Histomorphological studies of the distal internal thoracic artery which support its use for coronary artery bypass grafting.

The use of the internal thoracic artery (ITA) for myocardial revascularization in coronary artery disease increased because of its relative immunity to atherosclerotic obstruction. This study investigated the distal part of the vessel, the region of anastomosis by means of histology to focus the visualization of this region of interest. The histological examination of arterial segments showed minor intimal thickening in 48 out of 100 patients. Twelve patients demonstrated a severe intimal thickening, the residual patients were without any changes. In 52% the elastic type dominated in the distal part. Hybrid and muscular patterns were found in 22 and 26%, respectively. The media could be classified into three different types: muscular, hybrid and elastic type. There was no correlation concerning the different histological type and the incidence of intimal thickening. No evidence whatsoever of atherosclerotic lesion was encountered in any of the investigated vessels. There is no limitation in the use of the distal part of the ITA for coronary artery revascularization.

Fluoro-jade identification of cerebellar granule cell and purkinje cell death in the alpha1A calcium ion channel mutant mouse, leaner.

Cell death is a critical component of normal nervous system development; too little or too much results in abnormal development and function of the nervous system. The leaner mouse exhibits excessive, abnormal cerebellar granule cell and Purkinje cell death during postnatal development, which is a consequence of a mutated calcium ion channel subunit, alpha(1A). Previous studies have shown that leaner cerebellar Purkinje cells die in a specific pattern that appears to be influenced by functional and anatomical boundaries of the cerebellum. However, the mechanism of Purkinje cell death and the specific timing of the spatial pattern of cell death remain unclear. By double labeling both leaner and wild-type cerebella with Fluoro-Jade and terminal deoxynucleotide transferase-mediated, deoxyuridine triphosphate nick-end labeling or Fluoro-Jade and tyrosine hydroxylase immunohistochemistry we demonstrated that the relatively new stain, Fluoro-Jade, will label neurons that are dying secondary to a genetic mutation. Then, by staining leaner and wild-type cerebella between postnatal days 20 and 80 with Fluoro-Jade, we were able to show that Purkinje cell death begins at approximately postnatal day 25, peaks in the vermis about postnatal day 40 and in the hemispheres at postnatal day 50 and persists at a low level at postnatal day 80. In addition, we showed that there is a significant difference in the amount of cerebellar Purkinje cell death between rostral and caudal divisions of the leaner cerebellum, and that there is little to no Purkinje cell death in the wild type cerebellum at the ages we examined. This is the first report of the use of Fluoro-Jade to identify dying neurons in a genetic model for neuronal cell death. By using Fluoro-Jade, we have specifically defined the temporospatial pattern of postnatal Purkinje cell death in the leaner mouse. This information can be used to gain insight into the dynamic mechanisms controlling Purkinje cell death in the leaner cerebellum.

Internal thoracic artery: prevalence of atherosclerotic changes.

Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. The aim of this study was to ascertain the prevalence of atherosclerosis in the internal thoracic artery and to correlate the prevalence with other known risk factors. A total of 117 patients (male/female ratio 84:33; mean age 56.8 years) were investigated. Sixty-eight patients had coronary artery disease, 25 had combined coronary artery and valvular heart disease, 14 had acquired valvular heart disease, and 10 had other types of heart disease. All but one patient underwent bilateral semiselective internal thoracic arteriography. Evidence of atherosclerotic change was present in 6.6% of the opacified vessels in 11.1% of the investigated individuals. Although all patients with atherosclerotic lesions in the internal thoracic artery had coronary artery disease, no correlation could be found between coronary artery disease and internal thoracic atherosclerosis. Peripheral vascular disease and hyperlipidemia could be identified as predictors of atherosclerotic changes in the internal thoracic artery. Atherosclerosis is somewhat more prevalent in the internal thoracic artery in this study than in the literature. Although the internal thoracic artery is a protected vessel, there is a certain extent of atherosclerosis, that correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery.

Duplex sonography of the internal thoracic artery. Preoperative assessment.

