Conservative renal surgery for renal cell carcinoma. Technique and results of in-situ and ex-situ surgery.
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Adult↗
Biomedical subjects
B F Zachrisson
Publications and source records attributed to B F Zachrisson.
Bilateral asynchronous renal cell carcinoma. Computed tomography of the contralateral kidney 10-43 years after nephrectomy.
Computed tomography (CT) was carried out in 31 patients 10-43 years after surgery for renal cell carcinoma, 10 belonging to a consecutive series of patients operated upon at one urological department 10 years previously. Twenty-eight patients were symptomless, and 3 had flank pain, severe fatigue and hematuria, respectively. Cancers in the remaining kidney were found 13-21 years after nephrectomy in 4 of 31 patients (12.9%). The 3 patients with symptoms were among these 4. An adenoma was found in 1 patient 10 years after nephrectomy. The cancers were treated by renal resection in 2 patients, multiple tumors made nephrectomy necessary in 1 patient and 1 patient was not operated upon because of disseminated disease. The adenoma indicated future checkup by CT. Three of the 4 new cancers had a dismal outcome. The renal parenchyma was found to be essentially normal in all the other 26 patients, irrespective of the widely varying time interval between nephrectomy and CT. Asynchronous bilateral renal cell carcinoma has a poor outcome which presumably can be improved by early diagnosis and aggressive treatment. CT is the method of choice for early detection and follow-up of renal tumors. It should be carried out every other year after nephrectomy for renal cell carcinoma.
Adult↗
Chronic lower limb ischaemia. A prospective randomised controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA).
In a prospective randomised study, performed over a 6-year period, 102 patients with severe lower limb ischaemia or claudication resistant to exercise training were randomised either to percutaneous transluminal angioplasty (PTA) or vascular surgery. Only patients who could be treated by both methods were included, constituting only 5% of the total number of patients treated during this period. The two groups were similar regarding age, severity of symptoms and diabetes. The immediate and 1-year results showed similar success and complication rates. There was, however, a significantly shorter hospital stay for patients treated with PTA. Due to early complications and initial failures PTA should, however, only be used in institutions where vascular surgical facilities are available since PTA demands access to such treatment.
Adult↗
Use of a tamponade catheter in the bleeding nephrostolithotomy track.
Bleeding from the nephrostomy track, which is the most common major complication of percutaneous extraction of renal stones, was treated in 5 patients with the Kaye double-lumen nephrostomy tamponade catheter. This treatment was effective in all cases. The procedure eliminates the need for more invasive measures like embolisation and open surgery with renal resection, both of which cause loss of functioning renal parenchyma.
Adult↗
Outpatient-based extracorporeal shock wave lithotripsy using EDAP LT-01.
Between March 1988 and March 1990, 751 patients were treated with shock wave lithotripsy using EDAP LT-01. Six hundred and eight patients had renal stones while 143 patients had stones located in the ureter. Because of difficulties in locating ureteric stones with ultrasound 92% of them were pushed back to the kidney before treatment. The mean stone size was 10 mm, range 4-30 mm. Patients with stones bigger than 15 mm had a double J-stent placed before treatment. The mean number of treatments per patient was 1.7 (range 1-8). Sixty-six per cent of the patients with renal stones were completely stone-free after ESWL monotherapy. Another 5% became stone-free after auxiliary procedures in the ureter, because of retained fragments. Fragments equal to or less than 4 mm were retained in 14% of the patients with the renal stones. Of the patients with ureteric stones mobilised back to the kidney 95% were rendered stone-free after ESWL. Most patients experienced no or very little discomfort during the treatment and only 29% of them received analgesics. General of epidural anaesthesia was given to 1% of the patients. Because of the low demand for analgesia or anaesthesia, 99% of the patients with renal stones were treated on an outpatient basis. During the second year, 74% of the patients with ureteric stones were treated on an outpatient basis.
Adolescent↗
Percutaneous renal and ureteric stone extraction. Report on the first 500 operations.
