Intraoperative use of stents for the management of unacceptable distal internal carotid artery end points during carotid endarterectomy: short-term and midterm results.

PURPOSE: The management of unacceptable distal internal carotid artery (ICA) end points during carotid endarterectomy presents multiple dilemmas. The problem may be expeditiously solved by placement of an intraluminal stent, but reported clinical experience with this technique is limited. We retrospectively reviewed our experience with intraoperative stenting of the ICA for the correction of unacceptable distal ICA end points during carotid endarterectomy. We report our techniques and document the 30-day stroke morbidity-death rate and midterm outcomes of patients treated in this manner. METHOD: The records of 316 consecutive carotid endarterectomies performed by the authors from January 1997 through June 1999 were reviewed to identify those cases in which adjunctive intraoperative stenting of the distal ICA was used. For those patients treated with adjunctive ICA stents, we assessed technique, 30-day outcomes, and midterm outcomes. RESULTS: The 30-day combined stroke and death rate for the entire group of 316 carotid endarterectomies was 1.9%. Adjunctive distal ICA stents were used in 13 cases-4.1% of the total carotid endarterectomy group-for the correction of unacceptable distal ICA end points. All patients were male; the average age was 70 years. Stents were used in 11 patients because in each of these cases the surgeon recognized an unacceptable end point and desired to limit further distal anatomic exposures and/or ischemia times. Stents were used in two patients to correct unexpected defects identified on intraoperative completion ultrasound scan. No 30-day periprocedural deaths, strokes, or transient ischemic attacks were observed. Average postoperative length of stay was 1.8 days (range, 1-5 days). All patients have been followed up with serial carotid duplex scans, and one patient has been studied by means of angiography. No patients have died, and all remain in active clinical follow-up. Mean length of follow-up has been 15 months. No significant asymptomatic recurrences have been observed, but one patient experienced an isolated episode of amaurosis fugax without demonstrable restenosis at 8 months postoperatively. CONCLUSION: Our experience suggests that the adjunctive use of stents for the correction of unacceptable distal ICA end points during carotid endarterectomy is safe and provides acceptable short-term and midterm outcomes. Continued follow-up will be required before this technique can be considered a primary choice rather than an expeditious secondary alternative in this infrequent clinical circumstance.

Management of incidentally discovered cervical paragangliomas: report of two cases and review of current issues.

Paragangliomas of the head and neck are uncommon neoplasms arising from the extra-adrenal paraganglia and include carotid body and glomus vagale tumors. These lesions may be discovered incidentally by imaging studies performed to evaluate carotid atherosclerotic occlusive disease. Incidental paragangliomas of the head and neck may be smaller than those discovered due to symptoms. Although surgical resection remains the definitive treatment for head and neck paragangliomas, important issues of management arise when such lesions are discovered. Two recent cases are reported. Epidemiology, pathophysiology, diagnostic evaluation, and issues of management of head and neck paragangliomas are discussed.

Ceftriaxone versus cefazolin in peripheral arterial operations: a randomized, prospective trial.

Serious morbidity and mortality are associated with postoperative wound infections in peripheral vascular surgery. The use of prophylactic antibiotics is considered the standard of care, with attention focused on the most efficacious agent. A prospective, randomized study was conducted to evaluate the efficacy of ceftriaxone versus cefazolin in prevention of postoperative wound infections in a group of patients who had peripheral arterial operations between October 1991 and February 1993. Patient characteristics associated with an increased risk of postoperative wound infection were evaluated. Prophylaxis was provided for 105 operations with cefazolin and 103 operations with ceftriaxone. The overall wound infection rate was 3.85%. Six operations (5.7%) in the cefazolin group were complicated by wound infection versus 2 operations (1.9%) in the ceftriaxone group. Diabetes (6 infections/64 operations; infection rate, 9%) and a personal history of previous aortocoronary bypass (5 infections/49 operations; infection rate, 10%) were characteristics associated with an increased chance for postoperative wound infection. Ceftriaxone is therapeutically equivalent to cefazolin in the prevention of postoperative wound infections in peripheral vascular surgery.

Effect of regulatory and professional guidelines on the development and marketing of a dental device: case history.

The FDA encourages organizations such as the ADA to develop voluntary standards for drugs and dental devices. The landmark process of gaining ADA approval of an oral irrigator as the first therapeutic device is described. The process was time consuming and expensive, and obligates the manufacturer to submit all future marketing and advertising claims for ADA review. The ADA should continue to ensure standardized guidelines for all product categories. Education of the dental profession and the consumer concerning the significance of the ADA seal of approval is encouraged.

Carcinoma of the male breast: a review of 41 cases.

