bluuebunny/crossref_metadata_2025 huggingface dataset:
Intrathoracic esophagojejunostomy following the resection of the lower esophagus—Tohru Ohsawa, pioneer in surgery of the esophagus
Authors: Imamura Masayuki , Tobe Takayoshi
Published: May 2005

In 1929 Ohsawa of Kyoto performed an intrathoracic esophagojejunostomy on a 52‐year‐old male through the thoracoabdominal route. This was the first successful case of anastomosis between the intrathoracic esophagus and the intra‐abdominal digestive tract, previously attempted so many times the world over. This marked the opening of the era of esophageal surgery. As early as 1938, Ohsawa detected esophageal cancer of 1 × 2 cm size by fluoroscopy. Successful surgery on this tumor highlighted the ultimate approach for the satisfactory treatment of esophageal cancer, i.e., early detection and early treatment.
New aspects of parenteral nutrition with fat emulsions in injured patients
Authors: Kleinberger G.
Published: May 2005

Adequate nutrition is essential to recover from injury. There is a close correlation between the severity of injury and the catabolism in the flow phase. During the last few years, many contraindications against the intravenous infusion of fat emulsions have been discussed and determined to be invalid. The development of clinical applicable intravenous fat emulsions and the introduction of all‐in‐one (AIO) solutions for continuous intravenous nutrition have been a great success in the care of injured patients with and without major complications. Careful investigations of the stability of fat emulsions in AIO solutions by examination of visible changes, light and electron microscopic abnormalities, zeta potential, and coulter counting of the size distribution of liposomes revealed that fat emulsions are now safe for long‐term complete parenteral nutrition.

The metabolic response to trauma and operation is characterized by the ebb and flow phase. While the patients in the ebb or shock phase should not receive nutrition, patients in the flow or catabolic phase resulting from the combination of decreased nutritional intake and increased nutritional requirement due to injury and its complication as sepsis and organ failure should receive sophisticated intravenous nutrition. The most probable means of achieving sufficient nutrition without metabolic derangement is the partitioning of the energy supply on carbohydrates and fat and the continuous intravenous administration of an AIO solution. Data that have been gathered reveal that the partial use of fat as energy source in injured patients with and without major complications (diabetes mellitus, acute pancreatitis, acute renal failure, liver insufficiency, and sepsis) diminishes the metabolic derangements and improves the standard of nutritional care. After many years of worldwide experimental and clinical investigations, fat is contraindicated only in the shock phase and in primary or secondary disturbances of fat metabolism that lead to a triglyceride level in serum above 4.5 mmol/l during continuous intravenous nutrition.
Medium‐chain triglycerides (MCT) for total parenteral nutrition
Authors: Wolfram G.
Published: May 2005

Total parenteral nutrition is an important measure in optimal treatment of patients under intensive care. Recently, the administration of macronutrients protein, carbohydrates, and fat has been extended to medium‐chain triglycerides. Meanwhile, the well‐known advantages of these fats in enteral feeding has also been confirmed for parenteral application. Medium‐chain triglycerides are quickly removed from the blood, taken up by extrahepatic tissues, carnitine‐independent transported into mitochondria, and oxidized more quickly than long‐chain fatty acids. Simultaneously formed keton bodies from the liver may be an additional energy source. Medium‐chain triglycerides, in combination with long‐chain fatty acids for essential fatty acid supply, provide easily available energy and have a protein‐sparing effect in patients after operation or injury.
Metabolic studies of a lipid emulsion containing medium‐chain triglyceride in perioperative and total parenteral nutrition infusions
Authors: Dawes Raymond F. H. , Royle Gavin T. , Dennison Ashley R. , Crowe Phillip J. , Ball Madeline
Published: May 2005

The effects of infusion of a 10% lipid emulsion containing equal proportions of long‐chain and medium‐chain triglyceride were studied in elective surgical patients and others receiving total parenteral nutrition (TPN). Nitrogen balance was better when the TPN patients received lipid containing medium‐chain triglyceride than during a similar period when long‐chain triglyceride alone was given. Only in the malnourished patients did the medium‐chain triglyceride lipid emulsion produce a significant ketonemia. This emulsion was administered without side effects.
Principles and indications of hypocaloric parenteral nutrition
Authors: Löhlein D.
Published: May 2005

Postoperative metabolism is characterized by increased energy demand and nitrogen loss. Whereas autoregulatory mechanisms are able to meet the energy needs by enhanced lipolysis without endogenous problems, nitrogen loss mainly affects functionally and metabolically important proteins. In order to prevent these protein losses during the acute postoperative period, hypocaloric parenteral nutrition is suggested. The concept of hypocaloric nutrition consists of adequate amino acid substitution of 1.2–1.5 g/kg body weight per day and a low‐dosed carbohydrate supply not to exceed 150–200 g per day. According to our own experience, this carbohydrate supply is best done with glucose substitutes like polyoles, since these substrates do no greater damage to the endogenous autoregulatory mechanism and give additional support to hepatic gluconeogenesis so that amino acids can be spared. Analyzing a 6‐year period of using both hypocaloric and caloric‐adequate postoperative parenteral nutrition we believe that hypocaloric nutrition is as beneficial as higher caloric parenteral nutrition, which in its application and monitoring is more expensive and time‐consuming.
Perioperative parenteral nutrition in the stressed diabetic patient
Authors: Vandewoude Maurits F. J. , Van Gaal Luc F. , De Leeuw Ivo H.
Published: May 2005

