Hypophysectomy for palliation of breast cancer with especial reference to surgical technique

In a series of 19 patients who had hypophysectomy for palliation of cancer of the breast, all had striking relief of pain. Objective evidence of remission of disease was observed in ten patients. The survival time after operation averaged 19.8 months for patients who had remission and 2.1 months for patients who did not. Results were better in patients who had had cancer for a long time before operation than in those who had had the disease a relatively short time. Also it was noted that results were better in patients who had had preoperative response to endocrine therapy than in those who had not. Hence these factors may be considered in selection of patients for hypophysectomy.     

Actue Cholecystitis Following Unrelated Surgery

In a series of 26 cases of acute cholecystitis occurring after an operation for an unrelated condition, 88% of the patients were over 50 years of age and males outnumbered females by 2 to 1. In some of the cases diagnosis was difficult and delay was responsible for the death of one patient. Acalculous cholecystitis occurred in 20% of the cases and in these gangrene or perforation supervened early in the course of the disease.Efforts should be directed to ensuring adequate hydration after operation; resumption of a diet low in fat may be important. Even in the absence of a history of biliary disease, there is a place for the radiological study of the biliary tract before major elective operations are performed. If gallstones are discovered on the occasion of the initial surgery, cholecystectomy should be performed whenever it is feasible. In any patient with postoperative cholecystitis early operation is generally indicated.     

Secondary abdominal contour surgery: a review of early and late reoperative surgery

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (chi2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher's exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or "touch-ups," accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.     

One-stage repair of blepharophimosis

Congenital blepharophimosis is a congenital anomaly characterized by abnormalities in the area of the eyes, including bilateral ptosis, shortening of the horizontal fissure of the lid, expansion of the intercanthal distance, and epicanthus inversus. The condition is subject to autosomal-dominant heredity and is said to occur more frequently in Orientals than in Occidentals. Over the past 9 years, we have surgically treated 11 cases of congenital blepharophimosis using a procedure in which levator resection and medial canthoplasty are performed in one stage. It has been commonly believed that when levator resection and medial canthoplasty are performed at the same time, tension in the eyelid becomes too strong to achieve favorable results; therefore, the standard procedure has been to divide the operation into two stages. In all 11 cases we experienced, however, it was possible to obtain good results with a single-stage operation.     

Congenital cardiac defects; indications for surgical repair

The optimum ages for the operative repair of the various congenital defects have not as yet been definitely established. With certain exceptions, it has generally been the authors' preference to delay elective operations until after the age of 18 months. In the usual case, the optimum age for the closure of septal defects is believed to be three to five years. Operative relief of stenosis of the aortic or pulmonic valves, however, is related entirely to the extent of the obstruction, age not being a factor. Although the surgical treatment of coarctation of the aorta is probably best delayed beyond the period of infancy, it is the authors' belief that in the presence of extreme hypertension, cardiomegaly or cardiac failure, early resection of the aortic block should be accomplished. As to the treatment of tetralogy of Fallot, the authors' policy is to delay operation until such time as definitive repair becomes less hazardous. Patients with severe symptoms, however, are given the benefit of some form of operative relief as soon as possible. Whether this is palliative or corrective depends upon the characteristics of the individual case. Definitive diagnostic studies are of great aid in assessing the urgency of operative intervention. The fact that approximately one-third of the patients dealt with required operation at less than 18 months of age suggests that, in selected cases, these studies should be performed early in infancy.     

Mesentericocaval “Jump” Graft in Management of Portal Hypertension: Experience with 24 Cases

A series of 24 patients with cirrhosis have undergone mesentericocaval shunt operations for the relief of portal hypertension. Overall the results have been satisfactory. Four of the five patients treated as an emergency and 17 of the 19 who had the operation two to six weeks after haemorrhage had been controlled left hospital alive and well. Separation of the patients into three categories according to the findings of clinical and biochemical tests, however, showed that subsequent survival was satisfactory for patients in categories A and B but that all four patients in category C had died within one year after surgery. Assessment at three months showed that in three patients moderate hepatic encephalopathy had developed.Evidence that the shunt remains patent was shown by a low incidence of repeated gastrointestinal haemorrhage and a marked diminution in variceal size in 18 of the 19 cases examined serially. Radiographic techniques for confirming shunt patency were compared and cannulation of the graft via the femoral vein was found to provide a reliable and rapid means of assessment.     