A consecutive series of the first 500 percutaneous renal and ureteric stone extractions in 451 patients was analysed. During the period studied, percutaneous extraction was offered to all patients with conventional indication for stone removal except a few, very early ureteric stone patients in whom open lithotomy was carried out. Ureteroscopy and extracorporeal shock wave lithotripsy had not come into routine use. Four hundred and seventy-eight stone operations (96%) could be performed by the percutaneous route; early in the series, 21 open operations and one transurethral Dormia basket extraction were performed, mainly because of failed mobilisation of ureteric stones (12 patients) or various peroperative complications (9 patients). The target stones were completely removed in 88% of all percutaneous procedures, with the best results in the largest group of patients with 6-20 mm solitary stones or 2-3 stones less than or equal to 10 mm. Stones in the ureter and pelvi-ureteric junction without any other concomitant stones were all completely removed. Bleeding was the most frequent peroperative complication. No kidney was lost. An 84-year-old man died of intercurrent disease postoperatively.
Female↗
Percutaneous surgery for stones in pyelocaliceal diverticula.
The technique used for percutaneous extraction of stones in pyelocaliceal diverticula and the results of the procedure in 13 patients are presented. Nine patients have been free of their pre-operative symptoms, pain and/or bacteriuria, since removal of the stones.
Adult↗
Early diagnosis of and surgical strategy for adrenal medullary disease in MEN II gene carriers.
Sixteen multiple endocrine neoplasia type II (MEN II) gene carriers--12 who had undergone thyroidectomy because of medullary carcinoma of the thyroid and 4 whose thyroid glands had been removed because of C cell hyperplasia--were examined for the presence of pheochromocytomas. No patient had sought medical advice for pheochromocytoma symptoms. Fourteen patients had MEN IIa syndromes, one patient had a MEN IIb and another patient had a mixed syndrome of von Recklinghausen's neurofibromatosis and MEN II. Eight patients had undergone unilateral adrenalectomy for pheochromocytoma 11 +/- 4 years before. The patients underwent clinical examination, determination of the urinary excretion of catecholamines and metabolites, and 131I-metaiodobenzylguanidine (131I-MIBG) and CAT scans. 131I-MIBG scanning was performed with images 1, 4, and 7 days after the radionuclide injection. In seven of eight patients who had undergone unilateral adrenalectomies, the 131I-MIBG scans showed accumulation of the radionuclide in the remaining adrenal gland. Bilateral adrenal accumulation of the radionuclide was demonstrated in seven of eight MEN IIa gene carriers who had not undergone adrenalectomy. Five patients, two of whom had undergone adrenalectomy, were found to have unilateral pheochromocytomas less than 2 cm in diameter. Only one of these five patients had an elevated excretion of urinary catecholamines. Between day 4 and day 7 after 131I-MIBG injection, adrenal glands with pheochromocytomas increased their relative accumulation of the radionuclide significantly more (p less than 0.02) than did adrenal glands without any demonstrable pheochromocytomas. All the pheochromocytomas were viewed by means of CAT scans. Only one MEN IIa patient had bilateral pheochromocytomas, but our findings indicate that there is a tendency to bilateral adrenal medullary hyperfunction in most MEN II gene carriers. As 131I-MIBG and CAT scans can facilitate the early diagnosis of pheochromocytomas, unilateral adrenalectomy can safely be performed in most MEN IIa patients. Bilateral pheochromocytomas develop in a majority of patients with MEN IIb syndromes. Bilateral adrenalectomy should therefore be performed in these patients.
3-Iodobenzylguanidine↗
Renal cell carcinoma with vena cava extension: diagnostic and surgical features of 41 cases.
