bluuebunny/crossref_metadata_2025 huggingface dataset:
Bile reflux and degree of gastritis after highly selective vagotomy, truncal vagotomy, and partial gastrectomy for duodenal ulcer
Authors: Dewar E. Paxton , Dixon Michael F. , Johnston David
Published: May 2005

Enterogastric reflux of bile has been shown to be associated with chronic gastritis. We have investigated preoperative duodenal ulcer patients and patients treated by highly selective vagotomy, Polya partial gastrectomy, truncal vagotomy and pyloroplasty, and truncal vagotomy and gastrojejunostomy to assess the incidence of endoscopically observed bile reflux and gastritis, and to quantitate the degree of reflux of bile acids and histologically proven gastritis. The correlation between observed and proven gastritis was poor when the observed incidence of bile reflux was low (preoperative duodenal ulcer, highly selective vagotomy) but was good when the observed reflux was high (partial gastrectomy, truncal vagotomy, and drainage). Bile acid concentrations in the stomach were significantly lower after highly selective vagotomy than in preoperative patients and those treated by partial gastrectomy and truncal vagotomy and drainage. The antritis and body gastritis found before operation did not improve after highly selective vagotomy, but antritis showed a tendency to worsen after partial gastrectomy and truncal vagotomy and drainage. Body gastritis after highly selective vagotomy was significantly less (P < 0.001) than after partial gastrectomy and less than after truncal vagotomy and gastrojejunostomy and truncal vagotomy and pyloroplasty. The beneficial effects of highly selective vagotomy in the treatment of duodenal ulcer may be enhanced in the long term by reduction of enterogastric reflux and postoperative gastritis.
Thromboembolic complications after renal transplantation: A retrospective analysis
Authors: Arnadottir Margaret , Bergentz Sven‐Erik , Bergqvist David , Husberg Bo , Konrad Peter , Lindholm Torsten
Published: May 2005

In a retrospective study of 125 transplanted patients, 8.8% developed thromboembolism (diagnosed with objective methods) during the first year after transplantation. In one patient pulmonary embolism was the cause of death and in one it was contributory. The thromboembolism developed rather late after transplantation. The side of the transplant did not determine the site of the thrombosis. Juvenile diabetes mellitus was found to be a significant risk factor.
Nitroprusside‐epinephrine administration in acute myocardial ischemia
Authors: Pass Harvey I. , Turner M. Don , Neely William A. , Crawford Fred A.
Published: May 2005

Administration of nitroprusside (NP) and epinephrine (EP) was investigated in 2 groups of dogs during periods of acute myocardial ischemia. Blood flow to a normal area, to a marginal area of ischemia, and to an area of maximal ischemia was measured using the radioactive microsphere technique before periarterial balloon occlusion of the left anterior descending coronary artery, during NP infusion alone, and in combination with EP. In 10 awake, unanesthetized animals (group 1), NP infusion alone significantly increased blood flow to the subendocardium of the maximally ischemic zone. NP‐EP infusion increased transmural and regional flow significantly to the marginal and normal zones. In a second group of 8 anesthetized animals, NP‐EP infusion significantly increased coronary sinus flow without a corresponding increase in myocardial oxygen consumption, cardiac index, or left ventricular stroke work. As in group 1, significant increases in transmural flow were noted to the marginal and normal zones with NP‐EP infusion. These findings suggest that the combination of a vasodilating agent and an inotropic agent will improve coronary flow during periods of acute myocardial ischemia, and favorably alter the ratio of oxygen supply to oxygen demand.
Mirizzi syndrome
Authors: Lubbers Evert‐Jan C.
Published: May 2005

In recent years there have been several case reports of patients suffering from the so‐called Mirizzi syndrome. Personal experience with 5 patients, together with published data from 19 others, is used to consider whether this syndrome is a true entity. It is concluded that the involvement of the hepatic duct in gallstone disease may result in a wide range of lesions of differing severity with no common pattern. Consequently, the term “Mirizzi syndrome” has no well‐defined meaning and should be abandoned.
Arterial surgery of the upper extremity
Authors: Bergqvist D. , Ericsson B. F. , Konrad P. , Bergentz S. ‐E.
Published: May 2005

Over a 10‐year period, 116 arterial operations in the upper extremity were performed. Sixteen patients had suffered from trauma, 52 from gross embolism, and 48 from chronic ischemia. The groups differ in age, duration of symptoms, and localization of the lesion. In patients with chronic ischemia, the most common lesion was a left‐sided subclavian stenosis, with microembolization to the fingers as the most prevalent symptom. Several types of reconstructions were used with satisfactory results. One patient in each group underwent amputation. The mortality rate in the group of patients with gross embolization was high, both postoperatively and during follow‐up.
Distribution and characterization of steroid hormone receptors in human thyroid tissue
Authors: Chaudhuri Prabir K. , Patel Nili , Sandberg Leslye , Prinz Richard A.
Published: May 2005

