Long-term results of femorotibial bypass with vein or polytetrafluoroethylene

BACKGROUND

This was a retrospective review of the long-term results of femorotibial bypass using autologous vein and polytetrafluoroethylene (PTFE) over 24 years.

METHODS

Some 518 patients who underwent 635 femorotibial bypass grafts were studied. Outcome measures analysed included primary and secondary graft patency, limb salvage rates and death.

RESULTS

Overall primary and secondary graft patencies were 62 and 67 per cent respectively at 12 months, and 44 and 48 per cent at 24 months. For vein grafts, the primary and secondary patencies were 63 and 66 per cent at 12 months, and 54 and 56 per cent at 24 months. For PTFE grafts, the primary and secondary patencies were 48 and 54 per cent at 12 months, and 31 and 37 per cent at 24 months. Limb salvage and patient survival rates were 81 and 84 per cent at 12 months, and 73 and 74 per cent at 24 months. Primary and secondary graft patencies for vein were significantly better than for PTFE (P = 0.0001). There was no difference in patency between reversed and in situ grafts.

CONCLUSION

Femorotibial bypass can produce excellent long-term results. Vein remains the conduit of choice but in the absence of vein acceptable results can be achieved with PTFE.

Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial

BACKGROUND

Sclerotherapy is widely used for acute variceal bleeding, although in emergencies bleeding makes it difficult to obtain the clear view required for safe and effective treatment. We investigated whether early administration of somatostatin would improve the efficacy of sclerotherapy.

METHODS

In this double-blind, prospective trial, patients who had cirrhosis with upper-gastrointestinal bleeding were randomly assigned natural somatostatin (6 mg per 24 h) or placebo for 120 h. In addition, intravenous bolus doses of somatostatin (250 micrograms) or placebo were injected after the start of the infusion, before emergency endoscopy or sclerotherapy, and when active bleeding was observed. The primary endpoint was treatment failure, defined as the occurrence during the infusion period of at least one of: excess transfusion of blood products, haematemesis, haemodynamic instability, need for rescue therapy, or death.

FINDINGS

205 patients were enrolled: 101 received somatostatin and 104 received placebo. Treatment failed in 35 somatostatin and 57 placebo recipients (p = 0.004); death or use of rescue therapy occurred in nine and 19 patients, respectively (p = 0.05). The mean quantity of blood products transfused over 120 h (adjusted for baseline haemoglobin) was 2.64 (SD 0.35) units in the somatostatin group versus 3.62 (0.35) units in the placebo group (p = 0.05). At endoscopy, active bleeding from oesophageal varices was less frequent (27 vs 42 patients, p = 0.012) and the sclerotherapy procedure was easier (2.8 vs 4.7 cm, p = 0.0027) in the somatostatin than in the placebo group.

INTERPRETATION

Early administration of natural somatostatin continued for 120 h, combined with additional bolus injections, is more effective than placebo in the overall control of acute variceal haemorrhage in patients with cirrhosis undergoing sclerotherapy.

Endocarditis after angiography and angioplasty of a subclavian artery stenosis

A case of bacterial endocarditis following percutaneous angiography and angioplasty of a subclavian artery stenosis is described. Septic complications following angiography and angioplasty, and the role of prophylactic antibiotics are discussed.

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

BACKGROUND/AIMS

Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage.

METHODS

Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment.

RESULTS

The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively).

CONCLUSIONS

Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.

Coronary microcirculation evaluation with transesophageal echocardiography Doppler in type II diabetics

Evaluation of coronary microvascular function can be obtained through coronary flow reserve measurements. The aim of this study was to evaluate the coronary microvascular function by using transesophageal-Doppler echocardiographic assessment of coronary flow reserve. The study included 32 normotensive patients with type II diabetes mellitus (group A) of short duration (6.1+/-3.8 years) aged 55.4+/-9.4 years and 14 healthy volunteers matched for age, gender and BMI (group B). No patients had clinical evidence of coronary artery disease and all of them produced a negative recent stress ECG test. Excluded from the study were patients with anemia, left ventricular hypertrophy, arrhythmia, congenital, or acquired structural heart disease. All subjects underwent transesophageal-Doppler echocardiography. Satisfactory coronary blood flow velocity recordings could be obtained from the initial segment of the left anterior descending coronary artery in healthy volunteers and in 27 patients at baseline and 2 min after dipyridamole infusion (0.56 mg/kg, for 4 min). In the remaining 5 patients no satisfactory recordings were available. The indexes of coronary flow reserve, i.e. the ratios of dipyridamole over basal maximum and mean diastolic velocities were calculated. Dipyridamole/rest maximal coronary reserve (Table 3) was 1.946+/-0.743, while this ratio for the mean diastolic velocity was 1.969+/-0.805 in group A. The respective values for group B, were 2.811+/-0.345 (P=0.000 vs. group A) and 2.914+/-0.303 (P=0.000 vs. group A). Thus, the increase in coronary flow reserve although present in both groups, it was more impressive in the normal group. Multiple regression logistic analysis of: age, sex, smoking, glucosylated hemoglobin, duration of diabetes and type of therapy, did not show any correlation of these parameters with the above ratios. This study shows that coronary flow reserve, as measured with transesophageal echocardiography-Doppler, is severely impaired in normotensive patients with type II diabetes, with relatively short duration of the disease.

Anterior, posterior, or laparoscopic approach for the management of adrenal diseases?

BACKGROUND

At the advent of laparoscopic adrenalectomy it seemed timely to us to assess the advantages and the overall results of the different techniques that are currently used in an approach to adrenalectomy.

