HYPOTHESIS Patients with mild gallstone pancreatitis may undergo an early laparoscopic cholecystectomy (LC) within 48 hours of hospital admission without awaiting the normalization of pancreatic and liver enzyme levels. This may decrease the hospital stay without increasing morbidity or mortality and may minimize the unnecessary use of endoscopic retrograde cholangiopancreatography. DESIGN A retrospective review. SETTING Two university-affiliated urban medical centers. PATIENTS A total of 303 patients with mild gallstone pancreatitis, of whom 117 underwent an early LC and 186 underwent a delayed LC. MAIN OUTCOME MEASURES Hospital length of stay, morbidity and mortality rates, and the use of endoscopic retrograde cholangiopancreatography. RESULTS Similar hospital admission variables were observed in the early and delayed LC groups, although the delayed group was older (P = .006). The median hospital length of stay was significantly less for the early group than for the delayed group (3 vs 6 days; P < .001). There were no patients who died, and the complication rates were similar for both groups. However, the patients who underwent an early LC were less likely than patients who underwent a delayed LC to undergo endoscopic retrograde cholangiopancreatography (P = .02). CONCLUSIONS An early LC may be safely performed for patients with mild gallstone pancreatitis, without concern for increased morbidity and mortality, resulting in shortened hospital stays and a decrease in the use of endoscopic retrograde cholangiopancreatography. The practice of delaying an LC until normalization of laboratory values appears to be unnecessary.

Free tissue transplantations are lengthy procedures that result in prolong tissue ischemia. Restoral of blood flow is essential for free flap recovery; however, upon reperfusion tissue that is viable may continue to be nonperfused. To further elucidate this pathophysiology skeletal muscle microcirculation was investigated during reperfusion following 4‐hour single arteriole occlusion.

BACKGROUND:Prompt diagnosis and treatment of acute mesenteric ischemia (AMI) requires a high index of suspicion for timely management. Poor clinical outcomes and delays in surgical treatment are demonstrated even in modern clinical series. Recognition of exhaled volatile organic compounds (VOCs) specific to AMI may facilitate early detection and diagnosis and improve patient outcomes. METHODS:Adult Wistar rats (n = 5) were intubated and anesthetized, and control tracheostomy breath samples were collected using Tedlar gas sample bags. Intestinal ischemia was induced by placing an occlusive clip across the superior mesenteric artery, and breath samples were collected after 1 hour of intestinal ischemia and after 15 minutes of intestinal reperfusion. Gas chromatography was used to identify and measure levels of VOCs obtained, and measured retention indices were compared with known values in the Kovats retention index database. RESULTS:Multiple retention indices (n = 41) were noted on gas chromatography, representing a variety of VOCs detected. Z,Z-farnesol (C15H26O), an isoprenoid, was the only compound detected that was undetectable during the control phase (median = 0 cts/sec) but which significantly elevated during the ischemic (median = 34 cts/sec, range = 25-37) and reperfusion (median = 148 cts/sec, range = 42-246) phases. Three other isoprenoid compounds (E,E-alpha-farnesene, germacrene A, and Z,Z-4,6,8-megastigmatriene) were also detected in all five animals, but their levels did not differ significantly between control, ischemic, and reperfusion phases. CONCLUSIONS:This pilot study demonstrates the feasibility of analyzing exhaled VOCs using a novel rat model for AMI. These findings may be useful for the development and identification of similar assays for the rapid diagnosis of AMI.

