP and GRP are novel tumor markers for MTC. In tumor cells, CT, CGRP, and GRP were often revealed in identical cells. Familial patients showed more multiple substances than sporadic patients. In the 2 inoperable patients with extremely aggressive progression, tumors showed undifferentiated histology and poor staining for peptide hormones, suggesting that specific qualities such as neuroendocrine tumor had been lost. These 2 patients particularly revealed an inverse relationship between CT and CEA distribution such that small amounts of CT were present in cells which have homogenous staining for CEA. This study suggests that CGRP and GRP, in addition to CT and CEA, may be a histologically potential tumor marker for MTC. CT and CEA may be possible markers for differentiating patients with high malignancy from those with ordinary malignancy.
The vascular laboratory: Advances in noninvasive techniques
Authors: Bollinger Alfred , Jäger Kurt , Jünger Michael , Seifert Hildegard
Published: May 2005

Recent advances in technology have further increased the diagnostic potential of the noninvasive vascular laboratory. They include measurement of transcutaneous oxygen pressure, laser Doppler flowmetry and intravital microscopy with and without the use of fluorescent dyes for analyzing hemodynamics of the skin and microvascular morphology, capillary flow velocity, and transcapillary exchange of solutes. Moreover, duplex scanning opens a way to detect stenoses in previously inaccessible arteries such as the mesenteric and renal trunks. The combination of B‐mode and pulsed Doppler ultrasound is also suited to map and quantify occlusive lesions from the aorta down to the proximal calf arteries with an accuracy similar to arteriography. The clinical implication of these new techniques is discussed in this review article.
Advances in the development of grafts for bypass of small‐caliber arteries
Authors: Sauvage Lester R.
Published: May 2005

The standard for coronary bypass is now clearly the autogenous internal mammary artery (IMA). Complete revascularization of the left ventricle can be attained in most cases using only the IMA's with as many sequential anastomoses as necessary. This advance has freed the saphenous vein (SV) for use below the knee joint.

Properly preclotted, noncrimped, externally‐supported Dacron® grafts with an external velour surface merit consideration as the standard for axillofemoral bypass. The limitation of this graft is its dependence on a precise technique of preclotting to transform the Dacron® framework into a biosynthetic complex of dethrombinated fibrin and Dacron®.

The autogenous SV is clearly the standard for below‐knee bypass. However, for above‐knee femoropopliteal bypass, the results obtained with polytetrafluoroethylene, umbilical vein, and externally‐supported, noncrimped, knitted Dacron® prostheses are sufficiently competitive with the results obtained with the SV to make their use an acceptable option in the above‐knee location. The saphenous vein is, thus, saved for use in the more demanding below‐knee sites such as a femoropopliteal, femorotibial, or femoroperoneal bypass.
Progress in the treatment of anastomotic aneurysms
Authors: Courbier R. , Aboukhater R.
Published: May 2005

One hundred and twenty‐five patients underwent surgery for 166 anastomotic aneurysms. The most frequent location was the inguinal area. Among the hypotheses advanced to explain this frequency, the role played by the inguinal ligament was underlined. When the prosthesis adheres firmly to this structure, movements in the hip create permanent shear stresses on the distal part of the anastomosis. This can explain why the suture line is often undamaged whereas the arterial wall is ruptured. In operations where the prosthesis is located in front of or below the inguinal ligament (axillofemoral, femoropopliteal bypasses), the incidence of anastomotic aneurysms is lower (p<0.001).

Preventive measures have been adopted since 1981. Partial section of the inguinal ligament, enlarging the tunnel in which the prosthesis lies, is combined with free omental wrapping of the entire suture line. No cases of necrosis have been recorded. The comparison between 2 groups of patients operated for aorto‐(or ilio‐) femoral bypass before 1981 (2,602 anastomoses—99 anastomotic aneurysms) and after 1981 (1,409 anastomoses—no anastomotic aneurysms) using this technique shows a highly significant difference:p<0.001.

