Use of the biomedicus pump in resection of renal carcinoma invading the vena cava.

The authors report a 7-year old boy suffering from a renal carcinoma with a tumoral thrombus invading the vena cava. The kidney and the tumoral thrombus were removed with the help of a Biomedicus pump. This paper shows how to avoid a cardiopulmonary bypass procedure in order to perform safely a tumoral thrombectomy with this relatively new technique.

The use of homologous veins in arterial reconstructions. An experimental study.

In order to evaluate under what conditions the use of venous homografts could yield the best results. 230 arterial reconstructions were performed in mongrel dogs bypassing their ligated femoral arteries. Cumulative 6-month patency-rates were: Group 1: Prosthetic materials: a) Dacron grafts: 48%, b) PTFE grafts: 53%. Group 2: Fresh veins: a) autografts: 100%, b) allografts: 37%, c) allografts treated with cyclosporin 4 mg/kg.day for one month: 74% (100% after one month). Group 3: Veins preserved in saline at 4 degrees C. for one month: a) autografts: 44%, b) allografts: 34%. Group 4: Frozen veins preserved in saline at -70 degrees C. for one month: a) autografts: 58%, b) allografts: 47%. Group 5: Veins preserved in glutaraldehyde 0.25% for one month: a) autografts: 26%, b) allografts: 22%. Group 6: Veins preserved in 15% DMSO in Hanks solution at -160 degrees C for one month: a) autografts: 77%, b) allografts: 35%, c) allografts treated with cyclosporin 4 mg/kg.day for one month: 72%, d) allografts treated with methylprednisolone 1 mg/kg.day for one month: 38%, e) allografts treated with cyclosporin 4 mg/kg and methylprednisolone 1 mg/kg daily for one month: 83%. Fresh veins and veins preserved in 15% DMSO at -160 degrees C. are viable but immunologically active grafts. In allografts rejection phenomena cause a relatively high occlusion rate which, however, can be prevented with low dose cyclosporin. The optimal duration of immunosuppressive therapy remains to be determined. Veins stored at 4 degrees C or at -70 degrees C are not viable and only weakly antigenic. Their results are not better than those obtained with prosthetic material.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative identification of parathyroids by means of methylene blue.

In 134 cervical explorations for hyperparathyroidism, methylene blue was administered intraoperatively to stain parathyroid glands. Seventy-seven out of 79 adenomas (97.5%) and 199 out of 204 hyperplastic glands (97.6%) were clearly stained. The only recurrences were observed in patients undergoing surgery for hyperplasia of the parathyroid glands. The recurrences (12%) were mainly due either to initial wrong diagnosis of parathyroid adenoma, or they were graft dependent. Methylene blue is an effective, safe and easy way to localize and identify abnormal parathyroid glands, thereby improving the results and shortening the operating time.

Intraoperative identification of parathyroid glands with methylene blue infusion.

Intraoperative staining of parathyroid glands with methylene blue was used in 120 cervical explorations for hyperparathyroidism. The dye clearly stained 66 of 67 adenomas (98%) and 194 of 198 hyperplastic glands (98%). No recurrences were observed in 66 patients undergoing surgery for an adenoma. Six of 48 patients (12%) had recurrences of hyperplasia of the parathyroid glands. We found methylene blue to be an effective, safe, and easy applicable method to quickly identify abnormal parathyroid glands, thereby considerably shortening the operating time.

Intrapleural quinacrine instillation for recurrent pneumothorax or persistent air leak.

From 1982 to 1990, 27 patients with recurrent pneumothorax or persistent air leak (28 episodes) underwent pleurodesis with intrapleural administration of quinacrine, according to a standardized scheme. A first evaluation was done about 1 month after the intervention. In August 1990, all patients were invited for a second check-up. In 4 patients quinacrine plasma concentrations were determined. There was one early failure. No late recurrences were observed. Neither serious nor late complications were seen with our low-dose regimen. Transient fever was the only constant side effect. In contrast to other chemicals proposed for pleurodesis, quinacrine did not cause major pain. Only very low quinacrine plasma concentrations (peak, < 10 ng/mL) were found. In conclusion, chemical pleurodesis with quinacrine can be considered a safe and effective treatment. The number of administrations as well as the dosage are important to prevent morbidity and recurrence.

A case against parathyroid autotransplantation.