In the diabetic surgical patient, the effects of absolute or relative insulin deficiency are superimposed on the metabolic alterations of stressed nondiabetic subjects. Stress hyperglycemia, ketosis, and insulin resistance in the perioperative period should be interpreted differently when adequate parenteral nutrition must be provided in a diabetic. Insulin must be added following rigid but sliding scales. Depending on stress levels the administration of calories must be chosen from different possible energy substrates: carbohydrates, lipids, and amino acids. Only during high stress levels with concomitant severe insulin resistance does enrichment of the feeding solution with branched‐chain amino acids seem appropriate. In metabolically more stable situations, preference should be given to carbohydrate and fat calories. Although recent innovations such as nonglucose carbohydrates and medium‐chain triglyceride infusions are very promising, their use in diabetics should be under close clinical and metabolic control to avoid major side effects such as intracellular substrate accumulation and ketosis.
Parenteral nutrition in pediatric surgery
Authors: Schärli A. F.
Published: May 2005

Malnutrition in childhood alters the defense mechanisms toward infections and leads to hypoalbuminemia. The risk of delayed wound healing and infections is highly increased. Parenteral nutrition is always indicated when a child will be unable or presently cannot or will not eat for more than 3 days. More than 50 substances are currently employed to fulfill the metabolic requirements. The needs for water, electrolytes, and energy are well understood, but the adequate amounts of amino acids, lipids, vitamins, and trace elements still need to be investigated. Although parenteral nutrition has become a lifesaving measure for many conditions in infants and children, the intravenous route is still far from being a substitute for the bowel. A number of complications related either to the catheter or to the metabolism are more frequently seen in children than in adults. Among these, rickets, anemia, hypoalbuminemia, and cholestatic jaundice are the most frequent. Ten recommendations are given to increase the utilization of infused substances and to minimize the risk of adverse reactions.
All‐in‐one: Conventional versus two different all‐in‐one solutions for total parenteral nutrition of surgical intensive care patients
Authors: Leutenegger Adrian F. , Frutiger Adrian
Published: May 2005

Three randomly selected groups of 10 surgical patients under intensive care were prospectively studied concerning the utility and effectiveness of postoperative or posttraumatic parenteral nutrition during 7 days with different solutions: conventional total parenteral nutrition (TPN) with amino acids and glucose (AA/G), or all‐in‐one solutions with amino acids, fat, and carbohydrates either as glucose (AIO/G) or as a mixture of the polyoles sorbitol and xylitol (AIO/P). The AIO solutions were delivered in stable ready‐to‐use mixtures and needed no further processing before administration. Efficiency of all regimens in improving nutritional status was documented. Comparing the 3 groups, we found one important difference: the blood glucose level was significantly lower in the AIO/P group than in the other 2 groups with glucose as the carbohydrate (p<0.001). Furthermore, the bilirubin increase observed in all 3 groups, probably a sign of cholestasis, was significantly higher in the AIO/P group versus conventional TPN. We, therefore, conclude that immediate postoperative or posttraumatic nutrition with an AIO solution was safe and its handling simple. In our patients with stress‐induced glucose intolerance early after major surgery or trauma, the AIO/P solution without glucose produced less hyperglycemia and compared favorably with conventional TPN or an AIO glucose solution. Both AIO solutions were well tolerated and side effects requiring interruption of the therapy did not occur.
Rupture of splanchnic artery aneurysms
Authors: Salo Jarmo A. , Salmenkivi Kari , Tenhunen Anssi , Kivilaakso Eero O.
Published: May 2005

The results of surgical therapy for acute ruptured splanchnic artery aneurysms in 6 patients treated at Helsinki University Central Hospital from 1964 to 1984 were analyzed. There were 3 patients with ruptured splenic, 2 with ruptured hepatic and 1 with ruptured superior mesenteric artery aneurysms. The condition remained undiagnosed in all patients preoperatively, and the diagnosis was obtained only at emergency laparotomy performed for severe shock, abdominal pain, and distension. Five of the 6 patients survived, including a pregnant woman, who gave birth to a living baby by ceserean section. The results indicate that immediate, aggressive surgical approach dictated by the clinical condition of the patient affords good survival in patients suffering from acute rupture of splanchnic artery aneurysms.
Stomal ulcer complicating bypass for duodenal crohn's disease
Authors: Shepherd A. F. I. , Alexander‐Williams J.
Published: May 2005