Surgical treatment of anastomotic aneurysms consists of resection and end‐to‐end anastomosis. To avoid injury to the profunda femoral artery in the case of a femoral aneurysm, this vessel should not be dissected but only occluded temporarily.
Aortic‐iliac occlusive disease
Authors: Charlesworth David
Published: May 2005

This article is divided into 4 sections which deal with changes in the management of short stenoses in the iliac arteries, the management of aorto‐iliac disease and the effects of concomitant myocardial ischemia, changes in the design of prostheses, and “multisegmental” disease. Myocardial ischemia may be apparent from clinical or electrocardiogram evidence, or it may be covert. The mortality rate after aortic bifurcation grafting may improve if patients with severe coronary artery disease are either refused operation or have a coronary bypass first. It was postulated over 10 years ago that increased porosity would encourage the formation of a functioning intima on the inner surface of a prosthesis. Since then, the fashion has been to use porous prostheses, and recent developments to offset the loss of blood at implantation are described. Methods of predicting which patients with multisegmental disease will require combined aorto‐iliac and femoropopliteal reconstructions are discussed in the light of the problem of early occlusion of aortobifemoral grafts.
Renal and intestinal artery occlusive disease
Authors: van Dongen René J. A. M.
Published: May 2005

Significant progress has been achieved in the treatment of renal and intestinal artery occlusive diseases during recent years so that surgery can be performed with good results, with survival in over 95% of patients. Vascular surgeons, therefore, have become more aggressive, frequently combining aortic graft replacement with visceral artery repair. Such operations have become progressively safer, and, in centers in which these operations are performed on a regular basis, morbidity and mortality rates are quite low.

The improvement in morphologic and functional results is due to proper selection of patients, adequate preoperative preparation, detailed aortographic investigation, and increased technical experience. The use of simplified reconstructive procedures, refinements in anesthesia, and postoperative care have played a large part in reducing the mortality rate even in complex aortic and visceral artery reconstructions.

This is a report of surgical procedures and techniques used in over 800 patients with renal and intestinal artery occlusive disease; 182 of these patients underwent combined aortic and visceral artery, or combined renal and intestinal artery repair. Emphasis is placed on the use of autologous vein grafts in reconstructing renal and intestinal arteries, and attention is paid to technical and hemodynamic details of the different procedures to be preferred. Due to recent advances in surgical techniques, the results of surgical treatment have improved, justifying a more aggressive surgical approach.
Percutaneous transluminal angioplasty: The surgeon's role
Authors: Menges H. ‐W. , Jaschke W. , Trede M.
Published: May 2005

The technique of percutaneous transluminal angioplasty (PTA) was developed by radiologists and it is the interventional radiologist who mostly performs these procedures—often with little angiological background. But the latter seems indispensable when it comes to selecting patients for PTA and dealing with its complications.

For this reason, PTA has been performed at the Mannheim Surgical Clinic for the past 10 years in close cooperation between surgeons and radiologists; 196 iliac arterial stenoses, 397 femoropopliteal stenoses and occlusions, and 65 renal artery stenoses have been treated with an initial success rate of 100%, 84%, and 96%, respectively. In 79 cases, PTA was used intraoperatively as a complement to reconstructive surgery on ipsilateral or contralateral vessels.

Since PTA is not free of complications (2–6%), which may jeopardize limb or organ, indications for its use are restricted to patients who are symptomatic and, therefore, would otherwise require surgery. PTA of asymptomatic stenoses is not recommended.
Extraanatomical bypass procedures
Authors: Blaisdell F. William
Published: May 2005

Those extraanatomical bypass procedures which are useful for revascularization of the lower extremities include femorofemoral, axillofemoral, and iliofemoral transobturator bypass. All of these procedures became firmly established during the 1960's, and have added greatly to the armamentarium of the vascular surgeon.

