Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease

AIM

Surgical repair of recto-vaginal fistula (RVF) in Crohn's disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion.

METHOD

A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004.

RESULTS

Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy.

CONCLUSION

RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Blastomyces dermatitidis of the perianal skin: report of a case

Isolated fungal infections of the perianal skin are rare and their diagnosis is frequently overlooked. We report a case of a 78-year-old male patient who presented with a friable, violaceous, papulopustular lesion, with heaped-up edges along the anal verge. Biopsy revealed unicellular yeast consistent with blastomycosis. The patient was treated with itraconazole with resolution of this lesion. An extensive MEDLINE literature review from 1958 to the present indicates that this is an uncommon manifestation of cutaneous blastomycosis. A summary of the medical literature is presented with a review of the characteristics, diagnosis, and management of blastomycosis.

Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

OBJECTIVE

To review the use of transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography (TCCS) for diagnosis.

METHODS

The authors searched the literature for evidence of 1) if TCD provides useful information in specific clinical settings; 2) if using this information improves clinical decision making, as reflected by improved patient outcomes; and 3) if TCD is preferable to other diagnostic tests in these clinical situations.

RESULTS

TCD is of established value in the screening of children aged 2 to 16 years with sickle cell disease for stroke risk (Type A, Class I) and the detection and monitoring of angiographic vasospasm after spontaneous subarachnoid hemorrhage (Type A, Class I to II). TCD and TCCS provide important information and may have value for detection of intracranial steno-occlusive disease (Type B, Class II to III), vasomotor reactivity testing (Type B, Class II to III), detection of cerebral circulatory arrest/brain death (Type A, Class II), monitoring carotid endarterectomy (Type B, Class II to III), monitoring cerebral thrombolysis (Type B, Class II to III), and monitoring coronary artery bypass graft operations (Type B to C, Class II to III). Contrast-enhanced TCD/TCCS can also provide useful information in right-to-left cardiac/extracardiac shunts (Type A, Class II), intracranial occlusive disease (Type B, Class II to IV), and hemorrhagic cerebrovascular disease (Type B, Class II to IV), although other techniques may be preferable in these settings.

Transanal excision for T1 and T2 rectal cancer--efficacy of local resection vs. adjuvant therapy. Extended abstract

The principal goal in the management of any patient with rectal cancer is to provide the optimum chance for cure while maintaining their quality of life. Treatment options over the past century have reflected our ability to provide safe surgical care and, more recently, a greater understanding of tumor biology. Prior to the introduction of the abdominoperineal resection (APR) that was reported in the Lancet in 1908 by Sir Ernest Miles, perineal excision was the accepted approach for nearly all rectal cancer. Unfortunately, inconsistent surgical outcomes and high local recurrence even in Miles personal experience promoted alternative treatment. The acceptance of APR and subsequently low anterior resection reduced recurrence and improved long-term survival but often with the cost of decreased quality of life. A recent review by McCall et al. report disease specific recurrence at 8.5 percent, 16.3 percent and 28.6 percent for cancer stages I, II and III respectively with an overall reported recurrence rates following APR ranging from 10 to 29 percent. Reported five-year survival rates range 78 to 100 percent for stage I, 45 to 73 percent for stage II and 22 to 66 percent for stage III. The wide variations in recurrence and survival rates likely reflect differences in tumor size, proximity to the anal canal, depth of penetration in the rectal wall and unfavorable histologic characteristics. An additional confounding variable in the management of rectal cancer has been the use of adjuvant therapy do in part to the timing and dose/fractionation differences utilized. Given the variation in outcomes with APR and ongoing concerns regarding morbidity and quality of life issues associated with radical resection, many centers have revisited local therapy as a means of managing select patients with distal rectal cancers. These therapies include transanal and transcoccygeal excision as well as endocavitary radiation and even fulguration. It is the belief of many surgeons that our ability to more accurately stage patients preoperatively and add adjuvant therapy when indicated will improve our success with local excision.

Association of intraoperative transcranial doppler monitoring variables with stroke from carotid endarterectomy

BACKGROUND AND PURPOSE

The outcomes of carotid endarterectomy (CEA) are, in addition to patient baseline characteristics, highly dependent on the safety of the surgical procedure. During the successive stages of the operation, transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was used to assess the association of cerebral microembolism and hemodynamic changes with stroke and stroke-related death.

METHODS

By use of data pooled from 2 hospitals in the United States and the Netherlands, including 1058 patients who underwent CEA, the association of various TCD emboli and velocity variables with operative stroke and stroke-related death was evaluated by univariable and multivariable logistic regression analyses in combination with receiver operating characteristic (ROC) curve analyses. The impact of basic patient characteristics, such as age, sex, preoperative cerebral symptoms, and ipsilateral and contralateral internal carotid artery stenosis, on the prediction of operative stroke was also evaluated.

RESULTS

We observed 31 patients with ischemic and 8 patients with hemorrhagic operative strokes. Four of these patients died. Emboli during dissection (odds ratio [OR] 1.5, 95% CI 0.8 to 2.9) and wound closure (OR 2.3, 95% CI 1.2 to 4.4) as well as > or =90% decrease of MCA peak systolic velocity at cross-clamping (OR 3.3, 95% CI 1.3 to 8.5) and > or =100% increase of the pulsatility index of the Doppler signal at clamp release (OR 7.1, 95% CI 1.4 to 35.7) were independently associated with stroke. The ROC area of this model was 0.69. Of the patient characteristics, only preoperative cerebral ischemia (OR 1.9, 95% CI 1.0 to 3.7) and > or =70% ipsilateral internal carotid artery stenosis (OR 0.5, 95% CI 0.2 to 0.9) were associated with stroke. Adding these patient characteristics to the model, the area under the ROC curve increased to 0.73.