The authors report about a recurrence in a uremic patient who underwent a subtotal parathyroidectomy with autotransplantation in the sternocleidomastoid muscle for hyperparathyroidism. Reexploration revealed an enlarged parathyroid graft. This paper illustrates the potential complication of parathyroid autografts in patients with chronic renal failure.

Venous allografts for vascular reconstructions.

In order to evaluate various protocols for the preservation of venous allografts 162 arterial reconstructions were performed in mongrel dogs bypassing their ligated femoral arteries. The cumulative 6-month patency-rates as determined by weekly palpation and regular angiography were. Group I = Synthetic grafts: (a) Dacron 48%, (b) PTFE 53%. Group II = Fresh venous grafts: (a) autografts 100%, (b) allografts 37%. Group III = Veins preserved in saline at 4 degrees C for 1 month: (a) autografts 44%, (b) allografts 34%. Group IV = Veins preserved in saline at -70 degrees C: (a) autografts 58%, (b) allografts 47%. Group V = Veins preserved in glutaraldehyde solution: (a) autografts 26%, (b) allografts 22%. Group VI = Veins preserved in Hanks-solution with 15% DMSO at -160 degrees C: (a) autografts 77%, (b) allografts 35%. Histological as well as immunological studies suggest that these results are determined by the preservation protocol in Groups III, IV and V and by the presence of rejection in Groups I and VI. As the results with the allografts are not superior to those obtained with synthetic grafts, their use should be confined to those cases where the use of synthetic materials should be avoided at any price. Further experiments with immunosuppression and antigenic matching are indicated to see whether this would improve the results obtained with viable venous allografts.

Chylothorax after blunt chest trauma.

An unusual patient with chylothorax following blunt chest trauma is presented. Diagnosis was, in this acute case, clear after thoracostomy. In our patient conservative therapy with total parenteral nutrition failed and he was cured with a surgical closure of the duct leak. Chylothorax can be the cause of important morbidity and mortality, and straightforward diagnosis and therapy are mandatory.

Immunosuppressive treatment of venous allografts.

In order to evaluate whether temporary immunosuppressive therapy is able to improve the results obtained with viable venous allografts and achieve better results than with synthetic grafts, 142 arterial reconstructions were performed in mongrel dogs bypassing their ligated femoral arteries. Histological as well as immunological studies were performed and patency determined by weekly palpation and regular angiography. The 6-month cumulative patency rates were: Group I: synthetic grafts (a) Dacron: 48%, (b) plasma-TFE: 53%. Group II: fresh grafts (a) autografts: 100%, (b) allografts: 37%, (c) allografts treated with cyclosporin 4 mg kg-1 daily for 1 month: 74% (100% after 1 month). Group III: grafts preserved in Hanks' solution with 15% DMSO at -160 degrees C for 1 month (a) autografts: 77%, (b) allografts: 35%, (c) allografts treated with methylprednisolone 1 mg kg-1 daily: 38%, (e) allografts treated with cyclosporin and methylprednisolone: 83%. Group IV: human saphenous veins implanted as xenografts and treated with cyclosporin and methylprednisolone: 18%. Immunosuppressive therapy with cyclosporin seems to be able to prevent early thromboses due to rejection seen after implantation of viable fresh or cryopreserved venous allografts, and the results are significantly better than those obtained with synthetic grafts. Tissue matching might further improve these results. This study suggests that cryopreserved venous allografts could be used for the creation of a vein-bank and their use, in combination with tissue typing and temporary immunosuppressive therapy may be warranted for arterial reconstructions when autologous saphenous vein is not available.

[Meconium peritonitis: diagnosis, etiology and treatment]. / Meconiumperitonitis: diagnose, etiologie en behandeling.

Fetal intestinal perforation causes a sterile inflammatory reaction of the peritoneum called meconium peritonitis. Twelve patients studied in the perinatal period serve to describe the classical fetal and neonatal signs and symptoms, the iconographical findings, treatment and prognosis. All but one infant, with a meconium pseudocyst, presented with the fibro-adhesive variety. Two were caused by cystic fibrosis, two by organic obstruction, one by fetal appendicitis and another two by ischemic necrosis of part of the ileum. In one of the latter two, the probable mechanism was feto-fetal embolisation following the in utero death of a co-twin. One idiopathic perforation, diagnosed in a preterm infant, healed spontaneously. The neonatal mortality rate was 18%. Primary enteric anastomosis was feasible in 3, Bishop-Koop anastomosis in 2 and an intestinal stoma in two others. Apart from the two survivors with cystic fibrosis, seven have no late gastro-intestinal sequelae.

