The silicone gel breast implant controversy: current status and clinical implications.

The silicone breast implant controversy has amassed a great deal of media coverage in the past year. Unfortunately, separating fact from fiction has been extremely frustrating and difficult, not only for physicians but for women who have either had or are considering cosmetic or reconstructive surgery of the breast. At a recent meeting attended by most of the board eligible and certified Plastic and Reconstructive Surgeons in the State of Arkansas, it was felt that a consensus statement was needed to clarify the issues and inform other Arkansas physicians of the most up to date information. The result is a fairly comprehensive review which will require your indulgence. Breast implants are placed not only by Plastic and Reconstructive Surgeons, but by Otolaryngologists, "Facial Plastic Surgeons", Obstetricians/Gynecologists, General Surgeons, Dermatologists and Family Practitioners. We believe it is the ethical and legal responsibility of the physicians who elect to perform these procedures to provide adequate care and follow-up for these patients when either real or perceived problems arise. Accurate information, reassurance and occasionally re-operations are required for many of these patients.

Monitoring of blood pressure and heart rate during routine endoscopy: a prospective, randomized, controlled study.

Six hundred and eighteen patients were randomized to have automated cardiovascular monitoring or clinical observation during routine endoscopy. Hemodynamic parameters were recorded at 3-min intervals before, during, and after the procedure. Upper gastrointestinal endoscopy resulted in an increased heart rate (HR), while colonoscopy caused a decreased blood pressure (BP) and HR. Hemodynamic aberrations occurred in 71% of monitored patients, including hypotension 6%, hypertension 30%, bradycardia 26%, and tachycardia 32%. Only one-third of the hypotensive episodes were recognized as aberrations, and therapeutic intervention did not improve outcome. No monitored or control patient had an adverse result. Certain hemodynamic changes were directly correlated with the baseline BP or HR and associated with the presence of coronary artery disease, particular medicines with cardiovascular effects and longer procedure duration. We conclude that automated monitoring during routine endoscopy unmasks frequent hemodynamic aberrations that are clinically insignificant. Routine monitoring during endoscopy does not improve outcome.

Does the addition of methylene blue to the sclerosant improve the accuracy of injections during variceal sclerotherapy?

We evaluated the possibility that the addition of methylene blue to the sclerosant would improve the accuracy of intravariceal injections during endoscopic variceal sclerotherapy. Four patients had eight sessions of endoscopic variceal sclerotherapy with a sclerosant containing a combination of 3% sodium tetradecyl and 60% renograffin. For four sessions, 1 ml of methylene blue was added to 9 ml of sclerosant. The endoscopist judged each injection to be intravariceal or paravariceal. This was confirmed by fluoroscopy. There were 57 injections (28 with methylene blue, 29 without) in the eight sclerotherapy sessions. Intravariceal injections were confirmed fluoroscopically in 64.9% of injections (60.7% with methylene blue 69% without). The endoscopist correctly assessed intravariceal versus paravariceal injections 66.7% of the time (71.4% with methylene blue, 62% without). None of the differences approached statistical significance. The addition of methylene blue to the sclerosant does not improve the accuracy of intravariceal injections or the endoscopist's ability to recognize paravariceal injections during sclerotherapy of esophageal varices.

Gastroesophageal reflux and sclerotherapy strictures.

The development of esophageal stricture is common following endoscopic variceal sclerotherapy (EVS). Gastroesophageal reflux may be at least partly responsible. Twelve randomly selected male patients underwent chronic EVS for the management of bleeding esophageal varices. Six patients developed strictures during or after EVS, six did not. There were no significant differences between stricture and nonstricture patients during 24 hour esophageal pH monitoring. Three of the six stricture patients and four of the six nonstricture patients had an abnormal amount of reflux. Gastroesophageal reflux occurs frequently in patients undergoing EVS, and it is not likely to play a major role in EVS stricture formation.

The gastrostomy button: a prospective assessment of safety, success, and spectrum of use.

The gastrostomy button is a new, skin level, nonrefluxing, mushroom-tipped feeding device which can be used to replace conventional gastrostomy catheters. We have prospectively evaluated 31 consecutive patients managed with this appliance and our results show that the button can be successfully placed in 90% of cases without serious morbidity or mortality. The procedure is quick to perform, requires minimal intravenous sedation, and is well-suited to a broad range of socially active gastrostomy-dependent patients. Patients found the aesthetics, convenience, and independence of the low profile design attractive and no individual wished to return to the original method of feeding. Small and medium-sized buttons were easier to place than larger devices. Gastrocutaneous reflux through the appliance occurred in 11% of cases and was a common cause for replacement. Alert, ambulatory patients with an established gastrostomy and short or medium-sized gastrocutaneous fistulous tracts are ideal candidates for the button.

A critical analysis of the Sacks-Vine gastrostomy tube: a review of 120 consecutive procedures.

