1/170. Primary hepatic carcinoid in a renal transplant patient.There seems to be a world-wide increase in the incidence of tumors among immunosuppressed patients. Of 1350 renal allografts transplanted in the past 23 years at the Department of Transplantation and Surgery, 56 cases were malignant tumors. The case of a 58-year-old female patient is reported, with disseminated primary carcinoid in the liver detected 86 days after renal transplantation. According to the literature only 39 patients with primary liver carcinoids have been reported until 1997, but this is the first where the carcinoid developed in an immunosuppressed patient. The rapid progression of the carcinoid could be associated with the immunosuppression.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
2/170. Progressive brown discoloration of silicone intraocular lenses after vitrectomy in a patient on amiodarone.A patient who was treated with amiodarone for 3 years developed brown discoloration of the intraocular lenses in both eyes. contrast sensitivity and blue perception were reduced in the right eye. After vitrectomy for a vitreoretinal traction syndrome in the left eye, the discoloration appeared to increase. The apparent progression may have been related to breakdown of the blood-aqueous barrier after vitrectomy. However, because the discoloration developed before surgery and was bilateral, long-term administration of amiodarone may also have played a role.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
3/170. Surgical treatment of poliomyelitic scoliosis.Between 1968 and 1973 forty nine patients suffering from poliomyelitic scoliosis were treated surgically at the Rizzoli Institute. They were due to asymmetrical paralysis and contracture in the muscles of the trunk and limbs. Associated pathological conditions were found, such as pelvic obliquity, and vascular and trophic changes due to ganglionic lesions. The differing incidence and combination of these factors gave rise to various clinical types of spinal deformity. The average severity of curve was 39 degrees, the localisation was predominantly central, the average extent was ten vertebrae, and there was a marked predominance of right convexity (twenty nine out of thirty six). The rate of progression was maximum during puberty and almost negligible after bony maturity. It was greater in males and was unfavourably affected by the severity and asymmetrical distribution of the paralysis, by the early appearance of the disease, by high localisation of the deformity, and by the erect posture in patients who were ambulant. The most frequent visceral complications were in the respiratory system (ten patients with a deficit over 50%), followed by cardiac changes. Surgical treatment was adopted in patients with progressive curves over 60 degrees, because of the inevitable deterioration in their general condition and the tendency of the deformity to become fixed. Pre-operative correction by Halo-traction results (52% correction) than Risser plasters (38%). Posterior arthrodesis by Harrington's method was carried out in all the more recent cases (forty four). Post-operative plaster was maintained for eight months and then replaced by an orthopaedic corset. At bony maturity there was an averaged improvement of 35% in the angle of curvature, and an average improvement of 6% in vital capacity. The best corrections were obtained in patients under fourteen (42%), in dorso-lumbar scoliosis (40%) and in patients with curves above 100 degrees (38%). There was an average increase in height of 9.1 cms and a reduction in the gibbus of 3.4 cms. The complications included one traumatic pneumothorax, eight pseudarthroses, and breakage of the distraction rod in two cases resulting in complete relapse of the deformity. In six cases the upper hooks became loos and there were two cases of postoperative staphylococcal infection. In the distally sited curves our present policy is towards combining posterior arthrodesis with Dwyer's anterior interbody fusion.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
4/170. Percutaneous revascularization modalities in heart transplant recipients.Accelerated allograft vasculopathy significantly limits the survival of heart transplant recipients. The prevalence of allograft coronary artery disease is as high as 18% by 1 year and 50% by 5 years following heart transplant. heart failure and sudden cardiac death are the two most common clinical presentations. In heart transplant recipients with severe, discrete focal allograft vascular disease, percutaneous balloon angioplasty is a viable palliative option. However, its application is limited by a significant restenosis rate and progression of allograft disease in nontreated segments. Diffuse disease with tapering of vessels may be approached by debulking devices. Emerging revascularization modalities for focal stenoses and some of the diffuse tapering vessels include coronary stents, rotational atherectomy, various wavelength lasers, and, to a lesser extent, directional atherectomy. Conceivably, stents will reduce restenosis rates related to focal, discrete plaques; yet it is unknown whether they will be efficacious in short- and long-term treatment of diffusely diseased segments affected by allograft disease. Accurate assessment of clinical outcomes and long-term evaluation is imperative prior to acceptance of these devices as fundamental interventional tools for treatment of allograft coronary artery disease.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
