Results of Nephrectomy in Hypertension Associated with Unilateral Renal Disease

Nephrectomy has been carried out in 34 patients with hypertension associated with unilateral parenchymal renal disease (28 with unilateral pyelonephritis, 3 tuberculosis, 2 hypoplasia, and 1 adenocarcinoma). In 13 of the patients the blood pressure was corrected, in four it was improved, and in 17 it was unaffected. The intravenous pyelogram (by the infusion technique with nephrotomography if necessary) and renogram give adequate information in most patients with unilateral parenchymal renal disease but may need to be supplemented by aortography, or retrograde pyelography, or divided renal function studies in a few special circumstances. When the function of the damaged kidney is less than 25% of the total (which is well maintained), and the contralateral kidney is intact, nephrectomy is recommended provided the hypertension is significant; success is more likely in younger patients with a short history of hypertension.     

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.     

Review of pancreatic trauma.

In reviewing the literature on pancreatic trauma (1,984 cases), I found that it resulted from penetrating trauma in 73% and blunt trauma in 27% of cases. Associated injuries were common (average 3.0 per patient). Increased mortality was associated with shotgun wounds, an increasing number of associated injuries, the proximity of the injury to the head of the pancreas, preoperative shock, and massive hemorrhage. High mortality was found for total pancreatectomy, duct reanastomosis, and lack of surgical treatment, with lower mortality for Roux-en-Y anastomoses, suture and drainage, distal pancreatectomy, and duodenal exclusion and diverticulization techniques. Most patients required drainage only. The preoperative diagnosis of pancreatic trauma is difficult, with the diagnosis usually made during surgical repair for associated injuries. Blood studies such as amylase levels, diagnostic peritoneal lavage, and plain radiographs are not reliable. Computed tomographic scanning may be superior, but data are limited.     

肾移植术后移植肾动脉破裂4 例及文献复习

目的:提高肾移植术后移植肾动脉破裂的诊治水平。方法:回顾性分析临床所见4例肾移植术后移植肾动脉破裂诊治并复习国内外病例文献资料。结果:移植肾动脉破裂口均不在吻合口,离吻合口距离为0.5~0.8cm;破裂原因:3例为霉菌感染,1例为细菌感染;经行移植肾切除和抗真菌、抗菌治疗后,2例受者恢复血透,1例因术中肺梗塞死亡,1例因失血性休克而死亡。结论:移植肾动脉破裂临床上较少见,后果严重,不仅会影响到移植肾功能,更可能危及病人生命,早期诊断、紧急手术探查和特异性治疗可改善预后,挽救患者生命。     

Incontinence in a child with a duplex kidney: case report

Persistent incontinence after toilet training in young girls and urinary tract infections or epididymitis in prepubertal boys should raise suspicion of an ectopic ureter. This often occurs in the context of duplication of kidney structures or other parenchymal abnormalities. The presence or absence of reflux affects surgical treatment, which may consist of ureteral reimplantation, ureteroureterostomy, and/or upper pole nephrectomy.     

RENOGRAMS—Correlation with Renal Arteriography and Intravenous Pyelography

A study was carried out to determine how well the information supplied by a radioactive renogram correlates with that obtained by renal arteriography and intravenous pyelography. In 1962 35 patients at the UCLA Medical Center had all three studies. This represents a total of 70 kidneys (one kidney surgically absent). We found the radioactive renogram to be a very reliable and valuable aid in the diagnosis of kidney disease. When compared with the results of the intravenous pyelogram and aortogram, the renogram had false negative result in 11 per cent of cases, and a 14 per cent false positive result.     

Current concepts in the immediate management of acute spinal cord injuries.

The management of acute spinal cord injuries has changed considerably during the past 10 years owing to new information about the pathophysiology of cord trauma and new diagnostic and treatment methods. It is now known that the cord suffers not only from the immediate physical effects of trauma, but also from secondary pathologic processes, such as ischemia and edema, which are treatable in the first few hours after injury. New neuroradiologic and neurophysiological techniques, such as the recording of the somatosensory evoked potential, increase the accuracy of diagnosis and prognosis in the acute phase. Current immediate treatment includes the administration of steroids and mannitol, with careful attention to respiratory and cardiovascular homeostasis, to overcome post-traumatic ischemia and edema, and immobilization of the spine with devices such as the halo. New surgical procedures are used in selected cases to improve neurologic recovery, to provide rigid immobilization of the spine or to allow earlier mobilization of the patient. The care of spinal cord injuries in the acute phase is facilitated by multidisciplinary units.     

