Regional blood flow occlusion during extensive pelvic procedures for ovarian cancer: a randomized trial.

The objective of this study was to determine the effects of intraoperative aortic occlusion on blood loss and operative time when used during en bloc resection of internal reproductive organs, pelvic peritoneum, and rectosigmoid colon [modified posterior exenteration (MPE)] for primary cytoreduction of ovarian cancer. Patients undergoing MPE, without palpable distal aortic plaque or calcification, were randomized to: (a) complete distal aortic occlusion (

Exercise intolerance and poor performance in western performance and sprint horses.

This article deals with the presenting histories, clinical examinations, and therapies of the causes of poor performance and exercise intolerance in the western performance horse and the sprint racehorse. The veterinarian's ability to diagnose and treat various pathophysiologic conditions that affect these horses is crucial to the major goals of a return to optimal performance and a long athletic career. Although these horses are a significant portion of most veterinary practices, there exists a minimal amount of information on their clinical evaluation and treatment. This article intends to fill this void.

Results of peripheral endovascular procedures in the operating room.

PURPOSE: This study presents the results of closed (percutaneous) and open endovascular procedures performed exclusively by vascular surgeons in the operating room and compares them with results from combined series from the literature, including primarily closed procedures in radiology or cardiology facilities. METHODS: Retrospective review of 607 consecutive peripheral arterial and venous angioplasties, stents, thrombolytic cases, and inferior vena caval filters in 446 patients was analyzed for immediate success rate, complication rate, and 1-year life table patency rate. RESULTS: The incidence of initial technical success was: aorta, 89%; iliac artery, 91%; superficial femoral artery, 90%; popliteal artery, 91%; tibial arteries, 79%; arm arteries and veins, 86%; renal arteries, 100%; IVC filters, 98%; and iliofemoral veins, 100%. The 1-year primary patency rates, including technical failures, were 70.3% in 113 femoropopliteal procedures and 83.7% in 194 iliac arteries. Advantages to the use of the operating room included: (1) simultaneous angioplasty during a bypass operation for abnormalities proximal or distal to the graft, (2) correction of lesions first discovered during thrombectomy, and (3) optimum patient monitoring and sedation in the operating room. CONCLUSIONS: Endovascular procedures performed by vascular surgeons in the operating room lead to results comparable with procedures performed in nonsurgical interventional suites, and the use of the operating room has advantages.

Cost and quality-of-life analyses of surgery for early endometrial cancer: laparotomy versus laparoscopy.

OBJECTIVE: The purpose of this study was to determine whether the cost or quality of life associated with surgical treatment of presumed early-stage endometrial cancer differed on the basis of the surgical approach. STUDY DESIGN: A retrospective analysis was performed on a consecutive series of women with presumed early-stage endometrial cancer treated at the Women's Cancer Center of Northern California. The senior author was the surgeon, cosurgeon, or assistant on all cases. The women comprise two groups with different surgical approaches. The first group of 17 women underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic lymphadenectomy. The second group of 13 women underwent the same surgery by laparoscopy. The two groups were compared with a two-tailed Student t test. Variables analyzed included age, height, weight, Quetelet index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four cost categories: (1) operating room, (2) hospital bed, (3) pharmacy, and (4) anesthesia. A two-tailed Student t test was also used in this analysis. Issues examined regarding quality of life included (1) average hospital stay, (2) complications, and (3) time to return to normal activity. RESULTS: The patient population differed significantly (p < 0.05) with regard to weight and Quetelet index. The laparotomy group required significantly longer hospitalization than the laparoscopy group (6.3 vs 2.4 days, p < 0.001), resulting in higher overall hospital costs ($19,158 vs $13,988, p < 0.05). Similarly, patients undergoing laparotomy took longer to return to normal activity (5.3 weeks vs 2.4 weeks, p < 0.0001). CONCLUSION: Laparoscopic management of endometrial cancer may result in significant cost savings and improved quality of life as demonstrated by shortened hospital stays and an earlier return to normal activity.

Cytoreductive surgery in advanced epithelial cancer of the ovary: the impact of aortic and pelvic lymphadenectomy.

