Attempted enzyme replacement using human amnion membrane implantations in mucopolysaccharidoses.

Amnion membrane implantation has been proposed as an approach to enzyme replacement in mucopolysaccharidoses. Human amnion membranes have been subcutaneously implanted in the abdominal wall in 19 patients with mucopolysaccharidoses (MPS I, II and III). A protocol was developed for the objective evaluation of experimental treatments of these patients. Systematic evaluation of the clinical status before and 6 months after amnion membrane implantation reveals no change in function except improvement in joint mobility. The sum of all joint movements showed improvement from baseline values to 6 months after implantation by ANOVA followed by post-hoc analysis (p less than 0.056). The only specific joint movements to significantly improve after 6 months were shoulder extension (p less than 0.01) and hip internal rotation (p less than 0.05). Serial measurements of the deficient lysosomal enzyme activity in serum and white blood cells did not increase in any patient after amnion membrane implantation. Urinary glycosaminoglycan excretion decreased transiently in 2 of 10 patients after implantation, but a second amnion membrane implantation did not result in any change. Biopsy of the implantation site in 10 patients 6 months after amnion membrane implantation revealed a foreign-body reaction with giant cell formation and fibrosis and no recognizable amnion membrane tissue. We conclude that human amnion membrane implantation is not an effective therapy in mucopolysaccharidoses.

Surgical morbidity in patients with systemic lupus erythematosus.

Thirty-six surgical procedures were performed on 29 patients with systemic lupus erythematosus (SLE). Nineteen cases involved active lupus at the time of surgery and 11 were performed on an emergent basis. Most patients had multiple organ involvement and were on some form of systemic therapy at the time of surgery. Thirty-seven postoperative complications were confined to 20 of these cases. Comparing this complicated group with the remaining 16 uncomplicated cases, the patients in the former group had a higher mean dose of steroid preoperatively, more organ involvement by SLE, and more frequent renal involvement; a higher percentage of the cases in this group were emergent rather than elective. The majority of factors examined failed to show predictive value in the outcome of surgery in lupus patients. We conclude that surgical complications are frequent in SLE patients and have identified four factors predictive of increased morbidity.

Management of the surgically traumatized, irradiated, and infected pelvis.

A plan for staged management of pelvic wound complications after combined surgery and radiation therapy for pelvic cancer is presented. Principles emphasized are as follow: wide drainage and irrigation of infected tissues; creation of an abdominopelvic partition, to exclude bowel and gastrointestinal anastomoses away from the pelvis in order to reestablish intestinal function; wide excision of irradiated and infected tissue; and transfer of vascularized tissue into the pelvic defect to promote healing and obliterate space. When infection occurs in the surgically traumatized and heavily irradiated pelvis, an aggressive approach to treatment must be pursued and is usually successful.

The infected chest wall prosthesis: management by excision and contralateral transverse rectus abdominis musculocutaneous flap.

A patient with a chest wall sarcoma whose original prosthetic reconstruction became infected after a course of radiation therapy is described. After removal of the prosthesis, salvage reconstruction was performed using a transverse rectus abdominis musculocutaneous flap. Management of the infected chest wall prosthesis, with emphasis on the indications for use of the transverse rectus abdominis musculocutaneous flap, is discussed.

Total colonic necrosis. A catastrophic complication of systemic lupus erythematosus.

Diffuse ischemic colitis leading to colonic necrosis is a rare complication of systemic lupus erythematosus. A 16-year-old girl who developed such a complication and underwent emergency subtotal colectomy is described. The incidence and significance of intestinal symptoms and the difficulties in the differential diagnosis in patients with systemic lupus erythematosus presenting with abdominal manifestations are discussed.

Complete axillary lymph node dissection for stage I-II carcinoma of the breast.

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)

Pregnancy after breast reconstruction with a transverse rectus abdominis musculocutaneous flap.

The transverse rectus abdominis musculocutaneous flap has been used for breast reconstruction with increasing frequency in recent years. It has not previously been reported whether or not an abdominal wall weakened by the transfer of this flap can withstand the added stress of pregnancy. An experience with one such patient who successfully carried a pregnancy to term is described.

The tolerance of skin grafts to postoperative radiation therapy in patients with soft-tissue sarcoma.