CONCLUSIONS

In CEA, TCD-detected microemboli during dissection and wound closure, > or =90% MCA velocity decrease at cross-clamping, and > or =100% pulsatility index increase at clamp release are associated with operative stroke. In combination with the presence of preoperative cerebral symptoms and > or =70% ipsilateral internal carotid artery stenosis, these 4 TCD monitoring variables reasonably discriminate between patients with and without operative stroke. This supports the use of TCD as a potential intraoperative monitoring modality to alter the surgical technique by enhancing a decrease of the risk of stroke during or immediately after the operation.

Transcranial Doppler ultrasonography: year 2000 update

In this update, the main clinical applications of transcranial Doppler ultrasonography are reassessed. A specific format for technology assessment, personal experience, and an extensive review of the literature form the basis of the evaluation. The document is approved by the American Society of Neuroimaging and the Neurosonology Research Group of the World Federation of Neurology.

Time-scale detection of microemboli in flowing blood with Doppler ultrasound

Small formed elements and gas bubbles in flowing blood, called microemboli, can be detected using Doppler ultrasound. In this application, a pulsed constant-frequency ultrasound signal insonates a volume of blood in the middle cerebral artery, and microemboli moving through its sample volume produce a Doppler-shifted transient reflection. Current detection methods include searching for these transients in a short-time Fourier transform (STFT) of the reflected signal. However, since the embolus transit time through the Doppler sample volume is inversely proportional to the embolus velocity (Doppler-shift frequency), a matched-filter detector should in principle use a wavelet transform, rather than a short-time Fourier transform, for optimal results. Closer examination of the Doppler shift signals usually shows a chirping behavior apparently due to acceleration or deceleration of the emboli during their transit through the Doppler sample volume. These variations imply that a linear wavelet detector is not optimal. We apply linear and quadratic time-frequency and time-scale detectors to a set of noise-corrupted embolus data. Our results show improvements of about 1 dB using the time-scale detectors versus an STFT-based detector signifying that embolus detection is best approached as a time-scale problem. A time-scale-chirp detector is also applied and is found to have the overall best performance by about 0.5-0.7 dB while coming fairly close (about 0.75 dB) to a theoretical upper bound.

A clinical comparison of Dacron patch closure of small-caliber carotids compared with primary closure of large-caliber carotids after endarterectomy

The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 +/- 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (< or = 3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily.

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE

Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor.

METHODS

One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training.

RESULTS

Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms.

CONCLUSIONS

Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

The evolving role of transcranial doppler in stroke prevention and treatment

Without focusing on established indications for transcranial Doppler (TCD) such as monitoring vasospasm after subarachnoid hemorrhage and detecting intracranial stenosis (sickle cell disease, stroke, etc.), we describe the role of TCD in carotid endarterectomy (CEA) and angioplasty, acute ischemic stroke, as well as competence and the practice of TCD. In addition to duplex ultrasound and angiography TCD can be used to select patients for CEA because it detects hemodynamically significant extracranial stenosis and tandem intracranial stenoses, and identifies asymptomatic patients at potentially high risk of stroke because of exhausted vasomotor reactivity or brain microembolization. TCD identifies in real time brain hypoperfusion, embolism, and hyperperfusion and thus may be helpful in reducing cerebrovascular complications of CEA/angioplasty. In acute ischemic stroke, TCD can reliably identify the patency of middle cerebral and basilar arteries, high resistance flow patterns due to increased intracranial pressure, and progression to cerebral circulatory arrest. TCD also can monitor spontaneous or induced arterial recanalization. Limitations include operator and interpreter dependency, absent temporal "windows" leading to unsuccessful insonation in 10% to 15% of patients older than 60 years, as well as difficulties with probe positioning and fixation for monitoring. However, the use of ultrasound contrast agents and improved probe fixation devices help avoid these factors. The key to the successful practice of TCD is training of technical personnel and education of the interpreting and referring physicians as to when to use TCD and what to expect from it. The advantages of TCD should be given particular consideration: portability, repeatability, long-term monitoring, emboli detection, and inexpensiveness. TCD machines and transducers need to be tuned to the target disorders; that is, larger sample volume, higher power, and so forth, and TCD technology should be implemented in phases I to II as well as in phase III trials of preventive interventions and stroke therapies.

Influence of oxygen ventilation on Doppler microemboli signals in patients with artificial heart valves

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the influence of inhalation of 100% oxygen on microembolic signal (MES) counts in patients with artificial cardiac valves.

METHODS

A total of 134 outpatients were examined. Transcranial Doppler baseline monitoring (45-minute duration) was performed in all patients under resting conditions. The first 30 patients subsequently underwent transcranial Doppler monitoring for at least 20 minutes under noninvasive positive pressure ventilation with 100% oxygen and for an additional 30 minutes under resting conditions. The same protocol was applied to all following patients with a baseline MES count > or = 10, while the examination was discontinued in the remaining patients.