The incidence and molecular characteristics of cytosolic steroid receptors for estrogen (ER), androgen (AR), progesterone (PR), and glucocorticoid (GR) were analyzed in human thyroidectomy specimens. All assays were performed by a protamine sulfate precipitation technique and analyzed by the method of Scatchard. Selected specimens were analyzed by sucrose density gradient. A receptor content over 1 fmol/mg cytosol protein was taken as positive. Estrogen was found in 23 of 45 specimens including 8 of 8 papillary cancers. Mean ER content (Rc) was 29.8 ±6.7 fmol/mg cytosol protein with a dissociation constant (Kd) of 0.23 ±0.09 × 10−10M. The Rc of ER was higher in neoplastic than non‐neoplastic thyroid tissue. Androgen was found in 19 of 41 specimens, including 6 of 8 papillary cancers. Mean Rc for AR was 10.6 ± 7.1 fmol/mg cytosol protein with a Kd of 0.17 ± 0.11 × 10−10. The incidence of ER and AR was significantly higher (p<0.05) in neoplastic than in non‐neoplastic thyroid tissue. Progesterone was found in 7 of 25 specimens. Mean Rc for PR was 6.2 ± 2.9 fmol/mg cytosol protein with a Kd of 0.03 ± 0.02 × 10−10M. Glucocorticoid was found in 6 of 26 specimens. Rc for GR was 6.3 ± 2.3 fmol/mg cytosol protein with a Kd of 0.11 ± 0.05 × 10−10M. By sucrose density gradient, a 4S and 8S type of ER was identified, while AR was predominately 6S, and GR was predominately 8S. The steroid receptors identified were a single‐class, high‐affinity, and saturable similar to those found in other steroid hormone dependent tissues. These findings suggest that steroid hormones may influence the development and growth of thyroid tumors.
When is medullary thyroid carcinoma “medullary thyroid carcinoma”?
Authors: Riccabona Georg , Ladurner Diethelm , Schmid Kurt
Published: May 2005

Medullary thyroid carcinoma (MTC) is thought to develop from the parafollicular or C cells within the thyroid gland and, therefore, should not take up radioactive iodine. Recently, however,131I uptake has been reported in metastases of “medullary carcinoma” and, consequently, some authors have suggested that these tumors can be treated with radioactive iodine. On the basis of observations in 5 patients out of 11 with MTC, we would like to comment regarding this situation. In our 5 patients who were treated by total thyroidectomy, the diagnosis of medullary carcinoma was made by experienced pathologists using immunohistochemical staining methods (calcitonin and/or thyroglobulin), peroxidase‐antiperoxidase techniques, and electron microscopy. Evaluation of serum concentrations of calcitonin and serum thyroglobulin by radioimmunoassay was also performed. Data from our 5 patients provide evidence that patients with histopathological and immunohistochemical criteria for medullary thyroid carcinoma, and with high serum calcitonin levels, can take up131I. It is possible that these tumors represent poorly differentiated thyroid carcinomas with C‐cell metaplasia or mixed tumors originating from both follicular and parafollicular cells. Other neoplasms classified as “medullary cancer” seem to be unspecified thyroid cancers with C‐cell hyperplasia in the periphery of the tumor.
The endocrine function of heterotopic islets of Langerhans
Authors: Merrell Ronald , Kakizaki Kenji , Basadonna Giacomo
Published: May 2005

Islets of Langerhans may be removed from the pancreatic environment and transferred as autografts to a heterotopic site such as the spleen or liver. The success of such grafts has been equated with normoglycemia but success in dogs has been variable. We have developed a model of canine islet autografting that entails total pancreatectomy, preparation of a pancreatic suspension by perfusion of the pancreatic duct with collagenase, and delivery of the autograft to the spleen by reflux through tributaries of the splenic vein. In this study, fasting insulin response to intravenous glucose (0.5 g/kg), tolbutamide (0.5 g), glucagon (1.0 mg), and arginine (460 mg/kg) was measured before and 3 weeks after intrasplenic islet autografts. The 5 animals studied achieved fasting normoglycemia immediately; therefore, they were successful grafts. The response to glucose, however, was distinctly abnormal with statistically different peripheral insulin levels at 1, 3, 5, and 10 minutes. The insulin response was graphed, the area under the curve determined, and the integrated response was only 20% of preoperative controls. This diminished insulin response was reflected in impaired glucose clearance with a K value of 1.95 ± 0.24 in grafted animals compared to 3.12 ± 0.74 in preoperative controls. Peak insulin responses, however, to tolbutamide (70.4% of normal), glucagon (85.4%), and arginine (94.7%) were not statistically different in grafted animals compared to controls. The disparity of beta cell response to these various secretagogues suggests significant alteration of beta cell function either as a consequence of heterotopic placement, grafting injury, or accommodation to reduced islet number. Comparison of these data with those obtained in other systems supports some sort of accommodation to explain these beta cell changes.
Release of corticosteroids from human adrenals in vitro
Authors: Hamberger Bertil , Curstedt Tore , Werner Sigbritt
Published: May 2005

From morphological criteria, it is often difficult to evaluate whether adrenocortical tumors secrete hormones or not. An increasing number of “nonfunctioning” tumors are detected using modern imaging techniques. In a consecutive series of 13 patients with adrenocortical disease, a functional characterization was done by determining the ability of the resected tissue to release cortisol and aldosterone in vitro. Significant secretion of aldosterone was only found in tumors from 4 patients with hyperaldosteronism, 1 of whom turned out to have a cortisol‐secreting tumor as well. All other tumors, both from patients with Cushing's syndrome and patients judged to have “nonfunctioning” adenoma, released cortisol in vitro. The method provides valuable pathophysiological information on adrenal tumors.
Total thyroidectomy: Complications and technique
Authors: Harness Jay K. , Fung Lit , Thompson Norman W. , Burney Richard E. , McLeod Michael K.
Published: May 2005

