Indications For Operative Intervention Research Articles

Management of Blunt Abdominal Trauma in Children

Surgery| July 01 2002 Management of Blunt Abdominal Trauma in Children AAP Grand Rounds (2002) 8 (1): 8–9. https://doi.org/10.1542/gr.8-1-8-a Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Management of Blunt Abdominal Trauma in Children. AAP Grand Rounds July 2002; 8 (1): 8–9. https://doi.org/10.1542/gr.8-1-8-a Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: blunt abdominal injuries, splenectomy, spleen injuries Sources: (1) Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children with blunt splenic trauma. J Pediatr Surg. 2002;37:294–299. (2) Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg. 2002;37:386–389. Two articles by investigators at the University of Pittsburgh and Children’s Hospital of Pittsburgh, Pennsylvania, examine issues related to blunt abdominal trauma in children. The first study reports a retrospective review of 754 children (ages 0–16) who received care for blunt splenic trauma between 1993–1997 at 1 of 2 pediatric and 24 adult trauma centers and were identified through the Pennsylvania Trauma Outcome Study registry. Factors associated with increased frequency of splenectomy were identified using multivariate logistic regression. Of the 754 children with splenic injury, 15% underwent splenectomy, 7% were managed with operative splenic repair (splenorrhaphy), and 78% of children were managed non-operatively. Factors associated with splenectomy included increased grade of splenic injury, presence of severe, nonsplenic abdominal injuries, Glasgow Coma Scale of 3–8, and age range of 15–16 years. Children treated at designated pediatric trauma centers had significantly fewer splenectomies than those treated at adult trauma centers (7.8% versus 15.7%, P<.05). Authors of the second article retrospectively reviewed 152 children with blunt hepatic injury treated from 1995–2000 at Children’s Hospital of Pittsburgh and graded liver injury severity based upon CT scan evaluation using the American Association for the Surgery of Trauma (AAST) grading system (Grades I–V). They found that AAST injury grade did not correlate with mortality, hospital length of stay or intensive care unit (ICU) length of stay. The authors conclude that the AAST radiographic liver grading system does not accurately predict outcome in the pediatric population. Both of these studies serve to underscore unique aspects of pediatric trauma management with respect to blunt abdominal injury. The nonoperative management of solid visceral injury has become increasingly accepted in the treatment of the pediatric population and is becoming more so in adult trauma management. Nonetheless, indications for operative intervention are still under refinement, as both of these articles indicate. A 15% splenectomy rate is excessive. A recent article from the American Pediatric Surgical Association Liver/Spleen Trauma Study Group found early operation (for hemorrhage) in only 1.3% of the 316 patients studied.1 While it is generally conceded that operation for solid viscus injury alone (usually identified by CT scanning) is indicated for ongoing, severe hemorrhage, the comfort level of surgeons managing children with any degree of hemorrhage varies greatly. Based on the results in the first article, children treated outside of a designated pediatric trauma center, presumably by non-pediatric surgeons, had far higher rates of splenectomy than those who were in designated pediatric trauma centers. Unfortunately, the second article does not identify a grading system for liver injuries that correlates with severity of injury and thus might serve as a safe triage tool. Based on these studies, the... You do not currently have access to this content.

Carotid endarterectomy in the elderly: does gender effect outcome?

Objectives: Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded octogenarians. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. Additionally, we evaluated the elderly group based on gender. Methods: Over the past 10 years, all patients undergoing CEA for asymptomatic and symptomatic carotid disease have been entered into our vascular surgery registry. Demographics, indications for operative intervention, outcomes and survival of patients who had undergone CEA were reviewed. Procedures were preferentially performed under regional anesthesia with selective shunting. Chi square analysis was used to assess significance and assumed for P<0.05. Results: Over the last 10 years, 125 carotid endarterectomies were performed in 125 patients eighty years of age or older. Fifty-six were male and 69 were female. Mean age was 83 (range: 80–97). Asymptomatic disease was identified in 28 of the male patients (50%) and 44 of the female patients (64%). There were no deaths and a permanent neurological deficit occurred in one female patient. There was no difference in thirty-day morbidity or mortality in female patients compared to males. Conclusions: These observations suggest that CEA can be safely performed in selected elderly patients with asymptomatic or symptomatic carotid artery stenosis. Furthermore, women over 80 may expect equally optimistic results as their male counterparts.