RESULTS

Baseline MES counts < 10, which remained unchanged during oxygen inhalation and the subsequent resting period, were observed in 26 of 30 initial patients. A total of 46 patients with MES counts > or = 10 were identified. Oxygen application was feasible in 43 patients. An exponential MES decrease was noted in 42 patients during oxygen inhalation (statistically significant in 38 patients), followed by a subsequent increase in 38 of 43 patients (statistically significant in 25 patients) under resting conditions.

CONCLUSIONS

The exponential reduction of MES counts observed in this study corresponds to blood denitrogenation, thus strongly arguing for nitrogen bubbles as underlying embolic material in prosthetic valve carriers.

Computed tomography-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome

PURPOSE

This study was designed to assess the efficacy of computed tomography-guided percutaneous abscess drainage in intestinal disease.

METHODS

Retrospective chart review of patients who underwent percutaneous abscess drainage for complications of intestinal disease with or without surgery between 1990 and 1994.

RESULTS

Eighty-two patients with 111 abscesses were identified. Causes of abscess included anastomotic leaks (35 percent), postoperative complications without leak (30 percent), and diverticular disease (23 percent). Complete success (no surgery necessary) was achieved in 53 of 82 patients (65 percent). Nine patients (11 percent) who underwent interval surgery were classified as having partial successes. Twenty-six of 26 (100 percent) well-defined unilocular collections containing pus were successfully drained. Complex abscesses (loculated, poorly defined, multiple, associated with fistula, draining feces) were successfully drained in 35 of 55 patients (63 percent). Success rates varied inversely with the number of complicating factors present. Apache II scores of 15 or higher were associated with decreased success rates.

CONCLUSION

Percutaneous abscess drainage is a highly successful technique for treatment of patients with intra-abdominal infection related to intestinal disease. Although several factors are associated with decreased success rates and multiple complicating factors combine to reduce success rates, no identifiable factor or combination of factors preclude the possibility of a successful outcome.

Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy

BACKGROUND AND PURPOSE

The value of carotid endarterectomy (CEA) depends on the safety of the operation. Transcranial Doppler ultrasound (TCD) was used to evaluate the possibilities of hypoperfusion, hyperperfusion, and embolization as causes of stroke and to evaluate the significance of Doppler microembolic signals (DMES).

METHODS

Five hundred CEAs were monitored with TCD of the ipsilateral middle cerebral artery during various phases of CEA to determine hemodynamic changes and incidence of DMES. Complications were graded according to their severity, and their probable cause was determined from TCD criteria and review of hospital charts.

RESULTS

We observed 24 cerebrovascular complications (4.8%), including 9 with transient ischemic attacks and 15 (3%) with permanent deficits. Among all cerebrovascular complications, embolism was judged to be responsible in 13 (54%; P < .02 compared with hypoperfusion), hyperperfusion in 7 (29%; P < .14 compared with hypoperfusion), and hypoperfusion in 4 (17%; P < .08 compared with embolism plus hyperperfusion). The surgeons responded to TCD information by several strategies depending on the TCD information. The incidence of permanent deficits diminished from 7% in the first 100 operations to 2% in the last 400 (P < or = .01). Shunting was more strongly associated with cerebrovascular complications than nonshunting, but this difference was not significant (P = .24). Intraoperative prevalence of DMES was strongly associated with cerebrovascular complications (P = .02).

CONCLUSIONS

Embolism is the principal cause of cerebrovascular complications from CEA; hyperperfusion and hypoperfusion are also important causes. TCD provides information that allows prompt identification and treatment of these three major causes of stroke from this operation. The perioperative stroke rate can be reduced by appropriate measures, taken by the surgeons, based on findings of TCD monitoring.

Transcranial Doppler intraoperative monitoring during carotid endarterectomy: experience with regional or general anesthesia, with and without shunting

To determine whether continuous transcranial Doppler (TCD) can significantly alter therapeutic conduct during carotid endarterectomy, a retrospective study of 117 carotid endarterectomies was done. There was no perioperative mortality; one perioperative stroke was recorded in a patient who was symptomatic preoperatively. Continuous TCD of the ipsilateral middle cerebral artery (MCA) was attempted in 99 cases, and successful in 90; nine patients (9.1%) had inadequate temporal windows for MCA access. MCA velocities and emboli were recorded before and during carotid cross-clamping, and on clamp release. There were no significant velocity differences between the patients with regional and general anesthesia, and patients with and without carotid shunts, but there was a statistically significant difference in the total number of emboli (air and particulate transients) noted for the shunted and nonshunted patients after clamp release: 12.7 versus 23.6, respectively (p = 0.05). There was no significant difference when particulate and air microemboli were compared. During surgery TCD identified residual flow of less than 40% in the MCA in 17 patients (18.8%). TCD also identified hyperperfusion in two patients, shunt abnormalities in three patients, and influenced postop treatment in four patients, one of whom was returned to surgery. TCD is an important tool for identifying patients who would benefit from a shunt, preventing hyperperfusion, identifying postop emboli, and detecting technical errors.

