Demonstration of rectosigmoid fistula dynamic scintigraphic peritoneography.

Intraperitoneal installation of chemotherapy through a Mediport implanted subcutaneously in the abdominal wall is used currently for treatment of peritoneal metastases from ovarian, gastric and colonic carcinoma. There is a variable incidence of complications due to the procedure reported in the literature. The main predisposing factor for these complications is the inhomogeneous distribution of the chemotherapeutic drugs within the peritoneal cavity. We report an unusual case of a rectosigmoid fistula that developed 6 wk following the insertion of a Bardport subcutaneously in the abdominal wall for intraperitoneal therapy. The fistula was clearly demonstrated by dynamic scintigraphic peritoneography. This is a new modification of scintigraphic peritoneography as practiced routinely. We endorse the previous recommendation that scintigraphic peritoneography be performed before every intraperitoneal installation of a chemotherapeutic drug or radiopharmaceutical to ensure the homogeneous distribution of the drugs and to prevent complications.

Evaluation of mitral valve repair by intraoperative transoesophageal echocardiography.

BACKGROUND: Mitral valve repair is the procedure of choice in the surgical management of mitral regurgitation. Intraoperative confirmation of successful repair is essential to the effectiveness of this procedure. AIMS: The aims of this study were: (a) to compare intraoperative transoesophageal echocardiography (TOE) with the surgeon's assessment of valve competence; (b) to assess the impact of routine intraoperative imaging on the hospital echocardiography laboratory. METHODS: Eighty-six consecutive patients undergoing mitral valve repair formed the study population. Valve competence following repair was assessed intraoperatively by: TOE; saline insufflation of the flaccid left ventricle; and evaluation of the pulmonary capillary wedge pressure for the presence of a significant V wave. RESULTS: TOE demonstrated successful valve repair (< or = 1 + residual regurgitation) in 75 patients (87%) and detected significant residual regurgitation (> or = 3+) in seven (8.2%). The mechanism of regurgitation was also clearly shown. Of these seven patients, four underwent immediate valve replacement, two had successful revision of the initial repair and one required valve replacement one week later. In all seven patients the valve repair had been assessed as successful by saline testing and only one had a post-repair V wave 10 mmHg above the mean pulmonary capillary wedge pressure. In 30 non-selected patients the imaging equipment was required in theatre for 43 +/- 18 minutes. CONCLUSIONS: TOE is currently the most sensitive method for detection and quantitation of residual mitral regurgitation following valve repair. Evaluation can be performed within a similar time to that required for one complete transthoracic study and can usually be performed with minimal disruption to the hospital echocardiography laboratory.

Left ventricular false aneurysm complicating mitral valve repair.

Left ventricular false aneurysm is a rare complication of mitral valve replacement or myocardial infarction. A case of left ventricular false aneurysm complicating mitral valve repair is presented. The patient was clinically asymptomatic, and the diagnosis was made on postoperative transesophageal echocardiography. The patient subsequently underwent successful mitral valve replacement and false aneurysm repair.

Raman, fluorescence, and time-resolved light scattering as optical diagnostic techniques to separate diseased and normal biomedical media.

Studies of Raman scattering, fluorescence and time-resolved light scattering were conducted on cancer and normal biomedical media. Fourier transform Raman spectroscopic measurements were performed on human normal, benign and cancerous tissues from gynecological (GYN) tracts. A comparison of the intensity differences between various Raman modes as well as the number of Raman lines, enables one to distinguish normal GYN tissues from diseased tissues. Fluorescence spectroscopic measurements on human breast tissues show that the ratio of fluorescence intensity at 340 nm to that at 440 nm can be used to distinguish between cancerous and non-cancerous tissues. Separate studies on normal and cancerous breast cell lines show spectral differences. The measurements of back-scattered ultrafast laser pulses from human breast tissues show differences in the scattered pulse profiles for different tissues. These studies show that various optical techniques have the potential to be used in medical diagnostic applications.

Multiple cardiac papillary fibroelastomas and rheumatic heart disease.