Stress incontinence in women; treatment by retropubic urethrovesical suspension

Twenty-four retropubic urethrovesical suspension operations were performed in a five-year period. Twenty-one of the patients were satisfied with the results, although the objective success of the operation did not always correlate with subjective relief of symptoms. The commonest apparent cause for failure was the coincidence of urgency with stress incontinence, and the few true failures, due to secondary relaxation of the paraurethral supports, were often mitigated by compensatory learning on the part of the patients, many of whom remain blissfully unaware of the underlying weakness. The retropubic urethrovesical suspension operation is simple, effective, and free of complications. It is indicated as a primary procedure whenever a vaginal operation has failed to cure (or, worse, has caused) stress incontinence. It is advised as a complementary procedure for women with a secondary complaint of stress incontinence who must undergo laparotomy for other cause.     

The first 1000 coronary artery repair operations in Toronto

The present status of the aortocoronary bypass procedure is described in general terms by a review of the first 1040 patients who received this operation in Toronto, before November 15, 1973. The operative risk was related to the status of the left ventricular function. In those with fair or good ventricular function the risk of hospital mortality was less than 3% in the entire series and less than 2% in the past year. Advances in investigative and surgical techniques have allowed this operation to become an increasingly safe, effective and recommended procedure for patients suffering from medically intractable angina pectoris. The operation has been of great benefit to such individuals. In addition it has been an effective stimulus to research and development in Canadian cardiology and cardiovascular surgery.     

CONGENITAL CARDIAC DEFECTS—Indications for Surgical Repair

The optimum ages for the operative repair of the various congenital defects have not as yet been definitely established. With certain exceptions, it has generally been the authors'' preference to delay elective operations until after the age of 18 months. In the usual case, the optimum age for the closure of septal defects is believed to be three to five years. Operative relief of stenosis of the aortic or pulmonic valves, however, is related entirely to the extent of the obstruction, age not being a factor. Although the surgical treatment of coarctation of the aorta is probably best delayed beyond the period of infancy, it is the authors'' belief that in the presence of extreme hypertension, cardiomegaly or cardiac failure, early resection of the aortic block should be accomplished. As to the treatment of tetralogy of Fallot, the authors'' policy is to delay operation until such time as definitive repair becomes less hazardous. Patients with severe symptoms, however, are given the benefit of some form of operative relief as soon as possible. Whether this is palliative or corrective depends upon the characteristics of the individual case.Definitive diagnostic studies are of great aid in assessing the urgency of operative intervention. The fact that approximately one-third of the patients dealt with required operation at less than 18 months of age suggests that, in selected cases, these studies should be performed early in infancy.     

THE SURGICAL TREATMENT OF MITRAL STENOSIS

A surgical procedure known as commissurotomy, devised by Bailey for the relief of certain cases of mitral stenosis, gives promise of considerable benefit to a large number of patients who have the disease. The technique of the operation involves the introduction of the right index finger and an especially designed valvulotome through the left auricular appendage into the left auricle. The mitral valve commissures are then divided. Twentyfive cases of mitral stenosis in which this operation was performed are discussed.     

