Biomedical subjects
Publications and source records attributed to W P Shutze.
Concentrations of uric acid in carotid endarterectomy specimens in men and women were measured using high-performance liquid chromatography in comparison wo nonatherosclerotic control specimens.
Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the incidence of both early and late complications. Controversy continues, however, over the ideal patch material. Bovine pericardium (Vascu-Guard Biovascular Inc., Saint Paul, MN) offers an attractive alternative to other patch materials because of its handling and suturing characteristics that are similar to that of autogenous material. This study examines the perioperative and midterm results of bovine pericardial patch angioplasty during CEA. We studied 112 patients who underwent 129 CEAs with bovine pericardial patch angioplasty during an 18-month period. Data were collected regarding demographics, operative indications, perioperative complications, and the occurrence of late adverse outcomes based primarily on follow-up arterial duplex studies. Among this group there were 63 male (56%) and 49 female (44%) patients whose mean age was 71.8 +/- 9.1 years. In these patients there was the typical distribution of atherosclerotic risk factors. Seventy-four patients (66%) had symptomatic disease preoperatively and the remaining 38 patients (34%) were asymptomatic. Temporary cranial nerve palsy occurred in three patients (2%). There were no perioperative strokes, acute occlusions, bleeding episodes requiring reoperation, or deaths. The patients were followed up to 54 months postoperatively with a mean follow-up time of 41.7 +/- 4.4 months. During this period two patients (2%) developed three significant restenoses (70-99%). All required reoperation. There were no asymptomatic occlusions, infections, aneurysms, or rupture. These data demonstrate that bovine pericardial patch angioplasty during CEA is associated with a low incidence of both perioperative and midterm adverse outcomes.
During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occured and only 12 patients (2%) required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.
One of the rarer anatomic variants is persistent sciatic artery. Only 93 cases have been reported since the first description of this anomaly. The earlier reports were mainly pathologic descriptions, whereas the more recent have been clinically oriented. There is a slight male predominance, and the average age of presentation is 49 years old (range 6 months to 85 years). The majority of patients have symptoms of a mass, ischemia, or gluteal pain. There is no preference for the right or left side, and one in four patients has both legs affected. In this anomaly the sciatic vessel acts as the principal blood supply to the lower limb. One half of all patients develop aneurysms that are characteristically located caudal to the sciatic notch as opposed to gluteal aneurysms that are cephalad to this landmark. Various methods (some now obsolete) have been tried to treat these aneurysms, but the best results were obtained through aneurysm ablation and vascular reconstruction. Arterial bypasses succeeded when used for ischemic complications of persistent sciatic artery. Optimal management of this condition requires prompt recognition, an understanding of the developmental anatomy, exclusion and bypass of aneurysms, appropriate vascular intervention for ischemic sequelae, and close observation of asymptomatic individuals.
An arterioureteral fistula is a rare but intriguing anomaly. Fewer than two dozen cases have been recorded, and all have relayed the extreme diagnostic and therapeutic challenges that this entity presents to the clinician. Factors contributing to the development of such a fistula include prolonged ureteral catheterization, prior pelvic vascular or urologic surgery, cancer or radiation. These patients are severely debilitated, and repair has a mortality rate in excess of 15%. Experience with such a patient is reported, as well as use of a minimally invasive approach to repair the abnormality. By using transvascular balloon occlusion of the involved iliac vessel and extra-anatomic vascular reconstruction, the significant morbidity and mortality associated with this disorder were avoided. Suspicion of an arterioureteral fistula should be increased in those at risk and treatment can be effected with this minimally invasive method.
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From 1976 to 1988, 35 patients were treated for Stage IE and Stage IIE primary gastric lymphoma (non-Hodgkin's). Pain and weight loss were the predominant symptoms, physical findings were usually absent and 20 per cent of the patients were anemic. The results of gastrointestinal contrast studies suggested a malignant condition in 75 per cent, but findings were not specific for lymphoma. Endoscopic findings suggested a malignant process in 85 per cent, but the yield for biopsy was only 60 per cent. Of 28 patients undergoing operative exploration, 75 per cent were resectable. Nine patients received postresectional adjuvant therapy. Five had chemotherapy; three, radiotherapy, and one patient, a combination of the two. Primary nonsurgical treatment consisted of chemotherapy in 11, radiotherapy in two and combined therapy in one instance. Three of five recurrences were successfully treated. The five year survival rate was 65 per cent without significant differences between surgical and nonsurgical regimens. Those with tumors smaller than 7 centimeters had a five year survival rate of 100 per cent versus 50 per cent for larger neoplasms. Patients more than 60 years of age appeared to have a more favorable course after surgical therapy compared with those who had nonsurgical treatment. We concluded that endoscopy is a most useful, although limited diagnostic study and since no treatment program is obviously superior, the choice of therapy can be individualized accordingly.
Potentially curative radical pancreaticoduodenectomy for ampullary adenocarcinoma was performed in 24 patients over a 35-year period. The overall operative mortality was 12.5%. Actuarial survival rate at 5 years was 61% +/- 13.4 standard error of the mean (SEM) and subsequently remained unchanged. In the same time period, 21 patients underwent potentially curative radical pancreaticoduodenectomy for periampullary tumors of pancreatic origin. Similar analysis showed an overall operative mortality of 23.8% and a survival rate at 5 years of 27% +/- 12.5 SEM. The results of radical pancreaticoduodenectomy for ampullary carcinoma in the most recent years (1976 to 1988) were compared with those of former years (1953 to 1975). There were no statistically significant differences in the 5-year survival rate; however, the operative mortality decreased from 25% in the former period to 6.3% in the recent period. Survival was dependent on nodal status. The 5-year survival rate was 78% +/- 11.5 SEM in the absence of nodal metastasis versus 50% +/- 25 SEM in the presence of regional nodal metastasis. These findings support the concept that radical pancreaticoduodenectomy offers a realistic probability for cure in a selected group of patients with carcinomas of the ampulla of Vater.
Fewer than 100 cases of Paget's disease located in the perianal skin have been reported since the extramammary location was first described in 1893. Two patients seen and treated in the authors' institutions with disease limited to the epidermis and its adnexae are described to illustrate the usual presentation and pathobiology of the disease. A staging classification based on the disease pathology has been developed from the cases reported in the literature and correlated with appropriate surgical treatment. Stage I disease treated with wide local excision promises unlimited survival, whereas the prognosis worsens for Stage II, with synchronous localized malignancies, and for Stages III and IV, with regional and distant metastatic disease, respectively.