Le diagnostic précoce et le traitement de l'ischémie mésentérique aiguë (IMA) exige un indice de suspicion élevé pour une prise en charge rapide. Des résultats cliniques médiocres et des retards au traitement chirurgical sont mis en évidence, même dans les études récentes. La reconnaissance de composants organiques volatils (COV) expirés spécifique à l'AMI peut faciliter la détection et le diagnostic précoce, et améliorer les résultats de ces patients. Des rats Wistar adultes (n = 5) étaient anesthésiés et intubés, et des échantillons de contrôle du gaz expiré trachéal étaient recueillis à l'aide de sacs Tedlar. L'ischémie intestinale était induite en plaçant un clip occlusif sur l'artère mésentérique supérieure, et des échantillons de gaz expiré étaient prélevés après 1 heure d'ischémie intestinale et après 15 minutes de reperfusion intestinale. La chromatographie en phase gazeuse était utilisée pour identifier et mesurer les niveaux de COV obtenus, et les indices de rétention mesurés étaient comparés aux valeurs connues de la base de données Kovats. Les multiples indices de rétention (n = 41) étaient observés sur chromatographie en phase gazeuse, qui représente la variété des COV détectés. Le Z, Z-farnesol (C15H26O), un isoprénoïde, était le seul composant détecté qui était indétectable dans la phase contrôle (médiane = 0 cts / sec), mais qui était considérablement élevé au cours de l'ischémie (médiane = 34 cts / sec, extrêmes = 25-37) et de la reperfusion (médiane = 148 cts / sec, extrêmes = 42-246). Trois autres composants isoprénoïdes (E, E-alpha-farnésène, A et Z germacrène, Z-4, 6,8-megastigmatriene) étaient également détectés chez les cinq animaux, mais leurs niveaux ne différaient pas significativement entre le contrôle, l'ischémie et la reperfusion. Cette étude pilote démontre la faisabilité de l'analyse des COV expirés en utilisant un nouveau modèle de rat avec une IMA. Ces résultats peuvent être utiles pour le développement et l'identification de tests similaires pour le diagnostic rapide de l'AMI.

Saltzman, Darin J. MD, PhD; Cazzoli, Lorenzo MSc; Cabrales, Pedro PhD; Tsai, Amy G. PhD; Thompson, Jesse E. MD, FACS; Intaglietta, Marcos PhD Author Information

Acute gallstone pancreatitis has traditionally been managed by early cholecystectomy with intraoperative cholangiography (IOC). To evaluate the effect of IOC on patient outcome, we analyzed all patients operated on for acute gallstone pancreatitis at our institution over a 3-year period. A total of 200 patients (37 open, 163 laparoscopic) were evaluated. Nineteen of 34 patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) were found to have common bile duct (CBD) stones. The 59 patients who underwent cholecystectomy with IOC had significantly longer operative times compared to the 141 patients who underwent cholecystectomy alone (167 vs. 105 minutes for open [P= 0.008] and 89 vs. 68 minutes for laparoscopic [P< 0.0001] operations). Of the 59 patients who underwent IOC, only nine (15%) had abnormal cholangiograms, and CBD exploration in seven revealed stones in four patients, edematous ampullae in two, and no abnormality in one. Six of eight patients (5 IOC, 3 no IOC) who required immediate postoperative ERCP were noted to have CBD stones. Patients who underwent IOC had significantly longer postoperative hospital stays (3.8 vs. 2.0 days [P= 0.007]). The incidence of retained CBD stones following surgery was similar (5.1% IOC, 2.8% no IOC). Although 7 of 122 patients who underwent laparoscopic cholecystectomy without IOC were readmitted, only one was found on ERCP to have a retained CBD stone. Age, sex, preoperative days, procedure type, and biliary-pancreatic complications after discharge did not differ significantly between patients with and without IOC. We conclude that IOC in patients operated on for acute gallstone pancreatitis results in a longer operative time and a prolonged postoperative course, but has no effect on the incidence of retained CBD stones.

Carotid body tumors are rare neoplasms and must be considered in the evaluation of all lateral neck masses; early surgical removal has been recommended. In this study, the medical records of 29 patients with 34 carotid body paragangliomas who were treated at our institution between 1971 and 2001 were retrospectively reviewed. An overview is provided of this lesion, including diagnosis, classification, metastatic potential, possible secretory function, operative techniques, and nonsurgical methods of management. Carotid body tumors may be familial and are more often bilateral in these instances; five patients (17%) had bilateral tumors in this series. The criterion for malignancy is demonstrated by metastatic tumor in lymph nodes or distant organs. Three patients (10%) had malignant tumors, one with hepatic metastases. One patient (3%) in our series exhibited abnormal serotonin production. Vascular reconstruction was necessary in eight cases (28%). No stroke occurred, however, two arterial thromboses (7%), five permanent cranial nerve deficits (17%), and one death (3%) from massive pulmonary embolism were seen. Our experience demonstrates that early operative management is warranted to avoid the possibility of eventual metastasis and progressive local invasion to the point of inoperability.