Crohn's disease of the duodenum is a relatively rare condition. It is observed in 0.5–4% of patients with Crohn's disease, and about 200 cases have been reported in world literature. Obstruction is the main indication for operation, and the most common procedure is gastrojejunostomy. Opinion is divided as to whether or not a vagotomy should be performed. We report a patient treated by gastrojejunostomy without vagotomy who developed a stomal ulcer within 8 weeks of operation.
Experimental and clinical results with a simplified left heart assist device for treatment of profound left ventricular dysfunction
Authors: Rose Daniel M. , Laschinger John , Grossi Eugene , Krieger Karl H. , Cunningham Joseph N. , Spencer Frank C.
Published: May 2005

During the last few years patients with profound heart failure following cardiac surgery have been managed with increasing success with the use of a variety of left heart assist devices. Although some previous experimental studies suggested that cannulation of the left ventricle was superior to that of the left atrium, present studies demonstrate that left atrial cannulation can effectively unload the left ventricle, and significantly decrease left ventricular work. Since 1978, a roller pump type of left heart assist device with cannulation of the left atrium and ascending aorta has been employed in 46 patients with severe postoperative cardiac failure. Twenty‐one patients were successfully weaned from the device; 5 patients died within 90 days of removal of the device, and there were 2 other late deaths 4 months and 4 years postoperatively. There were 14 long‐term survivors (6 months to 54 months). Thirteen of these patients are New York Heart Association class I or II, and 1 patient is New York Heart Association class III. Thus, satisfactory early and late results can be attained with this system. However, it has been postulated that if more complete left heart bypass were utilized, more patients would ultimately survive.
A decade of experience with a left heart assist device in patients undergoing open intracardiac operation
Authors: Litwak Robert S. , Koffsky Robert M. , Jurado Roy A. , Mitchell Bennett A. , King Philip
Published: May 2005

Over a decade has elapsed since the first clinical application of our left heart assist device (LHAD). The basic concepts underlying its development evolved from prior experience in which, given adequate support time, less than total left heart bypass (LHB) was found to result in gradual improvement of depressed left ventricular function. Hence, the long‐held view that functional recovery of the heart could occuronlyunder conditions of total LHB seemed unsupportable by clinical realities. As a result, a simple LHAD was devised. Requiring only special silicone elastomer cannulas, the system uses a roller (or other continuous flow) pump and diverts blood from the left atrium to the ascending aorta. We believe a major asset of the system is the ability to separate the patient subsequently from the LHAD without need to re‐enter the thorax. This is accomplished by permanently occluding each cannula lumen with an obturator, thereby allowing the biocompatible cannulas to remain permanentlyin situ.To date, 27 patients have undergone LHAD support. Of 18 patients who could be separated from the device, half (9) were discharged from the hospital. Seven remain alive and well, the longest now more than 10 years after the operation. Although rarely needed, broadening operative indications in patients with severely compromised left ventricular function suggests that there will be continued need for a method of LHB for the foreseeable future.
Use of a centrifugal pump without anticoagulants for postoperative left ventricular assist
Authors: Magovern George J. , Park Sang B. , Maher Thomas D.
Published: May 2005

Following experimental studies using the vortex pump (Bio‐Medicus) for left heart assist (LHA) in dogs and lambs for periods up to 3 weeks without anticoagulation and minimal thromboemboli, we initiated the clinical work without anticoagulation in 21 patients. All previous clinical attempts at LHA using anticoagulation eventually resulted in intracerebral or other hemorrhagic complications. The key factors we experienced to prevent bleeding or microthrombus were to omit heparin, but to maintain flows constantly around 2 liters or more per minute. At lower levels, fibrin split products became elevated and microthrombus could be detected in the pump. To further safeguard against thromboembolism, the commercial pump was changed every 24 hr. No clinical intracerebral or thromboembolic complications occurred.

From February 18, 1980, to February 4, 1983, three thousand patients underwent cardiopulmonary bypass at Allegheny General Hospital. Twenty‐one patients required prolonged postoperative LHA. The patients were predominantly male and ranged in age from 38 to 74 years (mean age 56.2 years). The Bio‐Medicus, asynchronous, vortex pump was used on all cases, and decompression was performed via a left atrium/left ventricle cannula and arterial return via a Sarns arch cannula. During LHA the sternum was open, but the skin was approximated. The activated clotting time was maintained at 140, but heparin or anticoagulation was not routinely employed. Only 4 patients received one 10,000‐unit dose. Bleeding was controlled by using fresh frozen plasma, autotransfusion, and platelets. Serum calcium (Ca), sodium (Na), chloride (Cl), potassium (K), total protein, serum osmolality, white blood cell count (WBC), red blood cell count (RBC), hematocrit (Hct), platelets, serum hemoglobin (Hgh), fibrinogen, prothrombin time (PT), partial thromboplastin time (PTT), and fibrin split products (FSP) were measured every 4–8 hr, as indicated. Intracardiac pressures and cardiac output (CO) were measured every 2–4 hr as indicated. Hematologic and physiologic results are discussed. Ten patients were successfully weaned from LHA. Five hospital deaths occurred later (2–9 days) from low cardiac output and arrhythmia (2), septicemia (1), and pulmonary complications (2). Five patients were discharged from the hospital and are alive 1–3 years following surgery (22%). The longest assist was 144 hr, and the patient died of pulmonary complications 2 days after the assist was discontinued. The marked simplicity of using a commercially available pump, without anticoagulation, was a salient feature of this series and has led us to employ this method routinely for resection or repair of the thoracic aorta in acquired aneurysms or traumatic tears or dissection as well as temporary left ventricular assist up to 5–7 days.
Reduction of blood trauma in roller pumps for long‐term perfusion
Authors: Noon George P. , Kane Larry E. , Feldman Louis , Peterson Julia A. , DeBakey Michael E.
Published: May 2005

