The economics of kidney transplantation versus hemodialysis.

Using 1998 data for 8 transplantation centers located in New York City, this study found that kidney transplantation was a more cost-effective treatment than hemodialysis for the Medicare program. The initially higher costs of transplantation were fully recouped by Medicare 2 years and 10 months after surgery. For persons who are eligible for Medicare solely due to their end-stage renal disease status, transplantation would generate average monthly savings of $3800 over dialysis for the 2 years following the break-even point. For those eligible for reasons other than end-stage renal disease, for example, the aged, the average savings would be $2400. The savings difference arises because Medicare coverage for immunosuppressants for the former group ends 36 months after transplantation.

Activating SRC mutation in a subset of advanced human colon cancers.

The discovery of Rous sarcoma virus (RSV) led to the identification of cellular Src (c-Src), a non-receptor tyrosine kinase, which has since been implicated in the development of numerous human cancers. c-Src has been found to be highly activated in colon cancers, particularly in those metastatic to the liver. Studies of the mechanism of c-Src regulation have suggested that c-Src kinase activity is downregulated by phosphorylation of a critical carboxy-terminal tyrosine (Tyr 530 in human c-Src, equivalent to Tyr 527 in chicken Src) and have implied the existence of activating mutations in this C-terminal regulatory region. We report here the identification of a truncating mutation in SRC at codon 531 in 12% of cases of advanced human colon cancer tested and demonstrate that the mutation is activating, transforming, tumorigenic and promotes metastasis. These results provide, for the first time, genetic evidence that activating SRC mutations may have a role in the malignant progression of human colon cancer.

Bricker-Johnston sigmoid colon graft for repair of postradiation rectovaginal fistula and stricture performed with mechanical sutures.

In patients with postradiation rectovaginal fistula who are otherwise healthy and cured of their cancer, repair of the fistula with return to a normal lifestyle is indicated if this repair can be achieved with minimal morbidity, no mortality, and a good prospect for a functionally satisfactory result. The Bricker-Johnston vascular sigmoid colon graft fulfills these conditions by respecting the tissular equilibrium of the radiated rectum and supplying the area with a sound, vascular sigmoid pedicle graft. While this improves tissue vitality locally, it restores rectal function to a near-normal preradiation level and preserves the previously intact sphincter muscles. The concept of this repair is very sound, and its implementation is greatly facilitated technically by the use of mechanical suture instruments. In this presentation, we describe and show the use of stapling instruments in achieving a three-stage repair of a rectovaginal fistula with Bricker and Johnston's technique.

Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?

The patency of anastomoses joining the pancreas to either a Roux-Y loop of jejunum or the stomach was evaluated in 26 dogs. At a preliminary operation, the head and uncinate process of the pancreas were resected while carefully preserving the duodenal blood supply. The remaining body and tail of the pancreas were totally obstructed. After obstruction for a mean of 22 (range: 6 to 42) days, one of three anastomoses was performed: (1) inversion pancreatogastrostomy with two layers of sutures; (2) a similar inversion pancreatojejunostomy to the side of a Roux-Y jejunal loop; or (3) pancreatojejunostomy in which the major duct was joined to the jejunal mucosa with interrupted sutures. Six animals were kept for controls. Anastomotic patency was assessed after 8 to 12 weeks by pancreatography, with minimal pressures to achieve anastomotic flow recorded. Weight trends were consistent with anastomotic status. The eight dogs with duct-to-mucosa sutures clearly achieved superior anastomotic patency.

Acquired immune deficiency syndrome--related lymphadenopathies presenting in the salivary gland lymph nodes.

Homosexual males at risk for acquired immune deficiency syndrome (AIDS) frequently present with peripheral lymphadenopathies that precede the opportunistic infections and neoplasias of this disease. Two homosexual males had enlarged salivary glands due to lymphadenopathies initially affecting intraparotid and perisubmaxillary gland lymph nodes. Both the hyperplastic and the atrophic histologic patterns of AIDS-related lymphadenopathies were observed in the lymph nodes. Subsequently, the two patients developed lymphoma and opportunistic infections, respectively. The AIDS-related lymphadenopathy developing in salivary gland lymph nodes is an entity that should be considered in the differential diagnosis of salivary gland tumors.

Embolization and vessel wall perforation in argon laser recanalization.

The primary concerns in the development of a laser catheter for intravascular use are the potential hazards of vessel wall perforation and distal embolization. We present evidence, using technetium 99-labeled thrombi in two rabbit aortas and one human cadaver coronary artery, that distal embolization does not occur after argon laser recanalization. Also, no vessel wall perforation was observed during recanalization of 15 thrombosed rabbit aortas and 1 inferior vena cava, used because of their extremely thin walls. Laser recanalization of three peripheral arteries with atherosclerotic plaque obstruction, in amputated human legs, showed no evidence of vessel wall perforation. The incidence of vessel wall perforation can be minimized by preferential use of the argon laser, strict maintainance of a coaxial relationship between the laser catheter and the vessel, and exercising care during the actual lasing process. Distal embolization does not appear to be an important consideration.

Carotid endarterectomy under regional (conductive) anesthesia.

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.

Scanning electron microscopic and X-ray energy spectrographic analysis of the inner surface of human atherosclerotic carotid plaques.

Forty specimens of carotid plaque from 30 patients who had suffered cerebrovascular accidents and 10 asymptomatic control patients were examined by light and scanning electron microscopy (SEM). The SEM revealed the finely detailed surface characteristics of the plaque including cell deposits, endothelial damage, and exposed subendothelium. X-ray energy spectrography scans revealed that 7 specimens had calcium deposits. Presurgical treatment with dipyridamole and aspirin inhibited or substantially reduced thrombus formation.

Traumatic false aneurysm and arteriovenous fistula of the profunda femoris artery: surgical management and review of the literature.

Successful surgical repair of a false aneurysm and an arteriovenous fistula of the deep femoral vessels has been achieved 8 years after the initial injury. A review of the literature disclosed 20 other similar cases from military and civilian practice; ligation of the artery was utilized 14 times with generally poor results when long-term follow-up was available. Most vascular wounds were due to fragments, as was the case in our patient, and involvement of the deep femoral vessels was recognized more frequently in delayed complications than in acute injuries. Ten cases of false aneurysm of the deep femoral artery without arteriovenous fistula have been found to be associated with fracture or orthopedic precedures. Mild intravascular hemolysis was present in our patient and was corrected promptly after operation. Only one other such case was found in the literature. The profunda femoris artery, which was dilated and elongated, resumed a normal caliber in its proximal segment on arteriography performed one year after the operation. Preservation of the deep femoral artery may be of significance for a good clinical result in the treatment of arteriovenous fistulas and is of special interest in view of its potential importance in reconstructive procedures for atherosclerotic occlusive disease. Early diagnosis and treatment of arteriovenous fistulas for the prevention of hemodynamic, systemic, and structural changes in the vessel wall are advocated.

Dilation of intraheptic bile ducts in choledochal cyst: case report with follow-up review of the literature.

Fifty-five cases of intrahepatic dilation of the bile ducts associated with choledochal cyst have been found in the literature, mostly reported over the past five years. Obstructive jaundice is often not present at an early stage in this group of patients, but dissociation of the serum bilirubin and alkaline phosphatase levels could be an early manifestation of this condition. Recent advances in diagnosis and new concepts of the cause and surgical management are reviewed. A case is reported where choledochocystojejunostomy was performed using automatic stapling instruments. Disappearance of symptoms, normalization of liver functions, and reduction in size of the cysts were observed during the two-year postoperative period.