(1998). Vascular Surgery at Baylor University Medical Center. Baylor University Medical Center Proceedings: Vol. 11, No. 3, pp. 129-133.

Rupture of thoracoabdominal aortic aneurysm (TAAA) or abdominal aortic aneurysm (AAA) is a vascular emergency associated with high rates of morbidity and mortality. Rupture of AAA has been extensively studied, but the outcome of ruptured TAAA is less clearly defined.We retrospectively compared outcomes of ruptured TAAAs and AAAs seen at Baylor University Medical Center. Twenty-one patients presented with TAAA rupture from 1985 to 1995:15 of them underwent emergent repair, 10 of whom died (67% mortality). Of the other 6 patients, 3 did not have surgery because of their moribund conditions or prohibitive comorbidities on presentation, 1 patient was transferred elsewhere for treatment, and 2 patients died before surgery. In comparison, from 1990 to 1995, 31 patients presented with ruptured AAA; all received immediate operative repair, and 14 of them died (45% mortality). Multiple postoperative morbidities occurred in all 5 TAAA survivors (100%), including renal failure in 4 patients (80%). In comparison, the 17 ruptured AAA survivors had a 59% (10) morbidity rate; 23% (4) had renal insufficiency. Paraplegia occurred in 1 of the 5 TAAA survivors and in none of the AAA survivors.The morbidity and mortality rates for patients who have TAAA or AAA rupture remain high despite advances in operative and postoperative care. Comparison of the TAAA and AAA cohorts reveals a higher morbidity rate in the TAAA group-specifically, an increased incidence of paraplegia and renal failure.

PURPOSE:The purpose of this study was to compare the results of carotid endarterectomy (CEA) in a young population with premature atherosclerosis with the results of an older control group, examining perioperative morbidity and mortality data, recurrent stenosis and symptoms, late stroke, and survival data. METHODS:We retrospectively studied 26 patients less than 50 years old (mean, 43.2 +/- 3.8 years) and 30 patients greater than 55 years old (mean, 69.1 +/- 7.4 years) who underwent CEA during the same time period. Data were obtained regarding demographics, atherosclerotic risk factors, indication for CEA, perioperative complications, recurrent stenosis and symptoms, late stroke, and survival. RESULTS:Smoking was more prevalent among young patients who underwent CEA (92% vs 70%; p = 0.036). Young patients were also more likely to be symptomatic at presentation (92% vs 57%; p = 0.003). The perioperative mortality rate (0% vs 0%) and neurologic morbidity rate (0% vs 3%; p = 1.000) were low for the study patients. During a mean follow-up of 67 +/- 42.7 months, there was no significant difference in survival rate (5-year survival rate, 93% vs 81%; p = 0.373), rate of late ipsilateral (4% vs 3%) and contralateral (4% vs 3%) stroke, restenosis and occlusion (26.9% vs 14.3%), recurrent symptoms (22% vs 17%), reoperation (11.5% vs 5.7%), or contralateral disease (17% vs 23%) development that required surgery for the study or the control cohorts. CONCLUSIONS:Our data show that there is a high incidence of smoking and symptomatic presentation among young patients in whom carotid occlusive disease develops. CEA may be performed in young patients with low perioperative morbidity and mortality rates. Recurrent disease, late stroke, and survival rates are not significantly different than for older patients. Follow-up with serial duplex ultrasound and reoperation for symptomatic and high-grade asymptomatic restenosis may decrease the risk of late stroke.

