Annals of surgery
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Peroneal artery revascularization was performed in 61 cases for limb salvage and compared to a comparable group of 89 tibial artery reconstructions. Preoperative arteriography is essential to define runoff quality and pedal arch integrity. Intraoperative arteriography and flow determinations minimize failures due to technical error and provide some indication of the prognosis for graft patency. ⋯ The mortality rate at 30 days was 3.3% and compared favorably with other limb salvage procedures and with primary amputations. Cumulative patient survival with functional limbs was 79 +/- 9% at 30 months and was distinctly superior to reported data on survival of amputees. A cumulative limb salvage rate of 79 +/- 6% at 30 months for the peroneal group makes such reconstructions definitely favorable to uniform limb ablation.
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Dissatisfied with standard techniques for pulmonary diagnosis in children, we have evaluated the usefulness of thoracoscopy for diagnosis of intrathoracic pathology. Between July 1, 1975, and May 1, 1978, 65 thoracoscopy procedures have been performed in 57 children at the University of Florida. Thirty-four procedures were performed in immunosuppressed patients to rule out Pneumocystis carinii pneumonia. ⋯ In patients with pulmonary infiltrates, the accuracy has been 100%. The capability of viewing the entire hemithorax has proven valuable in evaluating children with intrathoracic tumors. Complications have included pneumothorax in six patients and bleeding in two.
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Comparative Study
A multifactorial analysis of melanoma: prognostic histopathological features comparing Clark's and Breslow's staging methods.
A multifactorial analysis was used to identify the dominant prognostic variables affecting survival from a computerized data base of 339 melanoma patients treated at this institution during the past 17 years. Five of the 13 parameters examined simultaneously were found to independently influence five year survival rates: 1) pathological stage (I vs II, p = 0.0014), 2) lesion ulceration (present vs absent, p = 0.006), 3) surgical treatment (wide excision vs wide excision plus lymphadenectomy, p = 0.024), 4) melanoma thickness (p = 0.032), and 5) location (upper extremity vs lower extremity vs trunk vs head and neck, p = 0.038). Additional factors considered that had either indirect or no influence on survival rates were clinical stage of disease, age, sex, level of invasion, pigmentation, lymphocyte infiltration, growth pattern, and regression. ⋯ Within each of Clark's Level II, III and IV groups, there were gradations of thickness with statistically different survival rates. Both microstaging methods (Breslow and Clark) were less predictive factors in patients with lymph node or distant metastases. Clinical trials evaluating alternative surgical treatments or adjunctive therapy modalities for melanoma patients should incorporate these parameters into their assessment, especially in Stage I (localized) disease where tumor thickness and the anatomical site of the primary melanoma are dominant prognostic factors.
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Randomized Controlled Trial Clinical Trial
Failure of low dose heparin to prevent pulmonary embolism after hip surgery or above the knee amputation.
In a randomized, double-blind trial, 5,000 USP units of sodium heparin or saline were give subcutaneously at least two hours before surgery and at 12 hour intervals thereafter to patients requiring total hip replacement, surgical correction of hip fracture, or major lower extremity amputation for vascular insufficiency. Lung perfusion scans were performed before surgery and at weekly intervals during the postoperative period. Pulmonary arteriograms were requested in patients developing new perfusion defects on serial scans. ⋯ The incidence of acute pulmonary embolism in 94 patients undergoing above the knee amputation was 25% in patients receiving heparin and 27% in patients receiving saline. The incidence of acute pulmonary embolism in 78 patients undergoing hip surgery was 13% in patients receiving heparin and 12% in patients receiving saline. We conclude that the regimen used had no significant effect on the incidence of acute pulmonary embolism in patients undergoing hip surgery or above the knee amputation.
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Case Reports
Treatment of Budd-Chiari syndrome by side-to-side portacaval shunt: experimental and clinical results.
The Budd-Chiari syndrome caused by occlusion of the major hepatic veins, often of unknown etiology, is typically characterized by massive ascites, hepatomegaly and abdominal pain due to intense congestion of the liver. The outcome has almost always been fatal. This report describes an evaluation of side-to-side portacaval shunt in dogs with experimental Budd-Chiari syndrome and in six patients with hepatic vein thrombosis. ⋯ One patient died following an emergency IVC thrombectomy and portacaval shunt, which was undertaken when, during the course of his workup, his condition deteriorated suddenly because the thrombotic process extended from the hepatic veins into the IVC. The everpresent risk of this complication, and the dangers associated with delaying operation were emphasized by this case. It is concluded that side-to-side portacaval shunt, which decompresses the liver by converting the portal vein into an outflow tract, provides effective treatment of the Budd-Chiari syndrome when the occlusive process is confined to the hepatic veins.