Initial report of a case of carcinosarcoma of the supraglottis.

Minor salivary gland carcinosarcoma is a rare malignancy with an ominous prognosis. This report recounts a single case of supraglottic minor salivary gland carcinosarcoma that was treated aggressively. We discuss the peculiarities of the histology, with special mention of the distinction that must be made between mucosal-origin and salivary-gland-origin carcinosarcoma. Carcinosarcomas are aggressive regardless of their origin, but differentiating their origin is important because the prognosis is worse for those that arise in salivary glands than for those that originate in the surface epithelium. This report adds to the literature a new case of minor salivary-gland-origin carcinosarcoma involving the upper airway. It is the first case we could identify in which the supraglottis was involved.

Use of intravascular ultrasound in evaluating repeated balloon rupture during coronary stenting.

Balloon rupture during coronary angioplasty is a well-recognized complication of PTCA. Coronary angiography commonly fails to elicit the cause of balloon perforation. We present a case with multiple balloon rupture during additional high-pressure inflations of a Palmaz-Schatz stent where intravascular ultrasound was useful in revealing a calcified lesion protruding through the struts of the stent.

Incidentally detected renal cell carcinoma: pathological features, survival trends and implications for treatment.

OBJECTIVES: To compare treatment outcomes in symptomatic and incidental renal cell carcinoma (RCC) with specific interest in the role of radical nephrectomy. PATIENTS AND METHODS: The records of 189 patients with a clinical diagnosis of RCC were reviewed. The mode of presentation, tumour size, grade and stage at presentation were correlated with final outcome, as measured by the disease-free and overall survival of the patients. RESULTS: The rate of incidental detection was 15%; incidental tumours were of a lower stage and patients with incidentally detected tumours had a significantly longer disease-free and overall survival than had those with symptomatic tumours (P < 0.05). CONCLUSIONS: The increased detection of incidental tumours should further improve survival in RCC. We continue to advocate radical nephrectomy for incidentally detected tumours, as it offers the best outcome and simplifies the follow-up.

Applying the results of large clinical trials in the management of acute myocardial infarction.

Mortality from acute myocardial infarction has declined in recent years, largely due to the widespread application of new pharmacologic and mechanical interventions that have been tested in large, prospective, randomized clinical trials. For practicing generalists, we review the key data from such trials that have shaped the current management of patients with acute myocardial infarction. We discuss the roles of thrombolytic therapy, coronary angioplasty, nitrates, beta- and calcium channel blockers, angiotensin-converting-enzyme inhibitors, magnesium, and antiarrhythmic and antithrombotic agents. In addition, we highlight critical unanswered questions in the management of this disorder.

Intraoperative thrombolytic therapy as a treatment of small vessel thrombosis: an experimental study.

OBJECTIVE: This paper studies the effect of three doses of Streptokinase infused intra-operatively into an animal model of small vessel thrombosis. EXPERIMENTAL DESIGN: This is a controlled trial of intraoperative infusion of thrombolytic agent into a thrombosed arterial segment compared to no infusion into the contralateral limb. EXPERIMENTAL SUBJECTS: 19 New Zealand White rabbits were stratified into 3 groups. INTERVENTIONS: Thrombosis was achieved by infusing a mixture of topical thrombin and autologous blood into individual iliac arteries of the New Zealand white rabbit. A randomly selected hind limb had an infusion of one of three doses of streptokinase (A = 2,500u; B = 5,000u; C = 10,000u) in saline over 20 minute period. Preinfusion and post infusion angiography was performed. MEASUREMENTS: Angiograms were ranked by a radiologist blinded to the side of infusion and clotting parameters were assessed. RESULTS: All limbs at all doses of streptokinase infusion (SK) showed significant clot lysis when compared to the non-infused limb(C). The percentage of improved segments is as follows: iliac: SK = 100%, C = 79%; femoral SK = 79%, C = 32%; tibial SK = 52%, C = 5%. Although there was an elevation in clotting time and a reduction in fibrinogen, levels remained within normal limits. CONCLUSIONS: Streptokinase infused directly into thrombus in arteries even in low doses significantly enhances thrombolysis of vessels which are too small to be cleared by mechanical means. No significant systemic complications were encountered.

An unusual complication of appendectomy.

Intraabdominal abscess formation is a well-recognized complication of perforated appendicitis. Extraabdominal complications, however, are rare. The authors present the case of an 8-year-old boy who had an acute painful right-sided scrotal mass 2 days after an operation for perforated appendicitis. During exploration, an abscess within a previously undiagnosed patent processus vaginalis was found and successfully managed by drainage. This case demonstrates that a persistent patent processus vaginalis may predispose to scrotal pathology secondary to intraabdominal sepsis and represents a unique complication of perforated appendicitis.

Management of ductal carcinoma in situ of the breast.

Ductal carcinoma in situ (DCIS) of the breast is thought to represent a number of biologically different processes, ranging in clinical presentation from a palpable mass to a mammographically-detected abnormality. The optimal management of DCIS is controversial. We reviewed our experience in 40 patients with DCIS, 26 with gross disease and 14 with microscopic disease. Treatment was by total mastectomy (n = 21), complete local excision (n = 16), and local excision followed by radiotherapy (n = 3). At a mean follow-up of 34 months (range 3-120), 35 patients (88%) are disease-free. All patients treated by mastectomy remained disease-free, but 3 patients (16%) treated by breast conservation surgery have had local recurrences. All local recurrences were in the same area as the original lesion, two manifesting the same subtype of DCIS and one an invasive carcinoma. The margins of excision were close to the resection margin in all cases that recurred. All four recurrences were successfully managed by mastectomy. Mastectomy is still the most secure and reliable management for DCIS, but pathologically verified wide local excision may be appropriate.