HomeStrokeVol. 27, No. 8The Evolution of Surgery for the Treatment and Prevention of Stroke Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBThe Evolution of Surgery for the Treatment and Prevention of StrokeThe Willis Lecture Jesse E. Thompson Jesse E. ThompsonJesse E. Thompson the Department of Surgery, Baylor University Medical Center, Dallas, Tex. Originally published1 Aug 1996https://doi.org/10.1161/01.STR.27.8.1427Stroke. 1996;27:1427–1434Thomas Willis, the man for whom this lecture is named, was an Englishman and a leading neuroanatomist of the 17th century. Born in 1621, he attended Oxford University, graduating from Christ Church College in 1639. While still at Oxford, he became Sedleian Professor of Natural History in 1660. He did much experimental work with his associate Richard Lower. He performed injection experiments on cadavers and noted that if he injected the carotid artery on one side, the dye solution would come forth from the carotid on the opposite side.In 1664 Willis published his monumental work Cerebri Anatome, the most complete and accurate account of the nervous system that had hitherto appeared. In it he contributed the term "neurology" to medicine, a word derived from the Greek, meaning "sinew," "tendon," or "bowstring." The word was translated and introduced into the English language in 1681 in Samuel Pordage's translation of Willis' work.Cerebri Anatome contains a classification of the cerebral nerves, the first description of the eleventh nerve, and a description of the hexagonal network of arteries at the base of the brain that we know as the circle of Willis. Although others had described the circle before Willis, he was the first to grasp its physiological and pathological significance. He records the clinical histories of two patients in whom he suggests that the anatomic configuration of the arteries at the base of the brain could prevent apoplexy. The book was illustrated by Christopher Wren, an associate of Willis at Oxford, later to become England's leading architect and designer of St Paul's Cathedral, numerous other English churches, and many historic secular buildings.Willis moved to London in 1666 and acquired the largest fashionable practice of his day. He continued his careful clinical observations and made a number of other important contributions. He was the first to recognize that lesions in the region of the internal capsule will produce hemiplegia. He was the first to notice the characteristic sweetish taste of diabetic urine. He described myasthenia gravis. He gave the first account of epidemic typhoid fever and typhus. He was the first to describe and name puerperal fever. He described the phenomenon of Willis' paracusis: a deaf person who can hear only in the presence of noise.Thomas Willis died in London on November 11, 1675, of pneumonia at age 54. He is buried in the north transept of Westminster Abbey. He was indeed a remarkable man.1234Changing concepts of the etiology, diagnosis, and treatment of ischemic stroke syndromes in the past 45 years have been responsible for widespread renewal of interest in this disease. Increasing awareness of the extracranial location and segmental nature of atherosclerotic occlusive disease in a large proportion of patients with cerebrovascular insufficiency was followed by the development and use of appropriate vascular surgical techniques for removing or bypassing offending plaques, thus increasing cerebral blood flow or eliminating sources of cerebral emboli. Since extracranial carotid lesions are those most frequently encountered, surgery of the carotid artery has become a subject of heightened interest and importance.56It is the purpose of this article to review the historical aspects of surgery for stroke, emphasizing surgery of the carotid artery but discussing briefly surgery of the vertebral artery and the great vessels of the aortic arch. As Thomas Carlyle said, "History is the essence of innumerable biographies."The first recorded reference to the nervous system is found in ancient Egyptian records. The Edwin Smith Surgical Papyrus, composed about 3500 BC, or more than 5000 years ago, contains the first use of the word "brain," along with a description of its coverings and the fluid beneath them.2The word "carotid" is derived from the Greek term karotide or karos, meaning to stupefy or plunge into a deep sleep. According to Rufus of Ephesus (circa AD 100) the term was applied to the arteries of the neck because compression of these vessels produced stupor or sleep.2 The ancient Greeks were aware of the significance of the carotid artery: the 31st metope from the south side of the Parthenon in Athens depicts a centaur applying left carotid compression to the neck of a Lapith warrior.With the advent of Hippocrates (460 to 370 BC), ancient descriptive neurology was born. It was known that paralysis and convulsions followed injuries to the brain, with paralysis on the opposite side to the wound. Hippocrates described paralysis of the right arm with loss of speech in what is probably the first written description of aphasia. In one of his aphorisms Hippocrates stated, "Unaccustomed attacks of numbness and anesthesia are signs of impending apoplexy," a description