PATIENTS AND METHODS

Between 1984 and 1995, 165 patients underwent adrenalectomy. Eighty-six patients (37 men and 49 women with a mean age of 46.4 years) underwent adrenalectomy via the anterior approach, 61 patients (18 men and 43 women with a mean age of 43.8 years) underwent posterior extraperitoneal adrenalectomy, and 18 patients (8 men and 10 women with a mean age of 48.7 years) underwent anterior laparoscopic adrenalectomy. For statistical analysis of the different comparisons between the groups we used the t test for independent samples, the Wilcoxon test, chi-square, and one way analysis of variance.

RESULTS

There was no operative mortality. The morbidity was 13.9% in the anterior approach, 9.8% in the posterior approach, and 0% in the laparoscopic approach. The mean operating time for unilateral adrenalectomy was 155.3 min (range 75 to 315) for the anterior approach, 108.6 min (range 60 to 195) for the posterior approach and 116.1 min (range 75 to 180) for the laparoscopic approach. For bilateral adrenalectomy the mean operating time was 165 min for the anterior and 178 min for the posterior approach. The average diameter of tumors resected anteriorly was 8.07 cm (range 2.5 to 20), posteriorly was 5.25 cm (range 0.5 to 14), and laparoscopically was 4.03 cm (range 2 to 6.5). The mean length of postoperative hospitalization for patients undergoing unilateral adrenalectomy was 8 days (range 2 to 25) for the anterior approach, 4.5 days (range 1 to 11) for the posterior approach, and 2.2 days (range 1 to 5) for the laparoscopic approach. Patient controlled analgesia lasted 3.4 days for those operated anteriorly, 2.3 days for those operated posteriorly, and 1.08 days for those that underwent laparoscopic adrenalectomy.

CONCLUSIONS

The laparoscopic approach to the adrenal promises the safest and least painful operation with shorter in-hospital stay and the best cosmetic and long-term results. The posterior approach is the fastest of all and a better overall operation than the anterior approach that should only be reserved for removing very large adrenal tumors and when concomitant intra-abdominal procedures, that can't be handled laparoscopically, are anticipated.

Arterial injury in the lower limb from blunt trauma

BACKGROUND

The present study was performed to identify the factors associated with amputation in patients with blunt injuries to the lower limb associated with arterial injury. The ability of a scoring system to predict the outcome was tested.

METHODS

There were 122 lower limb arterial injuries in 119 patients treated at the Royal Adelaide Hospital in the years 1962-1994. Prognostic factors considered were the site of the injury, the severity of the soft-tissue injury and shock, the presence of associated injuries and a description of the bone or joint injury. The mangled extremity severity score (MESS) was calculated retrospectively for each patient.

RESULTS

The outcome was primary amputation in 27 patients, delayed amputation in 36 patients and limb salvage in 59 patients. The seven deaths were all due to associated injuries. Factors associated with amputation were the severity of shock and soft-tissue injury (P < 0.01), and tibial artery injury compared with more proximal injury (P < 0.001). Factors that did not affect outcome included delay before repair, method of fracture fixation, or performance of fasciotomy. Amputation was performed in 48/71 (68%) patients with Gustilo type-IIIC fractures of the tibia. Applying the MESS to our patients resulted in a positive predictive value (PPV) of 71%, a negative predictive value (NPV) of 84% and an overall accuracy of prediction of 75%.

CONCLUSIONS

The major factor determining outcome was the severity of the soft-tissue injury. Progressive necrosis and infection was a major cause of late amputation. The MESS is not sufficiently precise to allow the decision regarding amputation to be made at the initial operation.

Codon 12 ras mutations in patients with myelodysplastic syndrome: incidence and prognostic value

To determine the prevalence of activated rasoncogenes (N-ras, Harvey-ras Kirsten-ras), DNA derived from peripheral blood of 51 patients with myelodysplastic syndrome (MDS) was investigated. The method was based on the polymerase chain reaction (PCR) technique to amplify DNA, followed by restriction fragment length polymorphism (RFLP) analysis. Among the French-American-British (FAB) subtypes, N-ras mutations were found in two patients with refractory anemia with excess of blasts (RAEB), in one patient with refractory anemia with excess of blasts in transformation (RAEB-t), and in two patients with chronic myelomonocytic leukemia (CMML). MDS patients with a mutation at codon 12 of the N-ras gene showed shorter survival duration than other MDS patients of the same FAB subtypes, although these findings proved to be not statistically significant (P > 0.1). Interestingly, all but one patient with N-ras mutation developed acute myelogenous leukemia (AML). In conclusion, the presence of mutation at codon 12 of the N-ras gene might serve as a negative prognostic factor at diagnosis of MDS.

'Trash foot' following operations involving the abdominal aorta

BACKGROUND

Acute lower limb ischaemia following aortic surgery is commonly termed 'trash foot'. The exact cause of the ischaemia is unknown, but it has been attributed to athero-emboli from native arteries, thrombo-emboli from any prosthetic graft or thrombosis of small vessels in the distal arterial tree.

METHODS

Review of 1601 aortic reconstructions performed between 1976 and 1995.

RESULTS

'Trash foot' occurred in 32 patients (44 limbs): 23 cases followed aortic aneurysm repair and nine cases followed an aorto-femoral bypass for occlusive disease. Six cases of 'trash foot' (13.6%) underwent an early amputation (one above-knee, two below-knee and three cases of amputation of one or more toes) while a further nine cases (20.5%) underwent a delayed amputation (four above the knee, two below the knee and three cases of toe amputation). Eight patients (25%) with 'trash foot' died within 30 days of surgery.

CONCLUSION

'Trash foot' following aortic surgery is an unwelcome complication that is associated with a high morbidity and mortality. Attempts to reduce the incidence involve early mobilization and clamping of the iliac arteries, and irrigation of the aortic anastomosis and graft with heparin saline solution.

