George Todd

The accuracy of CT scanning in the diagnosis of abdominal and thoracoabdominal aortic aneurysms

As CT scanning has evolved as a reliable clinical tool, the use of angiography in the diagnosis of aortic aneurysmal disease has diminished. Fewer than 25% of patients with aortic aneurysmal disease undergo aortic angiographic evaluation at our institution. A prospective clinical study was undertaken to assess the validity of this policy. One hundred patients with clinical or ultrasonographic evidence of aortic aneurysms were evaluated prospectively during the period July 1987 to December 1989. All patients underwent CT scanning as an initial evaluation. Patients were selected for angiography if they fulfilled any of the following criteria: radiographic evidence of thoracoabdominal or juxtarenal aneurysms, or horseshoe kidney; or clinical suggestion of renal artery stenosis, mesenteric arterial insufficiency, aortoiliac occlusive disease, or lower extremity aneurysmal disease. During this period 19 patients (19%) underwent both CT scanning and angiography. The indications for angiography were thoracoabdominal aneurysms (7), juxtarenal aneurysms (2), clinical evidence of mesenteric insufficiency (1) or renal insufficiency (2), evidence of lower extremity aneurysmal disease (3), or severe aortoiliac occlusive disease (4). Eighty-one patients (81%) underwent CT scanning as the only radiographic evaluation. No patient was adversely affected by elimination of angiographic evaluation. CT scanning revealed inflammatory aneurysms (4), retroaortic renal veins (2), and horseshoe kidney (1). This study suggests that most (81%) patients with aortic aneurysmal disease can be adequately evaluated by CT scanning, and that a very selective policy of angiographic evaluation is indicated.

Reconstruction of urinary andgastrointestinal tracts in total pelvic exenteration: Experience at columbia-presbyterian medical center

OBJECTIVES To examine the effectiveness of and complications from total pelvic exenteration (TPE) with maintenance of urethral and anal sphincter function for locally invasive tumors of the pelvis. METHODS A retrospective review of 4 patients who have undergone TPE with urethral and anal sphincter preservation at Columbia-Presbyterian Medical Center in the last 2 years was performed with attention to perioperative morbidity and mortality, disease-free status, and need for further operative procedures. RESULTS Two patients had colorectal adenocarcinoma, 1 had squamous cell carcinoma of the cervix, and 1 had prostate sarcoma. All had urinary tract reconstruction with orthotopic neobladder creation, and 3 of 4 had primary low rectal anastomoses for gastrointestinal reconstruction. One patient underwent creation of a J rectal pouch. One of 4 patients had received radiation therapy for the disease prior to surgery. There was no operative or perioperative mortality. Two of 4 patients required reoperation, 1 in the immediate postoperative period for repair of a left ureteral stricture, and the other 13 months postoperatively for repair of a rectal-neobladder fistula. With a mean follow-up of 25 months (range, 21 to 43 months), 3 of 4 patients are alive and free of disease. All living patients are continent of urine and 2 of 3 are continent of stool. CONCLUSIONS Our experience confirms that TPE can be effective in controlling a variety of locally advanced pelvic tumors and can be performed in conjunction with simultaneous genitourinary and gastrointestinal reconstruction with minimal morbidity.

Urokinase perfusion for axillary-subclavian vein thrombosis

We report a single case of urokinase perfusion of axillary-subclavian vein thrombosis with the restoration of normal venous outflow of the arm. It is hoped that this will halt the usual sequelae causing chronic venous insufficiency.