Vena cava extension of renal cell carcinoma was diagnosed in 33 men and 8 women, 29 of whom had right-sided and 12 left-sided tumours. Angiography was performed in all and cavography in most patients. Computed tomography was available in 16 cases. The tumour thrombus did not reach the diaphragm in 32 patients, and extended above it in 9 cases. Macroscopically, complete cavathrombectomy was performed in 33 patients. All tumours except one were of high grade type (grades III and IV). Serum creatinine and liver enzymes were normal at the first postoperative check-up. The 5-year-survival rate in patients subjected to complete cavathrombectomy was 24%. The 5-year-survival was 33% in patients whose tumours extended to below the diaphragm, 0% in patients whose tumours extended above the diaphragm (NS), 33% in grade III tumours and 0% in grade IV tumours (NS), 33% in patients without evidence of metastases and 0% in patients with preoperative metastases (NS).
Adult↗
"Half-way" venous catheters. II. Anatomoradiological basis.
In order to develop a "half-way" venous catheter for clinical use, anthropometric (n = 200), radiographic (n = 101), and phlebographic (n = 44) investigations were undertaken to determine the lengths, diameters, and morphology of the basilic and cephalic veins from fossa cubiti to the lateral edge of the first rib. The lengths of basilic and cephalic veins varied from 25 to 45 cm, exceeding 40 cm in approximately 5% of cases. Catheter lengths to be inserted were correlated ("r" = 0.6-0.7) with body heights, accurately estimated by 1/5 of the body height (cm) plus 2 cm for the basilic vein, and 4 cm for the cephalic vein. The cephalic veins have small proximal end diameters (mean = 6 mm), and present terminal arches of 2-3 cm. These are connected by a rich anastomotic network to the superficial cervical veins. The basilico-axillary courses are regular with gradually increasing diameters (mean = 16 mm), but in some observations, with the arms maximally abducted, the axillary veins presented accentuated folds. With these considerations, we recommend the insertion of the "half-way" catheters by basilic approach with the patient's arm in 90 degree abduction. The axillosubclavian length (mean = 18.5 cm) ensures wide limits for accurate placement of the "half-way" catheter tips when a basilic approach is used. Further, their large diameters (16-19 mm) make flotation of the soft catheters probable.
Adolescent↗
"Half-way" venous catheters. IV. Clinical experience and thrombogenicity.
"Half-way", Secalon-Seldy, soft venous catheters, 40 cm long, were inserted by basilic (n = 90) and cephalic (n = 31) veins at the fossa cubiti in 121 patients (71 men and 50 women) aged between 19 and 88 years whose heights varied from 152-197 cm. The inserted catheter lengths approximated 1/5 of the patient's height. Sixty-five per cent of 106 radiologically investigated catheter tips were located proximally in the axillary veins, and 34% distally in the subclavian veins. The duration of catheterization varied from 1 to 44 (mean 9 +/- 7) days (means +/- 1 s.d.). Perfect function was recorded in 93 of 121 catheters. No serious, but some minor complications were registered such as temporary interruption of infusion flow with movements of the arm (n = 12), partial or total catheter occlusion (n = 16), leakage of the infusate at the insertion site (n = 1), and pain along the vein during infusion (n = 2). Five patients (4%) developed thrombophlebitis 2-.10 days after insertion. Pull out phlebographies at catheter withdrawal (4-35 days after insertion) were performed in 36 patients. Radiological thrombi were small and similar to those recorded in another 53 phlebographies of "long-way" brachial catheters of similar stiffness. Neither local infection nor episodes of sepsis were registered over a period of 1,081 catheter days. "Half-way" catheters proved able to take over all the functions of both peripheral and central venous catheters, lacking the frequent complications (phlebitis and infection) of the former, and the serious mechanical complications (pneumothorax, vein perforations, and injuries of the ductus thoracicus, nerves, arteries, and heart) of the latter.
Adult↗
Recurrent and metastasizing gastric leiomyoblastoma (epithelioid leiomyosarcoma) associated with multiple pulmonary chondro-hamartomas: long survival of a patient treated with repeated operations.