5/170. Occipitocervicothoracic fixation for spinal instability in patients with neoplastic processes.OBJECT: Occipitocervicothoracic (OCT) fixation and fusion is an infrequently performed procedure to treat patients with severe spinal instability. Only three cases have been reported in the literature. The authors have retrospectively reviewed their experience with performing OCT fixation in patients with neoplastic processes, paying particular attention to method, pain relief, and neurological status. methods: From July 1994 through July 1998, 13 of 552 patients who underwent a total of 722 spinal operations at the M. D. Anderson Cancer Center have required OCT fixation for spinal instability caused by neoplastic processes (12 of 13 patients) or rheumatoid arthritis (one of 13 patients). Fixation was achieved by attaching two intraoperatively contoured titanium rods to the occiput via burr holes and Luque wires or cables; to the cervical spinous processes with wisconsin wires; and to the thoracic spine with a combination of transverse process and pedicle hooks. Crosslinks were used to attain additional stability. In all patients but one arthrodesis was performed using allograft. At a follow-up duration of 1 to 45 months (mean 14 months), six of the 12 patients with neoplasms remained alive, whereas the other six patients had died of malignant primary disease. There were no deaths related to the surgical procedure. Postoperatively, one patient experienced respiratory insufficiency, and two patients required revision of rotational or free myocutaneous flaps. All patients who presented with spine-based pain experienced a reduction in pain, as measured by a visual analog scale for pain. All patients who were neurologically intact preoperatively remained so; seven of seven patients with neurological impairment improved; and six of seven patients improved one Frankel grade. There were no occurrences of instrumentation failure or hardware-related complications. In one patient a revision of the instrumentation was required 13.5 months following the initial surgery for progression of malignant fibrous histiosarcoma. CONCLUSIONS: In selected patients, OCT fixation is an effective means of attaining stabilization that can provide pain relief and neurological preservation or improvement.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
6/170. Bilateral contemporaneous posteroventral pallidotomy for the treatment of Parkinson's disease: neuropsychological and neurological side effects. Report of four cases and review of the literature.The authors report the underestimated cognitive, mood, and behavioral complications in patients who have undergone bilateral contemporaneous pallidotomy, as seen in their early experience with functional neurosurgery for Parkinson's disease (PD) that is accompanied by severe motor fluctuations before pallidal stimulation. Four patients, not suffering from dementia, with advanced (Hoehn and Yahr Stages III-IV), medically untreatable PD featuring severe "on-off" fluctuations underwent bilateral contemporaneous posteroventral pallidotomy (PVP). All patients were evaluated according to the Core Assessment Program for Intracerebral Transplantations (CAPIT) protocol without positron emission tomography scans but with additional neuropsychological cognitive, mood, and behavior testing. For the first 3 to 6 months postoperatively, all patients showed a mean improvement of motor scores on the Unified Parkinson's Disease Rating Scale (UPDRS), in the best "on" (21%) and worst "off" (40%) UPDRS III motor subscale, a mean 30% improvement in the UPDRS II activities of daily living (ADL) subscore, and 60% on the UPDRS IV complications of treatment subscale. Dyskinesia disappeared almost completely, and the mean daily duration of the off time was reduced by an average of 60%. Despite these good results in the CAPIT scores, one patient experienced a partially regressive corticobulbar syndrome with dysphagia, dysarthria, and increased drooling. No emotional lability was found in this patient, but he did demonstrate severe bilateral postoperative pretarsal blepharospasm (apraxia of eyelid opening), which interfered with walking and which required treatment with high-dose subcutaneous injections of botulinum toxin. No patient showed visual field defects or hemiparesis, but postoperative depression, changes in personality, behavior, and executive functions were seen in two individuals. Postoperative abulia was reported by the family of one patient, who lost his preoperative aggressiveness and drive in terms of ADL, speech, business, family life, and hobbies, and became more sleepy and fatigued. One patient reported postoperative mental automatisms, such as compulsive mental counting, and circular thoughts and reasoning during off phases; postoperative depression was found in two patients. However, none of the patients demonstrated these symptoms during intraoperative microelectrode stimulation. These findings are compatible with previous reports on bilateral pallidal lesions. A progressive lowering of UPDRS subscores was seen after 12 months, consistent with the progression of the disease. Bilateral simultaneous pallidotomy may be followed by emotional, behavioral, and cognitive deficits such as depression, obsessive-compulsive disorders, and loss of psychic autoactivation-abulia, as well as disabling corticobulbar dysfunction and apraxia of eyelid opening, in addition to previously described motor and visual field deficits, which make this surgery undesirable even though significant improvement in motor deficits can be achieved.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