Editorial comment

As surgeons, we have been instilled with the responsibility to assess the outcome of our operative interventions to prove efficacy and optimize patient care. The authors have added to the published data, advancing the argument that cystography is unnecessary for most patients after ureteroneocystostomy. This thesis is predicated on the fact that ureteroneocystostomy is highly successful, and those at risk of failing may be identified by clinical or noninvasive radiographic criteria. Patients who do not fall into such high-risk groups may thus be spared the discomfort and radiation exposure associated with VCUG. This approach appears to contravene traditional practice. When one examines published reports, the criteria whereby patients are considered at risk of failure and require VCUG after reimplantation vary. In the report by Bomalaski et al.1 Bomalaski M.D. Ritchey M.L. Bloom D.A. What imaging studies are necessary to determine outcome after ureteroneocystostomy. J Urol. 1997; 158: 1226-1228 Abstract Full Text Full Text PDF Scopus (37) Google Scholar patients identified as requiring postoperative VCUG included those with voiding dysfunction, preoperative hydronephrosis or renal scarring, and postoperative urinary tract infection. Bisignani and Decter, 2 Bisignani G. Decter R.M. Voiding cystourethrography after uncomplicated ureteral reimplantation in children is it necessary?. J Urol. 1997; 158: 1229-1231 Abstract Full Text Full Text PDF Scopus (57) Google Scholar and El-Ghoneimi et al.3 El-Ghoneimi A. Odet E. Lamer S. et al. Cystography after the Cohen ureterovesical reimplantation is it necessary at a training center?. J Urol. 1999; 162: 1201-1202 Abstract Full Text Full Text PDF Scopus (27) Google Scholar did not analyze the risk factors as such, but mentioned that VCUGs were likely to be obtained in the setting of voiding dysfunction, parental anxiety, and/or a thickened bladder wall noted at surgery. Barrieras et al.4 Barrieras D. Lapointe S. Reddy P.P. et al. Are postoperative studies justified after extravesical ureteric reimplantation?. J Urol. 2000; 164: 1064-1066 Abstract Full Text Full Text PDF Google Scholar showed that high-grade reflux, more commonly seen in males, was a risk factor for reimplantation failure. Lavine et al.5 Lavine M.A. Siddiq F.M. Cahn D.J. et al. Vesicoureteral reflux after ureteroneocystostomy indications for postoperative voiding cystography. Tech Urol. 2001; 7: 50-54 Google Scholar documented that patients with preoperative and postoperative hydronephrosis, renal scarring, and tapered ureteral reimplantations were at higher risk of reimplant failure. In the current study, the authors could not find a correlation with dysfunctional voiding, postoperative hydronephrosis or febrile urinary tract infection and reimplant failure. Thus, given the findings of the retrospective studies previously quoted, it is difficult to reach a consensus on which criteria place a patient at risk of reimplantation failure and merit the performance of a cystogram. One could argue that patients identified as having persistent reflux in the current series were asymptomatic, thus what does the persistence of reflux matter? If this is the case, the indications for operative intervention should be examined, as in this series 39% of patients underwent reimplantation for high-grade or worsening reflux in the absence of infection. If any of these patients went on to fail surgery and remained asymptomatic, the authors have argued it is irrelevant to the patient’s well-being.

Emergent extra-abdominal trauma surgery: is abdominal screening necessary?

