Neck irradiation: a risk factor for occlusive carotid artery disease.

OBJECTIVES: to determine whether irradiation is an independent risk factor for carotid atherosclerosis, and propose guidelines for patient follow-up. DESIGN: a retrospective case control study. MATERIALS AND METHODS: two groups of patients with severe carotid artery stenosis (>70%) were compared: 30 post-neck irradiation patients, and a control group of 100 patients with no history of neck irradiation. Disease location and severity were assessed by duplex. The relationship between atherosclerotic risk factors, time since irradiation and carotid artery disease was examined. RESULTS: the average age of study group patients was 67 years (43-86) compared to 69 years (46-89) in the control group. The average interval from irradiation to diagnosis was 14 years (3-53) (median 12.5 years). The study group suffered less from diabetes, ischaemic heart disease, and peripheral vascular disease ( p<0.02). There were no significant differences among risk factors with respect to age, gender, smoking, hypertension, and hypercholesterolemia. Post-neck irradiation patients had a significantly higher prevalence of bilateral disease (p=0.02), and a higher rate of common carotid artery lesions (p<0.002). CONCLUSIONS: neck irradiation should be considered a risk factor for occlusive carotid artery disease. Preoperative angiographic study should be considered, due to frequent involvement of the common carotid artery.

Carotid endarterectomy in awake patients with contralateral carotid artery occlusion.

OBJECTIVES: Patients with severe stenosis of an internal carotid artery with contralateral occlusion (ICO) are at an increased risk for stroke, and therefore surgical treatment is usually recommended. Carotid endarterectomy (CEA) under regional anesthesia enables constant monitoring of neurologic status and selective shunting in cases of clinically evident cerebral ischemia. In this study, we assess the selective use of shunts based solely on changes in neurological status in awake patients with ICO undergoing CEA as well as their complication rates. METHODS: During 1996-1998, we studied intraoperative findings and results of CEA under regional anesthesia with clinical monitoring of neurological status in two groups: (1) patients with stenosis (> 70% by NASCET) and contralateral occlusion (n = 50) and (2) patients with stenosis and no contralateral occlusion (n = 94). RESULTS: Shunt insertion was required in 42% of group 1, and 6% in group 2. All of the patients in group 1 requiring shunts had stump pressures < 50 torr. The average stump pressure of group 1(40 torr) was significantly lower than that of group 2 (75 torr), and was also lower than that of patients with severe contralateral stenosis (35 patients, 76 torr). Perioperative stroke rates were identical in both groups (2.1%). CONCLUSION: Since ICO patients are at a high risk for brain ischemia during ICA clamping, they require shunt insertion frequently. Patients with no contralateral occlusion require shunting at a much lower rate - even in the presence of severe contralateral stenosis. Regional anesthesia allows for early detection of brain ischemia and therefore, the perioperative results in both groups are similar.

Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair.

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.

Autoimmune destruction of islet grafts in the NOD mouse is resistant to 15-deoxyspergualin but sensitive to anti-CD4 antibody.

Islet allografts transplanted into Type I diabetic recipients may be destroyed by allorejection or recurrent autoimmune diabetes. We studied islet transplantation in three murine models in order to determine the relative sensitivity of autoimmunity and alloimmunity to two immunosuppressive agents that may be useful in clinical islet transplantation: 15-deoxyspergualin (DSG) and anti-CD4 antibody (GK 1.5). In the model in which only allorejection occurs (BALB/c islets transplanted into streptozotocin-induced diabetic CBA or streptozotocin-induced diabetic NOD recipients), both DSG and anti-CD4 antibody treatment led to indefinite survival of allogeneic islets (>100 days in both treatments). In the second model in which only recurrent autoimmunity can destroy islet grafts (islets from NOD donors transplanted into spontaneously diabetic NOD recipients), only anti-CD4 treatment caused prolonged graft survival [MST 36.7 +/- 6.8 days vs 9.8 +/- 1.8 days (controls), P < 0.0002]. Treatment with DSG did not cause any increase in graft survival (MST 12.6 +/- 5.4 days, NS). Finally, using a model in which both autoimmunity and allorejection may occur (BALB/c to spontaneously diabetic NOD mice), treatment with anti-CD4 caused marked graft prolongation [42.0 +/- 14.5 days vs 7.2 +/- 0.8 days (control), P < 0.002] while DSG again did not prolong graft survival with respect to untreated recipients (9.8 +/- 3.0, NS). We conclude that recurrent autoimmunity in the NOD mouse involves a CD4+ T cell that is not sensitive to DSG. Anti-CD4 antibody may be useful in human clinical islet transplantation trials because it seems to prevent both allorejection and recurrent autoimmunity.

[Facial injury by fishing harpoons].

The methods of removing penetrating fish-hooks or harpoons are unique and require understanding of the structures of these instruments and their mechanisms, and methods of neutralization. We describe 2 cases of penetrating spear-gun fishing harpoon to the face and the recommended clinical management.

[Total colectomy and mucosal proctectomy with J-pouch anal anastomosis for ulcerative colitis and familial colonic polyposis].

Total colectomy and mucosal proctectomy with ileal pouch-anal anastomosis is the accepted surgical procedure for ulcerative colitis and familial polyposis of the colon. During 1981-1990, 25 patients with ulcerative colitis or familial polyposis underwent this operation in our department. In the majority a J-pouch was performed. In the early years, an 8 cm rectal muscular sleeve was left. In later cases, in accordance with opinions expressed in the medical literature, the length of the sleeve was shortened to about 3 cm. We present the functional results and the early and late complications on follow-up of up to 10 years (mean 3.5 years). Although this operation is not the ideal solution, it is better than the alternatives and is the surgical procedure of choice.