Ultrasonic duplex scanning was used to examine 211 internal thoracic arteries. The investigating vessels were classified as normal, abnormal, and occluded. The results of the duplex examination were compared with angiography as the reference method. The diameter measurements showed virtually no differences between the two methods. Normal internal thoracic arteries showed a continuous decrease of the systolic flow velocities from proximal to distal and a narrow to moderate spectral flow curve, whereas arteries classified as abnormal showed a velocity profile distinct from that--in particular, no decrease of the systolic peak velocities and an increased spectral broadening during systole with peak frequencies greater than 4 kHz at 60 degrees (> 1.2 m/sec). In occluded vessels no flow could be detected. The majority of changes were found in the proximal part of the internal thoracic artery. All lesions were detected by duplex sonography. Six normal vessels were misjudged as abnormal by the duplex method. The sensitivity, specificity, and accuracy of duplex sonography compared with angiography as the reference method were 100% (95% CI, 74.4% to 100%), 96.9% (95% CI, 93.2% to 98.8%), and 97.2% (95% CI, 93.6% to 98.8%), respectively. Duplex sonography is a reliable, noninvasive technique for the preoperative assessment of the internal thoracic artery. It allows the detection of potential atherosclerotic changes in the internal thoracic artery and the assessment of adequacy of caliber and flow.

Effect of N-ethyl-N-butyl-nitrosamine on the esophageal mucosa of the rat. Histometric investigation of early tumor stages.

80 male Wistar rats received an oral ad libitum application of N-ethyl-N-butyl-nitrosamine in a concentration of 0.18 g per litre of drinking water. The changes induced in the esophageal mucosa and determined at three intervals (up to 48 days, up to 91 days, and up to 112 days after commencement of carcinogen exposure) were compared by microscopy with the results from a control group of 10 male Wistar rats of the same age. Several histomorphometric parameters were investigated with the aid of a Leitz ocular micrometer. The earliest localized changes found were an increase in the thickness of the epithelium and the horny layer, and an elongation of the papillary bodies and a widening of the parabasal cellular layer. Later--with a substantial increase in the rate of mitosis in all layers of the epithelium, there was a significant thickening of the non-papillomatous and papillomatous epithelium, an enlargement of the nuclei, especially in the middle and upper layers of the epithelium and a thickening of the horny layer, parts of the latter being parakeratotic. The papillomatous changes corresponded in some cases to moderate epithelial dysplasias. As expected, no fully-developed invasive carcinomas occurred in the early period investigated. The histometric data permit the conclusion to be drawn that the lesions described are demonstrable not only at the exophytic-papillomatous epithelium but also in multifocally localized form at the flat, non-papillomatous mucosa, and that they can definitely be regarded as the expression of an incipient field cancerification.

Grafting with the internal mammary artery: correlation between preoperative angiography and intraoperative findings.

No data exist on the relation between angiography of the internal mammary artery and intraoperative findings during bypass surgery. We studied 47 consecutive patients and found no atherosclerotic changes. Intraoperatively, however, 4 left internal mammary arteries were judged unsuitable for grafting. No relation could be found to the diameter of the vessel as judged angiographically. Possible causes of unsuitability are discussed.

Combined two-dimensional and Doppler echographic examination of internal mammary artery grafts from the supraclavicular fossa.

The noninvasive examination of internal mammary artery grafts is gaining importance with the increasing use of this vessel in the surgical treatment of coronary atherosclerosis of the left anterior descending artery. We studied 36 patients (37 internal mammary artery grafts) with combined two-dimensional and pulsed Doppler echography from the supraclavicular fossa. Adequate visualization and Doppler signals were obtained in 95% of arterial grafts. Twenty-four grafts leading to an area without evidence of old myocardial infarction or ischemia and 10 grafts leading to an area of old myocardial infarction but without evidence of ischemia on exercise showed a significant decrease of the peak systolic velocity and of the peak systolic velocity/peak diastolic velocity ratio as compared to the controls, which consisted of the contralateral internal mammary arteries in situ. One patient with a distally subtotally occluded mammary artery graft had a flow pattern different from the other bypassed mammary arteries. It seems that combined two-dimensional and pulsed Doppler echography is a useful method to evaluate the functional status of internal mammary artery grafts.

Tricuspid valve repair in right-sided endocarditis.

BACKGROUND AND AIMS OF THE STUDY: Tricuspid valve endocarditis traditionally has been treated with either valve resection or valve replacement. To avoid implantation of foreign material in an infected area and to circumvent anticoagulation, tricuspid valve repair was applied and the results assessed. METHODS: Tricuspid valve repair was performed in five patients with right-sided endocarditis. All patients had tricuspid regurgitation grade 3-4 on preoperative transesophageal echocardiography, and developed progressive deterioration associated with heart failure. The indications for surgery were congestive heart failure, persistent sepsis, recurrent emboli, concomitant left-sided endocarditis, and fungal infection. Surgical procedures included cusp resection, annular plication and annuloplasty, pericardial patch replacement, and construction of artificial chordae. RESULTS: There were no hospital deaths and major associated morbidity. Follow up is complete at a mean of 20.4 months. There were no reoperations or cases of recurrent infections. All patients are in NYHA class I-II. Postoperative echocardiography revealed no signs of major valvular dysfunction. CONCLUSIONS: Valve repair in right-sided endocarditis is a relatively new application for repair techniques, but may become an attractive alternative to tricuspid valve excision or prosthetic valve replacement.