Results from 120 patients managed with a Sacks-Vine gastrostomy tube were analyzed. In our experience, this device can be successfully placed in almost all cases (96%), and has a low rate for procedure-related mortality (0.8%) and major (4.4%) and minor (12.4%) complications. Advantages and problems associated with this feeding catheter are discussed. The Sacks-Vine gastrostomy tube is a reasonable alternative to other catheters placed by different methods.

Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract.

Percutaneous endoscopic gastrostomy (PEG) could be potentially more hazardous in patients with prior abdominal surgery. To minimize risk of complications following PEG, we have modified the conventional method to include selection of a "safe gastrocutaneous fistulous tract," using an aspirating, lidocaine-filled syringe and needle. "Safe tracts" prior to PEG placement were determined by simultaneous air return in the aspirating syringe and endoscopic visualization of the intragastric needle. This technique was used to compare the results of PEG in 27 operated and 80 nonoperated patients. Our results show that morbidity and mortality rates and types of complications following PEG in previously operated and nonoperated patients are comparable, but technical success rates are slightly lower in the surgical group (88 vs 100%). The incidence of failed PEGs was highest in patients with partial gastric resection compared to those with intact stomachs (29 vs 5.0% p less than 0.05). PEG was safely and successfully performed in all cases (surgical and nonsurgical) when safe tracts were confirmed. Selection of a safe tract should be made prior to PEG placement, especially in patients with prior abdominal surgery.

Alterations in plasma copper, zinc, and ceruloplasmin levels in patients with thermal trauma.

This review was undertaken to elucidate the trends in copper, zinc, total serum protein, and ceruloplasmin levels in patients with thermal trauma. Medical records of pediatric and adult patients were retrospectively reviewed. The findings showed a significant linear decline in mean plasma copper, ceruloplasmin, and total serum protein during the first three days postburn, followed in general by a gradual rise in levels; however, patients with burns larger than 60% TBSA maintained copper, zinc, and ceruloplasmin levels significantly below the lower limits of normal during the observation period. Significant decrements in copper, zinc, total serum protein, and ceruloplasmin levels have been demonstrated in these patients. Trace metal determinations should be obtained in patients with significant burns soon after admission and routinely throughout their hospital course. Specific trace metal supplementation should be administered when indicated.

The current evaluation of nonpalpable breast lesions.

To understand the suspected low yield of malignant neoplasms from biopsies guided by needle localization, we reviewed 122 biopsies performed from January 1985 to November 1986 at University Hospital and Arkansas Baptist Medical Center, Little Rock. The positive biopsy rates were 3.5% and 10.6%, respectively. After review of these cases, the following guidelines for biopsy were developed: (1) Do not perform a biopsy on a low-density mass less than 1 cm in diameter. (2) Do not perform a biopsy for asymmetric density or questionable mass. (3) Do not perform a biopsy for secondary signs of malignancy such as skin thickening or asymmetric vasculature. (4) Biopsy is indicated for clustered calcifications, a dominant mass greater than 1 cm in diameter, stellate lesions, or interval change from a previous mammogram. These changes resulted in a positive biopsy rate of 15% for the period from November 1986 through April 1987.

Course and complications of endoscopic variceal sclerotherapy: a prospective study of 50 patients.

Fifty consecutive patients with bleeding esophageal varices were treated with endoscopic variceal sclerotherapy (EVS) using the free hand method and a flexible fiberoptic endoscope. During the study period, November 1981 through April 1984, 11 patients (22%) rebled after the initiations of EVS and six patients were lost to follow-up. Obliteration of esophageal varices was achieved in 14 patients and none of these patients rebled for a mean follow-up time of 305 days. Survival curves generated by Willcoxson life table analysis demonstrated 51% 1-year survival for all patients, 21% for Child's class C patients, and 100% for Child's A and B patients. The complications associated with EVS were ulcerations 78%, strictures 20%, fever 44%, and perforations 2%. This study indicates that EVS is a safe and effective treatment for acute variceal hemorrhage and obliteration of esophageal varices can be achieved. Once varices are obliterated rebleeding may not occur. Survival in Child's A and B patients may be improved with EVS but the survival in Child's C patients is unaffected.

The effect of estrogen on protein and RNA concentration and on de novo synthesis of RNA in the uterus of aging ovariectomized mice.

A study was made of RNA concentration and de novo synthesis and protein concentration in the uterus of ovariectomized C57BL/6J mice with and without estrogen treatment. Young adult animals (4 to 7 mo.) were compared with mice during the age period of reproductive decline (11 and 15 mo.). Concentration of RNA was significantly lower in 15-mo.-old mice than in 4- to 7- and 11-mo.-old animals. De novo RNA synthesis, as indicated by incorporation of 3H-uridine, was also lower in 15-mo.-old mice than in young adults. Estradiol -17beta increased RNA concentration at all ages studied and the percentage increase did not decline with age. De novo synthesis of RNA was also increased in response to estrogen treatment, but the response was less in 15-mo.-old mice. Protein concentration did not change with age, but the concentration decreased in the estrogen treated mice. The biochemical changes in the uterus may be associated with the declining ability of this organ to support pregnancy as it grows older.