A 15-year-old girl was operated for gastric leiomyoblastoma (epithelioid leiomysocarcoma) with metastasis to a regional lymph node. She has subsequently been operated on twice: once for local recurrence and metastases 9 years after her initial operation and once for an intraabdominal lymph node metastasis. Now, 13 years after her first operation for gastric leiomyoblastoma she is free from symptoms and signs of disease. Preoperative angiography was helpful in diagnosing the recurrence and planning the second operation. Our observations speak in favor of surgical treatment of recurrent and metastasizing gastric leiomyoblastoma. This patient was also operated for multiple pulmonary chondro-hamartomas, primarily suspected to be metastases. Coincidence of gastric leiomyoblastoma and pulmonary chondro-hamartoma does not seem to be due to chance alone.
Adolescent↗
Infusion cholecystography--an aid in the diagnosis of acute cholecystitis.
Early operation of patients with acute cholecystitis is nowadays accepted as the treatment of choice. One prerequisite for this policy is, however, the availability of diagnostic procedures that can rapidly secure or, even more important, exclude the diagnosis to avoid unnecessary operations. Infusion cholecystography was here shown to be an accurate method giving decisive information in patients with clinically suspected acute cholecystitis. The gallbladder was not visualized in 26 out of 45 patients with inconclusive clinical signs of acute cholecystitis. The diagnosis of acute cholecystitis was confirmed at operation or by a typical clinical course in these 26 patients. In the 19 patients with visualized gallbladder diagnosis other than acute cholecystitis were established by acute operation or by other means.
Acute Disease↗
Massive parathyroid hemorrhage in a case of water-clear cell hyperplasia.
A case of water-clear cell hyperplasia of the parathyroid glands is reported. As far as we know this case is unique in respect of the following features. All the parathyroids were located in the superior mediastinum. One abnormal parathyroid gland was removed with the help of a mediastinoscope. The patient survived a massive parathyroid hemorrhage. This case draws attention to the facts that enlarged parathyroid glands can appear as mediastinal tumours and that massive bleeding can occur in abnormal parathyroid glands.
Adenoma↗
Management of hyperparathyroid patients with grave hypercalcemia.
During recent years the total number of patients undergoing surgery for hyperparathyroidism has markedly increased, but the annual number of cases with substantial hypercalcemia has remained unchanged. Parathyroid carcinoma and water clear cell hyperplasia cause more severe hypercalcemia than other kinds of hyperparathyroidism. Grave hypercalcemia due to hyperparathyroidism is more common among the elderly, but can occur during pregnancy and also among children. Occasionally, a patient with hyperparathyroidism can also have another cause of the hypercalcemia and does not become normocalcemic until adequately treated for both. The suspicion of grave hypercalcemia should arise due to its clinical features. Determination of serum calcium and intact parathyroid hormone concentrations establishes the diagnosis. The basic treatment of grave hypercalcemia is to rehydrate the patient and to restore the sodium losses. To further lower the serum calcium value we have found bisphosphonates to be very effective. The definitive treatment of grave hypercalcemia due to hyperparathyroidism is surgery. As a last resort, frail patients with grave hyperparathyroidism can undergo surgery under local anesthesia. Repeat operations can improve the prognosis of patients with metastatic parathyroid carcinoma. Selective venous catheterization with blood sampling for determination of intact parathyroid hormone can be helpful in localizing recurrent disease.
Acute Disease↗
Low dose urography with a low osmolar contrast medium.
In a double blind study of 100 consecutive patients routinely referred for urography, a conventional contrast medium (Isopaque cerebral) was compared at a dose of 180 mg I/kg body weight with a low osmolar contrast medium (Hexabrix 160) at a dose of 90 mg I/kg body weight. In spite of 50 per cent dose reduction, equally good diagnostic effect was achieved with Hexabrix as with the conventional contrast medium.
Adolescent↗
Low dose urography. A clinical comparison of three low osmolar (ratio 3) contrast media.
Three modern low osmolar contrast media (Iopamiro, Omnipaque and Hexabrix) were injected intravenously in 150 patients. They were all effective for urography in a concentration iso-osmolar to blood and with a dose of 90 mg I/kg body weight in patients with normal renal function. In patients with decreased renal function, this low dose is not sufficient and should be doubled. No significant diagnostic differences between the three media were found. The subjective and objective adverse effects were minimal and transient.
Adult↗