Sequestered substernal goiter.

A young woman with a normally located and only subtly nodular thyroid gland in the neck was found to have a clinically distinct and radioisotopically "cold" anterior mediastinal mass, which proved to be a benign colloid adenoma. While this constellation of findings usually suggests the presence of a nonthyroidal neoplasm, eg, lymphoma, thymoma, or teratoma, our case illustrates that sequestered benign nodular goiter should also be considered in the differential diagnosis. Clinical clues, such as a nodular thyroid gland, movement of the mass with deglutition, and a family history of nodular goiter, should suggest this possibility. A characteristic computed tomographic appearance may also prove useful in recognition of this rare disorder.

Perforated diverticulum of the ileum.

A 54-year old man with abdominal pain and fever was found to have perforated a diverticulum of the ileum. Resection of the involved bowel and reanastomosis proved to be successful therapy. Five previously reported cases of perforated ileal diverticulum are reviewed. The need for prompt resection of the involved bowel segment is emphasized.

Factors contributing to the declining mortality rate in renal transplantation.

Recent modifications and refinements in the management of patients with renal allografts have diminished the mortality rate at our hospital to 2 per cent and 5 per cent at one year for patients receiving kidneys from related and cadaveric sources, respectively. Of 186 receiving transplants since 1974, seven (4 per cent) have died within one year of operation. The incidence of wound infections has been reduced from approximately 25 per cent in 1972 to 2 per cent since 1976 by the use of a single high dose of broad-spectrum antibiotics administered at the time of induction of anesthesia for any surgical procedure. Risk and limitations of immunosuppression have been better appreciated, ultrasound is used more often in the diagnosis of partial obstruction or perinephric fluid collections, and needle biopsy of the transplanted kidney has reduced the morbidity inherent in open biopsy. The contribution of sepsis as a cause of death has declined. The diminishing hazard of renal transplantation has made it an increasingly attractive treatment for end-stage kidney disease.

Rehabilitation profile of kidney transplant patients.

The rehabilitation of 132 patients with functioning grafts six months to ten years post transplantation was examined by review of self-report questionnaires. The patients were divided into three groups according to when they underwent transplantation. Results showed 62 per cent of patients in group A (transplant received between July 1, 1973 and December 31, 1973), 69 per cent in group B (transplant received between January 1, 1971 and June 30, 1973), and 90 per cent in group C (transplant received between January 1, 1964 and December 31, 1970) were productively active in July 1974. Nearly all attained productively active rehabilitation scores by twelve months, but one-third reported they were functioning at a lower level than before their illness, and a significant number of patients with physically strenuous jobs before illness acquired sedentary jobs post transplantation.

Ultrasound in renal transplantation.

Because of important differences in prognosis and treatment, prompt and accurate diagnosis of fever, decreasing function, and pain and tenderness around a renal allograft is crucial for differentiation between acute rejection and other post-operative conditions which may give a similar picture. Ultrasound examinations within 24 hours have been performed on all transplant recipients exhibiting symtoms compatible on all transplant recipients exhibiting symptoms compatible with an episode of acute rejection between September 1973 and June 1976 at the Peter Bent Brigham Hospital. The patients were separated into four groups dependent upon diagnosis by ultrasound; Group I(73 patients); allograft enlargment consistent with acute rejection; Group II (14 patients); dilitation of the collecting system; Group III (14 patients); perinephric fluid collections; Group IV (6 patients); miscellaneous conditions. The accuracy of the ultrasound technique was compared within each group to the results from intravenous pyelography, retrograde pyelography, serial renograms, kidney biopsy and/or surgical exploration. This convenient, non-invasive and reproducible method has been extremely effective in the differential diagnosis of rejection in clinical transplantation.

Calyceal-cutaneous fistulae in renal transplant patients.

Calyceal-cutaneous fistula is a serious sequela of renal transplantation occurring in approximately 3% of allografts. This complication occurred in 12% of allografts with multiple renal arteries. A localized area of poor parenchymal perfusion involving less than one-eighth of the kidney was noted at the time of transplantation in only one-third of the kidneys developing fistulae. Attempts of surgical correction of the fistulae in the presence of serious wound and urinary tract sepsis were usually unsuccessful, with the ultimate loss of 7 of 8 kidneys and the death of 3 patients from sepsis. One individual underwent successful partial resection and closure of the fistula with a muscular graft and survives with adequate function. This experience would suggest that if an initial aggressive surgical attempt at repairing a calyceal-cutaneous fistula fails, transplant nephrectomy should be performed.

Anatomic localization and step by step advancement of the fiberoptic colonoscope.

Anatomic localization of the tip of a colonoscope without the aid of fluoroscopy is adequate in a majority of patients. External check points of transilluminated light within the colon on the abdominal wall, characteristic internal appearance of the colon and gross anatomic landmarks have been used. An improved technique for advancement results if a routine sequence of maneuvers is used in a similar manner in all patients.

A twenty year survey of arterial complications of renal transplantation.

The significant arterial complications of renal transplantation are hemorrhage, infarction, stenosis and aneurysm formation. Hemorrhage is often associated with sepsis and may be lifethreatening. Large infarcts may be secondary to multiple small vessels or intraoperative hypotension with inadequate perfusion of the organ. Nephrectomy is invariably indicated in these situations. Renal artery stenosis with resultant hypertension may occur secondary to stenosis at the anastomosis, atherosclerotic plaque formation or intimal fibrosis of the renal artery. Operative reconstruction if the anastomotic site may relieve hypertension is selected patients but places the transplanted kidney greatly at risk. Aneurysm formation is often mycotic and is associated with multiple operations and wound sepsis. The iliac artery may be ligated without loss of limb, while the resultant claudication may be relieved by a surgical bypass procedure.