Esophageal cancer. Autopsy findings in 171 cases.

We present the autopsy findings in 171 patients with primary esophageal cancer and compare our results with those of other investigators. The ratio of men to women was 5.84:1. The average age of the women was 72.9 years. The average age of the men was 61.6 years. Squamous cell carcinomas were found in 91.8% of the cases, adenocarcinomas in 6.4% of the cases, and sarcomas in 1.8% of the cases. In the cases of squamous cell carcinoma, there was an ulcerating and infiltrating growth, primarily. In the cases of adenocarcinoma, there was a polypoid exophytic growth and an ulcerating growth. Most of the tumors were localized in the medial third of the esophagus (50.9%), followed by the distal third of the esophagus (39.7%), and, lastly, the proximal third of the esophagus (9.4%). Of all the tumors, 42.7% had an extension of more than 5 cm in the longitudinal axis at autopsy. The trachea was the organ most commonly infiltrated (21%). No metastases occurred in 28.6% of the cases. Lymph node metastases existed in 67.3% of the cases, and visceral metastases were present in 29.8% of the cases.

Intermittent aortic cross-clamping for coronary artery bypass grafting: a review of a safe, fast, simple, and successful technique.

Since the very beginning of coronary artery bypass grafting, the search for optimal myocardial protection has fascinated both clinicians and basic researchers. This retrospective review of a large patient cohort aims to display the advantages of one of the protective procedures, namely simple, intermittent aortic cross-clamping (IAC). Thus, this review aims to significantly contribute to daily bypass surgery. This review reports on coronary patients who were all operated on in international centers using IAC such that this review presents the state of the art on IAC. In addition, this review reports on the usage of IAC for more than 2 decades in the clinic of Dr. Bircks, Duesseldorf (DE) and the clinics of his former students. A meta-analysis of published data of international centers summarizes 7 837 operated patients with a total mortality of 123 (=1.6%). This excellent outcome compares well to the results of the Bircks'-related centers, where between 1978 and 2001, a total of 41 573 patients were revascularized with the help of IAC according to the original protocol. The total mortality was 778 (1.9%), with the lowest mortality rate (1.2%) in the largest center (Bad Oeynhausen, DE). According to the presented experience, IAC for coronary revascularization proves to be a highly effective method for myocardial protection; it has convincingly proven to be simple, safe and cost-efficient.

Budd-Chiari syndrome: some pathologic-anatomic aspects.

The obstruction of the outflow of blood from the hepatic veins is generally called the Budd-Chiari syndrome. In the present work the most important pathologic-anatomic findings concerning this rare disorder are discussed as are its possible causes.

Results of surgical treatment for acute pancreatitis.

The results following the surgical treatment of acute pancreatitis in 67 patients are presented. The male:female ratio was 1.5:1; the average age for all patients was approximately 54.5 years. From an etiological viewpoint, biliary pancreatitis was found in 50.7% of the cases, followed by alcoholic (32.8%), idiopathic (7.5%), postoperative (6%) and traumatic (3%) pancreatitis. In most cases drainage operations were performed (92.5%) in conjunction with necrosectomy, whilst resectional techniques were used in five patients (7.5%). The perioperative mortality for all patients was 30%; it was higher among patients operated upon in the first week (44%) than in those whose operation was delayed (12.9%). The extent of organ necroses and the presence of extrapancreatic necroses were of decisive prognostic significance. The findings are compared with data given in the literature.

Gastric carcinoma after surgical treatment for benign ulcer disease: some pathologic-anatomic aspects.