During the last ten years at the National Cancer Institute, 11 patients have received 12 courses of postoperative adjuvant radiation therapy to skin grafts used for wound closure after the resection of soft-tissue sarcomas. The intervals between grafting and the initiation of radiation ranged between 3 and 20 weeks, and 4 patients received chemotherapy at the same time as their radiation. Ten of the 12 irradiated grafts remained intact after the completion of therapy. One graft had several small persistently ulcerated areas that required no further surgical treatment, and one graft required a musculocutaneous flap for reconstruction of a persistent large ulcer. Acute radiation effects on the grafted skin sometimes developed at slightly lower doses than usually seen with normal skin, but these acute effects necessitated a break in therapy on only five occasions. Concurrent chemotherapy and a relatively short interval between grafting and the initiation of radiation seemed to contribute to more severe radiation reactions. This experience indicates that postoperative adjuvant radiation therapy can be delivered to skin grafted areas without undue fear of complications, especially if the graft is allowed to heal adequately prior to initiating therapy and if chemotherapy is not given in conjunction with radiation.

Toxicity of recombinant human interleukin-2 in rats following intravenous infusion.

The recent availability of recombinant human interleukin-2 (RIL-2) has increased interest in the potential clinical use of this lymphokine. We have examined the biologic effects of intermittent bolus and continuous intravenous administration of RIL-2 in rats. The mean (+/- SEM) half-life after an intravenous bolus injection of RIL-2 was determined to be 2.9 +/- 0.5 min (n = 4). The administration of intermittent intravenous bolus injections of RIL-2 of doses up to 10(6) units/kg every other day for 2 weeks was well tolerated without toxicity as determined by organ histology and serum chemistries. The continuous intravenous infusion of RIL-2 through an indwelling external jugular vein catheter was tolerated for 2 weeks at doses less than or equal to 3,000 U/kg/h and was associated with no abnormal serum chemistries or organ pathology. By contrast, animals that received less than 10,000 U/kg/h demonstrated RIL-2 toxicity leading to death of treated rats. Serum chemistries revealed a fourfold increase in serum glutamate oxaloacetic transaminase and serum glutamate pyruvic transaminase. Liver histology revealed hepatocellular necrosis with mononuclear cell infiltration. The thymus was depleted of lymphocytes and lymphoid infiltrates were present in liver, spleen, and lung. This is the first documentation of toxicity secondary to RIL-2 administration and suggests that hepatopathy may be the dose-limiting toxicity accompanying the administration of RIL-2.

Advances in plastic surgery.

Recent progress in plastic surgery has been rapid and many new techniques have been developed. Reconstructive procedures have been advanced by a better understanding of the anatomy of the blood supply to skin and muscle, with the subsequent development of the use of axial flaps, musculocutaneous flaps and neurosensory flaps. Burn treatment has advanced greatly, making it possible to successfully treat larger and more complicated burns. The development of microsurgery has made possible free-flap transfer and replantation of amputated parts. Advances in surgical procedures on the hands include a realization that primary repair of lacerated tendons and nerves will give good results. Replacement joints have been developed that can be used in hands for joints destroyed by arthritis or trauma. Craniofacial surgery is a new field of endeavor in plastic surgery, involving new techniques that can be used to treat exophthalmos of Graves' disease and the facial deformities resulting from gigantism and acromegaly. Head and neck procedures have advanced, with the emphasis on immediate reconstruction using new flaps. Techniques for treating cleft lip and palate have been refined. Encouraging results have been reported in the treatment of nevus flammeus with argon lasers. In aesthetic surgical procedures, the aim is for safety and consistent long-lasting results. Improved understanding of the physiology and treatment of radionecrosis has evolved.

Xenon ventilation-perfusion lung scans. The early diagnosis of inhalation injury.

The use of xenon Xe 133 ventilation-perfusion lung scans for the early diagnosis of inhalation injury was evaluated in 67 patients with acute thermal burns. Study results were interpreted as normal if there was complete pulmonary clearance of the radioactive gas by 150 seconds. Thirty-two scans were normal, 32 abnormal, and three technically inadequate. There were three true false-positive study results and one false-negative study result. Good correlation was found between the scan results and various historical, physical, and laboratory values currently used to evaluate inhalation injury. The scans appeared to be the most sensitive method for the detection of early involvement, often being abnormal several days before the chest roentgenogram. Xenon lung scanning is a safe, easy, accurate, and sensitive method for the early diagnosis of inhalation injury and has important therapeutic and prognostic implications as well.