[Renal autotransplantation]. / Renale autotransplantatie.

The progress of renal transplantation in the last 2 decades has made possible the development of autotransplantation and extracorporeal surgery of the kidney. By those techniques, it is possible to operate upon patients in which conservative conventional surgery is impossible. In this article the technique is described, and two typical cases are reported. The mean indications are renal vascular hypertension, malignant tumors of the kidney, traumatic lesions of the kidney and ureteral lesions. All these indications are described in detail.

Long-term results after carotid endarterectomy for carotid artery stenosis with contralateral occlusion.

Patients with one internal carotid artery occlusion and a contralateral stenosis run a significantly higher risk of stroke. We performed endarterectomy of the stenotic carotid in 44 such patients and followed them for mean 54 months (range 1-172 months). Early mortality was 2%. Life-table analysis shows that the incidence of a new stroke was 0.6% per year, the survival rate was 78% after three years, and 70% after five years. We conclude that carotid endarterectomy can be safely performed in patients with contralateral internal carotid artery occlusion and can significantly improve the long-term prognosis of these patients.

Repair of a high esophageal stenosis with a mucosal flap of a Zenker's diverticle.

A patient presented an esophageal stenosis due to lasertherapy by Dohlmann's technique for the treatment of a Zenker's diverticle. This esophageal stenosis has been repaired by taking a mucosal flap out of the Zenker's diverticle. The technique is presented in this paper, together with some analogue data from literature.

[Treatment of intra-abdominal sepsis and necrotizing pancreatitis with staged lavage using a Zipper]. / Behandeling van intra-abdominale sepsis en necrotiserende pancreatitis door middel van etappenlavage met behulp van de Zipper.

The mortality of generalised intra-abdominal sepsis and severe necrotising pancreatitis remains very high. The persistence of intra-abdominal septic foci leads to recurrent abscess formation, persistence of sepsis and development of multiple organ failure, ultimately leading to the death of the patient. Therefore we believe that a repeated and total elimination of all septic and necrotic material is the cornerstone of an adequate surgical therapy in these patients. We performed "staged lavage" with the aid of a Zipper in 24 patients (10 with intra-abdominal sepsis and 14 with severe necrotising pancreatitis). Via the Zipper 98 relaparotomies were performed (mean 4.1 per patient). The high Apache II-scores (12 to 45, mean 24) illustrate the severity of disease in most of these patients. The expected in-hospital mortality-rate was 59% while in our series 7 patients died on a total of 24 (28%).

[Analysis of severely injured patients admitted via an emergency service]. / Analyse van zwaar gekwetsten opgenomen via een spoedopnamedienst.

Data about the number and treatment of trauma-patients are, certainly in our country, very rare. In this study we showed that such a registration with grading of the severity of the injuries following the ISS-Score is feasible and useful. Further and more extensive registration seems necessary in order to obtain a better insight in epidemiology and treatment of trauma patients in our country.

Peritoneal lavage after abdominal trauma: indications, technique, results.

This study represents our experience with 1461 patients who were seen in the Emergency Room of the University Hospital in Ghent with multiple traumatic lesions, between 1978 and 1982. In 43% of these polytraumata, we did an explorative peritoneal lavage in order to obtain a quick evaluation of intrabdominal haemorrhage. In 65% of the patients, the lavage was negative; 221 positive lavages (35%) underwent abdominal exploration; in 85% of these there were evident positive findings. The remaining 15% showed either no lesions, or minor lesions not involving risk of life. The overall accuracy-rate of the technique described above is at least 93%.

[Treatment of aortic coarctation]. / Le traitement de la coarctation de l'aorte.

244 cases of coarctation of the aorta were treated surgically from 1953 to 1988. The age of the patients ranged from 3 days to 59 years with an average of 11.2 years. The average age of the patients decreased progressively over the years. 22% of the patients (54 patients) were less than one year old at the time of the operation. The percentage of infants presenting with decompensation and associated cardiac malformation increased progressively over the years. A total of 40 out of 54 patients belong to this group. The surgical procedure--resection and shunt--was a standard one in 89% of all cases. A prosthesis was required in 4.5% of all cases, and a widening patch in another 5.3%. An unusual technique had to be used in 1.7% of cases. The surgical mortality was of 12 patients (4.9%), all belonging to the infant group (3 days to 13 months old). No mortality was observed among older patients, nor among the elective surgical cases. 9 patients were treated for recurrence of coarctation. No case of paraplegia was noted in this series.