Prevalence of plaques and stenoses detectable by echo-Doppler examination in the femoral arteries of an elderly population

Using echo-Doppler evaluation, we assessed the prevalence of possible atherosclerotic lesions in the common femoral arteries (n = 478) and superficial femoral arteries (n = 478) in 239 subjects (age range 65-94 years) living in retirement houses in Seattle. Ankle pressure was measured with a pneumatic cuff and a continuous wave Doppler. There were 68 individuals with an ankle arm index less than 0.97 and 39 of these with a index below 0.90. An echo-Doppler examination was performed with an Advanced Technologies Laboratories Mark 600 Duplex Scanner. We found 167 (34.9%) common femoral arteries affected by non-stenosing plaque while 19 arteries (4%) had stenosis or occlusion. In addition, 178 (37.2%) superficial femoral arteries showed non-stenosing plaques. The subjects with common femoral disease were 27 (11.3%), those with evidence of superficial femoral artery disease were 48 (20.1%), and those affected by disease in both sites were 84 (35.1%). There were 80 people (33.5%) with no ultrasound evidence of femoral artery disease. We found that the presence and severity of disease increased progressively in the decades 65-74, 75-84 and 85-94. We also demonstrated a positive association between major cardiovascular risk factors and ultrasound evidence of peripheral disease. The prevalence of femoral artery disease in an apparently healthy population was relatively high, although stenoses in most instances were not severe.(ABSTRACT TRUNCATED AT 250 WORDS)

Strictureplasty for obstructive Crohn's disease: the Mayo experience

BACKGROUND

Strictureplasty for obstructive Crohn's disease of the small bowel continues to gain favor throughout the world. Although the potential advantages of preserving intestinal length are obvious, the optimal clinical setting for performing strictureplasty remains to be determined.

PATIENTS

Of 244 patients who underwent abdominal exploration for complications of Crohn's disease between Jan. 1, 1985, and Jan. 1, 1991, at the Mayo Clinic, 35 had a total of 71 strictureplasties. Concomitant resection of bowel with active disease was performed in 67% of the procedures.

RESULTS

In this series, no perioperative deaths occurred, and no anastomotic leaks, enteric fistulas, or intra-abdominal abscesses were noted during a 3-year follow-up. The overall perioperative complication rate was 14%. Postoperatively, 33 of the 35 patients were able to resume enteral nutrition and discontinue medical treatments. The symptomatic recurrence rate at 3 years was 20%; six patients have required reoperation.

CONCLUSION

These findings support the use of strictureplasty for isolated, quiescent, stenotic bowel lesions associated with Crohn's disease.

Relation between middle cerebral artery blood flow velocity and stump pressure during carotid endarterectomy

BACKGROUND AND PURPOSE

Many patient monitoring techniques have been used for detecting cerebral hypoperfusion during carotid endarterectomy. We compared middle cerebral artery blood flow velocities with carotid artery stump pressures to evaluate the indications for common carotid artery cross-clamp shunting and the probable hemodynamic causes of cerebrovascular complications.

METHODS

Blood flow velocities were monitored with transcranial Doppler ultrasound and carotid stump pressures were measured at the time of common carotid artery cross-clamping during 97 carotid endarterectomy procedures. Stump pressures measured with the gauge zero reference at the common carotid artery level were correlated with the percentage change of velocities.

RESULTS

Middle cerebral artery blood flow velocities usually decreased upon common carotid artery cross-clamping, depending on collateral availability and the autoregulation response. The best fit of the data was to an exponential function concave to the pressure axis, with velocity as a percentage of the pre-cross-clamp value reaching zero at 15 mm Hg stump pressure (r = 0.85 and p less than 0.001).

CONCLUSIONS

There is a less critical margin of error with percentage middle cerebral artery blood flow velocity decreases than with stump pressure measurements. This relation establishes changes in middle cerebral artery blood flow velocities as a reliable parameter for judging the effects of carotid cross-clamping on cerebral blood flow and providing an excellent indicator as to the necessity for shunting.

Dysplasia in chronic ulcerative colitis: implications for colonoscopic surveillance

Mucosal dysplasia has been used as a marker for patients with chronic ulcerative colitis considered to be most at risk of developing cancer, and its identification is the basis for colonoscopic surveillance programs. To evaluate the reliability of this premise, colectomy specimens from two groups of patients who had undergone surgery for chronic ulcerative colitis (50 with cancer and 50 without) were retrieved. The groups were matched by age, sex, duration of disease, disease extent, and symptoms at the time of surgery. Using a standard technique of multiple random biopsies, we utilized the standard colonoscopic biopsy forceps to obtain four biopsies from mucosa that was not macroscopically suspicious for dysplasia or cancer in eight defined regions in each of the 100 colon specimens. This technique mimicked exactly the methods used in our clinical surveillance program. All 3,200 biopsies were evaluated blindly by one pathologist for presence and grade of dysplasia. Twenty-six percent of colons with an established cancer harbored no dysplasia in any biopsy from any region in the colon. While an overall association between the presence of cancer and high-grade dysplasia was detected (relative risk = 9.00; 95 percent CI of 2.73-29.67), the sensitivity and specificity of random colonic biopsies to detect concomitant carcinoma were 0.74 and 0.74, respectively. These findings prompt concern that reliance on random biopsies, obtained during colonoscopic surveillance, may be misplaced.

Prevalence of extracranial carotid artery disease detectable by echo-Doppler in an elderly population

BACKGROUND AND PURPOSE

Little information is available on extracranial carotid artery disease in free-living elderly individuals. We sought to evaluate the prevalence of carotid lesions in the elderly.