Fine-needle aspiration cytology of metastatic ovarian carcinoma to the breast

Metastatic ovarian carcinoma to the breast is rare. It represents a diagnostic challenge to the cytologist. It usually signifies a progressive widespread metastatic ovarian tumor with a poor prognosis. This report evaluates the breast fine-needle aspiration (FNA) cytomorphologic features of six cases of metastatic ovarian carcinoma and compares them to those reported in the literature. The cytologic features included hypercellularity, abundant papillary fragments, and necrotic background. The tumor cells showed high nuclear/cytoplasmic ratio, anisonucleosis, prominent nucleoli, and psammoma bodies in cases of serous papillary carcinoma. In addition, the clear-cell carcinoma had prominent finely vacuolated and clear cytoplasm, multinucleated giant cells, and papillary fragments with hobnail nuclei. Recognition of these unusual patterns in a breast FNA cytology should raise the suspicion of a metastatic ovarian tumor. Direct comparison between the breast FNA cytology and the original primary ovarian tumor should confirm the diagnosis. The proper diagnosis of metastatic ovarian cancer to the breast will prevent unnecessary surgical treatment and ensure the appropriate therapy.

Treatment of high risk myelodysplastic syndromes with idarubicin and cytosine arabinoside supported by granulocyte-macrophage colony-stimulating factor. (GM-CSF)

In this prospective study, patients with "high risk' primary MDS, namely RAEB or RAEBt, were treated with combination chemotherapy (CT) supported by GM-CSF. The induction CT consisted of idarubicin 6 mg/m2 days 1-3 and cytosine-arabinoside 200 mg/m2 in 12 h infusion, days 1-5. The GM-CSF 3 micrograms/kg s.c. was given on day 6 until the neutrophil count was 1 x 10(9)/l. Postremission CT consisted of two similar courses. Patients not in remission after two courses of CT were considered as treatment failures. Twenty-two patients with a median age of 64 years, range 50-79 years (11 RAEB and 11 RAEBt) were evaluable. Twelve out of 22 patients (54.5%) achieved complete remission (CR) and four, partial remission. Six patients were resistant to treatment; there were two toxic deaths; seven patients achieved CR after the first course and five after two courses. The median time of neutrophil recovery to 1 x 10(9)/l was day 15 (range 3-22) after the first course of treatment and day 14 (range 4-21) after the second. Thirteen out of 22 patients developed febrile episodes after the first course of treatment and nine after the second. The median duration of CR was 12 months. The median survival for CR patients was 24 months, for non-CR patients, 12 months; while survival for the whole population was 18 months. In conclusion, the results of this study indicate that the administration of moderately intensive CT supported by GM-CSF in "poor risk' MDS gives promising results; the response rate is high for this disease, while the incidence of toxic death is low. GM-CSF appears to accelerate neutrophil recovery and probably reduces the incidence of infection.

Efficacy of balloon angioplasty of the superficial femoral artery and popliteal artery in the relief of leg ischemia

PURPOSE

To assess the efficacy of balloon angioplasty in the superficial femoral artery (SFA) and popliteal artery for relief of lower-limb claudication and critical ischemia.

METHODS

All patients who underwent SFA or popliteal balloon angioplasty at the Royal Adelaide Hospital between January 1989 and September 1994 were reviewed. Risk factors, indications, angiographic variables, and complications were assessed. Outcome was expressed in life-table form as patency, limb survival, and patient survival rates.

RESULTS

One hundred seventy-six patients (96 men, 80 women) who underwent 200 balloon angioplasty procedures were monitored for a mean of 25 months. Seventy-four percent of procedures were for claudication relief and 26% for critical ischemia. The cumulative patency rate at 24 months for all cases was 46%. The limb salvage rate was 95%, and the patient survival rate was 91% at 24 months.

CONCLUSION

Percutaneous transluminal angioplasty of the SFA and popliteal arteries is commonly used to treat claudication and critical ischemia but is associated with a high initial failure rate and poor patency at 24 months. Balloon angioplasty is not recommended to treat claudication.

Primary extranodal non-Hodgkin's lymphoma in adults: clinicopathological and survival characteristics

Among 318 cases of non-Hodgkin's lymphoma (NHL) treated in our unit, 145 (45.6%) had primary extranodal NHL (PE-NHL). The stomach was the most common site (42.1%), followed by the PE-NHL of the head and neck region. Histologically aggressive histologies (65.5% intermediate and 20.7% high grade) predominated. 89.6% of the cases were localized (stage IE, 51% and stage II, 38.6%) but 28% had B symptoms. CR was achieved in 82.1% of the cases. 5-years disease free survival and overall survival were both 65%. Factors that influence prognosis were stage and high grade histology. Among various primary sites the Waldeyer's ring, small intestine and testes had the worse prognosis. Compared to nodal NHL, the PE-NHL were more frequently localized, belonged more often to aggressive histologies and had more often distal extranodal relapses. CR rates and disease free and overall survival were significantly better for PE-NHL. The survival rates, however, listed according to stage and histology for nodal and PE-NHL were not different. We conclude that although PE-NHL differed from nodal NHL in several respects, prognosis is mainly a factor of stage and histology rather than of the primary localization per se.

Infected false aneurysms of the carotid arteries after carotid endarterectomy

OBJECTIVE

To determine the incidence and management of infected false aneurysms following carotid endarterectomy.

DESIGN

Case notes of patients undergoing carotid endarterectomy (CEA) between the years of 1980 and 1993 at two major teaching hospitals, or those patients who represented with complications were reviewed.

RESULTS

Eight patients were identified with infected false aneurysms, an incidence of 0.625%, in five CEA had been performed at one of the teaching hospitals, whilst in three other cases the primary operation had been done elsewhere. Presentation was a median 19 days following CEA. In five cases the original arteriotomy was closed by direct suture whilst in three a saphenous vein patch was used. Staphylococcal organisms were cultured in all cases. Antibiotics had not been administered at the original operation. Repair with saphenous vein graft from the common to the internal carotid artery had the least complications.