During the 27‐year period from 1957 to 1984, four hundred thirty patients underwent total thyroidectomies for malignant or benign disease of the thyroid gland at our institutions. Thyroid cancer was found in 83.4% of cases, and 47.2% of these had concomitant lymph node dissections. Transient recurrent laryngeal nerve injury occurred in 6.2% of the entire series. Permanent unilateral vocal cord paralysis occurred in 2.5% of the patients operated on, although only 1 patient (0.45%) sustained this complication in the past 14 years. No patient had permanent bilateral vocal cord paralysis. Transient hypoparathyroidism was seen in 16.8% of patients with permanent hypoparathyroidism occurring in 4.0%. The incidence of permanent hypoparathyroidism fell to 2.7% during the past 14 years and was directly related to the extent of thyroid cancer found at operation. Postoperative complications decrease with the experience of the surgeon and increase with reoperations and extensive disease. Total thyroidectomy continues to be our treatment of choice for thyroid cancer.
Effect of ethyl alcohol on the TSH‐receptor‐cyclase system in thyroid and nonthyroid tissues
Authors: Clark Orlo H. , Gerend Patricia L.
Published: May 2005

Alcohol has been documented to be an excellent stimulator of calcitonin secretion in patients with C‐cell hyperplasia and medullary thyroid carcinoma (MTC). We, therefore, investigated the effects of 3–9% ethyl alcohol (ethanol) on the binding of tracer quantities of125I‐labeled bovine thyroid‐stimulating hormone (125I‐bTSH) to its receptor in normal and neoplastic thyroid tissue as well as its effects on adenylate cyclase (AC) stimulation in an 8,000 × g particulate fraction from normal and neoplastic nonmedullary thyroid tissue from 10 patients (20 specimens). We also studied the effect of ethanol on AC activity in 16 other nonthyroidal tissues (5 parathyroid adenoma, 1 pheochromocytoma, 1 sarcoma, and normal and neoplastic breast, kidney, parotid, and colon). These studies demonstrated that ethanol increased the binding of125I‐bTSH to normal and neoplastic thyroid tissue. It also increased AC activity in all but 3 of the 20 thyroid tissues and in all but 3 of the 16 nonthyroid tissues [thyroid basal 20.9±7.1, ethanol maximum 45.9±12.3 (p<0.025); nonthyroid basal 83.0 ±21.5, ethanol maximum 137±31.1 (p<0.01) in picomoles/30 min per mg protein]. This increase was dose dependent over a range of 3–9% ethanol. There was no difference in the degree of ethanol stimulation of AC between normal (28.7±16.3) and neoplastic (21.4±7.8) thyroid or between normal (89.0±8.9) and neoplastic (75.2±23.7) nonthyroid tissues. When ethanol (5%) was given along with TSH, sodium fluoride, Gpp(NH)p, or forskolin, there was a greater increase in AC activity than when no alcohol was present. The combined effect of TSH and ethanol (140.1±49.4) at maximal concentrations was comparable or greater than the result when TSH and ethanol were added separately (121.5±41.8). Thus, ethanol stimulates TSH binding and also activates AC in nearly all normal and neoplastic human tissues. This may be important biologically as well as experimentally since some compounds used in AC assays (in particular, forskolin) are dissolved in ethanol.
Preoperative portal vein embolization for hepatocellular carcinoma
Authors: Kinoshita Hiroaki , Sakai Katsuji , Hirohashi Kazuhiro , Igawa Sumito , Yamasaki Osamu , Kubo Shoji
Published: May 2005

As a countermeasure to portal tumor thrombi, which are a serious danger in liver cancer, we did portal vein embolization (PVE) during percutaneous transhepatic portography. Our 21 patients later underwent hepatic resection. After PVE, portal pressure increased and there was slight liver function damage, but this procedure was safer than transarterial embolization (TAE). We examined the pathologic specimens to view the state of occlusion achieved and also for histological findings, and found that Lipiodol ® mixed with fibrin was most effective. PVE done before hepatic resection strengthened the anticancer effect of TAE, prevented intrahepatic metastases, and caused permanent hypertrophy of the liver that may be useful as a kind of preparation for surgery.
Management of acute colitis in inflammatory bowel disease
Authors: Morel P. , Hawker P. C. , Allan R. N. , Dykes P. W. , Alexander‐Williams J.
Published: May 2005

From January 1971 to December 1984, fifty‐three patients presented with severe acute colitis, defined clinically as a temperature above 38°C., a pulse above 100/min, and bloody diarrhea more than 5 times/day. Twenty‐eight patients (12 male) had ulcerative colitis, 25 patients (13 male) had Crohn's colitis. The severe attack occurred earlier in the course of the disease in Crohn's colitis. The mean age for those with Crohn's disease was 31 years (range 17–58) and 41 years (range 17–70) for those with ulcerative colitis. All patients were managed on a combined medical and surgical gastrointestinal unit. The initial treatment was medical; 49 patients received corticosteroids, 40 salazopyrine, and 7 antibiotics. Twenty‐seven patients settled on medical treatment in a mean of 11 days (range 3–30). Of these, 3 required resection later. Twenty‐six patients required urgent operation (panproctocolectomy in 9, total colectomy and ileorectal anastomosis in 11, and colectomy with retention of rectum in 6). Ten patients developed toxic megacolon, 9 requiring urgent surgery. The other one initially settled but had a colectomy later on during the admission. There were no deaths in this series. Postoperative complications were uncommon. No factors on admission could predict the need for an operation. We believe that with close cooperation between experienced physicians and surgeons, mortality and morbidity from severe, fulminating colitis can be avoided.
Diverticula of the mid‐ and lower esophagus: Pathogenesis and surgical management
Authors: Evander Anders , Little Alex G. , Ferguson Mark K. , Skinner David B.
Published: May 2005