A case of severe rheumatic mitral stenosis was found to have multiple echodense masses attached to the ventricular surface of the mitral valve and papillary muscle at preoperative 2-dimensional echocardiography. Subsequent surgery involved mitral valve replacement and excision of the masses. Complete excision was confirmed by intraoperative transoesophageal echocardiography. Histologic examination of the surgical specimens showed typical papillary fibroelastomas. This is the first case report of multiple papillary fibroelastomas in association with rheumatic valvular disease demonstrated by 2-dimensional echocardiography.

Warm blood cardioplegia as an adjunct to myocardial preservation during coronary artery bypass grafting.

A review of the first 52 consecutive coronary artery bypass surgery patients to receive oxygenated blood cardioplegia, with warm reperfusion cardioplegia ('hot shot'), was undertaken to evaluate its effectiveness in myocardial protection. The chosen parameters of ischaemia were: (i) the occurrence of ventricular fibrillation (VF) on release of the aortic cross-clamp (ACC); (ii) the occurrence of bradycardia due to cardiac conduction defects; (iii) the use of inotropes with or without the use of the intra-aortic balloon pump (IABP); (iv) evidence of myocardial infarction (MI) on the postoperative electrocardiograph (ECG); and (v) peri-operative cardiogenic mortality. Warm induction cardioplegia was cooled after cardiac standstill. Repeat cold cardioplegia was given as required at intervals and warm reperfusion cardioplegia was given prior to release of the ACC. Of the 52 patients studied none developed VF after release of the ACC; one patient with pre-operative complete heart block required temporary cardiac pacing; no patient required inotropes or IABP and there was no postoperative MI or mortality. The warm blood cardioplegia technique has not resulted in any detectable evidence of inadequate myocardial protection. A beneficial effect has been demonstrated by the absence of VF, cardiac conduction defects, myocardial failure, MI and mortality.

Clear cell carcinoma arising in extraovarian endometriosis: report of three cases and review of the literature.

The literature on malignancy arising in extraovarian endometriosis comprises only three cases of clear cell carcinoma. We wish to report the clinical features and pathologic findings of an additional three cases. The first concerns a 39-year-old oriental pregnant woman who presented with a large intraluminal obstructing lesion of the sigmoid colon, the second case deals with an abdominal wall mass that appeared in a cesarean section scar of a 45-year-old black woman, and the third case describes an ulcerating lesion of the perineum and the buttock in a 43-year-old white woman with a long history of endometriosis in an episiotomy scar. Our observations support the notion that clear cell carcinoma arising in extraovarian endometriosis behaves differently from its counterpart in ovarian endometriosis, but more in line with clear cell carcinoma of the endometrium.

Combined carotid and coronary surgery.

A retrospective review of 40 consecutive patients undergoing combined coronary artery bypass grafting (CABG) and unilateral carotid endarterectomy (CEA) was carried out to determine the stroke rate for the procedure. Patients presenting with severe coronary artery disease judged to be at risk of imminent myocardial infarction, who had signs of cerebral ischaemia (70%) or asymptomatic carotid bruits (30%), were investigated for extracranial carotid vascular disease. Patients with severe stenotic carotid lesions associated with high risk coronary artery disease underwent combined CEA/CABG. Three patients had a previous contralateral CEA. The average age of the patients was 62 years, and there were 31 males and nine females. CEA was completed prior to CABG under the same general anaesthetic. There were 24 CEAs on the left and 16 on the right. Six patients suffered a postoperative cerebral ischaemic event (15.4%): a reversible ischaemic neurological deficit in three (7.7%), a transient ischaemic cerebral event in two (5.1%), and a permanent stroke occurred in one (2.6%). Two deaths occurred and both were cardiac related. Combined CEA/CABG in patients with stenotic lesions of the coronary and extra-cranial carotid vascular systems who are at risk of cerebral or myocardial infarction, can be performed with a permanent stroke rate within the published range for either CEA or CABG alone and with a mortality of 5%.

Extracorporeal perfusion of the human uterus.