To evaluate the necessity of abdominal screening beyond physical examination in awake and alert blunt trauma patients who require emergent extra-abdominal trauma surgery. Data from an urban Level I trauma center was reviewed for all blunt trauma patients who underwent extra-abdominal emergency procedures during the period from January 1995 through August 1998. Awake and alert patients (Glasgow Coma Scale [GCS] score > or = 14) with negative abdominal physical examination results who underwent extra-abdominal emergent surgery were entered in the study. All patients entered were older than 14 years of age, hemodynamically stable, and underwent further abdominal evaluation with computed tomographic scan or diagnostic peritoneal lavage after the decision for extra-abdominal surgical intervention. Emergent surgery occurred within 8 hours of admission. Data was collected for results of diagnostic studies, hemodynamic status, mechanism of injury, indications for operative intervention, and admission blood ethanol (EtOH) levels. A total of 210 patients with an average age of 33 years (range, 14-92 years) were entered in the study. The most common mechanism of injury was motor vehicle crash (67%). Sixty-six (32%) patients presented with EtOH levels > 100 mg/dL; 181 (86%) patients presented with a GCS score of 15, and 29 (14%) presented with a GCS score of 14. The majority of surgical procedures were orthopedic (86%). Diagnostic peritoneal lavage was performed in 55 (26%) patients, and computed tomographic scans were obtained in 155 (74%) patients. Three (1.4%) intraperitoneal injuries were diagnosed in the study population. Two of the injuries were stable grade 1 liver injuries, and missed diaphragmatic injury was diagnosed on postadmission day 1. Before emergent extra-abdominal trauma surgery, abdominal evaluation with physical examination is sufficient to identify surgically significant abdominal injury in the awake and alert blunt trauma patient. Screening with additional studies does not impact patient outcome.

Maxillofacial trauma: principles of management, priorities and basic techniques

The management of maxillofacial trauma involves organs and regions managed by various well-established health care disciplines and is therefore multidisciplinary. The organization of this multidisciplinary care includes: •Facility and personnel - the facility requires all the relevant diagnostic material and the personnel must have a special interest in maxillofacial trauma and form a dedicated team. •Principles of management of facial fractures - these involve setting priorities, understanding the indications for operative intervention and developing techniques, of which one of the most significant is the wider exposure of the maxillofacial skeleton. This, together with interosseous fixation with mini- and microplates and the use of primary bone grafting, has brought about the most significant advances in this area of patient management. Three case studies are presented, the first of which illustrates the management of a fractured zygoma requiring open reduction and internal fixation, using modern radiology to make the diagnosis and to check the correction. Case study two is an orbito-cranial fracture with major cranio-cerebral injury, highlighting the problems associated with a breech of the anterior cranial base and a cerebrospinal fluid rhinorrhoea. The third case illustrates a complex fracture involving the orbit and nasoethmoid complex, maxilla and mandible and illustrates the practical implication of the principles outlined in the paper.

Budd-Chiari syndrome: shunt or transplant?

Background: Budd-Chiari syndrome is an uncommon disorder caused by obstruction to hepatic venous outflow, causing varying degrees of hepatic injury depending on the extent, severity, and acuity of the obstruction. Patients and Methods: We reviewed the indications for operative intervention and the results of treating 32 patients with Budd-Chiari syndrome seen at Toronto Hospital between 1968 and 1995. Results: Twenty-one patients underwent porto-systemic shunt (PSS) and 7 patients underwent liver transplantation (LT) as their initial operative management. Three patients who initially had PSS subsequently required LT. Patients with cirrhosis found on biopsy and preservation of hepatocellular function were treated with PSS and showed no difference in outcome when compared with patients without cirrhosis (P=0.35). Patients who were treated by PSS with retrohepatic vena caval compression, as shown by high caval gradients had outcomes similar to those for patients with low gradients (P=0.31). Using the Kaplan- Meier method, 5-year survival of PSS patients was 57%. Liver transplantation was used to manage patients with hepatic decompensation, as well as patients with vena caval occlusion or failed PSS. The 5-year Kaplan-Meier survival for LT was 67%. Conclusions: Both PSS and LT are effective options in the management of Budd-Chiari syndrome. Portosystemic shunt is the preferred initial approach even with cirrhosis or retrohepatic caval compression as long as there is preservation of liver function and a patent vena cava. Liver transplantation should be used as primary therapy for patients with irreversible hepatic decompensation or vena caval occlusion, and it can be an effective salvage procedure following failed PSS.