Ten patients with diverticula of the mid‐ or lower esophagus are reviewed with a focus on esophageal function, particularly motility, and its relation to surgical treatment. Median age is 56 years (range 16–79). There are 5 males and 5 females. The predominant symptoms were dysphagia and regurgitation, generally of 3 to 4 years' duration. All diverticula were identified by both barium upper gastrointestinal tract series and endoscopy. Three patients had 2 diverticula. The lower esophageal high pressure zone (LEHPZ) was assessed manometrically in 7 patients and the function of the esophageal body in all. LEHPZ pressure, length, and relaxation were normal in 4 patients, incomplete relaxation was present in 1 patient, and 2 had increased pressure. All 10 had abnormal esophageal body function including abnormalities of amplitude, duration, or propagation of contractions. pH assessment for reflux and clearance was performed in 4 patients. The acid clearance test was abnormal in all 4, and 2 patients had gastroesophageal reflux. One patient was managed medically and the other 9 surgically. Surgical treatment included diverticulectomy, myotomy, and an antireflux procedure in 7 patients; diverticulopexy, myotomy, and antireflux procedure in 1, and myotomy and antireflux procedure in 1. There was no operative mortality. Longterm clinical results are good. We conclude that symptomatic midesophageal and epiphrenic diverticula are caused by an abnormality of esophageal body or LEHPZ function which can be identified manometrically. These should, therefore, be thought of as pulsion diverticula. Surgery that addresses the underlying motor disorder can be performed safely and provides relief of symptoms.
Microvascular carotid end‐to‐end anastomosis with the Argon laser
Authors: Godlewski G. , Pradal P. , Rouy S. , Charras A. , Dauzat M. , Lan O. , Lopez F. M.
Published: May 2005

A carotid end‐to‐end anastomosis was performed in 50 Wistar rats (mean weight 260 g) by means of a Coherent 900 Argon laser. A micromanipulator coupled to an operating Zeiss OPMI 1 microscope provided a beam with a focused spot of 150 μm in diameter. After 2 stitches were made (180° apart from each other) to obtain good adjustment of the arterial ends, vessel anastomosis was achieved on common carotids (0.7–1.2 mm in diameter) using 19 laser shots of a mean power output of 300 milliwatts (mW) (1,700 W/cm2) for 5 sec. Good vascular flow was confirmed by Doppler spectral analysis and angiography performed on day 0, 3, 10, 20, and so forth up to 7 months. Light and scanning electron microscopy showed that the heating effects of the Argon laser caused collagenous fusion of the media on day 0, while the sealing line became reendothelialized on day 10. The patency rate was 76%. Complications such as thrombosis, disruption, and aneurysm must be attributed to initial technical drawbacks.
Pyogenic psoas abscess: Worldwide variations in etiology
Authors: Ricci Michael A. , Rose Frederick B. , Meyer Kenneth K.
Published: May 2005

Pyogenic abscess of the psoas muscle results from primary suppuration or direct extension of intraabdominal infection. The etiology varies with the country of origin. Our experience with 9 cases prompted a review of 367 cases from the world literature. A total of 286 primary abscesses occurred mainly in developing nations (200 cases), although 74 were reported from the United States. Younger patients predominated in developing nations (81.4% <20 years old), while only 47.8% from the United States were younger than 20 years. PureStaphylococcus aureus was commonly cultured (88.4%); simple incision and drainage cured 97.3% of patients with primary psoas abscess. Of 7 (2.5%) patients who died, 6 were from the United States; therapy was inadequate or delayed in all 7 patients. Ninety secondary abscesses appeared almost exclusively in reports from Europe, the United States, and Canada. Crohn's disease was the most common etiology followed by appendicitis and colon inflammation or cancer; mixed enteric infections predominated (55.7%). Although rare during the first decade, distribution was otherwise relatively even across all age groups. Simple drainage succeeded in only 49% of cases. Higher mortality accompanied secondary abscess (17 cases, 18.9%). The etiology of pyogenic psoas abscess guides the selection of proper medical and surgical therapy. While primary abscess is the likely etiology in developing nations and secondary abscess in Europe, either may occur in the United States. Early diagnosis and proper therapy are necessary to reduce mortality.
Intraoperative cholangiography using a balloon catheter in liver surgery
Authors: Kubo Shoji , Sakai Katsuji , Kinoshita Hiroaki , Hirohashi Kazuhiro
Published: May 2005

To prevent intraoperative injury of the bile ducts, we designed a balloon catheter and used it in the intraoperative cholangiography of 36 patients undergoing hepatectomy for primary carcinoma of the liver at the Second Department of Surgery of Osaka City University Hospital during the past 4 years. After cholecystectomy, the balloon catheter was inserted through the cystic duct up to the common bile duct, and cholangiography was performed before and after liver resection. This method makes intrahepatic bile ducts easier to visualize. In 14 of the 53 patients in whom cholangiography using a balloon catheter or conventional catheter was done, the abnormal branching of the intrahepatic bile ducts was found before resection, and the liver was resected without injuring the ducts. In 2 of the 36 patients in whom cholangiography with a balloon catheter was performed, leakage of the contrast medium from the resected liver surface was visible, and this part of the liver was sutured. With this new method, postoperative complications caused by bile leakage decreased. No side effects developed after the balloon catheter was used. We have used basically the same technique in other kinds of hepatobiliary disease.
Regeneration and function of autotransplantation of splenic tissue after splenectomy
Authors: Christenson J. T. , Owunwanne A. , Al‐Hassan E. E. , Ryd W.
Published: May 2005