7/170. Abdominal aortic aneurysmectomy with left-sided inferior vena cava and transplanted kidney.Aortic aneurysmectomy was performed in a 43-year-old man with left-sided inferior vena cava (It-IVC) after renal transplantation 10 years before. In the admission examination chronic rejection was found histopathologically. For renal protection, a temporary heparin-coated shunt tube was used to maintain continuous blood flow to the transplanted kidney. The shunt was placed between the left brachial artery and the right external iliac artery, because there was no segment healthy enough for cannulation of the shunt tube and the It-IVC crossed over the aorta above the aneurysm. Aortic aneurysmectomy was performed without complications and perioperative renal function was satisfactorily maintained without progression of the chronic rejection.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
8/170. Macular translocation with retinotomy and retinal rotation for exudative age-related macular degeneration.PURPOSE: To determine the effectiveness of macular translocation with retinotomy and retinal rotation in exudative age-related macular degeneration. methods: After written informed consent was obtained, 20 patients underwent macular translocation. We created a 180-degree retinotomy superior, inferior, and temporal to the macula near the equator. The hinged retinal flap was rotated superiorly or inferiorly to place the center of the fovea over an area of healthy retinal pigment epithelium. The retina was flattened under silicone oil and laser photocoagulation was placed. RESULTS: The fovea was moved 425 to 1,700 microm (965 /-262 microm) superiorly or inferiorly. Follow-up time was 2 to 12 months (median 8 months). Complications included macular pucker (3 eyes), subfoveal hemorrhage (2 eyes), macular hole (1 eye), and progression of cataract in phakic eyes (3 eyes). Thirteen of 20 eyes showed various degrees of proliferative vitreoretinopathy with epiretinal membrane formation over the inferior peripheral retina with the inferior retinal detachment stabilized by the silicone oil. One eye progressed to phthisis bulbi. Initial visual acuity ranged from 20/80 to 20/800 (median 20/150) and final visual acuity ranged from light perception to 20/200 (median 20/1000). CONCLUSION: The fovea can be moved up to 1,700 microm with retinotomy and retinal rotation; however, there is a high rate of complications. Proliferative vitreoretinopathy is the major complication of this technique and is probably related to the extensive retinotomy and subretinal irrigation inherent in the technique. Other techniques such as scleral shortening may have fewer complications.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
9/170. Video-assisted contralateral treatment for bronchial stump diastasis after left pneumonectomy.Postoperative bronchial stump failure is a life-threatening complication, and several surgical approaches and procedures have been developed to close the stump. In this report, we describe a case of left mainstem bronchial stump diastasis after pneumonectomy for lung cancer, in which the bronchial stump was re-closed using a contralateral approach with video-assisted thoracic surgery, with good success. The left main bronchus was closed with an automatic stapler device, but the stump reopened and left pyothorax developed postoperatively. Emergent intratracheal intubation and ventilation was required due to rapid progression of right pyothorax. Under strict nutritional management by IV hyperalimentation, administration of antibiotics to which the organisms were sensitive, and drainage, the patient recovered from pneumonia. However, thoracic air leak increased daily, and reoperation for bronchial diastasis was performed. Using this approach, the left main bronchus near the carina was easily exposed extrapleurally, with only the azygos vein being incised. Video-assisted contralateral treatment was effective in avoiding sternal osteomyelitis due to a transpericardial approach via median sternotomy in the case of mainstem bronchial stump failure, only after left pneumonectomy.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
10/170. Indications and results of chemotherapy in children with posttransplant lymphoproliferative disease after liver transplantation.Among 39 posttransplant lymphoproliferative diseases (PTLD) in a cohort of 450 pediatric liver transplant recipients, 3 had a malignant lymphoma, unresponsive to arrest of immunosuppression and to gancyclovir, interferon, and anti-interleukin 6 antibodies. lymphoma appeared 20, 46, and 96 months posttransplantation and 16, 43, and 90 months after primary Epstein-Barr virus infection. In one case, the patient had histological progression from plasmacytic hyperplasia PTLD, concomitant with symptomatic primary infection, to Burkitt-like lymphoma 43 months later. These three patients received five courses of chemotherapy, after a cyclophosphamide, doxorubicin, vincristine, and prednisone regimen for Burkitt-like or LH 89 scheme for Hodgkin-like PTLDs. Chemotherapy was well tolerated, and all three were free of disease and without immunosuppression 19, 14, and 4 months after chemotherapy. In Burkitt-like or Hodgkin-like PTLDs, immunomodulatory or antiviral drugs were inefficient. Chemotherapy is indicated and can be safely and successfully used. Long-term arrest of immunosuppression seems feasible without graft rejection.- - - - - - - - - - ranking = 1keywords = progression (Clic here for more details about this article) |
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