As part of an attempt to develop a roller pump for long‐term (2 weeks) cardiac assist, factors generating blood trauma in roller pumps were re‐examined. Fresh human blood was pumped for 4 hr in a simple closed circulatory loop. Samples drawn at regular intervals were examined for plasma hemoglobin, lactate dehydrogenase, platelet function, and activation of coagulation factors. Experiments were performed in which tubing diameters were varied (polyvinyl chloride, 1/2‐ and 3/8‐inch internal diameters), roller diameters were varied (3/4, 1 1/8, and 1 3/4 inches), and roller occlusion was varied from total occlusion to 0.020‐inch underocclusion. The results showed more hemolysis when the roller diameters and the tubing diameters were smaller and when the rollers were more occlusive. Changes in platelet function and activation of coagulation factors were observed, but were not correlated with occlusion. These results suggest that when roller pumps are used for long‐term cardiac support, the diameter of the rollers should be as large as possible, the tubing diameter should be as large as practical, and the occlusion setting should be as open as possible while still maintaining required flow rates. New techniques for setting occlusion are suggested.
Right heart interaction with the mechanically assisted left heart
Authors: Farrar David J. , Compton Peter G. , Hershon James J. , Fonger James D. , Hill J. Donald
Published: May 2005

Right ventricular (RV) failure has been reported to be a problem in 49 of 213 patients who received left ventricular assist devices (LVAD) at 12 different centers. Although the pathology of the problem is not understood, it is clear that the effect of an LVAD on hemodynamic ventricular interactions due to the right and left hearts being in series, and on mechanical ventricular interactions due to the anatomic coupling between the ventricles, could play a role in determining the ultimate fate of the right ventricle. Six hypotheses were generated concerning beneficial and detrimental effects of an LVAD on the determinants of right ventricular function (preload, afterload, contractility). The major potential effect on RV preload is increased venous return produced by the LVAD which can overload a marginal RV; but beneficial effects on RV preload and filling also can be produced by the LVAD unloading a dilated LV, thereby shifting the interventricular septum, which had encroached into the RV, back to the left. A significant beneficial effect on RV afterload can be produced with an LVAD by passive reductions in pulmonary artery (PA) pressure secondary to reductions in left atrial pressure; with pulmonary obstructive disease, however, PA pressures can increase due to the greater blood flow through the fixed pulmonary vascular resistance. The major effects on RV contractility produced by an LVAD are significantly beneficial since aortic and, therefore, coronary perfusion pressure is maintained. There also is a potential detrimental effect on RV contractility produced by decreased septal contribution to RV contraction during complete LV unloading with an LVAD. The initial therapy for the failing right ventricle in patients with an LVAD is volume loading. Isoproterenol, dobutamine, and dopamine can be used for inotropic support, and atrial pacing can improve the atrial contribution to filling. If these modalities fail, surgical techniques including pulmonary artery balloon pump or extracorporeal membrane oxygenation can be tried, but the recommended mechanical support is a right ventricular assist device.
New applications of total parathyroidectomy and autotransplantation: Use in proximal renal tubular dysfunction
Authors: Kinder Barbara K. , Rasmussen Howard
Published: May 2005

Total parathyroidectomy with autotransplantation is frequently used in the treatment of hyperparathyroidism associated with renal osteodystrophy because of the high incidence of recurrent disease following subtotal resection. A similar argument has been made to support the application of this technique to cases of recurrent or persistent hyperparathyroidism and to familial polyendocrine syndromes with parathyroid hyperplasia. We have recently had occasion to apply this approach in a new clinical setting of metabolic bone disease. Three patients with congenital hypophosphatemic rickets and 1 with pseudohypoparathyroidism were treated with total parathyroidectomy and autotransplant into the forearm. All 4 had developed secondary hyperparathyroidism with hypercalcemia while being treated with 1,25(OH)2D3(with or without inorganic phosphate). Each had a history of previous vitamin D intoxication. Reduction of parathyroid mass permitted effective treatment of severe bone disease in each case. Two patients developed graft‐dependent hypercalcemia which required resection of graft tissue from the forearm under local anesthesia. Both have shown a further recurrence. Total parathyroidectomy and autotransplantation may be useful in the management of selected patients with metabolic bone disease due to familial hyophosphatemic rickets or pseudohypoparathyroidism.
Proximal gastric vagotomy and pyloroplasty for duodenal ulcer with pyloric stenosis: A thirteen‐year experience
Authors: Lunde Ole ‐Christian , Liavåg Ivar , Roland Magne
Published: May 2005

Between 1970 and 1983, seventy‐eight patients with duodenal ulcer and pyloric stenosis causing gastric outlet obstruction have been operated on with a proximal gastric vagotomy (PGV) and a Heineke‐Mikulicz pyloroplasty. The mean observation time was 90 months. There was no operative mortality or major complications. The reduction in mean acid output was greater after PGV and pyloroplasty than after PGV without drainage in patients with duodenal ulcer without stenosis. The clinical results were excellent or good in 93% of the patients (Visick I and II). Only 1 patient (1.3%) developed a recurrent ulcer, while 5 patients (6.4%) had symptoms of slight or moderate dumping.