The study presents the autopsy findings on 55 patients with carcinoma of the operated stomach. This figure corresponds to a proportion of about 0.12% of the total number of autopsies (46,593) in the period under review (1950-1982), and of about 7.24% of the overall number of gastric carcinoma patients autopsied during that period. The male:female ratio was 5.1:1. The average "free interval" until the manifestation of cancer was 22.6 years after Billroth II resection, 23.4 years after Billroth I resection, and 34.4 years in the case of patients upon whom gastroenteroanastomosis had been performed without resection. The older the patient was at the time of the operation, the shorter was the interval before the occurrence of gastric cancer. In the majority of cases the carcinoma was localized in the gastric stump (65.4%), whereas in a quarter of the cases (25.5%) the carcinoma occurred in the area of the anastomosis itself, and in 9.1% of cases it was localized in the region of the cardia. Histologic classification of the tumors revealed 52.7% as being predominantly of the intestinal type, and 38.2% as being predominantly of the diffuse type. The organs most frequently affected by direct tumor infiltration "per continuitatem" were the pancreas (18.2%), liver (16.4%) and colon transversum (14.6%). The lymph nodes most often affected were the paragastric (63.6%) and parapancreatic lymph nodes (49.1%), those at the porta hepatic (38.2%) and the para-aortal (34.6%) lymph nodes. Haematogenous metastases were found most frequently in the liver (30.9%), skeletal system (16.4%), adrenal gland (10.9%) and lung (9.1%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of the surgical treatment of gallbladder carcinomas]. / Ergebnisse nach chirurgischer Behandlung des Gallenblasencarcinoms.

A retrospective study of 44 patients with carcinoma of the gallbladder is presented. It is noticeable that although the prognosis for advanced carcinoma of the gallbladder is poor, that of the early stages (stage I-III) is relatively better. In no case diagnosis was made preoperatively. In 86% gallstones were found. There has been no valid staging for tumors of the gallbladder or any generally accepted standardized therapy. Attention is drawn to the possibility of improving the results of therapy at the early stages by extended radical operation and to the necessity for early operative treatment of gallstone disease.

[Intracompartmental pressure in the anterior tibial compartment. Demonstration of the course of pressure in the gait cycle]. / Der intrakompartmentale Druck in der Tib. anterior Loge. Darstellung des Druckverlaufes whrend des Gangzyklus.

During walking the anterior tibial compartment pressure was measured continuously using a new technique. The test subjects were made to walk on a treadmill at the standardised walking spees fo 3, 6, and 8 km/h. Documentation of intrafascial pressure was obtained continously, while gait-analysis and pressure changes were simultaneously documented on video-tape. Readily reproductible pressure curves were obtained. The increase in walking speed correlated to increase in intracompartmental pressure, and the varying pressure was accurately correlated to gait phases. Minimum pressure was recorded in the phase immediately prior to initial heel contact (IC). During "mid-stand" (MST) the pressure remained constant. "Terminal-stand" (TSZ) and pre-swing (PS) are associated with peak pressure. The method described is suitable for continuous and reproducible measurement during walking.

[Secondary impingement syndrome in athletes]. / Das sekundäre Impingement-Syndrom beim Sportler.

Dysfunction of the shoulder joint is based not only on anatomic conditions. The consideration of the special kinesiology of the shoulder helps to understand the shoulder pathology. This mainly applies to young "overhead athletes" like swimmers, handball-, basketball-, volleyball-, and racketplayers. These disciplines cause stress on the anterior joint structures (capsule, ligaments, labrum, subscapularis tendon) and lead to anterior instability. This includes anterior subluxation or even dislocation. Finally, an impingement syndrome with the typical symptoms can frequently result from these conditions. The impingement-syndrome of the elderly must be considered as a primary disease, whereas the young overhead athlete suffers from the impingement syndrome as a secondary disease and does not take the first place in therapy. The first step in therapy should to be treat the muscular imbalance of the shoulder. To gain a regular pattern of motion the rotator cuff must be strengthened. This regimen is likely to be successful in 80-90% of the cases. If the conservative therapy fails the surgical treatment may come into consideration. Arthroscopic surgery has the advantage not to affect the proprioceptivity. To retain the previous level of performance an adequate rehabilitation programme is essential for the athlete.

[Possibilities for using sonography in sports injuries of the shoulder joint]. / Einsatzmöglichkeiten der Sonographie bei Sportverletzungen des Schultergelenkes.

Sonography is a useful tool for the examination of the shoulder joint. Concomitant cartilaginous and soft tissue lesions (Hill-Sachs, effusion, cuff-tears) can be visualized. Subacromial pathology can be differentiated. The type of instability in the unstable shoulder can be documented. The ultrasound investigation is of diagnostic value for the unstable shoulder as well as for the impingement shoulder in athletes. Therefore it may be helpful for planning the adequate treatment and also for the follow up of the patients.

Aortic rupture in manual dissection of the esophagus: a rare complication during palliative esophagectomy performed on account of radiated esophageal cancer. A pathologic-anatomic view.

The report concerns the rare complication of a rupture of the aorta thoracica descendens during a palliative esophagectomy without thoracotomy performed on account of radiated carcinoma of the esophagus. The pathologic-anatomic findings are discussed and the literature is indicated.