Long-term results of aortoiliac angioplasty.

Results of percutaneous transluminal angioplasty of 141 iliac arteries in 112 patients are reported, with a follow-up period extending to 36 months. Initial technical success was achieved in 95.7%, 1-year patency in 91.3%, and accumulated 2- and 3-year patency in 89%. The role of outflow disease and ankle:arm index measurement and the importance of eliminating or significantly reducing the intra-arterial pressure gradients are discussed.

Computed tomography for noninvasive imaging of the iliac arteries.

Angiography has been the standard means of preoperative evaluation of the arterial system. Although the noninvasive modalities (sonography, nuclide "flow" studies, and computed tomography) are also frequently used in preoperative arterial evaluation, they are generally followed by arteriography. We propose that in some instances computed tomography may be the sole means of preoperative evaluation and that sufficient information may be obtained with a high-dose contrast technic to plan the surgical intervention.

Hemodynamic measurements in the evaluation and follow-up of transluminal angioplasty of the iliac and femoral arteries.

Intra-arterial pressure measurements and ankle pressure indices (determined by Doppler ultrasound) were used to evaluate the hemodynamic response after transluminal angioplasty of the iliac and superficial femoral arteries. Intra-arterial pressure was the best determinant of the end point and technical success of the procedure, while improvement in the ankle pressure index was a good predictor of clinical success. Patients with clinical improvement had a significant increase in ankle pressure regardless of the status of peripheral runoff, while those without improvement did not; they demonstrated impaired distal runoff and required further surgical intervention. Peripheral Doppler pressures also provided a convenient noninvasive method of long-term follow-up.

Cecal volvulus: analysis of 50 patients with long-term follow-up.

Fifty patients operated upon for cecal volvulus were analyzed. The ages ranged from 14 to 88 years and averaged 53 years. Eighteen were males and 32 were females. The presentation was acute, requiring urgent surgery in 41 patients; nine patients presented with chronic symptoms and were operated upon electively. In 14 patients (28%) the cecal volvulus was temporally related to another acute medical problem. The diagnosis was made radiographically in 22 patients (44%) and at operation in 28 patients (56%). Cecal volvulus was correctly diagnosed by barium enema in 20 of the 29 patients (69%) undergoing the study. Eighteen of the patients were treated by cecopexy, 14 by resection, 12 by detorsion alone, and six by tube cecostomy. Mortality was 12% (6/50) and was associated with gangrenous cecum (33%, 3/9), other systemic diseases (24%, 5/21), age over 50 years (19%, 6/31), and acute presentation (15%, 6/41). In the absence of gangrenous cecum, enterotomy was associated with subsequent wound infection in 23% (7/30), as compared to none (0/11) when enterotomy was not performed. There were no recurrences of cecal volvulus in the entire series during follow-up which extended to 17 years, averaged 5.7 years, and was complete in 96% (42/44) of survivors. When gangrenous cecum is present, resection is the treatment of choice. In the absence of gangrenous bowel, cecopexy is recommended because of a low mortality (0/18), low morbidity (3/18), low recurrence rate (0/18) and absence of need to open the unprepped bowel.

Complications associated with the Baker tube jejunostomy.

1. The jejunostomy route for the intraoperative insertion of a Baker tube carries significant and probably excessive risks. 2. Such risks can be greatly reduced by introducing the Baker tube through a cecostomy or a gastrostomy. When possible, introduction through an ileal stoma or through the rectum when an ileoproctostomy has been performed, is probably even better. 3. For most patients, the cecostomy approach, if performed with great care, will prove to be safe, convenient, and effective.

Ex vivo surgical dissection. Autotransplantation in renal disease.

Ex vivo dissection, reconstruction, and autotransplantation have been performed in a total of five patients. Two had intrarenal aneurysms, and in three, this treatment was deemed best suitable. One patient has sustained normal renal function with as little as one third of his remaining kidney. There are techniques now available to provide a means of ex vivo preservation of organs adequate to sustain renal viability during bench surgery.

The evaluation of small-vessel flow; a study of dynamic non-invasive techniques.

A series of thirty-three patients with a variety of vascular problems in the hands were studied by one or more of four dynamic non-invasive techniques. Such non-invasive techniques can be used for diagnostic studies as well as operative and postoperative monitoring. The techniques, which are safe, reliable, and easily interpreted at the bedside, offer methods by which monitoring of flow can be done repeatedly and provide reliable and painless means to identify cases of thrombosis in which early operation may be vital to save a hand or finger.

Conversion of hydrocortisone to estrogen in carcinoma of the breast after oophorectomy and adrenalectomy.

PIP: This case report concerns a 52-year-old woman who underwent radical mastectomy. Microscopic study revealed the tumor to be infiltrating ductal carcinoma. Axillary lymph nodes contained metastatic tumor. About a year later tumor recurrence was demonstrated in the lumbar vertebrae. The disease progressed under local irradiation. After another year bilateral oophorectomy and adrenalectomy were performed. The patient died about 17 months after the last surgery with widespread metastatic disease. This study was conducted with the patient on hydrocortisone replacement therapy beginning about 1 month after removal of the ovaries and adrenal glands. 5 microcuries of 4-14C-hydrocortisone were administered and 3 successive 24-hour urine specimens were collected and kept frozen. The steroid conjugates were extracted from the urine, hydrolyzed, and the free steroids removed by solvent extraction. The estrogen fraction from the urine was separated by sodium hydroxide extraction and purified by counter-current distribution, then analyzed. It was found that the administered 4-14C-hydrocortisone was converted to 11 beta-hydroxyestradiol which possesses estrogenic activity. The identified conversion product represented 5% of the radioactivity of all the extracts and .7% of the total administered radioactivity. Other metabolic products of hydrocortisone isolated included cortol, urocortisol, and cortolone. The site of conversion and the mechanisms involved require further study. Such conversion to estrogens of circulating hormone used in adrenal replacement therapy could affect the mammary malignancies of these patients.^ieng