In traumatic rupture, it is often not possible to repair the spleen. Splenectomy results in increased susceptibility to sepsis with a high mortality rate. Autotransplantation of splenic tissue has been suggested, but its functional value is still in doubt, particularly the ability of autotransplanted spleen to resist intravenous bacterial challenge. The ability to sequestrate denatured99mTc (technetium‐99m) RBC (red blood cells) and to resist intravenous pneumococci was studied in sham‐operated (control) rats, splenectomized rats, and splenectomized rats with autotransplanted spleen. Histopathologic tests were also performed. There was a gradual increase in the splenic sequestration of the denatured99mTc RBC with a spleen‐to‐blood ratio of 0.19 to 1.5 at 2 and 30 weeks after the splenic reimplantation. Prior to 18 weeks after the splenic autotransplantation, no rat survived the intravenous pneumococcal challenge, but at 28–30 weeks, 80% of the rats survived the challenge indicating an increased splenic activity at this time. There was also a corresponding increase in splenic tissue weight from 241 mg at the time of autotransplantation to 417 mg beginning at the 24th week after the reimplantation. Four to 5 weeks after the transplantation, the spleens had a fairly normal histological architecture. The present study, therefore, indicates that autotransplanted splenic tissue is capable of restoring the ability to resist intravenously injected pneumococcal challenge, to sequestrate denatured99mTc RBC, and to regenerate normal splenic tissue within 24–30 weeks after the reimplantation.
Biliary strictures as a cause of primary intrahepatic bile duct stones
Authors: Matsumoto Yoshiro , Fujii Hideki , Yoshioka Masakazu , Sekikawa Takayoshi , Wada Toshisue , Yamamoto Masayuki , Eguchi Hideo , Sugahara Katsuhiko
Published: May 2005

We collected 51 cases of stricture in the upper portion of the biliary tract and discussed the pathogenesis and the clinical significance of the strictures. All 51 patients had congenital cystic dilatation of the common bile duct (CCDB): 2 had infant‐type cysts which involved the choledochus and/or the common hepatic duct, and 49 had adult‐type cysts which included the entire extrahepatic bile duct and/or the main intrahepatic bile ducts. Thirty‐five of the latter 49 had intrahepatic bile duct stones proximal to the stricture. Considering the location and the clinical features, the strictures may have been formed congenitally. Furthermore, adult‐type cysts of the common bile duct with strictures in the upper portion of the biliary tract are thought to be the basis for the formation of primary intrahepatic bile duct stones.
Splenic artery aneurysms
Authors: Trastek Victor F. , Pairolero Peter C. , Bernatz Philip E.
Published: May 2005

The cause of splenic artery aneurysms and the indications for their treatment remain controversial. Splenic artery aneurysms occur more frequently in women and are associated with pregnancy and multiparity. Whether arteriosclerosis is the cause of the aneurysm or is a secondary phenomenon is unknown. Patients not treated do well, especially if the aneurysm is less than 2 cm in diameter. The rate of rupture is approximately 3%, and it appears to be decreasing as more patients are found to have this type of aneurysm. The mortality rate for ruptured splenic artery aneurysm is greatly increased if the patient is pregnant. Indications for removal include presence of symptoms, pregnancy or plan to become pregnant, increasing size, and a diameter of 2 cm or greater. Depending on the medical condition of the patient, aneurysms that are less than 2 cm in diameter can be removed electively, or they can be left and the patient followed closely. The risk of elective removal is extremely low and has minimal morbidity. In the treatment of this type of aneurysm, the spleen should be preserved if possible; splenectomy is reserved for those aneurysms found in the hilus of the spleen or during emergency situations.
Surgery of the traumatized spleen
Authors: Bongard Frederic S. , Lim Robert C.
Published: May 2005

Because of the increased awareness of the risk of over‐whelming sepsis following splenectomy, we have attempted splenorrhaphy in trauma victims whenever possible. Among 75 patients with splenic injuries, 44 (58.7%) were treated with splenorrhaphy. These patients were critically ill, and frequently had multiple associated injuries. We found that unless physiologic or anatomic considerations precluded its use, splenorrhaphy could be performed readily with minimal blood loss and no increase in operating time. The majority of patients undergoing repair (63.6%) had simple lacerations which were controlled either with topical hemostatic agents or repaired with absorbable sutures. The early complication and operative mortality rates for splenorrhaphy and splenectomy were similar. One patient undergoing splenorrhaphy required reoperation for bleeding. There were no episodes of delayed hemorrhage or capsular disruption. We conclude that splenorrhaphy is a viable and safe alternative to splenectomy under certain circumstances, and may be beneficial by reducing the risk of subsequent overwhelming postsplenectomy sepsis.
Accessory spleens: Clinical significance with particular reference to the recurrence of idiopathic thrombocytopenic purpura
Authors: Rudowski Witold J.
Published: May 2005