It is concluded that PGV and pyloroplasty is a good operation in patients with duodenal ulcer and pyloric stenosis. There is a low incidence of ulcer recurrence, a low risk of serious complications, and good long‐term symptom control.
Progress in pediatric trauma
Authors: Eichelberger Martin R. , Randolph Judson G.
Published: May 2005

The handling of trauma victims in the pediatric age group has undergone change and improvement in a number of ways. First, receiving facilities, emergency rooms, medical centers, and tertiary pediatric care facilities have all been brought together by community, state, regional, and national planning which has taken into account population needs and the resources of each facility. Communication by telephone, radio, and computerized information transmitters has linked together a series of medical facilities which now assures that each child is treated appropraitely or passed along to a different unit in the chain. The education of all members of the emergency medical services to the special techniques, equipment, and needs of pediatric patients has been essential to proper handling of injured children.

Improvement in body imaging, which allows details of injured sites intracranially and in other body cavities, has changed radically the diagnosis and early clinical management of all injured patients. This, in turn, has allowed more precise surgical decisions such as splenic salvage, and conservative handling of such organs as the liver and brain. All of these advances have taken place on a stage and in a time in which the handling of infection and the response to nutritional needs have improved so dramatically. Much has been done, but accidents still kill more children ages 1 to 14 years than all other causes combined. Thus, prevention holds the real solution for future progress.
Surgical treatment of high imperforate anus
Authors: Peña Alberto
Published: May 2005

One hundred thirty‐two operations for congenital anorectal malformations have been done employing a new surgical procedure. A sacroperineal approach through the midline with division of the external sphincter and levator muscle groups is used. The rectourinary fistula is separated by a submucosa dissection. The rectum is tapered to a smaller calibre and placed within the open levator system. The entire sphincter complex is reconstructed posterior to the pulled‐through rectum.

The approach provides excellent exposure of the important anatomical and functional structures of the pelvis. Our operative experience indicates that a reassessment of traditional concepts of the surgical anatomy of the perineum is necessary. The operation was used in 53 patients with high imperforate anus and rectourethral fistula, 19 patients with repair of previous imperforate anus operations, 14 patients with persistent cloaca, and 46 patients with similar anorectal conditions. The preliminary results are highly encouraging in regard to early continence and toilet training.
Progress in the treatment of biliary atresia
Authors: Ohi Ryoji , Hanamatsu Masahiro , Mochizuki Izumi , Chiba Tsuneo , Kasai Morio
Published: May 2005

Although the surgical results of biliary atresia have markedly improved following the introduction of hepatic portoenterostomy, further improvement is necessary. In a 31‐year period, from 1953 through 1983, we performed corrective surgery on 214 patients. In the first 18 years the disease was successfully treated in only 13% of 96 patients. In the next 7 years (1971 to 1977), jaundice was cleared in 55% of 65 patients, now 29 patients are alive without jaundice. In the last 6 years, the jaundice was cleared in 66% of 53 patients; more than 50% of patients are now without jaundice. Retrospective analysis revealed several important factors contributing to the improvement of operative results: (1) early diagnosis and operation, (b) precise dissection and adequate transection of the bile duct remnant, (c) progress in the postoperative management, (d) prevention of postoperative cholangitis, and (e) early reoperation whenever necessary. Corrective surgery performed within 60 days after birth can achieve sufficient bile drainage to normalize serum bilirubin level in more than 80% of the patients.
Emergent and therapeutic upper gastrointestinal endoscopy in children
Authors: Van Stiegmann G. , Stellin G. P.
Published: May 2005

Pediatric patients with upper gastrointestinal disorders have benefited significantly from recent advances in endoscopic technology. Improved techniques of esophageal endosclerosis and dilatation have reduced the morbidity associated with these 2 procedures. Twenty‐five patients underwent 136 endosclerosis treatments, with effective control of bleeding in all. Three of four deaths were caused by primary organ failure and one was due to a complication of endosclerosis. Fifty‐seven patients with esophageal stricture have undergone successful dilatation with uniformly good results and no major complications. Virtually all foreign bodies may now be successfully removed endoscopically from the esophagus or stomach and formerly unrecognized mucosal lesions have been defined as a common source of gastrointestinal hemorrhage. Continued advances in therapeutic pediatric endoscopy will be limited only by the imagination of the pediatric endoscopist.
Pediatric microsurgery
Authors: Pardo Juan A. Diez
Published: May 2005

The contemporary status of microsurgical techniques in different pediatric surgical categories is summarized. Employment of microsurgical techniques permits autografts of jejunum to be used for esophageal replacement and vascularized bone grafts to be used for bridging defects in long bones. The same techniques improve overall results in creating vascular access for hemodialysis. Combined with temporary nephrectomy, extracorporeal hypothermic organ preservation, and autotransplantation, microsurgery makes possible repair of injured kidneys, partial nephrectomy for bilateral Wilm's tumor, and correction of renal vascular hypertension.