Uterine specimens specially prepared for extracorporeal perfusions (arterial and venous stumps available for catheterization) were perfused with oxygenated Krebs-Ringer bicarbonate-glucose buffer for periods of up to 12 hours to investigate the feasibility of obtaining constant flow, stability of biochemical parameters, and adequate distribution of the perfusion fluid. Flow rates of 10 to 30 ml/min per artery could be maintained at pressures ranging from 80 to 120 mm Hg. Arteriovenous gradients of oxygen and carbon dioxide tensions were relatively stable and levels of lactate, lactic dehydrogenase, and creatine kinase released to the medium, indicators of tissue hypoxia or cell lysis, declined after 30 minutes of perfusion, remaining low and stable up to 12 hours. Distribution of methylene blue and radiopaque solutes was practically complete throughout the fundus and upper two thirds of the uterus. A mixture of tritium-labeled estrone sulfate and carbon 14-labeled estrone was injected as a bolus through an arterial catheter during perfusion. Perfusate samples were collected for 30 minutes, and tissue samples were taken at the end of this period. Tritium/carbon 14 ratios in myometrium and perfusate indicated preferential uptake of the unconjugated estrogen. Tritium/carbon 14 ratios were higher in endometrium than in myometrium, which suggests an enhanced permeability of endometrial capillaries to estrone sulfate.

Approach to the abdominal retroperitoneum in patients with gynecologic malignancies.

The treatment of patients with gynecologic malignancies is still widely dependent on clinical staging. The introduction of the concept of surgical staging has significantly altered treatment plans. Better staging allows better treatment and more accurate comparison of survival and cure rates. We describe a surgical technique to expose the abdominal retroperitoneum. Sixteen patients have been explored by this technique. There has been no apparent difficulty in this procedure, even when performed on obese patients.

Significance of cone biopsy margins in the management of patients with cervical neoplasia.

Too many patients in the United States undergo hysterectomy for cervical neoplasia following cone biopsy because too many gynecologists choose not to pay attention to the pathology present at the margins of the cone specimen. In view of the need to improve the management of cervical neoplasia--i.e., to reduce the number of needless hysterectomies--a retrospective study was done to verify the trend in our institution and to evaluate the utilization of cone biopsy to determine the extent of the process. Also, the methods used for procuring the cone sample and for interpreting the results of the biopsy were studied. The present study included 345 patients who underwent a cone biopsy; subsequently, 102 of them had a hysterectomy. Based on the evaluation of the cases in this study, information was obtained about the performance of cone biopsy and the guidelines for determining when a hysterectomy should be performed and when other, less drastic means of eradicating the neoplasia should be considered.

Use of indwelling right atrial catheter in gynecological oncology: a preliminary report.

Experience with the utilization of an indwelling right atrial catheter in patients with gynecological cancer is reviewed. The technique of placement is described and the complications in 21 patients are presented. Fever was the major complication in 5 out of 21 patients of whom 2 had positive blood cultures. The catheter had to be removed in 3 patients. The median duration of catheter placement was 45 days, the shortest being 8 hr and the longest being 1 year. Most of the patients were myelosuppressed or had no other venous sites accessible. A safe regimen for management of the catheter and indication for its removal are presented.

Aortic node metastases with negative pelvic nodes in cervical cancer.

A case of invasive squamous cell carcinoma of the cervix with aortic lymph node metastases in the absence of pelvic lymph node metastases is described. The spread of squamous cell carcinoma of the cervix is briefly reviewed.

Mallory-Weiss syndrome secondary to cis-platinum chemotherapy: an unusual complication.

The Mallory-Weiss syndrome is a relatively infrequent cause of digestive tract bleeding and most cases have been described in alcoholics. Nonoperative management is frequently successful. We present here a case of sudden onset of wretching and vomiting after IV infusion of cis-platinum for recurrent carcinoma of the uterine cervix in which the patient had profuse hematemesis secondary to three posterior gastroesophageal tears requiring operative intervention after failure of nonsurgical management. This is an unusual complication of antineoplastic chemotherapy and its prevention is emphasize in this paper.

Cerebral blindness in association with cis-platinum chemotherapy for advanced carcinoma of the fallopian tube.

A 62-year-old woman with a diagnosis of metastatic fallopian tube carcinoma was treated with cis-platinum and doxorubicin (Adriamycin) at a dosage of 50 mg/m2 intravenously every 3 weeks. After the 10th course of cis-platinum and doxorubicin, she complained of headache and inability to see. Physical examination was compatible with cortical blindness. The brain scan and computed tomographic scan were normal. Visual evoked potentials showed a delay in latency. Visual acuity completely returned over the next months, but right homonymous hemianopia persists. The temporal relationship between the findings and the treatment with platinum implicates this drug as the possible causative agent in the cortical blindness.