The problem of recurrent stenosis following carotid endarterectomy.

From 1977 to 1985, 306 consecutive patients underwent carotid endarterectomy by a single surgeon. The post-operative stroke and death rates were 1.3% and 2.6%. Of the 184 patients with follow-up duplex scanning, 24 (13%) had a recurrent stenosis of 50% or greater. Of 15 possible risk factors studied to assess a possible relationship with recurrent stenosis, four were definitely associated and a fifth probably implicated. The four definitely associated risk factors for recurrent stenosis were an age of 70 years or older (p = 0.0025), female gender (p = 0.0001), ulcerated lesions (p = 0.013), and asymptomatic lesions (p = 0.041). The fifth risk factor that may play a role (though not reaching statistical significance) was combined carotid endarterectomy and myocardial revascularization (p = 0.066). In these patients, we recommend using vein patch angioplasty to reduce the recurrence rate.

Adrenocortical carcinoma.

Ten patients, seven women and three men, ages 47 to 76 years (mean 58.6 years), treated for adrenal cortical carcinoma between 1971 and 1989, were reviewed. Three (30%) of the tumors were nonfunctioning. The remaining seven (70%) were functioning, six of them occurring in women. Common presenting features were hormonal excess, distant metastases, weight loss, and abdominal pain. The primary tumor was resected in all patients, only two of whom had disease confined to the adrenal gland. Tumor diameter ranged from 9 to 21 cm (mean 15.7 cm). Inferior vena caval or right atrial extension of tumor thrombus was present in two patients. Excluding two deaths from postoperative complications, seven patients died of their disease after a mean survival of 25 months (range 2 to 84 months). Of seven patients who received o,p'-DDD treatment for metastatic or recurrent tumor, three (43%) had an objective response. In two patients, tumor regression was complete and was associated with prolonged survival. The first patient underwent resection of recurrent tumor on two occasions in addition to receiving o,p'-DDD and survived 84 months. The second patient had complete regression of pulmonary and liver metastases confirmed at laparotomy and thoracotomy and remains free of disease at 78 months. None of the five patients treated with various combinations of cytotoxic chemotherapy had an observable response, and no measurable effect was seen in a single patient following abdominal radiotherapy. It is concluded that resection for local recurrence may prolong survival and that significant and lasting tumor regression is possible with o,p'-DDD administration. Beneficial results from cytotoxic agents, however, could not be demonstrated.

Prevention of pancreatic fistula by modified pancreaticojejunal anastomosis.

A major cause of morbidity after pancreatoduodenectomy is leakage from the pancreaticojejunal anastomosis. To prevent this complication, we have employed mucosal stripping from the proximal jejunum prior to end-to-end anastomosis in 19 patients with good results.

Combined carotid endarterectomy and myocardial revascularization.

From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.

Enhanced streptokinase-induced thrombolysis using heparin in a rabbit model.

Heparin potentiation of clot lysis by streptokinase was studied in a rabbit model. Clot was initiated in the rabbit aorta with stasis and thrombin and allowed to naturally propagate proximally until stasis met flow. The clot was allowed to age for 1 h before assigning treatment. Fifteen rabbits (group I) were given streptokinase (10,000 IU/h) and 11 rabbits (group II) were given streptokinase (10,000 IU/h) plus sodium-heparin (120 IU/h). Thrombolytic therapy was continued for 5 h. Clot lysis averaged 30% in group I and 70% in group II. Ten of 11 rabbits in group II had more than 50% clot lysis, whereas only 4 of 15 in group I had this degree of lysis. One group II rabbit and four group I rabbits died prematurely; each was noted to have clot propagation at the time of death. While a trend for amelioration of hypofibrinogenemia was observed in the group receiving both streptokinase and heparin, this difference was not statistically significant. We conclude, in the animal model, that thrombolysis by a combination of heparin and streptokinase is more effective than streptokinase alone. Systemic effects are apparently no worse with the combination.

Primary hepatic leiomyosarcoma.

We describe a case of primary hepatic leiomyosarcoma and review the previous reports on this entity. We stress the histologic differentiation of this tumor from similar neoplasms and point out the need for aggressive resection in operable cases.

Early breast cancer detected by mammography. Marshfield Clinic experience.

Use of mammography in asymptomatic women does discover breast cancer at an earlier point in development, as measured by size, invasiveness, and nodal involvement. The integration of mammography into routine periodic evaluation of asymptomatic women over 35 years of age should diminish the threat of breast cancer.

Benign cecal ulcers. Spectrum of disease and selective management.

Benign ulceration of the cecum is an uncommon lesion. Most cases are diagnosed intraoperatively and most authors have advocated right hemicolectomy due to the difficulty in differentiating benign from malignant lesions. Recently colonoscopic diagnosis and conservative treatment have been reported. We describe six cases of cecal ulcer ranging from asymptomatic lesions diagnosed at colonoscopy and healing with conservative management to perforated ulcers with intra-abdominal abscesses requiring right hemicolectomy. A selective approach to patient management is advocated, including stapler wedge cecectomy with frozen section diagnosis to avoid extensive bowel resection and retain the ileocecal valve.

Local intra-arterial streptokinase therapy for acute peripheral arterial occlusions. Should thrombolytic therapy replace embolectomy?

Locally administered low-dose streptokinase was used in 13 patients with acute arterial occlusions. Systemic fibrinolytic effects were noted in each of 11 patients in whom some effective thrombolysis was demonstrated. In the two patients with no angiographically demonstrable thrombolysis, a systemic lytic effect was absent. Bleeding complications were frequent (31%). Three patients required amputations and one patient died. The systemic lytic effects of streptokinase appear to be necessary for complete clot lysis. Locally administered streptokinase appears to have no significant benefit compared to high-dose systemic administration. Occlusions accessible to balloon embolectomy should probably be treated surgically, reserving fibrinolytic therapy for inaccessible lesions. More research is needed to clarify the specific indications, as well as to determine optimal methods of administration and dosage.

Axillo-axillary bypass for subclavian steal syndrome.

Since 1972, 14 patients with subclavian steal and four with primary vascular insufficiency of the arm have been operated on using the axillo-axillary bypass graft. Two grafts have been replaced, one after nine months for threatened erosion, and the other after three years for thrombosis due to disease progression in the donor artery. The new grafts were patent at three and at 2 1/2 years. One graft was occluded at six months and was not replaced. All other patients under observation in 1978 have grafts patent at one month to 6 1/2 years (average 2.2 years). Life table analysis shows the probability of graft patency (20 grafts) is 76% at three years. In the subclavian steal group steal on the left side predominated 2:1. Cerebral symptoms predominated with arm symptoms less often seen, although six patients had both. Associated vascular disease and hypertension were common. There was no mortality and few complications. Axillo-axillary bypass grafting is considered the operation of choice for patients with subclavian steal syndrome.