CONCLUSION

Infected false aneurysms are a rare complication following CEA, resection of the false aneurysm and reconstruction with autologous saphenous vein is recommended. Ligation alone is associated with a high incidence of stroke.

Locoregional chemotherapy versus locoregional combined immuno-chemotherapy for patients with advanced metastatic liver disease of colorectal origin: a prospective randomized study

BACKGROUND/AIMS

This reports presents the results of a prospective randomized controlled study of combined locoregional targeted immuno-chemotherapy for treatment of patients with liver metastasis from primary colorectal malignancies.

MATERIALS AND METHODS

Forty eight patients were randomly assigned into one of two groups. Group A (n = 15) included patients who had post-operatively locoregional chemotherapy and Group B (n = 33) included patients who had combined locoregional immuno-chemotherapy.

RESULTS

Statistical analysis shows a clear superiority in the survival and responses of patients treated with immuno-chemotherapy versus chemotherapy alone. Forty five percent of patients in Group B are alive with a mean survival of 20.3 months, ranging from 13 to 29 months, as opposed to no survivors from Group A and a mean survival of only 9.9 months, ranging from 3.6 to 22.5 months. Additionally, 64% of the immuno-chemotherapy group had a positive response while only 13% of the chemotherapy had such a response.

CONCLUSIONS

Our data supports the value of combined immuno-chemotherapy as a treatment for advanced metastatic liver disease.

Cytogenetic study of 11 gastric adenocarcinomas

We describe the cytogenetic findings in 11 gastric cancer cases. Nine cases showed a variable number of numerical and structural aberrations, while two cases had a normal karyotype. The chromosomes most frequently involved are chromosome 3 in six cases, 6 in four cases, and 13 in three cases. They mainly exhibited structural aberrations. An additional segment on chromosome 3p was observed in three cases, while two cases had a del(3q). A der(5) chromosome resulting from a translocation between chromosomes 3 and 5 was observed in two cases. Both cases had also a del(6q), a der(12), and an add(17p) chromosome as common abnormalities. Deletion of 6q chromosome distal to band 6q21 was observed in three cases. Trisomy 8 as a sole anomaly was found in one case. Our cytogenetic findings are discussed in relation to the reported in the literature data.

Somatostatin and octreotide in the management of acute variceal hemorrhage

In recent years, somatostatin and its long-acting analogue octreotide have been used as the initial treatment in acute variceal hemorrhage, with conflicting results. The aim of this study was to meta-analyse all the randomised controlled trials published in English, in which somotostatin or octreotide was compared with other vasoactive drugs, balloon tamponade and endoscopic sclerotherapy in variceal hemorrhage. Concerning the control of bleeding, somatostatin or octreotide therapy was shown to be significantly better than the other vasoactive drugs (p < 0.0012, x2 = 10.55). In contrast, the effectiveness of both agents appeared to be similar to that of balloon tamponade and sclerotherapy in arresting acute variceal hemorrhage during the infusion period. Regarding the complication rate, it appears that treatment with somatostatin or octreotide is followed by a significantly lower complication rate as compared with the other vasoactive drugs (p < 0.0001, x2 = 16.47) as well as than endoscopic sclerotherapy (p, 0.0002, x2 = 14.16). In conclusion, the results of this study suggest that in acute variceal hemorrhage, somatostatin or octreotide is better than any other combination of vasoactive drugs. As regards comparison with sclerotherapy or balloon tamponade, further evidence of benefit is needed before a recommendation can be made for the use of instead of these two kind of treatments of the former procedures.

Insulin sensitivity and antiandrogenic therapy in women with polycystic ovary syndrome

Polycystic ovary (PCO) syndrome is strongly associated with insulin resistance and the accompanying adverse metabolic profile. To distinguish the mechanisms of this association, we determined the interactions of PCO with obesity and the influence of ameliorating direct androgenic actions via short-term treatment with the antiandrogen flutamide. Insulin sensitivity was determined by the hyperinsulinemic euglycemic clamp in groups of lean and obese PCO women and weight-matched controls. Compared with control values, insulin-mediated glucose utilization in PCO women was significantly lower in lean (1.96 +/- 0.17 v 1.24 +/- 0.10, P < .01) and obese (1.23 +/- 0.18 v 1.03 +/- 0.09 mmol/m2/min, P < .01) subjects. ANOVA indicated that the effects of obesity and androgenicity are independent and additive. In both lean and obese PCO women, treatment with flutamide for 1 or 3 months markedly improved the clinical and biochemical androgenic features, but did not significantly influence the overall insulin sensitivity. A large disparity between individuals in the response to treatment correlated significantly with a simultaneous reduction in plasma levels of dehydroepiandrosterone sulfate (DHEA-S). Thus in women, PCO and obesity exert synergistic effects on insulin resistance. The decreased insulin sensitivity is mediated via indirect androgenic actions or nonandrogenic mechanisms. In some individuals, a direct effect of androgens might have been masked by a decrease in DHEA-S levels.

Acute lymphoblastic leukemia with a variant Philadelphia translocation, der(9), and der(19) chromosomes

We report here one of 15 cases of acute lymphoblastic leukemia (ALL) cytogenetically studied, with hypodiploidy, a variant Ph translocation, and der(9) and der(19) chromosomes. The patient, a 14-year-old girl, underwent combination chemotherapy and bone marrow transplantation and is still in remission 22 months after transplantation.