of a TIA. Apoplexy, a Greek word meaning "struck with violence," first appeared in the Hippocratic writings.2Galen (AD 131 to 201) was aware that hemiplegia resulted from a lesion in the opposite side of the brain but did not know about softening or hemorrhage as a cause of apoplexy, which he attributed to an accumulation of phlegm in the arteries of the brain.2 With Galen as the authority, European medicine remained at a dead level for nearly 14 centuries until the time of Vesalius, who in 1543, with the publication of his magnificent De Fabrica Humani Corporis, threw overboard Galenical traditions.1Ambroise Paré7 in the 16th century was familiar with the carotid phenomenon and stated, "The two branches they call carotides or soporales, the sleepy arteries, because they being obstructed or any way stopt we presently fall asleep."The 17th century saw the work of Thomas Willis and Richard Lower, mentioned above in connection with the circle of arteries at the base of the brain.Johann Jakob Wepfer, a Swiss physician, in 1658 was the first to describe carotid thrombosis, extracranially and intracranially, in a patient with a completely occluded and calcified right internal carotid artery. In his Apoplexia, he traced the carotid and vertebral arteries from their origins to the arterial circle at the base of the brain and noted that apoplexy could result from cerebral hemorrhage. In Apoplexia, examples of completed stroke, progressing stroke, TIA, and reversible ischemic neurological deficit were described.238Jean Luis Petit9 in the 18th century discovered that the brain may survive deprived of the contribution of one carotid artery. His patient had an aneurysm of the bifurcation of the right common carotid artery that was cured spontaneously. Seven years later, autopsy showed the lumen of the vessel to be completely occluded by organized thrombus.The first operations on the carotid artery were quite naturally ligation procedures for trauma or hemorrhage. Hebenstreit of Germany, in his translation of Benjamin Bell's Surgery in 1793, mentions a case in which the carotid artery was injured during operative removal of a scirrhous tumor. The surgeon ligated the vessel to arrest hemorrhage, and the patient lived for many years. This is thought to be the first case on record of ligature of the carotid.101112John Abernethy of London, a pupil of John Hunter, in 1804 reported a case of carotid ligation performed some years previously, probably in 1798. The patient, a man, was gored in the neck by the horn of a cow, and hemorrhage was profuse. Compression controlled the bleeding temporarily only to have it recur when pressure was released. Abernethy was compelled to ligate the common carotid artery. He states, "In attempting to secure the carotid artery I passed behind it. . . . a blunt hook with an eye in the point, and having previously introduced a ligature into it I drew back the instrument and thus enclosed the artery." Hemorrhage was controlled, and the patient appeared well. However, the man died 30 hours later of cerebral causes, and Abernethy abandoned the procedure.10121314With the beginning of the 19th century, the history of carotid surgery becomes more accurate as dates of operations are given with exactness. The first successful ligation of a carotid artery was performed by David Fleming on October 17, 1803. Fleming was a young naval surgeon aboard His Majesty's Ship Tonnant, the greatest two-decker in the British navy, carrying 80 guns and cruising off the Spanish coast during the Napoleonic era. Mark Jackson, a servant, attempted to commit suicide by cutting his throat on October 9, 1803. The knife had grazed the outer and muscular coats of the carotid artery but left the artery intact. Eight days later on October 17, the carotid ruptured. Fleming cut down on the artery proximal to the rupture and ligated it. He had not done this before, nor had he heard of Abernethy's case. The patient survived and made an uninterrupted recovery. The case was reported in 1817 by Dr Richard Warren Coley, an assistant surgeon on HMS Tonnant. This was the first authentic successful case of ligation of the carotid artery on record.1516The first case of ligature of the carotid artery in the United States was that of Mason F. Cogswell of Hartford, Conn, performed November 4, 1803; the report was published in October of 1824. The patient, a 38-year-old woman, had an extensive tumor of the left side of her neck that completely enveloped the carotid artery. During the course of its removal, the carotid artery had to be ligated and divided. The patient did well at first, but on the 20th day she died as a result of hemorrhage from the wound. Cogswell stated, "The circumstances attending this case were such as entirely to establish the practicability and safety of dividing the carotid artery on the living subject."101217The first successful ligation of the carotid artery in the United States was performed by Dr Amos Twitchell of Keene, NH, on October 18, 1807. John Taggart, a cavalry soldier, age 20, in a mock fight at a regimental review, was accidentally wounded in the neck by a pistol shot on October 8, 1807. The wound was treated by simple dressings, although Dr Twitchell