The absolute indication for extraanatomical bypass is infection, which precludes the placement of a graft in a conventional location in a patient who requires revascularization to save life or limb. Relative indications for extraanatomical bypass exist when the risk of standard operations is high because of associated disease or anticipated technical problems. The most common indication is to provide revascularization of ischemic extremities in patients who are high‐risk for conventional operations. Utilization of axillofemoral graft to bypass aortic aneurysms is a most controversial indication. Occasionally, there is an extremely high‐risk patient who has symptomatic abdominal aortic disease who may benefit from the potential for staging the operation. Axillofemoral bypass can be done as one procedure and proximal or distal ligation of the aneurysm can be carried out simultaneously or at a later date with less stress on the patient.

Important technical requirements of axillofemoral graft which will ensure optimal results are: (a) to place the proximal anastomosis on the first portion of the axillary artery, (b) to tunnel the graft well laterally so that it lies in the plane of flexion of the body, (c) to use an externally supported graft, (d) to ensure optimal outflow by using a femorofemoral graft in conjunction with axillofemoral bypass.

The technical problems with the femorofemoral graft are relatively few: (a) the anastomoses should be placed in such a direction so as to avoid kinking, (b) the graft may be placed in a subcutaneous or subfascial position depending on the degree of obesity of the patient and the presence of preexisting scars.

Technical aspects necessary for obturator bypass involve using whatever is the most accessible proximal vessel—usually the common iliac. The graft should be carried through the obturator membrane at its anterior medial portion, avoiding injury to the obturator nerve. The distal anastomosis is carried out in the low thigh.

The results of axillofemoral graft vary greatly in individual reports. The 1‐year patency for these grafts varies from a low of 50% to a high of 87%, with 5‐year patencies varying from a low of 25% to a high of 76%.

Regarding femorofemoral grafts, the literature documents 1‐year patency rates as varying between 82% and 93%, with 5‐year patency rates at approximately 75%, varying from 56% to 86.4%. Results for obturator bypass are not available since no one center has more than a limited experience with these operations.
Progress in the treatment of thoracic aortic aneurysms
Authors: Crawford E. Stanley
Published: May 2005

Progress in the management of thoracic aortic aneurysm includes the following aspects:

the concepts of the disease itself, which is frequently generalized so that the second most common cause of late death is rupture of another aneurysm;

the diagnostic techniques used: computed tomographic scanning as well as aortography;

the medical treatment: with beta blockade and antihypertensive drugs in stable aortic injury in the patient with multiple critical injuries;

that hypothermic circulatory arrest with cardiopulmonary bypass and brain temperatures down to 16–20°C has increased successful aortic arch replacement from 50–75% to over 90%;

that rapid autologous transfusion by means of a modified Hemonetics machine can collect and process a unit of shed blood in 2–3 minutes and has reduced transfusion requirements by more than half;

the vigorous treatment of both consumptive and dilutional coagulopathies;

the new reconstructive techniques: involving composite valve graft replacement of the aortic valve, root, and arch as well as coronary artery reattachment;

that the use of viable tissue flaps in the treatment of infected aortic grafts as well as intravenous and local irrigation with antibiotics was successful in 8 of 9 of our cases;

that graft replacement with intensive antibiotic therapy was effective in 19 of 22 of our patients with mycotic thoracic aortic aneurysm.
Pitfalls and progress in the management of abdominal aortic aneurysms
Authors: Trede Michael , Storz Leonhardt Werner , Petermann Christian , Schiele Ulrike
Published: May 2005

Based on a review of the literature and 241 cases of abdominal aortic aneurysm (AAA) operated at the Mannheim Surgical Clinic, the progress and pitfalls in the management of this lesion are discussed.

Progress in diagnosis is based on noninvasive imaging procedures, e.g., ultrasound, which lead to the detection of more aneurysms before they rupture. Ultrasound also plays a role in the observation of small asymptomatic aneurysms in high‐risk patients, helping some to avoid operation as well as rupture.

Progress in the treatment of AAA means simplification: rapid clamping of the aorta in case of rupture, minimal dissection, and aneurysmal repair with straight‐tube interposition by the inlay technique. The pitfalls of “trash foot,” colon, or renal ischemia as well as graft infection can be mostly circumvented by observance of technical detail.