Influence of a vein cuff on polytetrafluoroethylene grafts for primary femoropopliteal bypass

A retrospective investigation was performed to study the benefit obtained from a vein cuff inserted at the distal anastomosis of a primary femoropopliteal bypass graft with polytetrafluoroethylene (PTFE). When PTFE was preferred to vein an attempt was made to assess whether there was subsequent use for the spared vein. A series of 559 primary PTFE bypasses was studied and found to have a cumulative patency rate of 62 per cent at 36 months. Subgroups were also studied for a similar period. In the above-knee position there was no difference in the primary patency rate of PTFE with or without a cuff at 36 months (69 versus 68 per cent, P = 0.89). Below the knee, grafts with a cuff had a better 36-month patency rate than those without (57 versus 29 per cent, P = 0.01). Cuffed PTFE for claudication had a better patency rate than that for threatened limbs at 36 months (68 versus 60 per cent, P = 0.03). Thrombectomy of occluded cuffed PTFE grafts improved the 36-month patency rate from 64 to 74 per cent. The limb salvage rate at 36 months was 97 per cent for claudication and 89 per cent for threatened limbs with cuffed PTFE. Occlusion of cuffed PTFE was associated with preservation of outflow in 91 (51 per cent) of 179 cases, permitting subsequent graft thrombectomy or insertion of a new bypass. Spared vein was rarely used to salvage an occluded PTFE graft, and was associated with poor patency and a high amputation rate. Although this study does not support the use of PTFE for the primary graft, PTFE with a vein cuff interposed at the distal anastomosis is a reasonable substitute when vein is not available.

Tuberculous esophagitis. Report of a case and review of modern approaches to diagnosis and treatment

We describe a patient with tuberculous esophagitis who was referred to us with low-grade fever, but no esophageal symptoms. The diagnosis was established in biopsies obtained from a deep midesophageal ulcer seen on endoscopy. Investigation of the patient failed to identify any extra-esophageal tuberculous foci, but a computed tomography scan revealed mediastinal lymphadenopathy without lung involvement. Primary infection of the esophagus by tuberculosis is questioned, and widespread use of computed tomography may show it to be a fiction.

delta-Aminolaevulinic acid dehydratase as an index of lead toxicity. Time for a reappraisal?

delta-Aminolaevulinic acid dehydratase activity is traditionally accepted as the most sensitive measurable biological index of lead toxicity. We have measured delta-aminolaevulinic acid dehydratase activity and blood lead concentration in 47 healthy controls (A), 42 iron deficient patients (B) and 38 occupationally exposed to lead subjects (C). Blood lead levels [mean (SD)] did not differ between groups A and B [0.51 (0.21) and 0.43 (0.19) mumol L-1, respectively] while those of group C [2.28 (0.56) mumol L-1 were significantly higher (P < 0.001) as compared to the controls. delta-Aminolaevulinic acid dehydratase activity [mean (SD)] was significantly increased [3599 (1909) mumol L-1 h-1] in group B and decreased in group C [1052 (532) mumol L-1 h-1] as compared to the controls [2034 (446) mumol L-1 h-1] (P < 0.001). There was a significantly negative correlation of logarithm of delta-aminolaevulinic acid dehydratase with lead in both groups B (P < 0.05) and C (P < 0.001) but not in group A (P = 0.1). delta-Aminolaevulinic acid dehydratase activity had a high specificity (100%) but a low sensitivity (37%) as an index of toxic lead exposure. According to our data the value of delta-aminolaevulinic acid dehydratase measurement in the diagnosis of lead intoxication is doubtful in cases with low blood lead levels, while in the presence of iron deficiency its reliability is further reduced, since low blood lead levels may be falsely predicted. delta-Aminolaevulinic acid dehydratase activity should be restricted only to monitoring cases with moderate or severe lead poisoning.

The fate of the aortofemoral graft

OBJECTIVE

To determine the incidence and cause for reoperation following aortofemoral bypass surgery.

DESIGN

This paper describes the results of all aortofemoral grafts performed in the years 1978-1991, 251 of these patients underwent an aortobifemoral graft (ABF) whilst the remaining 50 had an aortounifemoral graft (AUF).

RESULTS

The aortofemoral bypass was the only operation performed in fewer than half of the patients. Sixteen per cent of ABF and 50% of the AUF patients had surgery before the index operation. Subsequently 33% of the ABF patients and 60% of the AUF group had one or more additional vascular procedures. Graft infections and false aneurysms continued to present in about 1% patients per year at least up to 10 years following surgery. The 5 year actuarial survival was 73% in the ABF group and 38% in the AUF patients. The primary patency at 5 years was 85% in the ABF patients and 81% in the AUF group. Amputation was performed in 6% of the ABF patients and in 20% of the AUF patients.

CONCLUSIONS

The frequent need for later surgery (1:3 for the ABF patients) should be considered in the decision to undertake the initial aortofemoral operation when the patient presents with intermittent claudication.

Upper extremity arterial injuries: experience at the Royal Adelaide Hospital, 1969 to 1991

PURPOSE

A review of upper extremity arterial injuries managed at the Royal Adelaide Hospital between 1969 and 1991 was undertaken because the optimal management of complex upper extremity trauma, particularly in proximal injuries, remains unclear.

METHODS

Patients were identified from the computer registry of patients treated by the vascular unit at the Royal Adelaide Hospital. They were studied in three groups: (1) subclavian and axillary artery, (2) brachial artery, and (3) radial and ulnar artery injuries. The mechanism of injury, associated injuries, treatment and outcome were reviewed.

RESULTS

There were 114 patients with upper extremity arterial injuries: 28 with subclavian and axillary, 62 with brachial, and 24 with radial and ulnar artery injuries. Good upper limb function was obtained in 32% of subclavian and axillary artery injuries, 79% of brachial artery injuries, and all radial and ulnar artery injuries. Amputation was performed in 14% of the proximal injuries and 8% of the brachial artery injuries. Three deaths occurred in this study group.