Microsurgical techniques facilitate correction of hypospadia, thereby reducing the complication of fistulas. These methods make possible the reimplantation of an accidentally amputated extremity or a traumatically amputated testicle or penis. Vas deferens injured during herniorrhaphy can be repaired and intra‐abdominal testes can be relocated. Improved drainage for congenital lymphedema of the extremities and varicocele are possible. Remnants of hilar bile ducts can be more accurately identified in children with biliary atresia and may thereby improve the results of Kasai portoenterostomy operations.

With the smaller size of organ structures in the pediatric age group, microsurgical techniques play an especially prominent increasing role in this particular population.
Training in pediatric surgery
Authors: O'Donnell Barry
Published: May 2005

Pediatric surgery is a small, popular specialty with a limited number of formal, structured training programs. Basic training should place emphasis on the general principles of surgery. Picking a trainer and working in a program that gives a genuine mix of training and experience with adequate supervision are the next steps. The importance of research, the discipline of writing, and the character‐building experience of ensuring publication are emphasized. Examinations are a necessary part of development. Depending on career objectives, a varied experience in a number of institutions is a valuable long‐term investment.
Research in pediatric surgery
Authors: Stolar Charles J. H. , Altman R. Peter
Published: May 2005

Pediatric surgical research continues to expand along technical avenues while addressing issues of basic science.

Splenic salvage is an established goal which can ordinarily be achieved without surgical intervention. Operative approaches, when indicated, can be done with minimal moribidity. Although the spleen acts as a bacterial monitor under normal circumstances by direct phagocytosis, opsonization, and modulation of macrophage function, our understanding of how the injured spleen resumes these activities remains fragmentary.

Extracorporeal membrane oxygenation shows increasing promise for newborns with refractory respiratory failure. New applications of pulmonary vasoactive meidators will yield a better understanding of how this radical therapy affects cardiopulmonary homeostasis. The lungs either synthesize, modify, or pass on a number of substances including eicosanoids, vasoactive amines, and carboxypeptidases which form a resonating feedback network that controls pulmonary vascular tone. Disturbed homeostasis results in the various disease states that have pulmonary hypertension and lung injury as common features.

Developments in fetal surgery have permitted creation of improved models of in utero conditions. These models variably mimic the human condition, particularly obstructive uropathy, congenital diaphragmatic hernia, and neural tube defects. Complex problems remain for patient/fetus selection and timing of surgical intervention.
Dehiscence of a prosthetic graft nineteen years after coarctation repair
Authors: Snow Norman
Published: May 2005

Total dehiscence of a prosthetic graft 19 years after coarctation repair is reported. This resulted in a large false aneurysm of the descending thoracic aorta, and at operation, no remnant of the suture material was apparent grossly or microscopically. Long‐term follow‐up is necessary in order to detect complications of thoracic aortic grafting.
Surgical anatomy and anatomical surgery of the liver
Authors: Bismuth Henri
Published: May 2005

The morphologic anatomy of the liver is described as 2 main and 2 accessory lobes. The more recent functional anatomy of the liver is based on the distribution of the portal pedicles and the location of the hepatic veins. The liver is divided into 4 sectors, some of them composed of 2 segments. In all, there are 8 segments. According to the anatomy, typical hepatectomies (or “réglées”) are those which are performed along anatomical scissurae. The 2 main technical conceptions of typical hepatectomies are those with preliminary vascular control (Lortat‐Jacob's technique) and hepatectomies with primary parenchymatous transection (Ton That Tung's technique). A good knowledge of the anatomy of the liver is a prerequisite for anatomical surgery of this organ.
Major and minor segmentectomies “réglées” in liver surgery
Authors: Bismuth Henri , Houssin Didier , Castaing Denis
Published: May 2005

Individualization of the segment as the functional anatomical unit of the liver permits the performance of surgical segmentectomies. These segmental resections are “réglées” because the plane of cleavage of the hepatic parenchyma follows the anatomical scissurae. From the technical point of view, liver segmentectomies are characterized by an exclusive transparenchymatous approach to the vascular pedicles of the segment to be removed. We have performed this type of surgery in 22 patients with no mortality. These operations are indicated in: (1) some benign tumors; (2) some liver trauma; (3) biliary operations above the hilus, where anterior resection of segment IV can be necessary; and (4) carcinomas of the gallbladder discovered histologically after cholecystectomy. Liver segmentectomies can also be indicated for malignant tumors when the liver is cirrhotic, or when an extended resection is likely to expose the patient to the risk of liver failure. Indeed, one of the main advantages of liver segmentectomies is that they permit an economical but safe surgical resection of the hepatic parenchyma.
Temporary liver dearterialization in patients with metastatic carcinoid disease
Authors: Bengmark S. , Ericsson M. , Lunderquist A. , Mårtensson H. , Nobin A. , Sako M.
Published: May 2005

The surgical treatment of liver metastases from carcinoid tumors is burdened by a relatively poor symptomatic relief and a high mortality rate. Temporary liver dearterialization, separating the operative trauma from the temporary hepatic occlusion, may have advantages. We have utilized this treatment in 16 patients. The effect of treatment was registered in symptomatic relief, changes in urinary 5‐HIAA, serotonin in platelet‐poor plasma, and morphologic changes shown by angiography.