Echotomography and excretory urography in the diagnosis of renal parenchymal "bridges"]

Sonographically detectable parenchymal 'bridges' in the median segment of the kidney may look atypical. The most incident parenchymal 'bridges' are asymmetric irregular ovoid incomplete connections, not reaching the parenchyma at the site of renal hilus; such 'bridges' may be compared to a 'humpbacked' overturned kidney. Besides that, double and Y-shaped connections were detected, occurring in different variants of fused kidneys. Clinical significance of atypical 'bridges' of the parenchyma consists in simulation by them of echomixed processes, of renal tumors first of all. Excretory urography should be the second stage of the diagnosis after initial ultrasonic examination of the kidneys; after it repeated pointed ultrasonography should be carried out, that will help rule out the diagnosis of a renal tumor.     

Kidney function after renal arterial embolism

Seven patients with atrial fibrillation had acute unilateral renal pain associated with suppression of function in the affected kidney. This was ascribed to renal embolism. Arteriography performed in four patients showed abnormalities in the renal arterial tree in three, though thrombus in a main artery was present in only one.Considerable function returned spontaneously to the affected kidney in six patients as judged by intravenous pyelography or renography. In two patients the sole functioning kidney was affected, leading to acute oliguric renal failure, but renal function recovered in each case. The routine use of anticoagulants in persistent atrial fibrillation is justified by such cases.     

The renal parenchyma evaluation: MAG3 vs. DMSA

Scintigraphy with Tc-99m dimercaptosuccinic acid (DMSA) is considered a reference method for assessment of parenchymal lesions and estimation of differential kidney function. The aim of study was to evaluate Tc-99m mercaptoacetyltriglycine (MAG3) dynamic renal scintigraphy for the same purpose. 188 patients, submitted to both studies within three months, were divided in two groups. In the first, 83 DMSA images were compared to parenchymal phase of MAG3 scintigraphy. Kidney morphology was independently evaluated by four observers. In the second group (N = 105), differential function was calculated in MAG3 and DMSA studies and the respective results were compared. Findings corresponded completely in 85% of patients. There were no statistically significant differences between calculated differential function on DMSA and MAG3 images. The results showed that most of parenchymal lesions detected on DMSA scans can be identified on MAG3 parenchymal scans. Both studies can be equally used for the calculation of differential kidney function.     

Current radiation diagnosis of pyelonephritis

The paper deals with the current diagnosis of nonspecific and specific (tuberculosis) acute and chronic pyelonephritis. Having rather ample materials (308 patients with different forms of acute and chronic pyelonephritis), the authors compared different introscopic techniques (plain X-ray study, excretory urography, retrograde pyelography, ultrasonography, computed tomography and angiography) used in the diagnosis and monitoring of patients with pyelonephritis. Based on their own findings and on the data available in the literature, the authors described the symptomatology of pyelonephritis in detail by using a great variety of diagnostic techniques. The paper shows the place and potentialities of conventional X-ray in a variety of current diagnostic studies and the potentialities of imaging techniques in recognizing pyelonephritis, assessing their extent and the reserve potentialities of the diseased kidney. The authors show that the rational use of routine and current radiographic techniques is of great diagnostic and prognostic value, enhances the efficiency of therapy for pyelonephritis, shortens treatment periods, reduces the number of radical nephrectomies by using organ-sparing operations more widely, and decreases mortality rates.     

Subcutaneous mastectomy. The excess skin problem.

Subcantaneous mastectomy through a lateral approach, with preservation of the nipple and areola on a dermal pedicle, removing the excess skin at the time of aubautaneous mastectomy, is a safe procedure which results in esthetically acceptable breasts. The surgical approach greatly facilitates the removal of the entire glandular portion of the breast. The need for a second surgical procedure is eliminated. Lateral biopsy scars can be reinforced by the dermal sling support, thereby decreasing the chances of exposure of the implant. The implant is also successfully and easily held in position by the use of the dermal-fat sling support. The nipple and areola survive quite well on the dermal pedicle, with preservation of contractility and sensation, as well as of blood supply.     