METHODS

Using echo-Doppler, we assessed the prevalence of possible atherosclerotic lesions in the internal carotid arteries (n = 478) and the external and common carotid arteries (n = 956) of 239 subjects 65-94 years of age living in retirement homes in Seattle, Wash.

RESULTS

We found that 152 (31.8%) internal carotid arteries were affected by nonstenosing plaque and 37 arteries (7.7%) had stenosis or occlusion. In addition, 193 (20.2%) external or common carotid arteries showed nonstenosing plaques. There were 128 subjects (53.6%) with internal carotid disease, 106 (44.3%) with evidence of external or common carotid disease, and 75 (31.4%) affected by disease in all three sites. There were 80 subjects (33.5%) with no ultrasound evidence of carotid disease. We found that the presence and severity of carotid disease increased between the decades 65-74 and 75-84. We also demonstrated a positive association between systolic blood pressure and ultrasound evidence of carotid disease that was independent of age.

CONCLUSIONS

The prevalence of extracranial artery disease in an apparently healthy population was high, although stenoses in most instances were not severe. We conclude that noninvasive ultrasound methods identify a relatively small fraction of individuals (5% of the total) at high risk for stroke or transient ischemic attack. Echo-Doppler might be used to monitor further disease progression and to evaluate the efficacy of different therapeutic or preventive interventions.

Radical pancreatectomy for pancreatic cancer in the elderly. Is it safe and justified?

Surgical resection provides the only potential cure for pancreatic cancer, yet resection in patients 70 years of age and older remains controversial because of presumed increased morbidity and mortality. Our aim was to determine the operative results in patients 70 years of age or older undergoing potentially curative radical pancreatic resection for pancreatic cancer from 1982 through 1987. Of 206 consecutive patients explored for potential resection, 42 patients (mean age, 75 years) had potentially curative procedures, including radical pancreaticoduodenectomy in 23 patients, total pancreatectomy in 8 patients, and distal pancreatectomy in 11 patients. Ductal adenocarcinoma was the most frequently encountered neoplasm (69%), but cystadenocarcinoma and islet cell carcinoma accounted for 12% and 7%, respectively. The overall operative mortality rate was 9%, while surgical morbidity was 28%, and medical morbidity was 12%. Overall median survival was 19 months, and 5-year survival was 4%. Despite the low overall incidence of resectability and postoperative cure rate for pancreatic carcinoma, exploration for potential curative resection should not necessarily be withheld for healthy, selected patients who are older than 70 years. Morbidity and mortality rates, although slightly greater than for patients who are older than 70 years, are acceptable.

Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography

The purpose of our study was to define the signal characteristics and clinical circumstances associated with emboli detected in the middle cerebral artery using 2-MHz pulsed transcranial Doppler ultrasound in patients undergoing carotid endarterectomy. Signals designating emboli were transients displaying harmonic qualities the signatures of which were clearly different from those of mechanical and electronic artifacts. We reviewed the audio/video tape recordings from 91 patients for signals of air bubble emboli occurring upon release of common carotid artery crossclamps; recordings from 35 patients (38%) demonstrated air bubble emboli. Transients with signatures identical to those of air bubble emboli were also discovered when bubbles in the bloodstream were improbable; we defined these transients as representing formed-element emboli. Such signals were found in recordings from 24 patients (26%), and they occurred before (both spontaneously and upon common carotid artery compression), during, and after surgical dissection. Signals indicating formed-element emboli were associated with intraluminal platelet thrombus, with ulcerations in the carotid artery, and with transient ischemic attacks or stroke. Most postoperative formed-element emboli did not cause symptoms but, when persisting for hours, they were associated with strokes and cerebral infarction. This Doppler ultrasound method of detecting emboli will be useful in the study of stroke mechanisms and as a clinical test to guide the medical and surgical treatment of patients at risk of stroke.

Jejunal regulation of gastric motility patterns: effect of extrinsic neural continuity to stomach

This study was designed to determine the role of extrinsic gastric innervation in mediating the inhibitory effects of jejunal infusion of mixed nutrients on canine interdigestive gastric motility patterns. Four dogs underwent transection of all extrinsic and intrinsic neural continuity to the stomach except for careful preservation of vagal innervation (stage 1). Antral manometry catheters, antral electrodes, intestinal electrodes, and a jejunal infusion catheter were placed. After a 2-wk recovery, stage 1 studies of myoelectric and contractile activity of the stomach and small bowel during fasting were recorded on four occasions during infusion of isomolar solutions of either nonnutrient NaCl (150 mM) or mixed nutrients (50% Meritene solution) into the jejunum at 2.9 ml/min for 6 h. Identical studies (stage 2) were repeated after completion of extrinsic denervation of the stomach by supradiaphragmatic vagotomy. In stage 1 studies, jejunal nutrients (83 kcal/h) inhibited the characteristic interdigestive cyclic motility patterns in the stomach and duodenum for greater than or equal to 172 min during jejunal infusion of mixed nutrients. After completion of extrinsic denervation (stage 2), jejunal infusion of nutrients had the same effects with inhibition of cyclic motility patterns in the stomach and small intestine. We concluded that inhibition of interdigestive gastric motility patterns by jejunally infused nutrients is mediated by hormonal mechanisms and not by nonvagal or vagal extrinsic neural input to the stomach.