CONCLUSION

Blunt proximal injuries were usually associated with neurologic, soft tissue, and bony damage, which was responsible for the poor functional outcome. Critical limb ischemia or severe hemorrhage rarely occurred. Complete brachial plexus lesions resulted in uniformly poor outcomes. More distal injuries were associated with fewer nerve and soft tissue injuries, resulting in a more satisfactory outcome.

Duplex ultrasonography of recurrent varicose veins

Varicose veins are a common clinical finding with a high recurrence rate following treatment with either surgery or sclerotherapy. Patterns of incompetence in 100 limbs with recurrent varicose veins were determined using duplex ultrasonography. Saphenofemoral or recurrent groin tributary incompetence was present in 44 limbs, an incompetent long saphenous remnant in 20, saphenopopliteal incompetence in 28, perforator incompetence in 35 and deep venous incompetence in 22. No significant incompetence was detected in 15 limbs. The findings suggest an important role for deep venous incompetence in recurrent veins and show that a re-exploration of the groin is unnecessary in over half of limbs with recurrent veins.

Urinary gastrin output and serum gastrin in patients with liver cirrhosis. Urinary gastrin output in cirrhosis

The aim of the present study was to examine the diurnal urinary gastrin output in cirrhotics and to clarify whether in patients with hepatorenal syndrome urinary gastrin output is reduced. Thirty-two cirrhotics and 25 age- and sex-matched, controls were studied. Cirrhotics were divided into 3 groups: (I: without ascites and normal serum creatinine; II: ascites and normal creatinine; III: ascites and increased creatinine). Mean fasting serum gastrin concentration was lower in the control group than in Group I, II (p < 0.01) or III (p < 0.001). In this latter group mean serum gastrin concentration was significantly higher (p < 0.001) than in the other two groups of cirrhotics. The mean 24 h urinary gastrin output was lower (p < 0.001) in Group III patients than in the other groups of subjects studied. Also in the controls urinary gastrin output was lower (p < 0.01) than in Groups I and II. These findings suggest that: a) in cirrhotics with normal serum creatinine the average serum gastrin levels over the course of the day are indeed higher than in normals and b) In cirrhotics with hepatorenal syndrome, impaired urinary gastrin output appears to contribute significantly to their hypergastrinemia.

Progression toward malignancy of hamartomas in a patient with Peutz-Jeghers syndrome: case report and literature review

Peutz-Jeghers syndrome, inherited in an autosomal dominant fashion, is characterized by hamartomatous polyps of the gastrointestinal tract and by mucocutaneous pigmentation. The frequency of gastrointestinal malignant disease in this syndrome is estimated to be 2% to 3%. The authors review reports associating Peutz-Jeghers syndrome with malignant disease and present a patient who had advanced jejunal adenocarcinoma in association with Peutz-Jeghers syndrome. It has not been determined with certainty whether the malignant lesions arise from hamartomas, from associated adenomatous polyps or from the normal mucosa. Histologic examination of the excised specimen from the patient reported in this paper showed areas typical of a hamartoma as well as areas of hyperplasia, adenoma with mild to severe dysplasia and carcinoma in situ all in the same polyp. These findings suggest that the hamartomatous polyps found in Peutz-Jeghers syndrome have the potential to undergo malignant transformation.

Vascular complications of elective lower lumbar disc surgery

Lower lumbar disc surgery is an extremely common operation from which vascular complications are reported rarely. However vascular injury can occur with perforation of the anterior longitudinal ligament. External haemorrhage is uncommon and the true cause of the patient's hypotension may be misdiagnosed. If the hypotension is severe or prolonged laparotomy is indicated, to prevent exsanguination and to effect a repair of the vascular injury. Alternatively, if the injury is missed, an arteriovenous fistula may develop; this diagnosis may be delayed for months or years. One case of severe haemorrhage following lower lumbar disc surgery is reported and a further 69 cases of similar arterial injury have been reviewed from the world literature.

Furosemide-induced hyperglycaemia: the implication of glycolytic kinases

Hyperglycaemia is a well known adverse effect of therapy with diuretics. In adipose tissue, hydrochlorothiazide and furosemide inhibit the rate of glucose transport. In skeletal muscle, furosemide decreases the rate of glucose phosphorylation and glycolysis. However, whether furosemide has any direct effect on the activities of any of the glycolytic enzymes is not known. In the present study, the effects of furosemide on the activities of the hexokinase, phosphofructokinase and pyruvate kinase were examined. Pieces of skeletal muscle (quadriceps) and liver were obtained from 10 non-diabetic subjects during surgery. Tissues were homogenized and the activities of the enzymes were measured in the presence or absence of furosemide (0-1.5 mM). Furosemide inhibited the activity of all three key glycolytic enzymes. The concentration of furosemide required to inhibit phosphofructokinase in muscle was lower than that required to inhibit the activity of this enzyme in the liver or to inhibit the activities of hexokinase and pyruvate kinase in both muscle and liver. These direct effects of furosemide may contribute to the decrease in glucose utilisation following therapy with this and similar agents in man.

Reversibility of unawareness of hypoglycemia in patients with insulinomas

BACKGROUND

A lack of appropriate autonomic warning symptoms before the development of neuroglycopenia occurs frequently in patients with diabetes mellitus. The pathogenesis of this phenomenon is unclear, but it is associated with intensive insulin therapy, prolonged duration of diabetes, frequent episodes of hypoglycemia, and impaired glucose counterregulation. Recently, it has been proposed that repeated episodes of hypoglycemia may themselves induce the phenomenon.

METHODS

To test this hypothesis and to determine whether the phenomenon is reversible, we assessed autonomic and neuroglycopenic symptoms, counterregulatory hormonal responses, and cognitive function during stepped hypoglycemic-clamp studies in 6 patients with insulinomas before and approximately six months after curative surgery and in 14 normal subjects matched for age, weight, and sex.

