Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery.

BACKGROUND: The efficacy of emergency carotid thromboendarterectomy (CTEA) for acute internal carotid artery (ICA) thrombosis has been questioned. We evaluated the use of CTEA in patients with recent ICA occlusion. METHODS: From August 1989 to December 1999 patients who underwent urgent CTEA for recent ICA thrombosis were retrospectively evaluated. Patient data analyzed included age, sex, comorbid risk factors, diagnostic evaluation, operative procedure, and long-term follow-up with clinical assessment and carotid duplex scan. Neurologic status was evaluated with the Modified Rankin Scale (MRS) before the operation, immediately after the operation, and at 3- to 6-months' follow-up. RESULTS: Twenty-nine patients underwent emergency ipsilateral CTEA for acute ICA thrombosis over the last 10 years. The average age of the patients was 69.9 +/- 1.7 years, and 66% were men. Patient risk factors included diabetes (7 [24%]), hypertension (21 [72%]), coronary artery disease (8 [29%]), and history of tobacco abuse (20 [69%]). Presenting symptoms included cerebrovascular accident (7 [24%]), transient ischemic attack (nonamaurosis) (10 [34%]), crescendo transient ischemic attack (7 [24%]), stroke in evolution (2 [7%]), and amaurosis fugax (3 [10%]). Diagnostic evaluation included computed tomographic scan (29 [100%]), magnetic resonance imaging/magnetic resonance angiography (4 [14%]), duplex scan evaluation of the carotid arteries (23 [79%]), and cerebral angiography (18 [64%]). Antegrade flow in the ICA was successfully established in 24 (83%) of 29 patients and confirmed with intraoperative angiography or duplex sonography. Postoperative morbidity included 2 hematomas (7%), 4 transient cranial nerve deficits (14%), and 1 conversion to hemorrhagic stroke (3.6%), which resulted in the only death (3.6%). MRS scores averaged 3.4 +/- 0.2 preoperatively. Follow-up averaging 74.1 +/- 21 months (range, 3-140 months) was obtained in 27 (93%) patients. Improvement or deterioration was defined as a change in MRS +/- 1. Immediately postoperatively, 14 (48%) patients were improved, 2 (7%) deteriorated, and 13 (45%) had no change. At 3 to 6 months, 20 (74%) of 27 patients were improved, seven (26%) had no change, and none deteriorated. Of patients with successful CTEA, 23 (96%) of 24 had a patent ICA on follow-up duplex scan evaluation, and there was no evidence of recurrent ipsilateral neurologic events at an average of 49 months. CONCLUSION: These data support an aggressive early surgical intervention for acute ICA thrombosis in carefully selected patients. In the previous decade we reported a 46% success rate for establishing antegrade flow in the ICA long term. Data from this decade show a 79% (P =.0114) success rate for establishing antegrade flow long term in all patients undergoing emergency CTEA. New and improved imaging modalities have allowed better patient selection, resulting in improved outcomes.

Laparoscopic assisted colectomies versus open colectomy.

Minimally invasive techniques are having an impact on a variety of surgical procedures. Before their widespread acceptance as the standard of care, studies need to document their efficacy in comparison to open techniques. This study compared 25 laparoscopic-assisted colectomies to 25 open colectomies all performed within the last five years by the same surgeon. In terms of adequacy of resection, laparoscopic assisted colectomy compared favorably with open colectomy in both length of resection (15.7 cm vs 19.3 cm) and average number of nodes (6 vs 10). In addition to lessening patient discomfort, the other advantages were earlier return of bowel function (regular diet postoperative day 2 vs postoperative day 5) and shorter length of stay (4 vs 8 days). Operating costs were significantly greater, but this was offset by the shorter length of stay. This study supports laparoscopic assisted colectomy as a technically safe procedure with substantial patient benefits.

Experience with desmoid tumor in a community teaching hospital.

Desmoid tumors are rare fibroblastic proliferations that occur primarily in the abdomen and extremities. They have an estimated incidence in the United States of two to four per million inhabitants per year. A recent case of desmoid tumor prompted us to review past medical records for previous cases with the same diagnosis. Since 1985, our institution has treated five patients with a total of eight desmoid tumors. Four patients (80%) were female with ages ranging from 24 to 32 years. The other patient was a 22-year-old male with a history of Gardner's syndrome and recurrent desmoid tumors. The majority of our patients were females in the fertile age group, substantiating the hormonal effects believed to play a role in the development of these lesions. In addition, it became obvious that more investigations must be done in appropriate treatment of desmoid tumors and the documentation of these tumors in registries would be of significant benefit.

Stimulation of the active transport of serotonin into mouse platelets by the sulfhydryl oxidizing agent diamide.

The purpose of this study was to determine the effects of diamide, a reversible sulfhydryl oxidizing agent, on the transport of serotonin (5-HT) by mouse platelets. Diamide produced a concentration-dependent (10-200 microM) stimulation of 5-HT transport that was rapid and sustained over 0-10 minutes of incubation. When platelets were incubated with diamide (10-200 microM) in the presence of glucose, the content of reduced glutathione was significantly decreased only at a final concentration of 200 microM, while washed platelets incubated with diamide (10-200 microM), in the absence of glucose, had a significant concentration-dependent decrease in their content of reduced glutathione. Fluoxetine, an inhibitor of the platelet 5-HT transporter, blocked diamide-induced stimulation of 5-HT transport. The kinetics of 5-HT transport showed that diamide caused a marked increase in the maximal rate of transport (Vmax control = 28.4 +/- 1.4 vs. Vmax diamide = 60.9 +/- 4.1 pM/10(8) platelets/4 min) but did not significantly alter the Km values. Ouabain, an inhibitor of platelet Na(+)-K+ ATPase, blocked the stimulation by diamide in a concentration-dependent manner. Dithiothreitol, a disulfide reducing agent, was able to partially reverse the stimulation of platelet 5-HT transport caused by diamide. This study has shown that diamide can stimulate the active transport of 5-HT by mouse platelets and suggests a possible role for free sulfhydryl groups in the regulation of this process.