Blunt abdominal trauma in children: impact of CT on operative and nonoperative management.

The purpose of this study was to evaluate the impact of CT on operative management of children examined after blunt abdominal trauma. Fifteen-hundred consecutive children who sustained blunt abdominal trauma were prospectively examined with CT. CT findings and the decision for operative or nonoperative management were recorded prospectively. In the children who underwent laparotomy, indications for operative intervention as determined by the attending trauma surgeon and surgical findings were also recorded. Three hundred eighty-eight (26%) of the CT scans had abnormal findings: solid viscus injury, 286; other CT abnormality, 102. Twenty (7%) of 286 children with a solid viscus injury and 25 (83%) of 30 children with a hollow viscus injury underwent therapeutic laparotomy. Abnormalities seen on CT were noted in all 20 children with solid viscus injury and 24 of 25 children with hollow viscus injury who underwent therapeutic laparotomy. The decision for laparotomy was based on CT findings in five (25%) of 20 children with solid viscus injury and 17 (68%) of 25 children with hollow viscus injury. Eleven hundred twelve children (74%) had normal findings on CT. Only one of these children later required laparotomy. CT rarely influenced the decision for operative intervention in children who sustained blunt abdominal trauma. CT findings affected the decision for operative intervention in most children with hollow viscus injury; however, CT findings affected such a decision in only a small subset of children with solid viscus injury. Normal abdominal CT findings strongly predicted a lack of subsequent deterioration requiring operative intervention.

Fiabilité de la cytoponction des nodules thyroïdiens solitaires en vue des indications opératoires

To evaluate the accuracy of fine-needle biopsy in the management of the solitary thyroid nodules, 320 biopsies without aspiration were performed in 212 patients, iteratively in 91 cases. Among the 212 initial biopsies, 93 smears were found presumably benign (43.9%), 6 malignant (2.8%), 49 benign implying cytologic control (23.1%), 24 suspicious with decision to operate (11.3%), 40 inadequate (18.9%). On 67 surgical indications (malignant or suspicious cytology, or clinical data), 59 operations were performed. The 11 diagnosed cancers (5.2% of the patients; 18.6% of the operations) correspond to six malignant and five suspicious cytologies at the first or second biopsy. On 145 cases without decision to operate, 125 were clinically surveyed, with sometimes another biopsy (mean survey: 27.6 months; range: 6-80 months), and it was never necessary to modify the initial expectancy attitude. Our results, rather similar to those related by most of the previous publications, confirm that the fine-needle biopsy is a reliable and effective means for the etiologic diagnosis of thyroid nodules and the indications for operative intervention. It spares many patients from a useless operation and is worthy to take a leading place in exploring these nodules.

Aortic valve repair and replacement after balloon aortic valvuloplasty in children

