Erich W. Pollak

Pancreatic pseudocyst: Management in fifty-four patients☆

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Thrombosis detection by radionuclide particle (MAA) entrapment: correlation with fibrinogen uptake and venography

Macroaggregated albumin (MAA) entrapment in areas of fibrin deposits has been used to detect intravenous thrombosis in the lower extremities. This study reports the correlation of MAA uptake in thrombosis with venography and autologous 125I-labeled fibrinogen uptake in approximately 30 cases. Correlation was good in most patients who underwent at least two of these procedures. The MAA thrombosis scan appears especially accurate in locating thrombosis in the upper thigh or pelvis where fibrinogen uptake is less helpful. The correlation suggests that the MAA scan has very few false negative results. The procedure is easily performed in conjunction with a perfusion lung scan.

Inflammatory carcinoma of the breast: A therapeutic approach followed by improved survival☆☆☆

Disappointing results of radical mastectomy for treatment of inflammatory breast carcinoma led to its abandonment and the use of alternative therapeutic methods without improvement of survival rates. Results of radical mastectomy combined with other therapeutic modalities have not been fully evaluated so far. In a series of nine patients with proven inflammatory breast carcinoma and no distant metastases, two underwent radiotherapy, oophorectomy, and adrenalectomy (group A) and seven underwent preoperative irradiation, radical mastectomy, postoperative irradiation, and chemotherapy (group B). There were no local recurrences in either group. Group A patients survived five and eight months (mean, 6.6+/-2.1) and patients of group B survived 45.5+/-26.2 months (p less than 0.05). Results show no rational basis for withholding radical mastectomy, but suggest that improved survival may be obtained when radical mastectomy is an integral part of a rational sequential therapeutic schedule.

Risk factors in healing of below-knee amputation: Appraisal of 64 amputations in patients with vascular disease

Healing of below-knee amputation was evaluated in 64 amputees with atherosclerosis to determine the effects of diabetes, anemia and preoperative infection on the healing process. No statistically significant effects of either factor could be proven, although more anemic patients (hemoglobin less than 11 g/100 ml) and preoperatively infected patients had higher rates of postoperative wound infection (45 and 36 percent, respectively) than less anemic patients (hemoglobin 11 g/100 or greater) and patients without preoperative infection (23 percent and 7, respectively). Younger patients (50 to 60 years old) had a greater incidence of wound infection (p < 0.001), stump necrosis (p < 0.001) and reamputation (p < 0.05) than older patients. Stump drainage increased the likelihood of infection from 20 to 46 percent (p < 0.025). Of all investigated correctable factors, the use of stump drainage carried the heaviest complication rate. It is suggested that the use of drains in below-knee amputation stumps be discontinued.

The Effect of Postural Changes Upon the Ankle Arterial Perfusion Pressure

The normal arterial blood pressure at the ankle, (AP), right brachial arterial pressure (RBP) and pressure index (PI) were investigated in 50 healthy young volunteers under basal conditions and during certain positions of the legs, utilizing Doppler ultrasound flow determination and standard size blood pressure cuff. The mean AP was 10 mm Hg higher than the mean RBP in 76 instances but AP was smaller than RBP in 24 out of 100 investigated lower extremities. Mean PI was 1.069 ± 0.158. There was no statistically significant difference between PI of heavier and leaner patients although increased weight was associated with a significantly higher brachial and ankle arterial pressure. Departure of the lower extremity from the horizontal position resulted in AP changes explained by gravitational effects. If the new posture was maintained, the new AP persisted, thus indicating an absence of significant corrective circulatory adaptation to the posture changes. Extreme flexion of hip and knee joints resulted in a marked decrease of AP and PI, suggesting arterial kinking. This change was not affected by the weight:height ratio of the subject. It is concluded, therefore, that the presence of a greater amount of periarterial soft tissues does not significantly prevent arterial kinking. These tensional shifts indicate changes of flow pattern occurring in normal subjects during extreme flexion. Even more marked shifts can be anticipated in arteriosclerotic patients under similar circumstances.