Ischemia-reperfusion Model of Acute Kidney Injury and Post Injury Fibrosis in Mice

Ischemia-reperfusion induced acute kidney injury (IR-AKI) is widely used as a model of AKI in mice, but results are often quite variable with high, often unreported mortality rates that may confound analyses. Bilateral renal pedicle clamping is commonly used to induce IR-AKI, but differences between effective clamp pressures and/or renal responses to ischemia between kidneys often lead to more variable results. In addition, shorter clamp times are known to induce more variable tubular injury, and while mice undergoing bilateral injury with longer clamp times develop more consistent tubular injury, they often die within the first 3 days after injury due to severe renal insufficiency. To improve post-injury survival and obtain more consistent and predictable results, we have developed two models of unilateral ischemia-reperfusion injury followed by contralateral nephrectomy. Both surgeries are performed using a dorsal approach, reducing surgical stress resulting from ventral laparotomy, commonly used for mouse IR-AKI surgeries. For induction of moderate injury BALB/c mice undergo unilateral clamping of the renal pedicle for 26 min and also undergo simultaneous contralateral nephrectomy. Using this approach, 50-60% of mice develop moderate AKI 24 hr after injury but 90-100% of mice survive. To induce more severe AKI, BALB/c mice undergo renal pedicle clamping for 30 min followed by contralateral nephrectomy 8 days after injury. This allows functional assessment of renal recovery after injury with 90-100% survival. Early post-injury tubular damage as well as post injury fibrosis are highly consistent using this model.     

SURGICAL PRINCIPLES OF INCISING THE RENAL PARENCHYMA

Attention, at nephrotomy, to the anatomy of the kidney will guide incision into a less vascular area and will result in less destruction of tissue. Complete exposure and gentleness of control of the renal pedicle are mandatory. Conservative surgery—removing renal lesions and preserving the remaining functioning tissue — is successful when the proper techniques of incision and hemostasis are employed. With proper drainage and control of infection, nephrostomy is not necessary. Three illustrative cases are presented.Full use of the operating room x-ray machine is helpful. Mattress sutures in the plane of the arteries is the commonest method of parenchymal hemostasis. Although helpful, Gelfoam® and Oxycel® probably predispose to infection which is the commonest cause of secondary hemorrhage.     

Traumatisme de la verge et des organes génitaux

The most frequent cause of testicular injuries is blunt trauma (following sports injuries or road accidents). Penetrating injuries are rare. Increased scrotal volume and a painful testis are the main symptoms and require scrotal ultrasonography. Scrotal ultrasonography is very sensitive and specific for testicular rupture or intratesticular haematoma. Two out of three patients with testicular injuries require surgical exploration. Secondary complications due to delayed management of trauma are testicular atrophy, sterility or impotence. Penile fracture (rupture of corpus cavernosum) is due to direct trauma by an excessive force applied to an erect penis. Swelling, penile ecchymosis, penile curvature and pain are the usual symptoms of rupture of the tunica albuginea. Urethral injury must be ruled out. Cavernosography, ultrasonography or MRI are not considered mandatory to establish a diagnosis but can be prescribed in the absence of typical signs or symptoms. Early surgical exploration and repair ensure a better outcome. Secondary complications are penile curvature, chronic pain and impotence.     

Common injuries of the athlete's hand.

Hand injuries are among the most frequent accidents seen in sports medicine. All too commonly they are considered trivial since the athlete may continue to participate actively and neglect his injury. The consequent delay in diagnosis and proper treatment may result in long-standing or even permanent disability. This paper describes the more commonly encountered hand injuries, their diagnosis and their optimal treatment. Included are soft-tissue injuries, ligamentous injuries, fractures and tendon avulsions. The basic principles applicable to skeletal and soft-tissue trauma of the hand, which physicians at all levels of sports medicine may encounter, are stressed.     

Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross.

OBJECTIVE--To describe and quantify patterns of injury from antipersonnel mines in terms of distribution of injury, drain on surgical resources, and residual disability. DESIGN--Retrospective analysis. SETTING--Two hospitals for patients injured in war. SUBJECTS--757 patients with injuries from antipersonnel mines. MAIN OUTCOME MEASURES--Distribution and number of injuries; number of blood transfusions; number of operations; disability. RESULTS--Pattern 1 injury results from standing on a buried mine. These patients usually sustain traumatic amputation of the foot or leg; they use most surgical time and blood and invariably require surgical amputation of one or both lower limbs. Pattern 2 injury is a more random collection of penetrating injuries caused by multiple fragments from a mine triggered near the victim. The lower limb is injured but there is less chance of traumatic amputation or subsequent surgical amputation. Injuries to the head, neck, chest, or abdomen are common. Pattern 3 injury results from handling a mine: the victim sustains severe upper limb injuries with associated face injuries. Eye injuries are common in all groups. CONCLUSIONS--Patients who survive standing on a buried mine have greatest disability. Non-combatants are at risk from these weapons; in developing countries their social and economic prospects after recovery from amputation are poor.     