Little is known about the incidence, indications, and results of surgical repair or replacement of the aortic valve after balloon aortic valvuloplasty (BAV) for congenital aortic stenosis in children. This study was designed to evaluate patterns of failure requiring operation after BAV for congenital aortic stenosis and to review our experience with successful repair, rather than replacement, of selected aortic valves after BAV. From March 1986 to June 1995, 60 patients with congenital aortic stenosis aged 1 day to 27 years (mean +/- standard deviation, 7.3 +/- 6 years) underwent BAV. Twenty-three patients (38%) required operation a mean of 44 +/- 37 months (range, 1 to 110 months) after BAV, because of severe aortic insufficiency in 13 patients and recurrent or residual aortic stenosis in 10 patients. Severe aortic insufficiency was invariably due to avulsion of a cusp from the annulus, with resulting cusp prolapse and insufficiency. Operative intervention consisted of valve replacement in 14 patients and valve repair in 9 patients. Repair techniques included reattachment of an avulsed cusp to the aortic annulus, relief of commissural fusion, and debridement of thickened cusps. Actuarial freedom from surgical intervention after BAV was 88% +/- 4% at 1 year, 70% +/- 6% at 5 years, and 51% +/- 12% at 9 years. The need for aortic valve operation was unrelated to age at the time of BAV, indication for operation (aortic insufficiency versus aortic stenosis), age of operation, or preoperative gradient. All patients survived aortic valve operation; there was one late death at an average follow-up of 27 +/- 20 months (range, 2 to 61 months) after aortic valve operation. Stenosis was well relieved in all patients undergoing valve replacement. The 9 valve repair patients have been followed for 22 +/- 14 months (range, 1 to 47 months). Echocardiographic follow-up of the valve repair patients revealed a mean residual aortic stenosis peak instantaneous gradient of 32 mm Hg and mild aortic insufficiency or less in all patients. Aortic valve operation is required in 5% to 7% of patients yearly after BAV. The need for operation appears to be unrelated to age at the time of BAV; aortic insufficiency predominates over aortic stenosis as an indication for operative intervention. Valve repair can be applied in some patients after BAV with good intermediate-term results and may delay the need for aortic valve replacement.

Scoliosis in familial dysautonomia. Operative treatment.

The results of operative treatment of scoliosis were reviewed for twenty-two patients (ten boys and twelve girls) who had familial dysautonomia, an autosomal recessive disorder affecting primarily Ashkenazi Jews. The indication for operative intervention was progressive kyphoscoliosis to 45 degrees or more in a skeletally immature patient for whom bracing had failed. The mean age at the time of the operation was fifteen years and five months (range, eight years and two months to nineteen years). Seventeen patients had a thoracic curve with a mean preoperative Cobb angle of 69 degrees (range, 47 to 112 degrees), and five patients had a double major curve with a mean preoperative Cobb angle of 71 degrees (range, 42 to 87 degrees) for the cephalad curves and 60 degrees (range, 45 to 72 degrees) for the caudad curves. Twenty patients had a rigid kyphosis; in fourteen, the apex was at the seventh thoracic vertebra or more cephalad. Two patients had a lordoscoliosis. The mean preoperative kyphosis was 64 degrees (range, 12 to 110 degrees) in the thirteen patients who had a thoracic curve and for whom information regarding kyphosis was available, and it was 70 degrees (range, 54 to 84 degrees) in the five patients who had a double major curve. Postoperior spinal arthrodesis and instrumentation was performed in all patients. Two patients had an anterior arthrodesis as well because of the severity and rigidity of the curve. Allograft bone was used in eighteen patients. Postoperatively, all patients were managed with a body cast or with a custom-molded thoracolumbar brace.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective study of the value of prebypass saphenous vein angioscopy

Background: The patency of a saphenous vein graft is directly related to the quality of the vein harvested. Thus, appropriate evaluation of the vein before implanting it as a bypass graft may help identify those veins at high risk for early failure. Accordingly, we prospectively investigated whether prebypass angioscopic assessment of the saphenous vein could identify those vein grafts at particularly high risk of early failure. Patients and methods: Thirty-two greater saphenous veins with a grossly normal appearance were evaluated angioscopically before their use as a bypass conduit. After modification of abnormal segments, all of the veins irrigated well and were used as bypass grafts. Results: Twenty-four patients were available for follow-up at 12 months. Seventeen (71%) had been prospectively classified as having angioscopically normal saphenous veins, while 7 were identified as having abnormal veins. The two groups did not differ significantly in demographics, cardiovascular risk factors, or indications for operative intervention. Twelve of the 17 (70%) normal veins were patent at 1 year; however, only 1 (14%) of the angioscopically abnormal vein grafts remained patent for 12 months (chi-square = 4.27; P = 0.039). Conclusion: Angioscopic inspection of the saphenous vein, before insertion as a graft, allows for identification of unrecognized venous disease that portends early graft thrombosis. Exclusion of abnormal veins, based on an abnormal angioscopic appearance, may lead to improved results for lower-extremity revascularization procedures; this supports the value of vein-graft angioscopy.