Effect of duodenectomy on interdigestive pancreatic secretion, gastrointestinal motility, and hormones in dogs

We tested the hypothesis that the duodenum is necessary to coordinate interdigestive pancreatic trypsin secretion with gastrointestinal motility and determined whether duodenectomy altered interdigestive cycles of plasma motilin and pancreatic polypeptide and their relationship to trypsin secretion and motility. Consequently, in normal and duodenectomized dogs, we measured trypsin secretion, gastrointestinal motility, and plasma concentrations of motilin and pancreatic polypeptide during the interdigestive period. After duodenectomy, peaks of trypsin secretion continued to cycle at normal intervals (102 +/- 15 min), but the amounts of trypsin were reduced during peaks of secretion (P = 0.02) and throughout the entire cycle (P = 0.02). Trypsin secretory cycles after duodenectomy, however, were not coordinated with cycles of interdigestive motility, and the plasma concentrations of motilin (P = 0.02) and pancreatic polypeptide (P = 0.05) were reduced and had no cyclic pattern. In addition, we confirmed that duodenectomy alters canine interdigestive antral motility, interrupts coordination between antral and intestinal motility, and shortens the period of jejunal migrating motor complexes. We conclude that duodenectomy disrupts the relationship between the cycles of interdigestive gastrointestinal motility and trypsin secretion and reduces the amount of interdigestive trypsin secretion. These effects of duodenectomy may be due to interruption of the duodenopancreatic neural connections or the hormonal abnormalities we have described. The loss of the cyclic pattern of plasma pancreatic polypeptide after duodenectomy suggests that the duodenum controls the release of pancreatic polypeptide by either a neural or hormonal mechanism.

Interdigestive gastric motility patterns: the role of vagal and nonvagal extrinsic innervation

Our study was designed to determine separately the roles of vagal and nonvagal extrinsic innervation in the initiation and coordination of patterns of gastric contractile activity and in the organization of the gastric slow wave. Four dogs first underwent transection of all extrinsic and intrinsic neural continuity to the stomach, except for careful preservation of vagal innervation to the stomach (stage 1). Manometry catheters and serosal electrodes were placed in the antrum, and electrodes were fixed to the small intestine. After recovery, motility was recorded during fasting and after feeding. A cyclic motor pattern occurred in the stomach with a period that was not different from that of the migrating motor complex in the small intestine (113 +/- 11 minutes vs 112 +/- 11 minutes; p greater than 0.05). Gastric and intestinal motility remained coordinated in time. Feeding inhibited this cyclic motor pattern in stomach and intestine. Antral tachygastria (slow wave frequency greater than 8 cycles/min) was infrequent (less than 1% of time). Each animal was restudied after completing extrinsic gastric denervation by a transthoracic vagotomy (stage 2). Vagotomy did not alter the presence, appearance, or period of cyclic gastric activity, nor did it disrupt temporal coordination with the duodenal migrating motor complex or increase the prevalence of tachygastria. In conclusion, neither vagal nor nonvagal extrinsic innervation to the stomach was required for initiation or coordination of the characteristic cyclic gastric motility pattern during fasting; although vagal innervation may modulate gastric myoelectric activity, its precise role is not evident in this study.

Postprandial disruption of migrating myoelectric complex in dogs. Hormonal versus extrinsic nervous factors

Our aim was to determine the mechanism whereby the jejunoileum regulates postprandial gastroduodenal motility. Five dogs were prepared with a proximal jejunal infusion catheter and with gastric manometry catheters and serosal intestinal electrodes for recording gastric and intestinal motility. After two weeks, fasted dogs were studied during jejunal infusion of either isosmolar NaCl (154 mM) or isosmolar mixed nutrient solution (50% Meritene) on four separate days each. After completion of these baseline studies, the dogs underwent a model of autotransplantation of the entire jejunoileum (extrinsic denervation, disruption of intrinsic neural continuity with proximal duodenum). Two weeks later, identical studies as before were repeated with the now "autotransplanted" jejunoileum. Before transplantation, infusion of NaCl did not interrupt the characteristic interdigestive migrating motor complex either in the gastroduodenum or in the jejunoileum. However, infusion of nutrients interrupted the migrating motor complex both in the gastroduodenum and jejunoileum for the duration of the infusion (5 hr). After autotransplantation of the jejunoileum, the migrating motor complex continued to occur in the gastroduodenum and in the jejunoileum during infusion of NaCl, but the migrating motor complex cycled independently in each region without any temporal coordination. Jejunal infusion of nutrients interrupted the MMC in both regions for the duration of infusion (5 hr). Because inhibition of the gastroduodenal and jejunoileal migrating motor complex continued to occur during infusion of nutrients into the transplanted jejunum, we concluded that jejunoileal regulation of postprandial inhibition of interdigestive motility in the stomach and duodenum is mediated by hormonal factors and does not require intrinsic neural continuity.