RESULTS

Before surgery, the patients with insulinomas had lower scores than the normal subjects for autonomic symptoms (mean [+/- SD], 3.5 +/- 0.8 vs. 9.6 +/- 4.5) and neuroglycopenic symptoms (2.8 +/- 1.5 vs. 8.9 +/- 5.3). The patients also had impaired counterregulatory hormonal responses (their plasma epinephrine, norepinephrine, glucagon, growth hormone, and cortisol responses before surgery were 187 +/- 227 pg per milliliter [1.03 +/- 1.25 nmol per liter], 223 +/- 85 pg per milliliter [1.32 +/- 0.50 nmol per liter], 86 +/- 21 ng per liter, 7.4 +/- 5.2 micrograms per liter, and 12.1 +/- 1.5 micrograms per deciliter [334 +/- 41 nmol per liter], respectively, as compared with 842 +/- 439 pg per milliliter [4.63 +/- 2.41 nmol per liter], 519 +/- 150 pg per milliliter [3.07 +/- 0.89 nmol per liter], 201 +/- 58 ng per liter, 25.3 +/- 13.7 micrograms per liter, and 26.3 +/- 1.2 micrograms per deciliter [726 +/- 33 nmol per liter] in the normal subjects) and less deterioration in cognitive function than the normal subjects during hypoglycemia (sum of z scores for seven tests of cognitive function, 1.7 +/- 1.9 vs. 8.9 +/- 3.5) (P < 0.02 for all comparisons). Surgical cure reversed all these abnormalities (P not significant for all comparisons with the normal subjects).

CONCLUSIONS

Hypoglycemia itself can induce unawareness of the autonomic and neuroglycopenic symptoms of hypoglycemia and decrease the counterregulatory hormonal responses to hypoglycemia.

Propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing endoscopic sclerotherapy. A randomized controlled trial

The purpose of this study was to investigate the possible value of continuous administration of propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing chronic endoscopic sclerotherapy. Among 239 patients admitted for acute variceal bleeding, 85 with cirrhosis were randomized to receive sclerotherapy either alone (40) or in combination with propranolol (45). Sclerotherapy was carried out with an intravariceal injection of 5% ethanolamine oleate through a fiberoptic endoscope. The procedure was performed every week, until the esophageal varices at the gastroesophageal junction were too small for any further injections. Varices were reinjected if they recurred. Propranolol was given orally twice a day until heart rate was reduced by 25% in the resting position. The mean follow-up period was 23.2 and 24.2 months for sclerotherapy and the sclerotherapy plus propranolol groups, respectively. During this period a significant (P = 0.001) reduction in the recurrence of esophageal varices was observed in patients treated with the combination of sclerotherapy plus propranolol compared with those treated with sclerotherapy alone. However, the time of rebleeding from any source or from esophageal varices did not differ significantly between the two groups. In the sclerotherapy group 21 patients rebled (35 bleeding episodes) compared with 14 (22 episodes) in the combination therapy group. Patients in the sclerotherapy group were more prone to bleed from gastric varices and congestive gastropathy than patients treated with the combination of sclerotherapy plus propranolol (P = 0.012). Twenty-five patients in the endoscopic sclerotherapy group developed complications attributed to sclerotherapy compared with 23 patients in the sclerotherapy plus propranolol group. Complications directly attributable to propranolol were observed in 11 patients. Three of these patients stopped taking the drug due to heart failure (1) and flapping tremor (2). Eight patients (17.8%) died in the latter group while the corresponding figure in the sclerotherapy group was nine (22.5%). It is concluded that the continuous administration of propranolol may reduce incidences of recurrent upper gastrointestinal hemorrhage from gastric sources in patients with cirrhosis undergoing chronic sclerotherapy.

Femorocrural grafting and regrafting: does polytetrafluoroethylene have a role?

Between 1980 and 1988, 263 patients received 307 femorocrural bypass grafts. 180 were primary infrainguinal grafts, 106 secondary, 18 tertiary and three quaternary. Rest pain or tissue loss was the indication in 96% of cases. Outflow vessels were the tibioperoneal trunk (n = 34), posterior tibial artery (n = 115), peroneal artery (n = 89) and anterior tibial artery (n = 69). 88 primary vein grafts were completed. 201 polytetrafluoroethylene (PTFE) grafts were inserted (92 primary and 109 subsequent reconstructions). There were no direct PTFE to crural vessel anastomoses. A Miller cuff was used in the majority (n = 175). The three year primary patency for primary vein grafts (36%) was similar to primary PTFE grafts (29%), but significantly higher than subsequent PTFE grafts (20%) (p = 0.03). Three year foot salvage for primary vein grafts (65%) was similar to primary PTFE (64%), but significantly better than subsequent PTFE (42%) (p = 0.02). The results support both redo femorocrural grafting for critical ischaemia, as judged by foot salvage rates, and the use of PTFE with a distal vein cuff in primary and subsequent femorocrural reconstruction if autologous vein is not available.

Vaginal squamous cell carcinoma with sarcomatoid spindle cell features

A vaginal squamous cell carcinoma with prominent sarcomatoid spindle cell features found in a 25-year-old female is presented. The exclusively spindle-shaped growth pattern of the neoplastic cells in the initial biopsy led to the diagnostic impression of a sarcoma. This in turn has resulted in an attempt at completely resecting the tumor. The 5.2 x 3.5-cm resected lesion, however, blended peripherally with a poorly differentiated squamous cell carcinoma. Moreover, the sarcomatoid component reacted with vimentin and cytokeratin, and tonofilaments and desmosomes were seen by electron microscopy. This apparently unique case indicates the need for obtaining representative tissue samples for providing an appropriate diagnosis prior to definitive therapy for vaginal squamous cell carcinoma. The primary treatment for large stage I squamous cell lesions of the vagina is radiotherapy, whereas an equally large sarcoma is best treated by wide local excision alone.