Beginning in July 1988, a planned program was undertaken to assess the role of aortic and pelvic lymphadenectomy in patients with advanced epithelial cancer of the ovary (Stages IIIa-IVa) undergoing cytoreductive surgery. Our intent was to perform a complete aortic and pelvic lymphadenectomy in all patients in whom we could surgically remove all intra- or retroperitoneal disease measuring 1 cm or greater. Accordingly, 56/77 patients (73%) underwent complete aortic and pelvic lymphadenectomy. The remaining 21/77 patients (27%) did not, either because the lymphadenectomy would not have impacted on the patient's cytoreductive status or because intraoperative conditions precluded it. Positive lymph nodes were found in 36/56 patients (64%). Of these, 23/36 (64%) were macroscopically positive, and if left in situ would have affected the patient's cytoreductive status. Thirteen of 36 (36%) were positive microscopically. Reassessment laparotomy was performed in 44/56 (79%) of the patients having had a lymphadenectomy and is correlated to disease status. Median follow-up is 30 months (range 2-64 months). Survival analysis reveals: 10/20 patients (50%) with negative lymph nodes; 6/13 patients (46%) with microscopically positive lymph nodes; 10/23 patients (43%) with macroscopically positive, but surgically removed lymph nodes; and only 2/21 patients (10%) with residual disease measuring at least 1 cm in diameter are alive without evidence of disease. These preliminary findings suggest that the removal of macroscopically negative lymph nodes offers little benefit to the patient with advanced epithelial cancer and minimal residual (less than 1 cm) disease. However, the concept of cytoreductive surgery, whether it be intra- or retroperitoneal, appears to be validated by the fact that the patients undergoing removal of macroscopically positive lymph nodes have approximately the same chance of survival as those with microscopically positive and/or negative lymph nodes.

Strategic planning in non-profits: profit from it.

Non-profit human service organizations, both public and private, face unique challenges and opportunities in the climate of the 1990s as human needs are increasing, funding is decreasing, and threats to organizational well-being are encountered. The purpose of this paper is to describe, advocate for, and illustrate a strategic planning model which facilitates a proactive, energizing, futuristic vision as services are being planned and delivered. Three case examples are used: a large state-run county social services department; a small, private, sectarian agency that provides group home services for the developmentally disabled; and a medium sized federal public health hospital.

Carotid endarterectomy monitored with transcranial Doppler.

Intraoperative transcranial Doppler monitoring of cerebral ischemia during carotid clamping under general anesthesia was done in 238 carotid artery operations, mostly endarterectomy. Depending on the severity of reduction of middle cerebral artery mean velocity, patients were classified as no, mild, or severe ischemia at clamping. With a carotid shunt, velocity was always in the "no ischemia" category during shunting. For patients with no ischemia, stroke was significantly lower without a shunt (2/175 no shunt versus 2/12 shunt). For mild ischemia, shunting did not affect the stroke rate (1/20 no shunt versus 0/9 shunt). For severe ischemia, strokes were less frequent with a shunt (4/9 no shunt versus 0/13 shunt). Intraoperative electroencephalogram predicted most, but not all severely ischemic cases. Carotid back pressure correlated with Doppler velocity, but transcranial Doppler was more helpful. Transcranial Doppler is a new and valuable technique in carotid surgery.

Sequential 2D inflow venography: initial clinical observations.

Sequential 2D inflow NMR (SDI) venography was employed to define venous anatomy and pathology in five healthy subjects and five patients, mean age 48 +/- 7 years, with documented deep vein thrombosis. SDI images were graded independently by two observers on a scale of 1,2 nondiagnostic and 3,4 diagnostic categories. All iliac and femoropopliteal SDI venograms were diagnostic. In contrast, only one out of nine calf SDI venograms was diagnostic. SDI is a promising new method to assess the proximal peripheral venous system. Improved imaging strategy is needed to produce flow images of the calf veins.

Peripheral arterial occlusive disease: prospective comparison of MR angiography and color duplex US with conventional angiography.

Conventional angiography, two-dimensional inflow magnetic resonance (MR) angiography, and color duplex ultrasound (US) were performed on 12 patients in a blinded, prospective study. The ability to grade arterial lesions and plan revascularization interventions were compared. Arterial lesions were categorized as nonsignificant (0%-49% diameter reduction) or significant (50%-100% diameter reduction). Determination of nonsignificant and significant lesions with MR angiography was in agreement with that at conventional angiography in 100 of 140 lesions (71%). Agreement between results of conventional angiography and color duplex US occurred with 114 of 123 infrainguinal lesions (93%). Twenty-one vascular interventions were planned by using conventional angiography; there was agreement with color duplex US in 11 cases and MR angiography in five. Color duplex US performed well in the assessment of infrainguinal disease but was limited in the evaluation of iliac segments because of nonvisualization. The iliac region was visualized in more patients with MR angiography than with color duplex US, but image quality with MR angiography was inconsistent. Strategies to improve MR angiography of the peripheral vasculature merit further study.

Urokinase infusion: feasibility of monitoring for complications in a non-intensive care setting.

In an effort to more effectively use critical care facilities and to reduce costs, during a 2 1/2-year period, the condition of 32 patients who received 37 local intraarterial urokinase (UK) infusions was monitored in a non-intensive care unit (ICU) setting. Techniques of infusion, mean total dose of lytic agent used (1.7 million IU), and mean duration of infusion (22 hours) were similar to those reported previously in series of patients monitored in the ICU. Complete lysis (no angiographically detectable residual clot within the treated segment) was achieved in 28 of 37 infusions (76%). Major complications occurred during two infusions (5.4%). In 33 of the 37 cases, systemic heparin was administered during UK infusion. No cases of pericatheter thrombosis were encountered. At the authors' institution, patients can be safely monitored during local UK infusion in a non-ICU setting without compromising effectiveness of therapy. This approach has resulted in enhanced cost-effectiveness of thrombolytic therapy and more effective use of critical care facilities.