Acute renal venous obstruction is more detrimental to the kidney than arterial occlusion: implication for murine models of acute kidney injury

In this study, we compared the traditional murine model with renal pedicle clamp with models that clamped the renal artery or vein alone as well as to a whole body ischemia-reperfusion injury (WBIRI) model. Male C57BL/6J mice underwent either clamping of the renal artery, vein, or both (whole pedicle) for 30 or 45 min followed by reperfusion, or 10 min of cardiac arrest followed by resuscitation up to 24 h. After 30 min of ischemia, the mice with renal vein clamping showed the mostly increased serum creatinine and the most severe renal tubule injury. After 45 min of ischemia, all mice with renal vasculature clamping had a comparable increase in serum creatinine but the renal tubule injury was most severe in renal artery-clamped mice. Renal arterial blood flow was most decreased in mice with a renal vein clamp compared with a renal artery or pedicle clamp. A 30-or 45-min renal ischemia time led to a significant increase in the protein level of interleukin-6, keratinocyte-derived chemokine (KC), and granular colony-stimulating factor in the ischemic kidney, but the KC was the highest in the renal pedicle-clamped kidney and the lowest in the renal vein-clamped kidney. Of note, 10 min of WBIRI led to kidney dysfunction and structural injury, although less than longer time clamping of isolated renal vasculature. Our data demonstrate important differences in ischemic AKI models. Understanding these differences is important in designing future experimental studies in mice as well as clinical trials in humans.     

Effects of dexamethasone on late radiation injury following partial-body and local organ exposures.

Dexamethasone was evaluated as a treatment for radiation-induced lung, kidney, liver, and spinal cord injuries in rats. One experimental group was partial-body-irradiated (22.5 Gy) with the head, femur, and exteriorized intestine shielded to prevent acute mortality. Other animals received local irradiation to the kidney (20 Gy), liver (25 Gy), or a 1-cm segment of cervical spinal cord (18 to 40 Gy). Following irradiation half of the animals in each radiation group were given drinking water containing 188 micrograms/liter of dexamethasone. Tests were done to assess kidney function (hematocrit, plasma urea nitrogen, ethylenediaminetetraacetic acid clearance), liver function (rose bengal clearance, plasma glutamic oxaloacetic acid transaminase), or spinal cord injury (paralysis). The effectiveness of dexamethasone in preventing radiation injury was tissue specific. Dexamethasone eliminated lethal pleural fluid accumulation after partial-body irradiation and delayed development of kidney dysfunction after local kidney irradiation. As a result, dexamethasone increased the median survival time from 63 to 150 days after partial-body irradiation and from 126 to 175 days after local kidney irradiation. After whole-liver irradiation, development of hepatic functional injury was retarded by dexamethasone treatment but without significantly changing survival time. Dexamethasone had no effect on spinal cord tolerance but significantly shortened the latent period between radiation and paralysis.     

An extended approach for the vascular pedicle of the lateral arm free flap.

We present an extension of the surgical approach for harvesting the lateral upper arm free flap by which an additional 6 to 8 cm of pedicle length may be gained. First, the flap is raised by the standard lateral approach. Then, by proceeding proximally and posteriorly, the triceps muscle is split between its lateral and long heads to expose the entire length of the profunda brachii vessels in the spiral groove. A tunnel is developed beneath the lateral head of the triceps, and the flap or its pedicle is delivered through this. We describe the surgical technique and present details of a dissection study on 25 fresh cadaver limbs. The nerve branches to the lateral head of the triceps, which are close to the vessels of the flap, are highly variable in number and location. When unusually short and distally placed, they are at risk of damage, but damage can be avoided if the tunnel is not unduly widened. We present our early clinical experience in 10 consecutive cases using the extended-pedicle lateral arm flap. The free pedicle length in this series ranged from 8 to 13 cm. The maximum flap size was 5 x 19 cm. All cases were successful, although one required reoperation for venous thrombosis. Although postoperative testing of upper arm muscle function showed some weakness and impaired endurance, this was found equally in the surgically disturbed triceps and in the untouched elbow flexors and thus could not be attributed to motor nerve damage to the triceps muscle.