Rehabilitation potential of elderly patients with major amputations.

This study was undertaken to determine the rehabilitation potential of patients undergoing amputation for vascular disease. A total of 101 patients were studied with a mean age of 69 +/- 14 years, 26 of whom were over age 80. Operative indications were gangrene or ulceration in 80% with rest pain in 20%. Eighteen patients were bilateral amputees. Fifty per cent of the patient population had previous vascular operations. The operative mortality was 13% and was not affected by the age of the patients or the presence of diabetes. Most operative deaths were due to cardiac or septic respiratory complications. Twenty-four of 88 surviving patients were not considered candidates for rehabilitation and the major determining factor was the occurrence of a remote or perioperative stroke. None of these 24 patients was discharged from institutional care. Sixty-four patients were considered rehabilitation candidates with equal distribution in all age groups. Ninety-five per cent of these patients were discharged home with 80% of those patients over 80 being discharged. Eighty-seven per cent of the elderly rehabilitation candidates were fitted with prostheses which compares favourably to other age groups. Seventy-three per cent of the elderly reached their rehabilitation goals (most frequently ambulation with the aid of a walker) which is only slightly less than the younger amputation group. From this study we conclude that amputations which are done for ease of nursing care and patient comfort in debilitated patients have a high mortality rate and rehabilitation goals are unlikely to be met. We have demonstrated high success rates with rehabilitation including patients over age 80. The majority of these patients may be discharged home after a period of aggressive rehabilitation.

Aneurysms of the inferior vena cava.

Aneurysms of the inferior vena cava are very rare. We describe a case of a saccular aneurysm of the inferior vena cava that thrombosed after vigorous exercise. This presented as deep venous thrombosis associated with a retroperitoneal mass. Laparotomy with biopsy confirmed the benign nature of this lesion, and symptoms gradually resolved. It is hypothesized that the increased intraabdominal pressure during exercise led to the thrombosis of what is presumed to be a congenital aneurysm of the inferior vena cava.

Ultrasound with graded compression in the evaluation of acute appendicitis.

Acute appendicitis is the most common diagnosis made (in the Western world) in patients with an "acute abdomen." Although the mortality rate has been vastly reduced, the diagnostic inaccuracy rate of 15% to 20% has remained unchanged in the past 100 years. In this article, the authors report the ultrasonographic findings in 80 patients examined using a small linear-array transducer, which enables direct visualization of the inflamed appendix. During 22 months, 80 patients (28 males and 52 females; age range, 3 to 81 years; mean, 32.3 years) with equivocal clinical signs and symptoms of acute appendicitis were examined sonographically. Of the 29 patients whose appendicitis was verified at surgery, ultrasonography was positive in 26, with an overall sensitivity of 90%. Of the 51 patients who did not have appendicitis, ultrasonography was negative in all, with a specificity of 100%. The authors concur with reports in the literature that ultrasonography is helpful in diagnosing appendicitis.

Confirmation of infection of an aortic graft.

The presentation of an aortic graft infection may be dramatic in the form of an aortoenteric fistula or drainage of pus from the wound. Some cases may be more subtle with presentations of fever of unknown origin. Prior to embarking upon major operative repair for these suspected lesions, it is essential to confirm the presence of infection. Under CT control, a fine needle may be inserted into the peri-graft space, and cultures may be obtained. Further confirmation may be achieved by an injection of a small amount of contrast material which will demonstrate lack of incorporation of the graft into surrounding tissues. Prior confirmation of graft infection permits a staged procedure to repair this technique is illustrated with a case history.

Extra-anatomic bypass grafting: a rational approach.

To determine predictors of long-term patency in extra-anatomic bypass grafting, the authors studied retrospectively the charts of 134 patients who underwent bypass grafting (axillofemoral in 17, axillobifemoral in 32 and femorofemoral in 85). Of the study group, 64% were men; the mean age was 65 +/- 12 years (+/- SEM). The indications for grafting were limb salvage (102), claudication (27) and replacement of septic grafts (5), and for using the extra-anatomic route included high risk (83), sepsis (8) and unilateral disease (34). Operative mortality was 6% and the early graft occlusion rate 7.4%. The late death rate was 44%. At 3 years, the life-table patency rates for the various procedures were axillofemoral 52.5%, axillobifemoral 67.7% and crossfemoral 86.9%. Smoking significantly (p less than 0.05) decreased the patency rate, but diabetes did not. However, amputation was more frequent in diabetics. Indications for operation did not alter patency rates, but did affect operative mortality. The authors conclude that extra-anatomic bypass grafting is highly successful, but not as successful as anatomic bypass. When appropriate, the axillobifemoral graft is preferred to the axillounifemoral graft because of its increased patency. Crossfemoral grafts must be carefully monitored to ensure that no donor limb stenosis occurs and this procedure should not be attempted unless the disease is truly unilateral.

Simple method of intraoperative blood collection and reinfusion during aortic surgery.

The increasing fear of acquired immune deficiency syndrome and other blood-transmissible diseases and increasing blood-bank shortages prompted a study of the safety and feasibility of a commercially available hand-held unit for collecting and reinfusing blood. The device was used on nine patients undergoing aortic surgery and permitted a mean saving of 2.6 units of banked blood. The reinfusion of collected blood did not result in any coagulation disturbances or changes in renal function. The hemoglobin and platelet levels were comparable to those in a group of patients receiving only banked blood. The unit does not require additional personnel or technical training for its use. The authors conclude that this autotransfusion device is a safe and feasible method of reducing the requirement for banked blood during aortic surgery.