One of the important stages during splenectomy is the search for accessory spleens. The average frequency of accessory spleens is an estimated 11%. In our own material in 611 patients who had splenectomy in hematological disorders, accessory spleens were found in 110 patients (18%). The surgical anatomy, embryology, and clinical significance of the accessory spleens, with particular reference to the recurrence of idiopathic thrombocytopenic purpura (ITP) are discussed. The group of 177 patients with ITP treated by splenectomy 2–25 years ago is analyzed. Recurrence of thrombocytopenia after a good immediate response to splenectomy developed in 52 patients. In 13 patients the recurrence was transient, but in 19 it was longlasting. In these patients the presence of the accessory spleens was suspected by the absence of Howell‐Jolly bodies in the peripheral blood. The accessory spleen was demonstrated by splenic scan in 16 cases and confirmed in 13 of the 15 patients who underwent reoperation. Removal of the accessory resulted in permanent disappearance of thrombocytopenia in 12 patients.
Splenectomy for malignant lymphomas
Authors: Mitchell Andrew , Morris Peter J.
Published: May 2005

Splenectomy may be indicated in malignant lymphoma for diagnosis, staging of the disease, or therapy. In the majority of cases of otherwise undiagnosed splenomegaly, it will allow histological diagnosis. A proportion of those who remain undiagnosed will subsequently develop lymphoma. Staging laparotomy has an established place in the management of Hodgkin's disease, but its role in non‐Hodgkin's lymphoma is very limited. Despite the poor general condition and long‐term prognosis of most patients with hypersplenism due to advanced lymphoma, splenectomy has a low morbidity and mortality, and usually results in correction of the hematological cytopenia which allows appropriate chemotherapy for the disease.

During the past 10 years, 287 patients had their spleen removed under the care of one surgeon. One hundred and forty of these splenectomies were carried out as part of a staging laparotomy for Hodgkin's disease and 20% were for hypersplenism complicating malignant lymphoma. A further 34 patients (12%) had a splenectomy to establish a diagnosis and 26 of these patients proved to have a lymphoma. Forty‐six patients, who are not discussed further in this paper, had a splenectomy for various hematological disorders. There was 1 hospital death (0.3%) as a result of splenectomy and the overall morbidity rate for splenectomy was 14% in this series.
Postsplenectomy sepsis: Historical background and current concepts
Authors: West Karen W. , Grosfeld Jay L.
Published: May 2005

Although most common in infancy and early childhood, susceptibility to postsplenectomy infection is not limited by age or underlying pathological condition. Postsplenectomy sepsis is a fulminant, rapid process which often begins with vague symptoms. Death may follow in hours unless appropriate fluid resuscitation and antibiotic therapy is promptly instituted. Experimental evidence suggests that spienectomy results in a loss of both mechanical and humoral protective factors. Elective spienectomy should be postponed until after age 4 years. Preoperative immunization with pneumococcal vaccine and prophylactic antibiotics may play a role in preventing postsplenectomy sepsis. In instances of trauma, all or part of the spleen should be preserved when possible.

Postsplenectomy sepsis is a life‐long risk. Patient and parent education and long‐term follow‐up are essential.
Donor‐specific transfusions in living‐related transplantation
Authors: Salvatierra Oscar
Published: May 2005

Two‐hundred thirty‐nine transplants have been performed following donor‐specific blood transfusions (DSTs) from 1978 through 1984 at the University of California, San Francisco (UCSF). The results of this experience show that DST provides excellent long‐term graft survival in 1‐haplotype mismatched pairs. Excellent graft survival has also been obtained in a limited 0‐haplotype matched experience. These results are comparable to those achieved with concurrent HLA‐identical sibling transplants. Azathioprine coverage during DST administration does appear to decrease DST sensitization to the blood donor in unsensitized patients undergoing a first transplant, encouraging early DST and transplantation in this group. The majority of patients formerly excluded from transplantation because of a post‐DST positive B‐warm crossmatch can now be successfully transplanted with the use of flow cytometry analysis to rule out previously undetectable low levels of anti‐class I antigen activity. The DST protocol by itself does not appear to preclude subsequent cadaveric transplantation in patients sensitized to their blood donor by the DST procedure. Preliminary results of cyclosporin treatment in 1‐haplotype matched living‐related donor‐recipient pairs is reported with a 1‐year graft survival rate that is similar to that obtained following cadaveric transplantation at this same center. In summary, the long‐term immunologic effect of DST has been confirmed, and the indications and considerations for the optimum use of the DST protocol appear to be more clearly defined.
Total lymphoid irradiation in renal transplantation
Authors: Myburgh J. Albertus , Smit Jacobus A. , Meyers Anthony M. , Botha J. René , Browde Selma , Thomson Peter D.
Published: May 2005

Total lymphoid irradiation (TLI), used in the treatment of some patients with Hodgkin's disease, produces profound immunological changes. In small rodents, mice and rats, a modified version of TLI results in transplantation tolerance for skin and heart allografts. The concept has been expanded to large outbred animals. In baboons transplantation tolerance has been produced for kidney and liver transplantation. The tolerance meets the in vivo and in vitro immunological requirements of durability and specificity. Baboons are currently surviving with normal graft function more than 6 years after kidney transplantation. Kidney‐donor derived skin grafts are accepted permanently, and third‐party skin and kidney grafts are rejected by these tolerant animals. Late chronic rejection occurs in a minority of animals between 6 and 12 months after transplantation. No grafts have been rejected by baboons with normal graft function at 1 year. The most successful protocol in baboons has involved a low cumulative dose (800 cGy), twice a week fractionation regimen of irradiation administered to a wider field than that used in the treatment of Hodgkin's disease. Up to two‐thirds of such animals are rendered tolerant. The role of adjuvant immunosuppressive drug therapy in increasing the tolerant fraction obtained is currently under evaluation. Encouraging results with the use of several methods of TLI in clinical renal transplantation are emerging from 5 centers. The prospect of achieving transplantation tolerance with TLI in the clinical context may be realized with further experience and modification of techniques.
Renal transplantation between identical twins: A review
Authors: Tilney Nicholas L.
Published: May 2005