Toxic megacolon secondary to acute ischemic colitis

A 72-year-old woman without significant medical history was admitted with abdominal pain, high fever, leukocytosis, bloody diarrhea and marked dilation of the transverse, descending and sigmoid colon. Toxic megacolon was diagnosed and responded well to medical treatment. Seven weeks after her admission, however, the patient developed a stenotic lesion in the sigmoid colon. The lesion was managed surgically. Histological examination of the resected colon revealed resolving ischemic colitis affecting only part of the thickness of the intestinal wall. The patient has been healthy since the surgery, i.e., for two years.

Thrombotic thrombocytopenic purpura: a multimodality model of treatment including plasma exchange, i.v. immunoglobulin, prednisone, antiplatelet agents, vincristine and splenectomy

Thirteen patients with thrombotic thrombocytopenic purpura were treated at our facility between 1985 and 1991. All patients were treated with plasma therapy (both plasma exchange and plasma infusions), prednisone, intravenous immunoglobulin, and antiplatelet agents. Twelve patients achieved remission (92.3%). One patient died from cerebral hemorrhage. Vincristine was administered to 5 patients who did not respond after the first two plasmaphereses. Splenectomy was performed in a patient who relapsed four times within a 2-year period. From the 12 patients achieving remission, 11 have been still in remission for a period of 3 to 69 months.

Treatment of myelodysplastic syndromes with human granulocytic-macrophage colony stimulating factor (GM-CSF) or GM-CSF combined with low-dose cytosine arabinoside

In a phase II study, 21 patients with MDS (RAEB, RAEBt, CMML and RA and RAS with severe cytopenia) were randomized to be treated with 3 courses of GM-CSF (3 micrograms/kg/day s.c.) alone (11 patients) or in combination with AraC (20 mg/m2/d s.c.) (10 patients) for 14-d periods, interrupted by 14-d rest periods. Eight patients discontinued the treatment. In the GM-CSF group a marked increase in WBC and neutrophil counts during each course of treatment administration were seen in most patients. Platelet counts decreased in 14 of 24 courses of treatment in the GM-CSF plus AraC group but in none of the GM-CSF group. Although the changes in the circulating blood cells were transient and the counts tended to return to the pretreatment levels during the rest periods, some more durable effects were seen. In 3/6 patients of the GM-CSF group who completed the designed treatment, both WBC and neutrophils remained elevated above the pretreatment levels throughout the 3-month period of treatment, while in one of them thrombocytopenia improved considerably. In the GM-CSF plus AraC group, 4 out of the 7 patients who completed the treatment showed an improvement of neutropenia as well as anaemia. In these 4 patients the BM percentage of blasts was also decreased. In conclusion, the results of this study indicate that GM-CSF given intermittently improves leukopenia in some patients with MDS. In addition, the administration of GM-CSF seems to prevent granulocytopenia of concurrent AraC treatment and may be of benefit in the treatment of these diseases.

Duplex ultrasound mapping of sites of deep to superficial incompetence in primary varicose veins

Most patients undergoing treatment for primary varicose veins have only a clinical assessment or examination with a continuous wave Doppler. In this study duplex ultrasound was used to determine the site of deep to superficial reflux in 137 limbs of 96 patients presenting with primary varicose veins. The incidence of saphenopopliteal (22%) and perforator (28%) incompetence was higher than that in previous studies based on clinical examination. Only five limbs had deep venous incompetence at the popliteal level and three of these limbs had lipodermatosclerosis or ulceration. The saphenopopliteal junction was either absent or more than 10 cm from the knee joint in 13% of limbs. The information obtained from duplex scanning of patients with primary varicose veins facilitates surgical management and may lead to a lower recurrence rate.

The effect of an eucaloric high carbohydrate diet on circulating levels of glucose, fructose and non-esterified fatty acids in patients with cirrhosis

Twelve cirrhotic patients and six controls were fed an eucaloric high carbohydrate (CHO) diet for 3 days. Fasting serum triglyceride (TG), non-esterified fatty acids (NEFA), glucose, insulin and glycerol were estimated daily. On the 3rd day of the study we measured NEFA, glucose, insulin, and fructose every 45 min from 07:45 h until 19:45 h, and then every 4 h until 07:45 h the next day. The patients were divided into two groups of six on the basis of plasma lecithin-cholesterol acyltransferase (LCAT) activity: group A cirrhotics (with good liver function--LCAT activity: 40.6-65.7 nmol.ml-1.h-1; mean 48.5), and group B (poor liver function--LCAT: 23.7-32.3; mean 27.4). On the high CHO diet there was an increase in the fasting serum TG with a peak after 2 or 3 days. The increase in serum TG in controls was greater (p less than 0.01) than in either group of cirrhotics. In the controls and in group A most of the extra TG was carried in VLDL; in group B only 39% of the TG increment was found in VLDL. Fasting NEFA fell with 3 days of CHO feeding in the control group (p less than 0.01); they were unchanged in group A, and rose in group B to a significantly higher level than in controls (p less than 0.01). During day 3 when a high CHO diet was fed plasma NEFA levels fell in cirrhotics, and for most of the day the mean NEFA concentration in group B patients was significantly (p less than 0.05) lower than in normals. On day 3 glucose and fructose levels rose after each meal--much more in cirrhotics than in controls (and more in group B than in group A), and for most of the day they were significantly higher in group B patients as compared to the controls (glucose p less than 0.01, fructose p less than 0.001). Our results supported the hypothesis that plasma NEFA would be lower following high CHO meals in cirrhotics than in controls. This suggests that a high NEFA utilisation, which occurs in fasting cirrhotics, is not present throughout the day. Following a CHO meal, we suggest that tissues derive energy directly from the dietary sugars which are present in high concentration during the period of absorption and that this reduces the post prandial requirement for NEFA.