Surgery
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The outcome of 29 patients who underwent lung resection for treatment of metastatic malignant melanoma from January 1976 to November 1988 was studied. Twenty-two patients underwent total resection for cure of all apparent metastatic disease, whereas seven patients did not undergo total resection. Of the 22 patients who underwent curative resection, the median survival was 11 months, with a 2-year survival of 13.6% and a 5-year survival of 4.5%. ⋯ The difference in survival of the patients who underwent curative resection compared with palliative resection was statistically significant. The thickness of the primary cutaneous malignant melanoma, the presence of regional lymph node metastases, the disease-free interval from primary diagnosis to metastatic pulmonary disease, and whether one or two metastatic nodules were removed during curative lung resection were not statistically significant in altering survival. These results demonstrate that although prolonged survival for metastatic melanoma is rare, lung resection in selected patients may be associated with long-term survival.
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The first known case report of a small-bowel obstruction caused by a long-term indwelling Foley catheter is presented. The balloon of the catheter passed into and obstructed the lumen of the distal ileum through a vesicoenteric fistula created by chronic irritation. With the exception of recurrent urinary-tract infections, complications of urinary catheters are rare. The patient presented a diagnostic dilemma that was solved with a preoperative computed tomographic scan.
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Comparative Study
Transthoracic approach in the thoracic outlet syndrome: an alternate operative route for removal of the first rib.
This retrospective study compares the results of two surgical procedures, a transaxillary and a transthoracic (that is, anterolateral thoracotomy) approach, in the treatment of the thoracic outlet syndrome by first rib resection. After transaxillary first rib removal (13 cases), initially our procedure of choice, 84% of conditions were improved, 8% were unchanged, and 8% were worse after 1 year. One permanent, disabling brachial plexus injury occurred after this operation. ⋯ Although two female patients felt mild paresthesia of the mammary gland, no one has been made worse following this route. These two approaches have achieved similar results in the surgical management of this syndrome. Nevertheless, when first rib resection is indicated, our favored and recommended procedure is transthoracic, because this route appears less hazardous for brachial plexus damage.
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The role of computed tomography (CT) in the diagnosis of blunt thoracic vascular injury is controversial. Several recent reports have advocated the use of CT to exclude aortic and major branch injuries in hemodynamically stable patients with blunt trauma. This approach potentially avoids invasive angiography and unnecessary treatment delays in multiply injured patients but risks missed aortic transections if the CT or its interpretation is not accurate. ⋯ Data from the remaining 104 stable patients indicate that the sensitivity of chest CT for diagnosis of major thoracic injury is 55%; specificity, 65%. If the chest CT had been used as a screening modality to perform aortic angiography, two transected aortas and three major aortic branch injuries would have been missed. We conclude that chest CT has no screening role in the evaluation of blunt trauma patients with possible major vascular injury.