We reviewed the cases of 41 consecutive men treated for breast carcinoma from 1950 through 1987 at Vanderbilt University Affiliated Hospitals to examine controversies in and methods of therapy for this disease. Twenty-two patients (52%) had stage I or II lesions potentially curable by operative therapy. The overall 5-year survival rates were 100% for stage I, 65% for stage II, 56% for stage III, and 0% for stage IV. Radical mastectomy offered no advantage over modified radical mastectomy in terms of survival or rate of recurrence. Diagnosis at an early clinical stage and no finding of disease in axillary lymph nodes were important factors in survival in this series of patients. All tumors evaluated for hormone receptors were positive. Although experience was limited, encouraging results were obtained with the use of tamoxifen citrate in adjuvant as well as palliative roles. With the exception of a predominance of centrally located lesions and a uniquely high frequency of positive hormone receptor status, carcinoma of the male breast appears biologically similar to the disease in women, and treatment should be guided by similar principles.

Diverticular disease of the jejunum and its complications.

Jejunal diverticulosis is an uncommon, acquired condition that has been encountered recently in four patients. These cases (two patients with diverticulitis, one patient with chronic abdominal pain, and one patient incidentally discovered at laparotomy for colonic diverticulitis) are reported. Acute complications of jejunal diverticulosis include diverticulitis, bleeding, and intestinal obstruction. Chronic complications include intractable abdominal pain, malabsorption, and intestinal pseudo-obstruction. Up to 15 per cent of patients with jejunal diverticulosis may require small-bowel resection for treatment of these acute or chronic complications. The clinical significance, proper diagnostic evaluation, and treatment of jejunal diverticular disease are reviewed.

Changes in gallbladder volume do not affect cystic duct resistance.

To our knowledge, the relationship between gallbladder volume and cystic duct function has not been studied. We hypothesized that changes in gallbladder volume would influence cystic duct resistance. The effect of gallbladder volume changes on cystic duct resistance to both prograde (emptying) and retrograde (filling) steady-state flow was tested in 12 dogs under basal cholecystokinin-stimulated conditions utilizing a multiport catheter with a highly compliant balloon placed within the gallbladder fundus. Gallbladder volume was regulated by varying balloon volume from empty to just beyond physiologic distention. Cystic duct resistance was not affected by balloon volume under basal or stimulated conditions or by the direction of perfusate flow. This study demonstrated no relationship between gallbladder volume and cystic duct resistance and did not demonstrate a cystic duct sphincter mechanism at physiologic gallbladder volumes.

Jejunoileal bypass arthritis.

Although intestinal bypass procedures are no longer performed, important lessons have been learned concerning clinical arthritides resulting from bacterial overgrowth and immune complex deposition. This information is of considerable value in patients who present with the clinical picture of intestinal bypass arthritis on the basis of other bowel abnormalities. Furthermore, the pathogenetic mechanisms involving bacterial overgrowth, release of bacterial antigens, and immune complex deposition may be pertinent to many types of inflammatory arthritis.

Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note.

Radical pancreatoduodenectomy for treatment of pancreatic carcinoma has been the surgical standard of care for the past four decades. The recent popularization of pylorus-sparing pancreatoduodenectomy to treat benign pancreatic disease, because of its decreased morbidity and long-term nutritional consequences, has led to the use of this procedure in cases of pancreatic carcinoma. We report recent experience with three patients with pancreatic carcinoma in whom pyloric preservation would have compromised the potential chance for curative resection or compromised palliation because of occult spread of tumor to a region not resected with this new operative approach. Two patients had proximal, microscopic intramural spread of pancreatic adenocarcinoma within the duodenum or antrum--a mode of spread not previously reported with pancreatic carcinoma. Both patients had no other evidence of metastatic involvement, and both would have had positive surgical margins in a pylorus-sparing pancreatoduodenectomy. A third case demonstrates a true submucosal recurrence of pancreatic carcinoma after a pylorus-sparing pancreatoduodenectomy. It is debatable that any case demonstrating intramural spread within the duodenum could be cured with a standard Whipple resection as this may well represent another sign of incurability, like lymphatic or perineural spread, but it is clearly a major potential obstacle to palliation if submucosal recurrences occur as a result of the use of the pylorus-sparing pancreatoduodenectomy in cases of pancreatic cancer. The use of pylorus-sparing pancreatoduodenectomy in resectable pancreatic cancers must be viewed skeptically at this time.

Common bile duct healing. Do different absorbable sutures affect stricture formation and tensile strength?

Few basic investigations have addressed the problem of common bile duct strictures. We systematically investigated the healing canine end-to-end choledochal anastomosis and tested the hypothesis that common bile duct anastomoses sutured with monofilament polyglyconate absorbable suture would heal with less stricture formation and greater tensile strength than those sutured with braided polyglactin 910 and chromic catgut sutures. Seventy-six canines, randomized to control vs sutured groups, underwent either mobilization (controls) or transection of the mid-common bile duct and were allowed to heal 5, 10, 15, or 50 days postoperatively before sacrifice. The type of absorbable suture used to construct a common bile duct anastomosis was found to have no major effect on anastomotic strictures nor on anastomotic breaking strength. Polyglyconate suture caused significantly less perianastomotic inflammation than did chromic suture, with polyglactin 910 sutures evoking an intermediate inflammatory response. Surgeons may safely choose sutures for biliary procedures based on the clinical circumstances and personal preference.