Acid Secretion and Serum Gastrin Levels in the Zollinger-Ellison Syndrome

Thirteen cases of patients with the Zollinger-Ellison syndrome were reviewed. In two cases the diagnosis was made by incidental biopsy of small liver nodules at operation for peptic ulcer disease.Seven patients had gastric secretory tests which showed a basal acid output to maximum acid output ratio of more than 65 percent. Five patients had bao:mao ratios less than 50 percent.A 30-month interval between incidental discovery of tumor and clinically evident disease was observed in two patients. Recurrence of symptoms after excision of tumor was noted after a similar interval in another case.Serum gastrin levels, before total gastrectomy, were elevated in all cases. The lowest preoperative level in this series of patients was 550 picograms per ml (normal 100 to 150 picograms). They were diagnostic in two patients with normal gastric secretory studies. The levels fell to normal following total gastrectomy in six patients. Two patients still had elevated levels five years and 14 years after total gastrectomy. One was discovered to have a parathyroid adenoma with hypercalcemia.Total gastrectomy was curative in all the patients with the Zollinger-Ellison syndrome; lesser operations were not.     

Comparative study between endoscopy and radiology in acute upper gastrointestinal haemorrhage.

A total of 158 patients with acute upper gastrointestinal haemorrhage were studied, and the 53 patients on whom emergency endoscopies were performed were compared with the remaining 105. The cause of the bleeding was found in 51 of the endoscopy group and 39 of the control group. Three patients in the endoscopy group and 16 controls died. In the endoscopy group the correct preoperative diagnosis was made in all cases and there was less delay before operation. In the control group five patients had no diagnosis before operation, the preoperative diagnosis was wrong in nine, and five had laparotomies during which no cause of bleeding was found. The patients in the endoscopy group who did not have operations had a shorter stay in hospital than the controls.     

STRESS INCONTINENCE IN WOMEN—Treatment by Retropubic Urethrovesical Suspension

Twenty-four retropubic urethrovesical suspension operations were performed in a five-year period. Twenty-one of the patients were satisfied with the results, although the objective success of the operation did not always correlate with subjective relief of symptoms. The commonest apparent cause for failure was the coincidence of urgency with stress incontinence, and the few true failures, due to secondary relaxation of the paraurethral supports, were often mitigated by compensatory learning on the part of the patients, many of whom remain blissfully unaware of the underlying weakness.The retropubic urethrovesical suspension operation is simple, effective, and free of complications. It is indicated as a primary procedure whenever a vaginal operation has failed to cure (or, worse, has caused) stress incontinence. It is advised as a complementary procedure for women with a secondary complaint of stress incontinence who must undergo laparotomy for other cause.     

Treatment of diabetic neuropathy by decompression of the posterior tibial nerve

A series of 58 operations on 36 patients were performed for decompression of the posterior tibial nerve for the treatment of diabetic neuropathy. Preoperative symptoms included lack of sensation, pain, or both. Eleven of the 36 patients had neurotrophic ulcers, which were treated simultaneously. The operation was found to be effective for relief of pain in 24 of the 28 patients with that complaint (86 percent). Restoration of sensation was less consistent with improvement noted in 18 of the 36 patients (50 percent). The follow-up period ranged from 12 to 84 months (mean, 32 months) and five patients had some degree of recurrent symptoms. No patient has developed a new ulcer after nerve decompression. Wound complications were minimal (12 percent), even though ulcers were treated simultaneously. No patient required surgical treatment for the decompression incision, although one did require hospital admission for treatment of a wound infection. In general, the procedure seemed to be a worthwhile treatment, which should be considered ill selected diabetics with symptomatic neuropathy.     

UNDESCENDED TESTES

Orchiopexy was performed upon 152 patients. Follow-up observation was inadequate, but of known results 14 per cent were poor.As an increasing number of investigators have observed spontaneous descent of undescended testes, this possibility should be considered in weighing indications for operation on boys before the age of puberty. Coexisting clinically demonstrable hernia (59 per cent in this series) is an indication for early operation. Otherwise, orchiopexy may be best delayed, perhaps until the twelfth year. This was done in 25 per cent of the cases in this series.Three methods of operation were used, the Torek, the Cabot-Nesbit, and the Bevan. There were fewer poor results with the Torek than with the Cabot-Nesbit procedure. The greatest number of poor results was in cases in which the Bevan technique was used.     