Role of extrinsic and intrinsic nerves in hormonal induction of the migrating motor complex in the jejunum

The mechanism of induction of the migrating motor complex (MMC) by neural or humoral agents and their role in the control of fasting motility are not well understood. Our aim was to determine the role of extrinsic and intrinsic nerves in mediating the induction of the MMC by motilin. Three groups of dogs were studied. Group I consisted of neurally intact control dogs. In group II, intrinsic neural continuity between the duodenum and the jejunum was interrupted by transection and reanastomosis of the distal duodenum. Dogs in group III underwent disruption of all intrinsic and extrinsic neural input to the entire jejunoileum. Serosal electrodes were sewn to duodenum and jejunum in all dogs. After a 2-week recovery, fasting myoelectric activity was recorded on four or more occasions. Motilin (0.1 microgram/kg iv) was given 30 min after a spontaneous duodenal phase III. In group I (controls), motilin induced a premature MMC, which originated in the duodenum and migrated along the small intestine. In group II (intrinsic neural disruption), motilin induced a premature MMC, which began simultaneously in the proximal duodenum and proximal jejunum. In group III (intrinsic and extrinsic neural disruption), motilin induced a premature MMC in the duodenum but not in the jejunum; rather, a short, nonmigrating burst of spike potentials occurred simultaneously in all jejunal electrodes. These observations suggest that extrinsic innervation is necessary for motilin to induce phase III activity in the jejunum. Extrinsic neural pathways appear to mediate motilin-induced MMC activity in the jejunum.

Nonoperative management of blunt hepatic trauma in adults

Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. CT criteria for nonoperative management included contained subcapsular or intrahepatic hematoma, unilobar fracture, absence of devitalized liver, minimal intraperitoneal blood, and absence of other significant intra-abdominal organ injuries. The predominant CT pattern in the 17 patients successfully managed nonoperatively included unilobar right-lobe fracture or intrahepatic hematoma. A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.

Carotid artery Dacron patch graft angioplasty: a ten-year experience

Of 394 carotid endarterectomies performed during a 10-year period, 36 (9%) included Dacron patch graft angioplasties. Patch graft angioplasties were used selectively in patients because they had undergone previous carotid endarterectomy or had small-caliber vessels. There were no postoperative infections, occlusions, emboli, stroke, or pseudoaneurysms. In addition, no clinically detectable recurrent stenoses developed in this high-risk group of patients. Twenty-four of the 27 patients available for follow-up were screened for asymptomatic stenoses with spectral analysis and B-mode imaging; there was no sign of hemodynamically significant recurrent stenosis in this group. These encouraging results support the continued selective use of Dacron patch graft angioplasty in carotid surgery.

Transorbital Doppler diagnosis of intracranial arterial stenosis

Forty-two intracranial internal carotid arteries were visualized by both arteriography and 2 MHz pulse ultrasonic Doppler examinations. The intracranial internal carotid artery Doppler signals were studied at 5-7 cm depth behind the eyelid using frequency spectral analysis. Stenosis criteria were developed and methods of avoiding confusion with collateral effects devised. Among 33 intracranial ICAs visualized on the arteriograms, 22 were normal without stenosis and 11 displayed some degree of stenosis ranging from 20 to 75 percent. An additional 7 were totally occluded. Doppler criteria of stenosis representing elevated frequencies and symmetrical prominent low frequencies (SPLF) were utilized and separated from collateral effects to provide an overall accuracy of the technique of 88 percent with a 95 percent specificity and a 73 percent sensitivity. The technique appears sufficiently promising to justify further development and utilization.

Carotid endarterectomy after Doppler ultrasonographic examination without angiography

We prospectively reviewed our experience with 32 carotid endarterectomies in 30 patients performed without angiography in a 7 year period. Although this represents 6.7 percent of our total experience with carotid endarterectomy in this period, carotid endarterectomy without angiography is increasing and comprises 17 percent of the last 2 years' total. We have adhered to strict criteria for patient selection that identifies circumstances for a safe operative experience in seven broad categories. Evidence is also presented to reduce an overriding concern for intracranial aneurysms and siphon stenosis if either one exists unrecognized. We are hopeful that in the future, the latter will be identified by intracranial Doppler studies currently being performed. Our experience in this small series has been favorable, with intraoperatively measured lesions equal to the preoperative noninvasive predictions. We suggest that Doppler ultrasonography in its current form can be effectively used in place of conventional angiography or digital subtraction angiography in selected patients.

Delayed sternal closure. An improved method of dealing with complications after cardiopulmonary bypass

Intraoperative closure of the median sternotomy after cardiac operations in patients with complications, including severe postoperative bleeding, impaired cardiac function caused by myocardial edema, and cardiac dilatation, may lead to a critical and possibly fatal deterioration of hemodynamic function. In an effort to prevent this complication, we delayed mediastinal closure in 15 patients, covering the wound temporarily with a sheet of rubber latex (Esmarch bandage). An oval patch of this material was sized and sutured to the skin edges with a continuous suture. This technique provided easy and fast access to the mediastinal structures in four of the 15 patients who required multiple surgical interventions in the early postoperative period. Delayed closure was indicated for severe bleeding in 10 patients, heart compression in four patients, and severe postbypass arrhythmias in one patient. Definitive closure of the chest was delayed until satisfactory hemostasis was achieved or the heart size returned to normal. Thirteen of the 15 patients were long-term survivors, none of them had wound infections, and their wounds healed well. Delayed closure of the median sternotomy was an effective and safe approach in these groups of critically ill patients.

