Annals of surgery
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A computerized analysis of prognostic variables was performed in 96 proven cases of extrahepatic bile duct carcinoma treated over a 24-year period at UCLA. Forty-nine percent of the lesions were in the upper third of the bile ducts and 47% of these were resected, for an operative mortality rate of 23% and a maximum survival rate of 4.5 years. ⋯ In the lower third lesions, 67% were resected by Whipple's procedures, for an 8% mortality rate and a five-year survival rate of 28% extending to nine years. Resection of these difficult carcinomas offers the best hope of survival but must be weighed against the high operative mortality risk in those lesions located in the hilar region.
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In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. ⋯ Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.
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Hyperglycemia, hypoinsulinemia and ketonemia often develop abruptly in previously normal young "BB" rats. The syndrome mimics human juvenile diabetes closely and is, thus, appropriate for assessing pancreatic transplantation. Transplantation of islet cells from closely histocompatible Wistar Furth (WF) donor resulted in permanent normoglycemia when immunosuppression with ALS was given. ⋯ Accordingly, 50 million bone marrow cells from WF donors were inoculated into half the newborn members of "BB" litters, leaving the littermates as unmodified controls. Most bone marrow recipients were protected, only four of 37 (10.8%) ever becoming diabetic, while the incidence of diabetes in noninoculated littermates was 22 of 39 (56.4%). The ultimate goal in human diabetes, which also seems very likely to be an autoimmune disease, may not be replacement of destroyed islet cells but identification of potentially susceptible children and prevention of islet destruction by immunologic manipulation.
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Forty-seven patients treated by at least 28 days of thoracic duct drainage (TDD) before cadaveric renal transplant are compared with 63 patients treated with standard immunosuppression. The TDD patients were begun on half the dosage of steroids, and at 30 days were receiving approximately two-thirds the dose that the non-TDD patients received. ⋯ The patient survival rates were not significantly different between the two groups. TDD pretransplant favorably affects cadaveric renal allograft survival for at least five years.
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Three patients with the obesity hypoventilation syndrome and one patient with the sleep apnea syndrome underwent gastroplasty for weight reduction. A tracheostomy was also performed in the patient with sleep apnea. The PaO2 rose from an average of 51 +/- 9 to 71 +/- 5 torr and the PaCO2 fell from an average of 51 +/- 21 to 41 +/- 6 torr within two to ten months following bariatric surgery. ⋯ All four patients have returned to productive lives in society. Given proper pre- and postoperative care, patients with respiratory insufficiency tolerate the operation well. Respiratory insufficiency associated with morbid obesity should be considered an indication for the gastroplasty procedure, rather than a contraindication as previously suggested.