Annals of surgery
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Paraplegia has been an unpredictable, devasting complication following operations upon the thoracoabdominal aorta for over 30 years. The frequency ranges from 0.5% with operations for coarctation to as high as 15% following surgery for thoracoabdominal aneurysms. Both uncertainty and controversy exist about the value of different protective methods during aortic crossclamping (AXC): heparinized shunts, partial bypass, and reimplantation of intercostal arteries. ⋯ No postoperative neurologic complications occurred. Continuous operative monitoring of SEP has exciting possibilities for preventing paraplegia. It is simple, highly sensitive, and seems to provide a precise measurement of adequacy of circulation to the spinal cord.
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Experiments in animals with organ allografts showed that Cyclosporin A (CyA) was an extremely powerful immunosuppressant with a good therapeutic index. A pilot study of the drug in human recipients of renal allografts revealed an unexpected side effect, nephrotoxicity, which made care of patients difficult. Following a policy of deliberate hydration of patients in the perioperative phase and withholding CyA until diuresis was occurring in the graft, excellent results have been obtained in clinical practice. ⋯ The authors' most recent segmental pancreas graft has been drained into a long roux loop without complications. The main objective in the use of this drug is to obtain consistent immunosuppression without nephrotoxicity. It is possible that maintaining blood level between defined limits would improve results.
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Randomized Controlled Trial Comparative Study Clinical Trial
The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy.
Between May 1975 and April 1981, 43 adult patients with high-grade soft tissue sarcomas of the extremities were prospectively randomized to receive either amputation at or above the joint proximal to the tumor, including all involved muscle groups, or to receive a limb-sparing resection plus adjuvant radiation therapy. The limb-sparing resection group received wide local excision followed by 5000 rads to the entire anatomic area at risk for local spread and 6000 to 7000 rads to the tumor bed. Both randomization groups received postoperative chemotherapy with doxorubicin (maximum cumulative dose 550 mg/m2), cyclophosphamide, and high-dose methotrexate. ⋯ Patients with positive margins of resection had a higher likelihood of local recurrence compared with those with negative margins (p1 less than 0.0001) even when postoperative radiotherapy was used. A simultaneous prospective randomized study of postoperative chemotherapy in 65 patients with high-grade soft-tissue sarcomas of the extremities revealed a marked advantage in patients receiving chemotherapy compared with those without chemotherapy in three-year continuous disease-free (92% vs. 60%; p1 = 0.0008) and overall survival (95% vs. 74%; p1 = 0.04). Thus limb-sparing surgery, radiation therapy, and adjuvant chemotherapy appear capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremity.
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Influenced by continuing improvement in results from Stanford, cardiac transplantation was resumed at the University Health Center of Pittsburgh in June 1980. Cyclosporin A (CyA) became available to the authors early in 1981. This report describes the preliminary experience with 21 patients who were treated between March 1981 and April 10, 1982 with cyclosporin A and low-dose steroids. ⋯ No late death has occurred because of rejection, and a unique feature is that three recipients with a lymphocytotoxic mismatch did not develop hyperacute rejection. The number of infectious episodes and nonviral infections appears to be less than that associated with the use of azathiaprine and larger doses of steroids. Cyclosporin A (5-10 mg/kg/d) and low-dose prednisone (rapidly tapered in seven days from 200 mg to 15-20 mg/d) is effective in preventing early morbid rejection of the transplanted heart.