CARDIAC OPERATIONS UNDER DIRECT VISION—Experience with Extracorporeal Oxygenation of the Blood

A heart-lung machine capable of oxygenating the blood and maintaining normal pressures during cardiopulmonary by-pass was used in 11 cases in which cardiac operations with the heart under direct vision were carried out. The first patient died. Improvements then were made in the machine and it was used in ten additional operations. One of the ten patients died, 18 hours postoperatively, of cardiac tamponade. Since then six more patients have been operated upon with no complications.     

Cardiac operations under direct vision; experience with extracoporeal oxygenation of the blood

A heart-lung machine capable of oxygenating the blood and maintaining normal pressures during cardiopulmonary by-pass was used in 11 cases in which cardiac operations with the heart under direct vision were carried out. The first patient died. Improvements then were made in the machine and it was used in ten additional operations. One of the ten patients died, 18 hours postoperatively, of cardiac tamponade. Since then six more patients have been operated upon with no complications.     

UNDESCENDED TESTES

Orchiopexy was performed upon 152 patients. Follow-up observation was inadequate, but of known results 14 per cent were poor. As an increasing number of investigators have observed spontaneous descent of undescended testes, this possibility should be considered in weighing indications for operation on boys before the age of puberty. Coexisting clinically demonstrable hernia (59 per cent in this series) is an indication for early operation. Otherwise, orchiopexy may be best delayed, perhaps until the twelfth year. This was done in 25 per cent of the cases in this series. Three methods of operation were used, the Torek, the Cabot-Nesbit, and the Bevan. There were fewer poor results with the Torek than with the Cabot-Nesbit procedure. The greatest number of poor results was in cases in which the Bevan technique was used.     

The application of ultrasound in neuroendoscopic procedures: first results with the new tool "NECUP-2"

In this paper, our experience with originally constructed Neurosurgical Endoscopic Contact Ultrasound Probe "NECUP-2" in neuroendoscopy is reported. Between June 1997 and June 2007, 132 neuroendoscopic procedures have been performed: 102 endoscopic thrid ventriculostomies (ETV), 15 arachnoid cysts and 5 intraventricular tumours operations. The "NECUP-2" was applied effectively in all cases in which blunt perforation was not possible: 38/102 ETY, 10/10 septostomies, 15/15 arachnoid cysts. In five cases of intraventricular tumours, neuroendoscopic procedure was combined with open microsurgery for tumour removal with preservation of vascular structures. There were no "NECUP-2" related complications. Of postoperative complications, we had liquorrhea (9 patients), and symptoms of meningitis (6 patients). In the follow-up period (6 months to 6 years), we had a patency rate of 80% (50/63 patients). All patients improved in clinical status. According to the first results, it seems that ultrasonic contact probe NECUP-2 presents a new device in neurosurgical armamentarium that can be used in various fields of neurosurgery. With minimal and controlled lesion that is produced at the tip of the probe, it can be used in highly demanding operations such as third ventriculostomy and tumour resection.     

Carotid sinus nerve stimulation in the management of intractable angina pectoris: four-year follow-up

Since February 1969 carotid sinus nerve stimulators have been implanted in 13 patients with intractable, incapacitating angina pectoris, unrelieved by medical management and, in some cases, revascularization procedures. Four patients died, one on the third postoperative day, the others at 15, 31 and 49 months postoperatively. Two other patients sustained myocardial infarcts, at two weeks and two months postoperatively. Complications were few and transient. The condition of two patients is now deteriorating.In all cases there was relief of pain and a decrease in blood pressure and heart rate. Exercise could be performed at a heavier load or for a longer time. Use of the stimulator was both intermittent and continuous, proving especially valuable in the relief of nocturnal angina. All patients were markedly improved and able to leave hospital.Four patients underwent aortocoronary bypass 14, 15, 22 and 28 months after implantation of the device; three obtained good results and no longer require the CSNS although it remains in place. The fourth obtained little improvement and continues to use the stimulator.