721-2 Aortic Valve Repair and Replacement After Balloon Aortic Valvuloplasty in Children

Little is known about the incidence, indications and results of surgical repair or replacement of the aortic valve following balloon valvuloplasty for congenital aortic stenosis in children. This study was designed to evaluate patterns of failure requiring surgery after balloon aortic valvuloplasty (BAli.) of congenital AS and to review our experience with successful repair, rather than replacement, of some aortic valves after BAV. From 1986 to 1994, 54 patients with congenital AS aged 1 day-27 years (mean ± sd; 8 ± 6 yrs) underwent BAV. Eighteen patients (33%) required surgery a mean of 33 ± 25 mos (range 1 to 80 mos) following BAV. because of severe AI in 10 patients and recurrent or residual AS in 8 patients. Severe AI was invariably due to avulsion of a cusp from the annulus with resulting cusp prolapse and insufficiency. Actuarial freedom from surgical intervention was 90 ± 4% at 1 year, 79 ± 6% at 3 years, and 64 ± 7% at 6 years. The need for aortic valve surgery was unrelated to age at the time of BAV. Surgical intervention consisted of valve replacement in 11 patients and aortic valve repair in 7 patients. Repair techniques included reattachment of an avulsed cusp to the aortic annulus, relief of commissural fusion, and debridement of thickened cusps. All survived operation and are alive 23 ± mos (range 2–44 mos) following aortic valve operation. LV outflow gradient has been well relieved in all patients undergoing valve replacement. The 7 valve repair patients have been followed 17 ± 10 mos (range 4–33 mos). Echocardiographic follow-up of the valve repair patients revealed mild levels of residual AS and mild (1–2+) AI in all patients. Aortic valve surgery is required in 5–10% of patients yearly following BAli. and appears to be unrelated to age at the time of BAV. AI predominates over AS as an indication for operative intervention. Valve repair can be applied in some patients following BAV. with good intermediate-term results and may delay the need for aortic valve replacement.

Treatment of femoral shaft fractures in children by external fixation

Non-operative management is still the treatment of choice for closed fractures of the femoral shaft in children. Indications for operative intervention would include: children with multiple injuries; severe soft tissue damage; cases where reduction is difficult to maintain; and children not suitable for management by traction. Since 1984, 16 children (mean age 10.3 years) have had stabilization of their femoral shaft fractures by external fixation (Monofixateur) in the Trauma Department of the Hannover Medical School. The external fixation remained in place for a mean of 63 days. Of the 16 children, 15 have been reviewed, with a mean follow-up of 28.2 months. No children who were completely managed with this fixation had any clinically relevant malalignment, but six cases had up to 2 cm difference in leg length. Our observations and experience show that external fixation is a useful alternative for the operative management of femoral shaft fractures in children. It produces good stability, is less invasive, and allows early mobilization. In order to avoid differences in leg length, we recommend a good anatomical reduction with the external fixation being carried out as early as possible.

Changing Patterns in the Management of Fractures in Children

Advances in radiographic imagery have greatly facilitated the diagnosis and treatment of pediatric musculoskeletal injuries. In recent years, the indications for operative intervention in the treatment of children's fractures have become more clearly defined.

Indications for Surgical Débridement in 125 Human Bites to the Hand

Indications for operative intervention following human bites to the hand were determined based on physical examination and time elapsed since injury. One hundred twenty-four patients admitted to Charity Hospital of New Orleans, La, were stratified according to time elapsed from injury to treatment (early, less than 24 hours; delayed, 1 to 7 days; and late, greater than 7 days). Patients in the early group were mainly treated with conservative wound care, consisting of local wound exploration and irrigation in the emergency department, while those in the late group underwent surgical débridement. Patients in the delayed group either received conservative wound care or underwent débridement in the operating room. The early and late groups recovered excellent hand function while results within the delayed group were variable with improved results depending on rapid surgical débridement or drainage.