Transcatheter thrombosis of a leaking saccular aneurysm of the main renal artery with preservation of renal blood flow.

Percutaneous techniques have been used in the treatment of aneurysms and pseudoaneurysms in a variety of anatomic locations, including the kidney. An elderly patient with a leaking saccular aneurysm of the main left renal artery was considered a poor operative risk. We were able to embolize and thrombose the aneurysm selectively by using a combination of coil springs, guidewire, thrombin, and bucrylate without occluding the renal artery.

Chronic arteriovenous fistulas masquerading as arteriovenous malformations: diagnostic considerations and therapeutic implications.

Arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs) may be difficult to differentiate angiographically, and this differentiation has important therapeutic implications. In five cases of chronic AVF, four originally misdiagnosed as AVMs, superselective angiography enabled the correct diagnosis. In two plantar arch fistulas, the technique was further enhanced by manual compression of arterial inflow to decrease the rate of blood flow through the fistula. All five AVFs were successfully occluded. The authors conclude that AVFs and AVMs can be distinguished by means of the appropriate angiographic techniques.

Preoperative evaluation of abdominal aortic aneurysm by MR imaging with aortography correlation.

Sonography, computed tomography, and most recently, magnetic resonance imaging (MRI) have been advocated as noninvasive imaging methods for the preoperative evaluation of patients with abdominal aortic aneurysms (AAA). We prospectively assessed the value of MRI in this clinical setting. Twenty of 23 patients with AAA referred for evaluation with biplane aortography underwent MRI within 3 days of aortography. MR and angiographic studies were interpreted prospectively and independently and then the results were compared with each other and with the operative findings. All angiographically demonstrated infrarenal and suprarenal aneurysms except one were documented as such by MRI. The distal extent of the aneurysm on MRI agreed with that on angiography in all but 3 cases. MRI is an accurate method for assessing the size and extent of AAA and its relationship to the main renal artery origins. MRI is not accurate in detecting vascular obstructions or accessory renal arteries. Therefore, the usefulness of MRI and the need for aortography in preoperative assessment of AAA depends upon the specific information the surgeon requires prior to aneurysmectomy in a given patient.

31P nuclear magnetic resonance spectroscopy: noninvasive biochemical analysis of the ischemic extremity.

The biochemical effects of peripheral vascular disease on skeletal muscle have not been characterized precisely because of the lack of satisfactory noninvasive analytic methods. 31P nuclear magnetic resonance (NMR) spectroscopy was used to measure the high-energy phosphate compounds, phosphocreatine (PCr) and adenosine triphosphate, as well as metabolic byproducts, such as inorganic phosphates (Pi) and phosphate monoesters in calf muscles of 214 limbs with peripheral vascular disease. Intracellular pH was also measured. The NMR index (Pi[PCr + Pi]) was used to quantitate the impairment of oxidative phosphorylation as a result of ischemia. Studies done at rest documented the impairment of oxidative metabolism only in limbs with severe ischemia (ankle-brachial pressure index (API) less than 0.4). Exercise resulted in a significant elevation of the NMR index in all limbs and the rate of return of this value toward normal following exercise was prolonged even in limbs with moderate ischemia (0.4 less than or equal to API less than or equal to 0.9). Correlation of 31P NMR parameters with arteriograms showed that infrapopliteal occlusions resulted in prolonged recovery times only when the superficial femoral artery was occluded and emphasized the metabolic consequences of multisegmental disease. Accumulation of glycolytic pathway intermediates correlated with the decrease in muscle cell pH observed with exercise. Despite immediate improvement in symptoms and hemodynamic parameters following revascularization, return to normal biochemical function occurs over a prolonged period of time. This study demonstrates that 31P NMR spectroscopy can successfully measure noninvasively the important phosphorus-containing compounds involved in the bioenergetics of skeletal muscle in vivo rapidly enough to permit real-time determination during exercise and recovery.

Problems in the evaluation of day hospitals.

The day hospital has been utilized as a means both to maintain and improve remission status of previously hospitalized patients and, more recently, as an alternative to inpatient treatment. Although uniformly encouraging, the reports of treatment success are ambiguous and complicated by the recency and diversity of the programs. Proposals to reduce confusion in the areas of identification of population, definition of treatment, treatment effects, and assessment procedures are discussed. The concept of therapeutic community with its emphasis on socialization processes makes symptom reduction alone an insufficient criterion of treatment success. More comprehensive measures of the permanency of remission and quality of social adjustment are advocated.