Noninvasive cerebrovascular evaluation: A prerequisite for angiography?

Results of cerebrovascular evaluation were reassessed in 768 patients to determine whether angiography performed in unselected patients was safe and economically efficient, and whether previous noninvasive screening was sensitive enough and effective in increasing the yield of subsequent angiography. In 543 patients undergoing angiography without previous noninvasive screening, positive results were obtained in 21 percent. Complications included hemorrhage (2.4 percent), neurologic deficit (2.2 percent), and death (0.2 percent). Of 225 patients undergoing previous screening with Doppler, ophthalmoplethysmography, and carotid phonoangiography, none with negative screening results had subsequent cerebrovascular complications. Of 82 patients having positive noninvasive test results, 53 underwent angiography with a 74 percent yield of positive results. Twenty-nine had no angiography or corrective therapeutic action. Of these, 3 percent died after a cerebrovascular accident, and 21 percent developed complete stroke (mean follow-up 3 years). Noninvasive screening reliably eliminated necessity for angiography in 64 percent of patients while increasing the angiographic yield from 21 to 74 percent. Therefore, performance of cervicoencephalic angiography is asymptomatic and unselected patients cannot be condoned any longer. Likewise, positive noninvasive screening results should not be ignored because in the absence of treatment, death (3 percent) and permanent neurologic deficit (21 percent) occur over a 3 year period.

Detection of anticoagulation therapy failures in patients with venous thrombosis.

Results of ultrasonic monitoring of venous patency and fibrinogen uptake testing were evaluated in ten patients with venous thrombosis receiving heparin therapy. Two propagating venous thromboses were detected 24 to 48 hours before massive pulmonary embolism developed, thus emphasizing the usefulness of these methods for detection of anticoagulation therapy failures.

Mural Thrombosis After Experimental Carotid Endarterectomy

The incidence of mural thrombosis following three types of experimental intimal injuries at common carotid arteries, was investigated in a series of 12 dogs. Mural thrombosis was obtained at each of the intimal lesions. Moreover, obstructive thrombosis occurred in three instances. Further investigation of thrombi revealed that partial fragmentation occurred when exposed to hydrodynamic forces. These results suggest that mural thrombosis following carotid endarterectomy in humans, is possibly more frequent and significant than it is generally appreciated, thus leading to the consideration of postoperative anticoagulation after endarterectomy, as a means to minimize the incidence of postoperative embolic cerebrovascular accidents.

The choice of test for diagnosis of venous thrombosis.

Doppler ultrasound is the preferred screening test in asymptomatic patients with high risk for venous thrombosis. Radiographic phlebography leads to definitive diagnosis in most instances. Radionuclide angiography using 99mTc MAA with delayed images to detect particle entrapment in venous blood clots can be used when radiographic phlebography is contraindicated or impractical. To detect active thrombosis in patients with past venous disease, the serial fibrinogen uptake test is the method of choice. This method is also used to monitor the efficacy of anticoagulation therapy and to detect propagating thrombosis in patients failing to respond to anticoagulation, hopefully before massive lethal pulmonary embolism occurs. Radionuclide methods are contraindicated in pregnant women and children where non invasive methods are preferred. No completely satisfactory test exists for detection of hypogastric vein thrombosis. Among the methods currently being evaluated in the laboratory the ultrasound B-scan imaging, 99mTc MAA uptake test and 99mTc mAA venous scan offer the best possibilities for successful clinical application.

Clinical Case Reports: THE DETECTION OF SHALLOW ARTERIAL ULCERATIONS

delayed, in part because of the absence of a reliable procedure for detecting these shallow lesions. A new method for diagnosis of these ulcerations is based upon the detection by external scanning, of radiolabeled particles entrapped in places of the artery where intimal coverage was missing. Irregular shaped electropositive 99mTechnetium albumin aggregated particles (99mTc MAA), measuring 10 to 50 microns in diameter were utilized and intraarterial