The experience of transplantation between identical twins, occurring primarily at the Peter Bent Brigham Hospital, is reviewed. The remarkable success of this human experiment beginning in 1954 and ending, at least for the present in our hospital, in 1976, has confirmed early hopes that clinical renal transplantation may be an extremely effective treatment for end‐stage renal failure. Based largely on this seminal experience, investigations into experimental aspects of transplantation immunology, autoimmunity, and the general host responses, as well as developments in the field of nephrology and overall care of patients with endstage renal disease, have burgeoned. Indeed, during recent years, transplantation of several organs including heart, heart‐lung, liver, and kidney have proven remarkably successful. As knowledge and application in this field continues to expand, increasing numbers of patients with organ failure can expect to return to relatively normal lives.
Progress in segmental pancreatic transplantation
Authors: Tydén G. , Lundgren G. , Öst L. , Kojima Y. , Gunnarsson R. , Östman J. , Groth C. G.
Published: May 2005

Twenty‐nine patients with type I diabetes mellitus and end‐stage diabetic nephropathy were subjected to combined renal and pancreatic transplantation. The 2‐year actuarial patient survival rate was 87% and the renal graft survival rate was 78% for the whole series. The 1‐year and 2‐year actuarial pancreatic graft survival rates were 54% and 40%, respectively. A substantial improvement in the pancreatic graft survival has occurred with time. Thus, in the first part of the series (1981–1983, n = 13), the 1‐year pancreatic graft survival was 31%, whereas in the second part of the series (1984–1985, n = 16), the figure was 75%. The improvement in results was probably due to a reduction in the cold ischemia time and the adoption of an aggressive anticoagulant treatment; using these measures the incidences of pancreatitis and graft thrombosis were much reduced. In all patients with functioning pancreatic grafts, insulin therapy was discontinued and an essentially normal glucose homeostasis was achieved. Among the patients whose pancreatic transplant has survived for a longer period, no further deterioration in retinopathy or neuropathy was found. Furthermore, biopsies from the simultaneously transplanted kidneys in 2 patients 3 years after transplantation have failed to show any increase in the thickness of the glomerular basement membrane indicative of a recurrence of diabetic nephropathy.
Liver transplantation in the adult
Authors: Calne R. Y. , Williams Roger , Rolles Keith
Published: May 2005

A total of 216 orthotopic liver transplants have been carried out in the Cambridge/King's College Hospital series. Over 16 years, changes in patient selection, immunosuppression, and surgical and anesthetic techniques have led to an improvement in results. These aspects are described and discussed. Although at considerable risk during the operation, patients with nonmalignant cirrhotic diseases who survive 1 year have a good long‐term chance of survival. A slow but steady improvement in survival after liver grafting has resulted from multiple and interesting factors. These include patient selection, technical changes, particularly regarding biliary drainage, increased availability of donors with transport of livers between different centers, and new immunosuppressive management. Although patients with primary carcinoma of the liver are better operative risks, the incidence of recurrent growth is about 60%. Patients with nonmalignant cirrhotic disease are more apt to develop perioperative complications. If they survive the first few weeks, their chances of long‐term rehabilitation are better than those of patients with malignant conditions. Many of the earlier patients in our series would now be considered too ill for the procedure, but still patients accepted for grafting die before a donor liver becomes available, and some patients who are suitable when first seen are gravely ill by the time a liver graft can be performed. The results and experience gained from the 216 orthotopic liver transplants performed in our series from May 1968, to August 1985, are described.
Liver transplantation in the child
Authors: Flye M. Wayne , Jendrisak Martin D.
Published: May 2005

Liver transplantation has become the accepted mode of therapy for the patient with end‐stage liver disease, with a 1‐year success rate of approximately 70%. This is particularly true in the child in whom the indications are sometimes more clear cut than in the adult patient. The limiting factor to transplantation, however, remains the availability of suitable pediatric donor livers. Presently, the major indication for pediatric liver transplantation is extrahepatic biliary atresia. Other diseases in the pediatric patient treatable by this modality are chronic obstructive liver diseases, primary tumors of the liver, and a variety of metabolic disorders such as alpha‐1‐antitrypsin deficiency, Wilson's disease, Crigler‐Najjar syndrome, and tyrosinemia, as well as acute and subacute hepatic failure resulting from viral or toxin insult. Liver transplantation is no longer an experimental procedure but now is an accepted therapy. This has resulted in large part because of improved surgical techniques, perioperative management, and immunosuppressive therapy with cyclosporin.
Current status of heart and lung transplantation
Authors: Starnes Vaughn A. , Jamieson Stuart W.
Published: May 2005

From March 1981, to August 1985, twenty‐eight heart‐lung transplants in 27 patients were performed at Stanford University. The actuarial survival at 1, 3, and 4 years was 64%, 55%, and 39%, respectively. In these 28 transplants, there were 8 perioperative deaths (29%) and 4 late deaths. Four of the perioperative deaths were related to previous operations and extensive adhesions which resulted in massive blood transfusion requirements. Of the 4 late deaths, 3 were attributed to primary pulmonary dysfunction resulting from obliterative bronchiolitis. One additional late death was due to cardiac allograft atherosclerosis with an anteroseptal myocardial infarction. The majority of the patients who have been discharged from the hospital have assumed normal lifestyles, with 3 of our patients participating in physically demanding athletic events.