Doppler measurement of the pressure drop caused by arterial stenosis: an experimental study: a case report

A stenotic arterial lesion which reduces the cross-sectional area of the artery causes an increased velocity and, as a consequence, a loss in kinetic energy and a pressure drop. A simplified formula, derived from the Bernoulli principle, relates the pressure drop to the maximum velocity of the blood flow in the stenotic segment: delta P (mmHg) = 4 Vmax2 (m/sec). This formula has been validated for stenosis of cardiac valves. Aim of our study was to test the hypothesis that this formula applies in the major arteries using Doppler ultrasound with spectrum analysis. In our experiments we created artificial graded stenoses of varied geometry in the thoracic aorta of dogs. Invasive pressure measurements were obtained using intra-arterial needles on both sides of the stenosis. A Doppler signal was obtained with a 2.5 MHz CW probe, insonating the stenotic area from a distance, with an almost parallel approach. In these conditions the maximum Doppler frequency shift is an accurate estimate of the maximum flow velocity, according to the Doppler equation. We compared the Doppler derived (delta P = 0.36 Fmax2) and the invasive measurements of pressure drops. Our results show a highly significant correlation between the intra-arterial and the Doppler measurements of the pressure drops caused by arterial stenoses and encourage efforts in applying similar techniques in the noninvasive evaluation of vascular patients.

Doppler ultrasound in the evaluation of the peripheral arterial circulation

This review summarizes the principle, advantages, and limitations of Doppler ultrasound flowmeters, and discusses the possibilities of applying these systems in evaluating the functional state of the peripheral arterial circulation. This discussion is not limited to the assessment of blood flow velocity and poststenotic arterial pressure with Doppler flowmeters, but includes among other things the recordings of flow patterns, the determination of the transit time of velocity wave forms, and the imaging of the arterial circulation.

Quantitation of carotid stenosis with continuous-wave (C-W) Doppler ultrasound

Two methods for determining the degree of stenoses developing on the origin of the internal carotid were tested using non-invasive Doppler ultrasonic imaging (DOPSCAN) of the carotid bifurcations. Spectral analysis of Doppler audio recordings was utilized in determining the maximum frequencies found within the stenosis, as well as the ratio of the frequency downstream to the stenosis, to the frequency within the stenosis. The theoretical relationships between blood flow, velocity, and pressure drop are defined for all grades of stenosis and they predict that carotid flow will not be reduced unless the lumen diameter is less than 1.5 mm. At critical diameter reductions, below 1 mm, the frequencies in human carotids do not exceed 16 KHz because turbulence limits peak velocities. If the maximum systolic frequency exceeds 5 KHZ, when 5 MHZ probes are directed at a 30 degree angle from the body axis, there is always present stenosis up to diameters of less than 3.5 mm by x-ray angiographic measurements. Frequency ratio studies confirm that plaque growth is not symmetrical but they did not improve x-ray angiography correlations because of the limitations of x-ray in measuring cross sectional areas from projection films and limitations of the spot size of x-ray tubes.

Decompression limits for compressed air determined by ultrasonically detected blood bubbles

The direct decompression limits for a group of divers over a range of pressure-time air exposures was determined using ultrasonic detection of venous gas emboli (VGE). In addition to dry chamber exposures, ranging from 233 ft for 7 min to 25 ft for 720 min, we exposed six divers to open ocean dives at 165 ft for 10 min. Findings demonstrated a strong individual propensity to form VGE, correlating with susceptibility to bends. No bends developed without the prior detection of precordial VGE. The present concept of no problems after any period of time at 30 fsw was not confirmed. Isopleths of equal percentage occurrence of VGE were computed between 10 and 60%. Open ocean exposures increased the percentage of VGE and bends, when compared to dry chamber exposures. Limiting tissue half times computed from the 20% VGE isopleth suggested that saturation exposures are controlled by a greater sensitivity of the short-half-time tissues than previously appreciated, rather than by additionally extended half times.

Cervical carotid imaging with a continuous-wave Doppler flowmeter

A noninvasive technique for carotid arteriography using an ultrasonic directional Doppler flowmeter to image the carotid bifurcations is described. The technique uses a position sensing arm to hold the sharply focusing probe and translates the position of arterial flow onto an image storage screen. By multiple manual sweeps across the cervical carotids, a two-dimensional projection of the locus of arterial flow is developed. The probe beam is then applied through the eyelids to assess the posterior orbital ophthalmic flow. The adequacy of the internal carotid circulation and the presence of stenosis and calcified plaques are determined. Experience with the first 60 patients surveyed using the Doppler technique demonstrated a high degree of accuracy and reproducibility. The ultrasonic angiography provided local flow and velocity information that x-ray angiography did not. X-ray angiography is frequently indicated by the ultrasonic findings when risks of x-ray angiography might not otherwise be taken. The technique was found especially sensitive in detecting calcified atherosclerotic plaques and may be used in screening for the stroke-prone patient and following arterial lesions over extended periods of time.

Ultrasonic Doppler technique for imaging blood vessels

Present ultrasonic Doppler flow detectors that use the Doppler effect on waves scattered from moving blood have provided useful information when directed by hand to trace the circulation of animals and man. By scanning with a highly directive flow detector, the areas of flow can be localized. Images can be formed of the interior of blood vessels. These images have the appearance of arteriograms and venograms made by dye contrast radiography, but have none of its hazards. The resolution appears adequate for useful images.