Inflammatory disease of the breast.
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Female↗
Biomedical subjects
J J Ferrara
Publications and source records attributed to J J Ferrara.
A new technique for sutureless intestinal anastomosis. A prospective, randomized, clinical trial.
A polyglycolic acid device has been designed for the performance of sutureless colonic anastomoses. The use of this biofragmentable anastomosis ring (BAR) was compared with conventional techniques in a prospective, randomized study of 59 patients (x age, 49 years) undergoing ileocolostomy (n = 23) or colocolostomy (n = 36). The anastomotic technique was determined at surgery by randomization (BAR, 27 patients; suture, 16 patients; staple, 16 patients). Performance of an anastomosis with the BAR required an average of 22 minutes, a stapled anastomosis required 33 minutes, and the suture technique required 37 minutes. Learning curve error contributed to the six intraoperative complications that occurred with performance of the anastomosis (BAR, three; end-to-end anastomosis [EEA] instrument, three). The two postoperative deaths were unrelated to the anastomosis. Length of hospitalization in uncomplicated patients was the same among the three groups. The 17 patients with prolonged hospitalization had complications unrelated to anastomotic technique. All patients were followed for a minimum of 6 weeks; no additional complications were identified. We concluded that 1) the BAR is a rapid, safe method for performance of sutureless anastomoses; 2) perioperative mortality and morbidity rates of the BAR are comparable to conventional techniques of suture and staple; and 3) long-term follow-up of BAR patients is warranted to determine the incidence of complications, such as structure and/or stenosis.
Anastomosis, Surgical↗
Nonsurgical management of breast infections in nonlactating women. A word of caution.
UNLABELLED: Management options for infectious mastitis have traditionally been limited to surgical drainage. With the advent of percutaneous fine needle aspiration (FNA), nonoperative treatment may be an alternative, though criteria for use have not been defined. During a 30-month period, 22 women presented with breast infection. Treatment was instituted based upon the clinical stage of infection. Patients with cellulitis (n = 8) were managed with diagnostic FNA/antibiotics. Those with focal abscess (n = 10) underwent FNA of the cavity/antibiotics. Patients with multiloculated abscess (n C = 3) underwent urgent surgical drainage. Of the 19 patients initially treated nonoperatively, resolution occurred in nine (47%); stage of infection did not effect outcome. Surgical drainage was required in the remainder; two cancers were found. FNA cytology in these (and all) patients was negative for malignancy. All underwent mammography during treatment. In 17 (77%) cancer was considered of low probability. The only patient with a mammogram highly suspicious for cancer had fat necrosis on biopsy. Bacterial cultures were positive in 79 per cent, virtually all with Gram (+) cocci. Four patients harbored Gram (-) organisms as well, two in concert with breast cancer. CONCLUSIONS: 1) select breast infections can be successfully managed nonoperatively, 2) the accuracy of FNA and mammography in the diagnosis of breast cancer may be impaired by coincident infection, 3) the finding of a Gram (-) breast infection warrants abandonment of nonoperative management in favor of tissue confirmation of the disease process.
Abscess↗
Indications for placement of drains in the splenic fossa.
Drainage of the splenic fossa has for years remained a controversial issue. A large potential space exists in the left hypochondrium following splenectomy. Proponents of the use of drainage maintain that drainage is safe, efficacious in removal of blood, serum, and pancreatic enzymes, and carries little, if any, risk of subsequent infectious morbidity. Critics of the use of drainage cite the heretofore reported high incidence of subphrenic abscess formation in those patients in whom drains are placed as the reason for abandoning routine or therapeutic drainage of the splenic fossa.
Drainage↗
In vitro effects of complement inactivation upon burn-associated cell-mediated immunosuppression.
Serum of severely burned patients possesses in vitro capacity to suppress cell-mediated immunologic responses. Failure to establish immune competence is predictive of mortality, usually from sepsis. In this investigation, the hypothesis that complement fragments, known to be elevated in the acute phases of burn injury, contribute to this suppression is tested. Serum taken from patients with massive (greater than 60%) and major (less than or equal to 60%) burn injury was analyzed for the ability to suppress mitogen-induced lymphocyte blastogenesis before and after exposure of the burn serum to (complement inactivating) temperatures. All patients in this study had immune suppressive serum. Heat inactivation partially restored immune competence in the serum of all patients, though significantly more so in patients with major burns compared with those with massive burns. Complement appears to play a contributory role in the acute stages of burn-induced, cell-mediated immunosuppression, though its role in patients with massive burn injury is overshadowed by the presence of serologic suppressive factors not present (or present in lower concentration) in patients with major burns.
Adult↗
Effects of fibrinogen degradation fragments D and E on cell-mediated immunity.