In this series, the mortality following repair of asymptomatic AAA was 3.7%; for symptomatic aneurysms, it was 8%; and for ruptured aneurysms, it amounted to 55%.
Function of the intrathoracic stomach as esophageal replacement
Authors: Hölscher Arnulf H. , Voit Herbert , Buttermann Götz , Siewert J. Rüdiger
Published: May 2005

The emptying, acid secretion, mucosal changes, and duodenogastric and gastroesophageal reflux of the intrathoracic stomach were studied in 12 patients together with the clinical course 6–12 months after esophageal replacement.

Although no pyloroplasty had been performed, the emptying of a semisolid meal from the interposed stomach was significantly accelerated compared to the controls. No residual food was found in the stomach at endoscopy after an overnight fast. Distinctly accelerated gastric emptying correlated with spontaneous duodenogastric reflux across the denervated pylorus.

Despite a persistent acid secretion of the vagotomized intrathoracic stomach, no pathologic gastroesophageal reflux and no esophagitis were found proximal to the cervical anastomosis. Gastric biopsies mostly revealed mild gastritis of the antral mucosa, whereas metaplasia was rare. The intrathoracic stomach does not need a drainage procedure to facilitate semisolid emptying. Postoperative reflux esophagitis is prevented by complete intrathoracic stomach transposition with cervical esophagogastrostomy.
Splenocaval shunt for selective portal decompression
Authors: Iliopoulos John I. , Thomas James H. , Pierce George E. , Hermreck Arlo S.
Published: May 2005

Splenocaval shunt is an option for selective portal decompression in patients who are not good anatomic candidates for distal splenorenal shunts because of massive hepatosplenomegaly and downward displacement of the splenic vein. The proximity of the splenic vein to the inferior vena cava makes the construction of this type of shunt anatomically and hemodynamically advantageous over the standard Warren shunt in these cases.
Transplantation of cryopreserved human pancreatic islets into diabetic nude mice
Authors: Ricordi Camillo , Kneteman Norman M. , Scharp David W. , Lacy Paul E.
Published: May 2005

If pancreatic islet transplantation becomes clinically applicable, cryogenic storage of human islet preparations could solve many problems related to transportation and banking of islets, HLA matching, recipient pretreatment, or the possible use of multiple donors. The diabetic nude mouse could offer a simple model to test in vivo the function of cryopreserved human islet preparations before transplantation into diabetic patients.

In this study, 6 nude mice made diabetic by an intravenous injection of streptozocin were transplanted with 400–600 cryopreserved human islets beneath the renal capsule. All the mice became normoglycemic within 3 weeks from transplantation. Nephrectomy of the kidneys bearing the grafts 45 days after transplantation resulted in an immediate return to the diabetic state, demonstrating that the only functional tissue was located in the excised kidneys. Histologic study of the renal subcapsular grafts demonstrated morphologic integrity of the islets with a normal degree of beta granulation.

The results demonstrated that cryopreserved human islets will function in diabetic nude mice. This model to test human islet preparationsin vivomay be of assistance in the application of cryopreserved islet transplantation in diabetic patients.
Increased incidence of pancreatic neoplasia in pernicious anemia
Authors: Borch Kurt , Kullman Eric , Hallhagen Stefan , Ledin Torbjörn , Ihse Ingemar
Published: May 2005

In a Swedish population, 361 patients with pernicious anemia were followed closely during a 7‐year period with regard to the occurrence of all forms of malignant neoplasia. In addition to an increased incidence of gastric neoplasia (0.6%/year), there seemed to be an increased incidence of pancreatic neoplasia (0.3%/year) in the series. With reference to age‐ and sex‐specific incidence rates in the general population, the number of malignant pancreatic tumors observed was significantly higher than expected (p<0.02, Poisson analysis). Pancreatic malignancy was the primary cause of death in 5 (4%) of 134 patients who died during follow‐up. Among 127 unselected patients with malignant pancreatic neoplasia, the prevalence of pernicious anemia was 3%. These findings indicate that there is a linkage between the two diseases which has not been previously recognized. Atrophic gastritis with hypergastrinemia may be the key to this linkage.