Allyn G. May

Survival improvement following aortic aneurysm resection.

Abdominal aortic aneurysm resections were performed on 298 patients between January, 1966 and December, 1973. The results were compared with 186 resections previously reported between 1955-1965. Hospital mortality rates for elective resections were 13% in 1955-1965, 8.4% in 1966-1973, and 4.2% in the 113 patients treated during the last 3 years. Urgent resections for intact aneurysms, previously associated with a 36% mortality, resulted in a 6% mortality rate in 1966-1973. The emergency resection mortality rate for ruptured aneurysm, originally 69%, was reduced to a present day over-all mortality of 55%, and 42% for the last 3 years. Calculated actuarial survival at 5 years was 65% for urgent (intact), 60% for elective and 40% for emergency (ruptured) groups. Atherosclerosis remains the major deterrent to long-term survival with myocardial infarction and stroke causing 43% of deaths occurring within 5 years. Improved survival appeared secondary to better operative technique, postoperative patient monitoring, increased surgical experience, and more elective resections of smaller, asymptomatic aneurysms than in 1955-1965. With present day low mortality rates, elective resection should be recommended in all patients without significant medical contraindications.

Anatomic and Hemodynamic Correlations in Carotid Artery Stenosis

Pressures were measured in the carotid arteries of 61 patients proximal and distal to atherosclerotic plaques which were carefully studied by angiography and anatomical dissection. (1) An atherosclerotic plaque causing a constriction of less than 47% luminal diameter leaving a lumen greater than 3.0 mm in diameter never caused pressure drops of greater than 10 mm Hg. Stenoses of greater than 63% luminal diameter leaving lumens less than 1.0 mm in diameter always caused pressure drops. (2) Atherosclerotic plaques producing defects which narrowed the lumen fell into a distinct pattern: (a) Type 1 lesions—This basic lesion filled the bulb of the internal carotid artery near its origin, causing a 1 to 2 cm smooth elliptical encroachment on the lumen. (b) Type 2 lesions—Short localized areas of thickening in addition to the basic lesion caused bar-like defects of the lumen at the origin of the internal carotid artery or near the distal end of the lesion. (c) Type 3 lesions—Multiple bar-like defects were sometimes seen. (d) Type 4 lesions—The areas of increased thickening of the lesion were sometimes quite narrow, producing diaphragm-like defeats on the lumen. Although theoretically these various types of stenoses should produce different hemodynamic changes, insufficient numbers of observations were made to corroborate these presumptions. (3) Angiograms in general mimicked the gross appearance of the plaques and predicted the actual degree of stenosis produced but did not identify many diaphragm defects, ulcerations, or small thrombi.

An analysis of cytomegalovirus infection and HLA antigen matching on the outcome of renal transplantation.

Eighty-five recipients and donors of renal allografts were examined for evidence of cytomegalovirus infection before and repeatedly after transplantation. The recipients were also divided into two groups on the basis of HLA antigen matching. Better allograft survival was noted in patients well matched for HLA antigens (0–2 mismatched antigens) compared to those poorly matched (three or more antigens mismatched), and in patients free of cytomegalovirus compared to those infected. Cytomegalovirus infection had a more marked influence on allograft survival than did HLA antigen matching. The differing rates of success of transplantation, apparently dependent on blood relationship between donor and recipient, have been assumed largely to be due to inherited factors. This study, however, revealed an important factor to be the disparate incidence of cytomegalovirus infection in sibling, parental, and cadaveric categories of transplantation. The mechanism of this disparity can be explained on the basis of the incidence of latent CMV infection in the recipients and various categories of kidney donors.

Management of acute ischemia of the upper extremity

Records of 76 patients who presented with ischemia of the upper extremity from 1966 to 1981 were reviewed. Patients were divided into three groups according to cause: Group 1, emboli from the artery; Group 2, ischemia after catheter injury; and Group 3, ischemia due to lesions of the axillary and subclavian arteries. Management varied among the three groups. Long-term anticoagulation therapy was helpful in Group 1 patients in preventing reembolization. Forty percent of patients with catheter-related trauma required angioplasty of some sort in addition to embolectomy. Management of Group 3 patients was most difficult and the results least acceptable (three patients required amputation). Management of this type of ischemia must be individualized; it should vary according to the underlying disorder.