Serum taken from severely traumatized victims suppresses in vitro the response of normal lymphocytes to the mitogenic stimulant phytohemagglutinin (PHA). In the postburn period, fibrin degradation products (fragments D and E) are elevated in a high percentage. Controversy exists as to whether these fragments contribute to what is clinically evident as cell-mediated immune (CMI) suppression. Purified fragments D and E were isolated over an ion exchange cellulose column after activating, with streptokinase, a solution containing fibrinogen and plasminogen. Lymphocytes from six volunteers were cultured with PHA and serial dilutions of fragments D and E; each was analyzed for ability to incorporate radiolabeled thymidine. Fragment E possessed in vitro CMI suppression at pharmacologic doses. Fragment D demonstrated immune suppressive capabilities at doses approximating those estimated to occur in the acute postburn phases of injury.
Fibrin Fibrinogen Degradation Products↗
Peri-operative management of severe thyrotoxicosis with esmolol.
A case of severe thyrotoxicosis with cardiac decompensation is reported. Use of propranolol was followed by cardiovascular collapse. Esmolol, the beta-1 adrenoceptor blocking agent was successfully used to control the thyrotoxic state. A discussion of possible advantages of esmolol is provided.
Adrenergic beta-Antagonists↗
A method of stapled skin closure by one surgeon.
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Humans↗
Fibrinogen degradation products in fresh frozen plasma. Possible contribution to immunosuppression.
Recent investigations implicate a variety of specific serum factors as immunosuppressive agents, among them variably sized fragments produced by the degradation of fibrin/fibrinogen. Random samples of fresh frozen plasma were tested for fibrinogen degradation products by a latex agglutination method. Thirty-one per cent of the units tested contained greater than 40 micrograms/ml fibrinogen degradation products, and a total of 86 per cent contained greater than 10 micrograms/ml fibrinogen degradation products. Fresh frozen plasma is often used in the treatment of critically ill trauma and surgery patients, and especially in severely burned patients, who are immunosuppressed by the nature of their injury. Since fibrinogen degradation products have been shown to have both in vitro and in vivo immunosuppressive effects, administration of fresh frozen plasma to these patients should be carefully evaluated in light of its potential ability to worsen their already compromised immune status.
Fibrin Fibrinogen Degradation Products↗
Diverticular hemorrhage in an elderly patient.
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Aged↗
Factors affecting mortality in patients operated upon for complications of peptic ulcer disease.
Surgical treatment of complicated peptic ulcer disease (PUD) is associated with a high mortality in selected, high-risk patients. The authors reviewed their operative experience for PUD over a five year period beginning in July 1982. One hundred and sixty-two operative procedures were performed on 160 patients. The indications for surgery were intractability (18); perforation (50); hemorrhage (81); and obstruction (13). The average ages of the survivors and those who died was 49.0 and 65.7 years respectively. Partial gastric resection (PGR), with or without vagotomy, was the most commonly performed procedure (54% of cases) while vagotomy and drainage (V & D) was used in 31 per cent of patients. The overall mortality in this series was 8 per cent; it was highest in the hemorrhage group (10%). Pre-operative transfusion requirements in this population were greater in those who died versus those who survived (12.1 and 7.3 units respectively, P less than 0.005). In addition, 75 per cent of the deaths were over 60 years of age. In elderly patients operated upon for hemorrhage, the procedure-related mortality for V & D and PGR was 24 per cent and 13 per cent respectively. (These groups were similar with regard to co-morbidity, hemodynamic stability, and transfusion requirements). It is the authors contention that PGR may be safely used for the treatment of bleeding peptic ulcer disease (particularly GU) in selected elderly, high-risk patients.
Adult↗
Metastatic colon carcinoma to the biliary tract mimicking choledocholithiasis.
This case is reported because of its rarity and in order to demonstrate that, using ERCP, it can be difficult at times to differentiate not only primary from metastatic diseases of the common duct, but also both of these malignant conditions from benign choledocholithiasis.
Adenocarcinoma↗
Influence of mastectomy technique on sex steroid receptor analysis.
Accurate analysis of hormone receptors in breast carcinoma is critical from prognostic and therapeutic standpoints. Controversy exists over whether there is receptor decay when specimens are obtained upon completion of, rather than prior to, mastectomy. In addition, the effect of mastectomy technique on receptor concentration has not been addressed. Twenty patients with breast carcinoma had biopsy specimens taken prior to and upon completion of modified radical mastectomy. Ten had axillary dissection followed by mastectomy (Group A). The others had mobilization of the breast before axillary dissection (Group B). The estrogen receptor concentration was higher in 14 of 20 premastectomy specimens. All 10 patients in Group B had positive receptors before mastectomy; 5 were negative after mastectomy. All seven patients in Group A with positive premastectomy receptors remained so postmastectomy. We concluded that if a tumor specimen for receptor analysis is not obtained prior to modified radical mastectomy, axillary dissection should precede breast mobilization.