Fourteen patients, who underwent only the dearterialization procedure, survived the immediate postoperative period, while 2 patients who had concomitant small bowel resection both died of complications, 1 and 3 months postoperatively, respectively. One patient died, 14 months postoperatively, of the carcinoid disease. All but 1 patient were free from symptoms for at least 6 months. Two patients have had no recurrence of the carcinoid syndrome for 34 and 42 months, respectively. A decrease in urinary 5‐HIAA was seen after 6 months in 10 patients, serotonin declined in 7 patients, and angiography showed regression in 7 patients. The results of this study indicate that temporary liver dearterialization is a safe procedure with low mortality and good symptomatic relief from the carcinoid syndrome.
The surgical management of primary carcinoma of the liver
Authors: Lee N. W. , Wong J. , Ong G. B.
Published: May 2005

From 1964 to 1981, a total of 165 patients with primary carcinoma of the liver underwent various types of hepatic resections. Eighty‐five percent of tumors were found in cirrhotic livers. In 78.4%, HBsAg could be demonstrated by the reverse passive hemagglutination technique, while 85.7% had positive alpha‐fetoprotein in the serum. The complication rate was high (42.1%), while the hospital death rate was 20%. The most frequent operations were a right hemihepatectomy (42.4%) and a left hemihepatectomy (34.5%), while 22 patients (13.3%) underwent extended right hepatectomy. The longest survival (a patient operated on in 1962) is now 20 years, and the 5‐year survival rate, as shown in the actuarial survival curve, is 20%.
Liver transplantation for liver cancer
Authors: Calne R. Y.
Published: May 2005

Results in the first 100 orthotopic liver allografts performed in the Cambridge‐King's College Hospital series (1968–1980) are reported. Twenty‐two patients survived beyond a year (age range, 16–59 years). Of these, 12 were cirrhotics and 10 were primary malignancies. Of the cirrhotics, 10 are alive, with the 2 deaths resulting from cholangitis. Two patients who had primary hepatic carcinoma are alive at 1 and 5 years following transplantation; the 8 deaths in this group were attributed to tumor recurrence (5 patients), sepsis (2 patients), and secondary cirrhosis possibly due to non‐A non‐B hepatitis (1 patient). Patients who survive for 6 months have a greatly increased chance of surviving the second 6 months and subsequently. Of the last 14 liver allografts (12 for cirrhosis and 2 for primary malignancy), there are 9 survivors. This mortality (36%) probably represents the results of better selection of the cirrhotics before they were too sick to withstand the operation; better control of rejection; and refinements in surgical procedure and anesthesia. For those patients surviving the first year, there is a 40% chance of the tumor's being eliminated. The late tumor recurrence rate is unacceptably high at 60%, however, and our criteria for patient selection have become increasingly selective.
Total hepatectomy and liver replacement (orthotopic liver transplantation) for primary hepatic malignancy
Authors: Iwatsuki Shunzaburo , Klintmalm Goran B. G. , Starzl Thomas E.
Published: May 2005

There has been a high incidence of tumor recurrence after liver transplantation for primary hepatic malignancy. Nevertheless, a small but significant palliation has been possible with this approach, even in patients who eventually died of recurrence. Two patients with incidental malignancies in their excised livers apparently have been cured. Further gains will be possible only with extremely discriminating selection of prospective recipients.
Low‐risk thoracic vagotomy for anastomotic ulceration
Authors: Lehr Leo , Pichlmayr Rudolf
Published: May 2005

Transthoracic truncal vagotomy for anastomotic ulceration was performed in 47 patients. In 24 cases, the risk for any procedure requiring a transabdominal approach was considered high because of the presence of multiple risk factors, the majority of which involved complicated prior laparotomies. The high virulence of the underlying ulcer diathesis was demonstrated by the number of previous unsuccessful reresections. In 17 patients 1 reresection; in 4 patients 2 reresections; and in 1 patient a reresection plus abdominal vagotomy had failed.

No mortality and only minor local complications were observed after thoracic vagotomy. Within 3 months ulcer healing was found in 46 patients. In 1 patient the ulcer persisted for 5 months, then healed under additional cimetidine treatment. Uniform healing was also achieved in 6 cases of retained gastric antrum. Complaints of gastric outlet obstruction resolved in 3 patients and persisted in one.