commented, "There was a good deal of arterial excitement." Taggart improved rapidly, however, until the 10th day when the internal carotid artery ruptured, and "the blood jetted forcibly in a large stream to the distance of three or four feet." Twitchell stopped the hemorrhage by compression, then made an incision lower in the neck and ligated the common carotid artery with the patient's mother acting as his assistant. To his surprise, backflow bleeding continued from the distal vessel. He then packed the wound with dry sponges and the bleeding stopped. Fourteen days later, after all the packing was removed, the wound granulated in, and the patient made an uneventful recovery. This case occurred 8 months before Astley Cooper's successful operation. At the time, Twitchell was ignorant of any other previous ligations of the carotid artery. The case was not reported until 1842, in the short-lived New England Quarterly Journal of Medicine and Surgery. Amos Twitchell, who died in 1850, became the leading surgeon in his area of New England.1018Sir Astley Cooper in London was the first to attempt ligation of a carotid artery for cervical aneurysm on November 1, 1805. This patient died of sepsis on the 21st day with a left hemiparesis. Cooper repeated the operation on June 22, 1808, at Guy's Hospital. The patient was 55 years of age and had a pulsating tumor the size of an egg at the angle of the jaw. Two ligatures were applied to the artery, which was divided. The patient made a perfect recovery with no untoward symptoms and lived until 1821. This was the first successful case of ligature of the carotid artery for aneurysm.1920The first successful ligation of the carotid for aneurysm in the United States was performed by Dr Wright Post of New York City on January 9, 1813. After a stormy postoperative course, the patient eventually survived.12Benjamin Travers, on May 23, 1809, first successfully ligated the left carotid for carotid-cavernous fistula, with disappearance of signs and symptoms. In 1885 Victor Horsley first successfully ligated the carotid in the neck for an intracranial aneurysm. The patient was well 5 years later. By 1868 Pilz was able to collect 600 recorded cases of carotid ligation for cervical aneurysm or hemorrhage with a mortality rate of 43%.14The American surgeon John Wyeth in 1878 published an extensive report detailing 898 collected cases of common carotid ligation. He found the mortality to be 41% in contrast to that after ligature of the external carotid, which was only 4.5%.21Until fairly recently, the prevailing notion held by most physicians was that strokes were caused by intracranial vascular disease. William Osler, in his textbook entitled The Principles and Practice of Medicine in the seventh edition of 1909 (the last edition that he himself wrote), attributed apoplectic stroke largely to cerebral hemorrhage. No mention is made of extracranial occlusive disease, and in the section dealing with cerebral softening, where embolism and thrombosis are mentioned, emphasis is on blockage of intracranial vessels.22 This is somewhat curious in view of the fact that several authors had already described occlusive lesions in the extracranial segments of the main arteries supplying the brain and noted the association of these lesions with symptoms of cerebral ischemia.William Heberden (1710-1801), a prominent London practitioner, described symptoms of transient cerebral insufficiency recurring in hours, days, or even months before the final episode of hemiplegia.323Gull,24 in 1855, wrote of a case of occlusion of the innominate and left carotid.W.S. Savory,25 in 1856, published a landmark article on cerebral ischemia. In it he described the case of a 22-year-old woman who had no pulsation in any of the vessels of the head, neck, or upper extremities. She had symptoms involving the left eye and right side of her body, both motor and sensory, as well as dizziness and convulsions. At postmortem examination, she had obliteration of the left carotid and both subclavian arteries. Savory commented on the relationship between the vascular occlusions and the clinical phenomena observed.In 1856 Virchow described carotid thrombosis associated with ipsilateral blindness but found the lumens of the ophthalmic and central retinal arteries to be patent.8Broadbent,26 in 1875, reported the case of a 50-year-old patient with absent pulses in both radial arteries. At autopsy, the origins of the innominate, left carotid, and subclavian arteries were tightly constricted, whereas the vessels distal to the narrowing appeared full and healthy.Penzoldt,27 in 1888, reported a case of thrombosis of the right common carotid artery. The patient developed a sudden permanent blindness in the right eye and later sustained a left hemiplegia. At autopsy, the right common carotid was thrombosed and the right cerebral hemisphere had a large area of softening.In 1905 Chiari28 described ulcerating plaques at the carotid bifurcation and on the basis of detailed pathological examinations found that emboli could break away from carotid-sinus area plaques and cause strokes. He was among the first to propose that occlusive disease of the extracranial blood vessels could be responsible for