CLINICAL AND METABOLIC STUDIES FOLLOWING BOWEL BY‐PASSING FOR OBESITY*

Some six years ago we examined the possibility of by-passing most of the small bowel in an effort to control massive obesity. We had had clinical experience and had done metabolic studies on several patients who had had most of their bowel resected for gangrene secondary to volvulus or embolism. We felt we understood and could control the potential problems of patients with extensive by-passing since the amount of bowel remaining in circuit would be about the same as that remaining after resection for extensive gangrene. Two other factors played a major role in our final decision to pursue this clinical investigation: First, excessive obesity (200 per cent or more of normal weight) is a serious health hazard and carries a significantly increased mortality and morbidity. Second, no matter how many specialists are involved in caring for these excessively obese patients, over three-fourths of these patients do not maintain any significant weight reduction for a prolonged period. We felt that if a safe surgical procedure could be developed that would bring about and maintain significant weight reduction without serious side effects, it might be reasonable to use it in selected patients.

Parathyroid hyperplasia and carcinoma within one gland

A 47-year-old Scottish woman vacationing in the United States presented with a serum calcium level greater than 20 mg/dl and a parathyroid hormone level 16 times greater than normal after a one-week history of severe vomiting and unrelenting abdominal pain. Surgical exploration of the thymus revealed the very rare association of a large (7 by 4 by 0.8 cm) parathyroid carcinoma adjacent to apparently normal parathyroid tissue, separated by a thin fibrous band. Two other hyperplastic and one normal parathyroid glands were also identified. Postoperatively, the patient became hypocalcemic and, for the past nine months, has received maintenance 1-alpha-hydroxycholecalciferol therapy (1 microgram per day) with normal calcium and barely detectable parathyroid hormone levels.

Cytomegalovirus infection blocks the beneficial effect of pretransplant blood transfusion on renal allograft survival.

Two factors which have gained attention as possible contributors to success of renal allografts are freedom from infection with cytomegalovirus (CMV) after transplant and administration of multiple blood transfusions pretransplant. In order to determine the interrelationship of these two variables, we analyzed 55 recipients of well matched (at least two antigens) cadaveric kidneys. In this study, absence of CMV infection and receipt of multiple transfusions both provided favorable outcomes. When patients were grouped by both factors, those who were free of infection and received multiple transfusions did significantly better than any other combination. Infection with CMV decreased the frequency of allograft survival in multiply transfused patients to a point intermediate between the above group and those who had not been multiply transfused. Since CMV infection can be predicted by measurements made pretransplant, and since up to one-quarter of CMV infection which develops post-transplant is transmitted with the allograft, administration of multiple transfusion to all patients and the use of donors who are free of latent CMV infection for CMV antibody-negative potential recipients should increase allograft success. For those potential recipients who already have latent CMV infection, further study will be necessary to determine what stimuli can be given pretransplant to prevent the interference with the beneficial effect of multiple transfusions.

Clinical study of pheochromocytoma

Seventeen patients underwent 22 operations for pheochromocytoma over a 26 year period. The patients included 11 in three kindreds of familial pheochromocytoma and 6 with sporadic tumors. The diagnosis was usually suggested by the patients history. Confirmation of the diagnosis frequently required repeated testing for urinary or plasma catecholamines. Arteriography was the most effective method of preoperative tumor localization. Two tumors were proven nonfunctional. Others secreted either norepinephrine or epinephrine and norepinephrine. The familial patients showed a high incidence of multiple, bilateral and extraadrenal lesions. In contrast to previous reports, the familial tumors were found more often in the right than in the left adrenal gland. HL-A genotyping analysis of the sporadic and familial patients failed to demonstrate any HL-A antigen association or interdependent segregation of tumor and HL-A antigens within kindreds.

Renal artery aneurysm

More and more renal artery aneurysms are being diagnosed, especially after the introduction of selective arteriography for the evaluation of renovascular hypertension. However, renal artery aneurysm still remains a rare entity. The pathogenesis of renal artery aneurysm is identical to the pathogenesis of arterial aneurysm in other arteries. Symptoms of aneurysm of the renal artery are dependent on a variety of factors, the most important of which are the size of the aneurysm, its location, and whether or not rupture has occurred. The indication for operation on renal artery aneurysm is rupture or threat of rupture. Herein we present a review of the literature and a report of 2 cases which exemplify the capabilities of the surgeon in dealing with such cases.

Bilateral nephrectomy and splenectomy in renal failure

Abstract Sixty consecutive patients treated by bilateral nephrectomy and splenectomy as a preparation for renal transplantation are reviewed. Only 8 (13.3 per cent) of the patients were totally free of complications related to the procedure. The most frequent complications noted were atelectasis, pneumonia, hypotension, hyperkalemia, pulmonary effusion, hypertension, and gastrointestinal bleeding. There were 7 deaths in the group (11.7 per cent). As a result of this review bilateral nephrectomy in preparation for transplant is recommended to patients only with the following problems: uncontrolled hypertension of the high renin variety; infected, obstructed kidneys or the presence of vesicoureteral reflux; Goodpastures disease or certain cases of rapidly progressive glomerulonephritis, and some patients with polycystic kidney disease. The role of splenectomy is still controversial.