Thirty‐seven patients were followed for up to 10 years: 31 personally, with gastroscopy in 26; 6 were followed by their house physicians. In no case was ulcer recurrence detected. Visick grading of those 31 patients reexamined in the clinic showed 27 in groups I and II, 4 in III, none in IV. Of the complaints requiring a classification as Visick III, only 2 syndromes are a direct consequence of cutting the vagus at the truncal level; these are 1 case each of moderate diarrhea and dumping, both controlled by conservative measures.

Thus thoracic vagotomy has proven to be a low‐risk procedure as well as a potent therapy for anastomotic ulceration. The morbidity seems acceptable. We recommend this method for standard surgical treatment for anastomotic ulcer in place of any transabdominal procedure.
Cytological diagnosis of pancreatic tumors
Authors: Bodner Ernst , Schwamberger Klaus , Mikuz Gregor
Published: May 2005

Cytological diagnosis of carcinomas as well as of other pancreatic tumors is of high validity. By use of the modified Papanicolaou staining method, the procedure is adaptable for rapid intraoperative diagnosis. In order to obtain representative cell material, we have tried both preoperative endoscopic fluid collection and intraoperative fine needle biopsy. Whereas the first procedure often fails because of its technique, the latter is suitable in all cases. No serious complication arose in the 181 patients studied. In 152 diagnostic‐ally proven cases, the cytological result was correct 135 times (88.8%). Forty of 44 resectable malignomas were diagnosed correctly. Consequently, the success rate is remarkably high with small tumors for which the indication for resection should be based on microscopic diagnosis.
A Glucagon‐secreting alpha‐cell carcinoma of the pancreas
Authors: Goto Hiraaki , Yamaji Yoichi , Konno Toshimitsu , Murata Etsuo , Tashiro Seiki , Yokoyama Ikuzo
Published: May 2005

A case of alpha‐cell carcinoma of the pancreas with classic manifestations of glucagonoma syndrome and hepatic metastasis is reported. A diagnosis of glucagonoma was made by the characteristic dermatological findings of necrolytic migratory erythema and hyperglucagonemia. Operative removal of the metastatic tumors resulted in rapid regression of the skin rash and hyperglucagonemia. But a primary focus 1 cm in diameter, with central necrosis, had been left in the head of the pancreas. This was verified by autopsy.
Nonpalpable breast lesions: Mammographic wire‐guided biopsy and radiologic‐histologic correlation
Authors: Blichert‐Toft M. , Dyreborg U. , BØgh L. , KiÆr H.
Published: May 2005

During a 1‐year period, 2,909 symptomatic women were referred for physical examination of the breast and mammography. In 44 women (1.5%), mammography discovered a total of 45 impalpable breast lesions that might represent an early cancer. Mammographic wire‐guided biopsy was performed using a self‐retaining hook wire for the marking of the lesion. The radiographic localization was facilitated by using a perforated compression plate with holes visible on the mammograms. The biopsy method showed high precision and accuracy. Only 1 guide wire was needed in each instance. In 96% of cases, the wire transfixed the lesion or was placed in close proximity (within 1 cm) to the lesion. Correct biopsy was achieved in all instances, but in some cases more than 1 biopsy was necessary. The malignancy rate was 29% of biopsies and 30% of patients. The metastatic rate to axillary lymph nodes was 17%. Generally, the histologic pattern showed great variety with several different components in most specimens. The radiologic‐histologic correlation is tabulated and the significance of preclinical breast cancer detection is emphasized. The biopsy method described is reliable and highly recommended. We found the procedure easy to handle and time‐saving. The method was fully acceptable to patients and the cosmetic results were excellent.
Pericardial tamponade caused by central venous catheters
Authors: Krog M. , Berggren L. , Brodin M. , Wickbom G.
Published: May 2005

Three cases of pericardial tamponade caused by central venous catheters are reported. Two essential factors have been recognized. First, the catheter material should be extremely soft and remain soft. Today the best material available seems to be a silicone rubber elastomer. Polyvinylchloride or polyethylene, which is widely used, is too rigid. These materials also contain phthalate esters to soften the plastic, and these softeners are gradually washed out into the bloodstream, rendering the catheters even more rigid in time. Second, a central venous catheter should enter the venous system proximal to the shoulder. When the catheter is inserted through a vein in the arm, the tip of the catheter will be able to progress 6–10 cm farther down in the venous system by extreme movements of the arm. This occurs regularly when a patient is turned in bed and his or her arm is elevated 108‡ at the shoulder. The internal jugular vein and the subclavian vein are the most suitable veins for catheterization. Veins in the arm should not be used.
Surgical procedures for gastric substitution
Authors: Herfarth C. , Schlag P. , Buhl K.
Published: May 2005

The most serious of the problems that arise after total gastrectomy and reconstruction of a continuous gastrointestinal tract by means of a simple esophagojejunostomy can be ascribed to the lack of primary reservoir formation and to alkaline reflux esophagitis. These difficulties can be overcome by means of pouch formation, low insertion of the bile duct, and jejunal plication. Personal follow‐up examinations in patients (over 1 year after gastric substitution have yielded both subjective and objective findings that are almost identical with those recorded in a subject with intact stomach. The one striking finding to emerge remains an elevated fat excretion.