Recent experience with benign biliary strictures.

The management of benign biliary strictures continues to represent one of the most difficult problems in the practice of general surgery. Twenty-eight consecutive patients with benign strictures treated between 1972 and 1987 are reviewed in this report. Stricture etiology was iatrogenic in 13 patients, pancreatitic in 11, idiopathic in three, and traumatic in one. The authors performed 27 operations and three percutaneous transhepatic balloon dilatations in the treatment of these patients. Operative morbidity was 18 per cent; there were no operative deaths. Treatment was successful in 23 of 28 patients with a mean followup of four years, and four of the five patients with initially unsuccessful results have undergone successful remedial operations. Roux-en-Y biliary enteric diversion procedures have been most successful in these patients: seven patients with Roux-en-Y choledochojejunostomy without recurrence (mean followup of 62 months) and eight patients with Roux-en-Y hepaticojejunostomy with a success rate of 87.5 per cent (mean followup of 50 months). Two patients underwent three percutaneous transhepatic balloon dilatations; one has had a good result with short followup and the other failed on two occasions and has required a remedial operation. Benign biliary strictures have multiple etiologies. Therapeutic approaches, which now include nonoperative procedures, must be tailored to the needs of individual patients. The potential for recurrence is always present. Longterm followup remains essential in the management of patients with this disorder.

Gastrointestinal disconnection and the treatment of intra-abdominal sepsis.

Current operative treatment for intra-abdominal sepsis secondary to internal gastrointestinal fistulas is aimed at wide drainage of septic foci and elimination of continued peritoneal soilage. Although methods for surgical drainage of abscesses and fistulous tracts are well established, the optimal method for surgical prevention of continued peritoneal soilage remains controversial. The authors applied the principle of complete gastrointestinal disconnection and performed diversion of the gastrointestinal tract and tube decompression proximal to the fistulous opening in the treatment of 22 critically ill patients with intra-abdominal sepsis from gastric or small bowel fistulas. Patient survival varied according to the level of the site of gastrointestinal leakage. All patients (5 out of 5) who had leakage in the distal small bowel survived. Six of nine (66%) patients with leakage from the proximal jejunum and six of eight (75%) of patients with gastroduodenal leakage survived. The overall survival rate of 77 per cent observed in this group of patients supports the authors' hypothesis that complete gastrointestinal disconnection is a valuable adjunct in the treatment of these severely ill patients.

Efficacy of computerized tomography in the preoperative staging of pancreatic carcinoma.

The increasing use of nonoperative methods for the diagnosis and palliative treatment of pancreatic cancer has placed greater emphasis on computerized tomography (CT) in staging of this malignancy. The present study was done to review our experience with CT in staging pancreatic cancer, specifically its efficacy in predicting lesions amenable to curative versus noncurative surgical treatment. Sixty six consecutive patients with pancreatic cancer who were considered potential candidates for surgical resection and who had preoperative CT scans over the 4-year period from 1982 through 1986 were studied. Preoperative CT scans were reviewed by a radiologist without knowledge of patients' surgical management. CT criteria for unresectable disease include hepatic and distant metastasis as well as evidence of locally advanced disease, including peripancreatic fascial extension, extension of tumor to locally contiguous structures, vascular encasement/invasion, and local lymphadenopathy. CT predicted resectability with a sensitivity of 75 per cent and a positive predictive value of 38 per cent. Unresectability was predicted with a sensitivity of 72 per cent and positive predictive value of 93 per cent. CT incorrectly predicted unresectable disease in three patients who had a curative resection. CT was most reliable when it predicted unresectability due to the presence of hepatic and/or distant metastasis. CT predicted unresectability with least sensitivity using criteria for locally advanced disease. Therapeutic decisions for nonoperative management of patients with pancreatic cancer based upon CT predictions of unresectable disease, especially predictions of unresectability solely on the basis of locally advanced disease, can not be recommended at this time.

Manpower planning for oral health.

The challenges to the dental profession include the unemployed dentists, the radical changes to the numbers of dental schools and their intake of new students; and the imbalance which exists on a global scale between oral health personnel and service need and demand. Workforce planning needs clearly defined goals which relate to the nature of disease, the shift from treatment to prevention and consumer expectations. A wide variety of information is required to facilitate communication and co-operation with elements of the political system, the educational system, professional bodies, health service agencies and consumers. It is essential that national planning and monitoring groups be established with membership from dental associations, educational institutions and government. In workforce planning there must be the ability to accept change, to be creative, to be positive, and to be decisive.

Bypass arthritis and the blind intestinal loop.

Arthritis and other inflammatory processes are well established complications of intestinal bypass operations, and recently have been reported after other gastrointestinal procedures. Bacterial overgrowth in blind intestinal loops, actual or functional, appears to be the underlying pathophysiologic mechanism responsible for these systemic inflammatory disorders. In the case we have reported, arthritis was the primary manifestation of blind loop remaining after incomplete reversal of a jejunoileal bypass. Surgical elimination of the blind loop was curative.