neurological symptoms.3A landmark article was that of J. Ramsay Hunt29 of New York City in 1914, who called attention once again to the importance of extracranial occlusions in cerebrovascular disease. He recognized that both partial and complete occlusions of the innominate and carotid arteries could be responsible for cerebral syndromes of vascular origin and even used the term "cerebral intermittent claudication." He suggested that extracranial obstructions had been largely overlooked and emphasized the importance of examining the cervical carotid system in patients with strokes. He also emphasized "the occurrence of unilateral vascular changes, pallor or atrophy of the disk with contralateral hemiplegia, in obstruction of the carotid artery."The next significant contribution was the report of Egas Móniz30 of Portugal, who in 1927 first described the technique of cerebral arteriography for the study of cerebral tumors, using sodium iodide as the contrast medium, and thus laid the groundwork of a practical method for the diagnosis of occlusive lesions. The first report of carotid thrombosis demonstrated by arteriography was that of Sjöqvist31 in 1936. The following year, 1937, Móniz, Lima, and de Lacerda32 reported four patients with occlusion of the cervical portion of the internal carotid artery in whom the diagnosis had been established by arteriography. Egas Móniz won a Nobel Prize in 1949, not for cerebral arteriography but for his work on prefrontal lobotomy.Chao and associates33 of Peking, China, in 1938 reported two cases similar to those of Móniz. They used thorium dioxide as the contrast medium and found the internal carotid artery occluded in both cases. Portions of the internal carotid artery were resected, and slight improvements in the patients' symptoms were reported. By 1951 Johnson and Walker34 were able to collect 107 instances of carotid thrombosis, all diagnosed by arteriography, and suggested that carotid occlusion was probably more frequent than generally realized.In two important articles published in 1951 and 1954, C. Miller Fisher,3536 working in Montreal and later in Boston, reemphasized the relationship between and frequency of disease of the carotid artery in the neck and cerebrovascular insufficiency. He defined the basic nature of the lesion as atherosclerosis, noted again partial and complete occlusions, and described several syndromes associated with such occlusive disease. He observed that with severe stenosis of the carotid bifurcation, the distal vessels could be entirely free of disease. He realized the importance of these observations and stated, "It is even conceivable that some day vascular surgery will find a way to bypass the occluded portion of the artery during the period of ominous fleeting symptoms. Anastomosis of the external carotid artery or one of its branches with the internal carotid artery above the area of narrowing should be feasible."Between 1916 and 1921, several surgeons reported successful repair of the cervical carotid artery for trauma, aneurysm, or tumor removal. Later in 1952, John Conley of New York reported anastomosing the distal ends of the internal carotid artery and external carotid artery to restore flow to the brain after tumor resection, a procedure previously reported by LeFevre37 in France in 1918. In 1953, Conley38 reported 11 cases in which the superficial femoral or saphenous vein had been used as an interposition graft to reconstruct a resected cervical carotid artery after tumor surgery.Surgical methods of treating carotid artery occlusive disease prior to 1951 were (1) stellate ganglion block, (2) cervical sympathectomy, (3) removal of thrombi with reestablishment of blood flow, (4) ligation and excision of the carotid bifurcation, and (5) intracranial ligation of the carotid artery with silver clips. The reasons given for using these methods were (1) the release of vasospasm in the vessels supplying the brain by interrupting periarterial sympathetics and (2) the prevention of forward embolism from clots in the cervical vessels. The methods listed had little or no success in the treatment of strokes due to extracranial vascular disease.3940A Portuguese surgeon, J. Cid Dos Santos,41 in 1946 introduced thromboendarterectomy for restoring flow in peripheral vessels, a major breakthrough.In 1951 E.J. Wylie introduced into the United States the procedure of thromboendarterectomy for the removal of atherosclerotic plaques from the aortoiliac segments, but it had not been used on the carotid artery.42Fisher's prophecy of surgical reconstruction of the carotid artery in the neck as therapy for occlusive disease was soon fulfilled. The first successful reconstruction of the carotid artery was performed by Carrea, Molins, and Murphy43 in Buenos Aires in 1951, after they read Fisher's article, and was reported in 1955. A 41-year-old male patient had recurring symptoms of right hemiparesis, aphasia, and left amaurosis over a 6-month period before being referred to the neurosurgical service of Dr Raul Carrea by Dr Guillermo Murphy. A left percutaneous arteriogram demonstrated an atherosclerotic plaque with severe stenosis in the internal carotid artery. On October 20, 1951, Dr Molins, a