Axilla↗
Combined surgical management of myasthenia gravis and Graves' disease.
It is rare that a patient with Graves' disease has concomitant myasthenia gravis, despite the impression that both diseases have an autoimmune basis. Even less common is the opportunity to simultaneously approach both diseases surgically. We have described a patient meeting these qualifications, and have reviewed the pertinent principles of diagnostic and perioperative management of these two disease entities.
Adult↗
A retrospective analysis of inferior vena caval filtration for prevention of pulmonary embolization.
Inferior vena caval (IVC) filtration employing transvenous devices represents a substantive technologic advance in the management of patients with deep venous phlebothrombosis and pulmonary embolization. The retrospective analysis reported herein of the use of the Kim-Ray Greenfield IVC filter in 22 patients revealed a 95 per cent efficacy in its prevention of pulmonary embolization. The minor acute morbidity (9%) and chronic morbidity (27%) associated with use of the device was well tolerated by this patient population. No mortality attributable to the device was observed. The data suggest that the use of this device represented the best therapeutic option among those patients who were not candidates (18/22) or who had failed alternative therapeutic modalities (1/22) for the treatment of deep venous phlebothrombosis or pulmonary embolization. The data also suggest that use of the device in a prophylactic context (3/22) among those patients deemed at "high risk" for the development of deep venous phlebothrombosis and pulmonary embolization may be beneficial.
Adult↗
Cholecystostomy. Expected outcome in primary and secondary biliary disorders.
Cholecystostomy is used for biliary-tree drainage when simplicity and speed are of prime importance. Its frequency of use and the subsequent mortality rates, vary among surgeons and institutions. This review analyzes 50 cholecystostomies performed over 6 years at one institution, and defines outcome as related to presenting symptoms. Twenty five patients (Group 1) presented with symptoms of acute cholecystitis, and underwent cholecystostomy. Twenty (80%) had gallstones and five (20%) were acalculous. Two patients died, a mortality rate of 8 per cent. Twenty five other patients (Group 2) developed signs suggesting cholecystitis during hospitalization for an unrelated illness. Only 50 per cent (13/25) of Group 2 patients were found to have cholecystitis at operation (eight calculous, five acalculous). Mortality was 62 per cent (8/13) in the Group 2 patients with inflammatory cholecystitis, and 50 per cent (6/12) for the patients with normal gallbladders. A positive outcome may be anticipated if cholecystostomy is used in patients admitted with acute cholecystitis who present too great a surgical risk for formal cholecystectomy. In contrast, the diagnosis of cholecystitis in the critically ill patient can be difficult and the prognosis for survival is not good, even after cholecystostomy.
Acute Disease↗
Surface oximetry. A new method to evaluate intestinal perfusion.
Accepted methods to evaluate intestinal vascularity intraoperatively include standard clinical criteria (SCC), doppler ultrasound (DUS), and intravenous fluorescein (FLF). A combination of methods is often used to overcome disadvantages of individual techniques. Assessment of intestinal vascularity by FLF was compared to SCC, DUS, and pulse oximetry (POX) in segments of intestine demonstrating arterial, venous and arteriovenous occlusion, to determine if POX might supplement the assessment of intestinal vascularity. POX uses a commercially available instrument to assess tissue oxygenation and arterial flow, and is rapid, reproducible, and noninvasive. POX appears to be a superior technique when compared to SCC and DUS.
Animals↗
Biliary reconstruction without transanastomotic stent.
Twenty three operations for common bile duct (CBD) stricture were performed on 22 consecutive patients by a single surgeon without the use of transanastomotic stents. All strictures resulted from operative injury; four were acute (less than 1 month postinjury), and 18 were treated a mean of 44 months (2-124 months) after injury. All but two of these patients had had previous repair attempts. Mean follow-up after reconstruction was 72 months (17-128 months). Reconstructive procedures included hepaticojejunostomy seven, choledochojejunostomy ten, and choledochoduodenostomy six. Twenty one of the 22 patients (95%) have had excellent results, with stable liver function an no evidence of cholangitis or jaundice. Early postoperative complications (one abscess, one fistula) resolved. In two of the 22, stricture recurred at one and five months, requiring balloon dilatation in one and reoperation in the other. Both are now asymptomatic at 37 and 64 months. Reoperation was also required to remove an infected distal CBD stump in one patient 29 months after reconstruction, and another had mild intermittent cholangitis, now resolved. The only death occurred 70 months after reconstruction in a patient who developed biliary cirrhosis. These results suggest that biliary enteric anastomosis for acute and chronic bile duct strictures associated with benign disease can be performed without stenting, yielding low postoperative morbidity and excellent long-term patency.
Adult↗