Haemangiomas of the Gastrointestinal Tract in Children

Haemangiomas of the gastrointestinal tract are unusual vascular anomalies either in children or in adults. There is a significant difficulty in their diagnosis because of this rarity. However, when they are present, haemangiomas of the gastrointestinal tract may be a source of acute or chronic blood loss and anaemia. The case histories of two children with severe gastrointestinal bleeding due to cavernous haemangioma of the duodenum and caecum are presented in this report. Progressive haemorrhage from the gastrointestinal tract was the indication for operative intervention in both children. Each child underwent complete resections of the haemangiomas and is well and symptom-free one year after the surgical treatment. The purpose of this paper is to draw attention to this uncommon benign condition which has a relatively high mortality due to the delays in diagnosis and inadequate treatment.

Reflections from a decade of carotid reconstructive surgery.

Carotid artery reconstructive surgery for atherosclerotic lesions of the extracranial cerebral circulation has become the most common operation in peripheral vascular surgery. A better understanding of the indications for operative intervention, enhanced monitoring during surgery, and more precise management of intraoperative anesthesia have all helped decrease the risks associated with internal carotid endarterectomy. To evaluate the safety and efficacy of extracranial carotid reconstructive surgery, we reviewed 2,857 operations done on 2,087 patients from 1976 to 1985. Operation was recommended because of hemispheric symptoms in 58%, and because of asymptomatic, significant stenosis in 14%. Postoperative hemiparesis occurred in 24 patients and was associated with thrombosis at the operative site in 18 patients. Antiplatelet drugs used during the last three years were found to be effective in preventing thrombosis at the operative site. Operative mortality during the study period was 1.5%. Follow-up has ranged from one month to 104 months, with 84% of the patients alive and 79% symptom free.

Liver resection in malignant disease.

As more surgeons become familiar with the techniques of hepatic resection and the mortality and morbidity decrease, the indications for resection of malignant disease within the liver broadens. The preoperative assessment of malignant liver lesions, as well as the definition of resectability, are outlined. Indications for operative intervention as well as the results obtained are covered. The personal experience of the authors at the Royal Postgraduate Medical School Hepatobiliary Unit, Hammersmith Hospital, in dealing with malignant lesions of the liver is detailed with respect to procedures performed and postoperative morbidity and mortality. Hepatocellular carcinoma, hilar cholangiocarcinoma, and metastatic colon carcinoma are discussed in detail. The authors' experience with each of these diseases is presented.

Two-dimensional echocardiographic identification of sinus of Valsalva-right heart fistula due to infective endocarditis

Two-dimensional echocardiographic identification of sinus of Valsalva-right heart fistula due to infective endocarditis

An evaluation of the tissue pH electrode for fetal monitoring using the fetal sheep as an experimental model

The performance of the Roche tissue pH electrode has been assessed by comparison of values recorded by the electrode with the pH of arterial blood, in fetal sheep. Observations were made under controlled conditions when the fetal pH was steady, during hypoxia, and after hypoxia. The results showed a highly significant correlation of the values recorded by the electrodes with the pH of arterial blood (r = 0.89, p < 0.001 during control; and r = 0.86, p < 0.001 during hypoxia and recovery). However, in about 10% of cases the insertion proved to be unsatisfactory, and in one half of the successful insertions there was a rapid initial drift which lasted up to 45 min. After stabilization, tissue pH values were symmetrically distributed about the arterial pH, with a SD of 0.07 unit. Multiple electrodes in the same fetus gave the same scatter. Movements of the electrode caused significant arterfacts. During hypoxia (produced by compression of the cord or administration of gas mixtures low in O2), the electrodes lagged behind the changes in arterial pH by up to 10 min. The conclusion is that the inherent variability of the tissue pH electrode makes it unsuitable as an absolute indicator of fetal well-being, and that it cannot be used alone as an indication for operative intervention. Nevertheless, because of the limitations of conventional techniques, it should be valuable as an adjunct and, in particular, it should help in the interpretation of equivocal fetal heart rate tracings, thereby reducing the risk of fetal death.