Heart‐lung transplantation continues to offer promise to patients with end‐stage heart and lung disease. Improvement in perioperative mortality may reasonably be anticipated with the refinement of patient selection and continued improvement of techniques of monitoring pulmonary rejection. Cyclosporin has made possible an effective method of immunosuppression without compromising the tracheal anastomosis. Presently, suitable donors for heart‐lung transplantation are difficult to acquire and will continue to be the limiting factor in the foreseeable future.
What happens to the parietal cell following truncal vagotomy?
Authors: Argov Samuel , Hershlag Avner , Mordohovich Daniel
Published: May 2005

The mechanism of gastric acid reduction following vagotomy is still unclear: does this reduction result from a decrease in parietal cell mass, or is the reduction just functional? In an attempt to settle the question, we used a litter of puppies, in which rapid multiplication of parietal cells takes place. We performed truncal vagotomy (histologically proven) on 4 puppies, using 3 puppies as a control group. Open gastric biopsies were taken every month from birth uncil 12 months of age. Parietal cells were counted and correlated with age. We found a significant reduction in the parietal cell mass in the vagotomized group during 4 months after delivery. The possible mechanisms explaining this phenomenon, as well as assumed clinical correlation, are discussed.
Intra‐atrial extension of renal and adrenal tumors: Diagnosis, management, and prognosis
Authors: Hugh Thomas B. , Jones Robert M. , Shanahan Mark X.
Published: May 2005

Intra‐atrial tumor thrombus arising from a renal or adrenal tumor is a serious development. Preoperative recognition by computed tomographic scanning and cavography is important, and these investigations should be considered even in patients without symptoms of venous obstruction, especially if the tumor is right‐sided and greater than 7 cm in diameter.

We report here our experience with the management of 3 patients with intra‐atrial tumor thrombus (2 adrenal, 1 renal). A combined midline and median sternotomy approach is preferred and cardiopulmonary bypass is essential. Moderate hypothermia and liver inflow occlusion may also be necessary. This technique provides effective vascular control for resection of the tumor and its intravascular extension, and is simpler than profound hypothermia, total body exsanguination, and complete circulatory arrest. Perioperative endoscopic examination of the interior of the inferior vena cava and hepatic veins, under bloodless conditions, helps to ensure that there has been complete removal of the thrombus.

A review of 28 reported patients who have had removal of intra‐atrial thrombus suggests that long‐term survival is rare, but the possibility of symptom relief makes this procedure worthwhile.
What's new in the Federal Republic of Germany: A survey
Authors: Heberer G. , Teichmann R. K.
Published: May 2005

A survey of the field of surgery in the Federal Republic of Germany finds numerous developments hi clinical, experimental, and professional activities within the country. For example, in 1985, a questionnaire found that almost all university hospitals and 70% of other hospitals now perform proximal gastric vagotomy without pyloroplasty on patients with duodenal ulcer. Further developments within clinical surgery include increased use of staplers, a resurgence in the use of pancreatic duct occlusion for chronic pancreatitis, the establishment of transplantation units, and the multidisciplinary approach to the care of multiple trauma patients.

Clinical research is actively engaged in developing a new continent colostomy; in perfecting intraoperative biochemical localization of insulinomas and gastrinomas; in expanding the use of intraoperative ultrasound; and in monitoring transplant patients. The most noteworthy experimental research project at present is the use of extracorporeal shock wave treatment to fragment gallstones.

Professional trends include a decline in the number of inpatient pediatric cases, an increased interest in quality control programs, and the expansion of postgraduate training in surgical subspecialities.
Fluid therapy in shock
Authors: Arturson Gösta , Thorén Lars
Published: May 2005

Three principal factors must be considered in initial fluid therapy in the treatment of shock: (a) blood volume deficit; (b) oxygen transport capacity; and (c) metabolic requirement of water and electrolytes. For the calculation of the initial volume to be used in compensatory blood volume loss, patients may be categorized thusly: group A—impending or slight loss [assumed loss of 20% of total blood volume (TBV)]; group B—moderate shock (20–35% of TBV); and group C—severe shock (>35% of TBV). These groups are treated initially with 20%, 30%, and 50% of TBV replacement, respectively. Treatment is individualized by continuous observation and changes are made as required. The relative merits and indications for use of crystalloid and colloid solutions are outlined. Oxygen delivery to the tissues must be guaranteed. The flow properties of the blood improve and the oxygen carrying capacity decreases with reducing hematocrit levels; a hematocrit reading of about 30 or slightly above is adequate. In determining the metabolic requirements, 3 factors must be considered: the physiologic daily requirement of water and electrolytes; the increased extrarenal fluid losses; and the reduction of the extracellular volume in trauma.
Intraoperative fluid therapy
Authors: Thorén Lars , Wiklund Lars
Published: May 2005

The principles for intravenous administration of water, carbohydrates, and electrolytes during operations in adults, who were considered to be “in balance” prior to surgery, are detailed. The problem of blood replacement is likewise surveyed, with a view to coordinating these 2 clinical areas. A practical fluid therapy program is presented.