vascular surgeon, and Dr Carrea performed an end-to-end anastomosis between the left external carotid and the distal internal carotid arteries after partial resection of the stenosed area, together with cervical sympathectomy. The patient made an uneventful recovery and died 23 years later from myocardial infarction. His neurological status was normal except for loss of vision in the left eye.On January 28, 1953, Strully, Hurwitt, and Blankenberg44 in New York operated on a patient with a frank stroke and a totally occluded internal carotid artery. They performed a thrombectomy but were unable to obtain retrograde flow; consequently, a section of the internal carotid was resected. They suggested that thromboendarterectomy should be feasible in such cases when the distal vasculature was patent.The first successful carotid endarterectomy was performed by Dr Michael DeBakey45 on August 7, 1953. A 53-year-old school bus driver gave a history of recurring episodes of transient right hemiparesis and dysphasia over a 2-year period. On examination, he had a mild residual right hemiparesis and a weak pulsation in his left carotid artery. No preoperative arteriogram was performed. During surgery, a severely stenotic atherosclerotic plaque with superimposed fresh clot completely occluding the left internal carotid artery was found. Thromboendarterectomy was carried out with good retrograde flow from both internal and external carotid arteries. An arteriogram performed postoperatively on the operating table showed the internal carotid to be patent in both its extracranial and intracranial portions. The patient made a good recovery and lived for 19 years without having further strokes. He died from complications of coronary artery disease on August 17, 1972.The operation that gave the greatest impetus to the development of surgery for carotid occlusive disease was that of Eastcott, Pickering, and Rob,46 performed on May 19, 1954, at St Mary's Hospital in London and reported in November 1954. In this case, a 66-year-old housewife, having suffered 33 transient episodes of right hemiparesis, aphasia, and left amaurosis over a 5-month period, was found to have a severe stenosis of the left carotid bifurcation after a percutaneous left carotid arteriogram. With the patient under general anesthesia with hypothermia to 28°C (82.4°F) by means of ice bags for cerebral protection, the bifurcation was resected and blood flow restored by end-to-end anastomosis between the common carotid and distal internal carotid arteries. The carotid was occluded for 28 minutes. The patient was completely relieved of her symptoms and was alive and well at the age of 86.Following these landmark cases, a number of different methods of carotid reconstruction were reported. The Table lists in chronological order the early procedures performed for the treatment of extracranial cerebrovascular disease. With increasing experience, the various procedures listed were abandoned with the exception of endarterectomy, which has become the standard operation. I performed my first carotid endarterectomy on April 16, 1957.52The case described by Cooley et al50 is of interest in that an external shunt was used for cerebral protection, the first reported use of a shunt for carotid endarterectomy. The shunt consisted of a polyvinyl tube with a 14-gauge needle at its lower end and a 16-gauge needle at its upper or internal carotid end. Additional cerebral protection was attempted by immersing the patient's head in crushed ice for 30 minutes. Despite this the patient suffered an operation-related stroke from which he recovered rapidly over the course of several weeks.I first used an external shunt similar to Cooley's, using 13-gauge needles, on January 6, 1958, and continued to use the external shunt selectively until October 14, 1960, when I first used an intraluminal inlying shunt. I have continued to use the inlying shunt, first selectively and then routinely, ever since. Austin and I53 described our early experience with this type of shunt in 1962.The use of a shunt is still provoking discussion. Some surgeons such as ourselves use it routinely, others use it selectively on the basis of an assessment of the collateral circulation, while some say they rarely or never use it. Methods to determine the adequacy of the cerebral circulation include determination of cerebral blood flow by the xenon method, temporary carotid occlusion under local anesthesia, determination of the stump pressure in the occluded distal internal carotid artery, electroencephalographic monitoring, transcranial Doppler monitoring, and sensory evoked potential monitoring.54In the early 1950s, we tested the patient's tolerance preoperatively by manually compressing the cervical carotid for up to 20 minutes and observing any untoward symptoms. This sometimes took place daily for up to 2 weeks or until the patient could tolerate the compression.53In the past, hypothermia, hypercarbia, and hypocarbia were used for cerebral protection. Today the temporary shunt remains the most effective means of providing cerebral protection when such is judged necessary. General anesthesia is also helpful.54 Another controversy revolves around the use of patching the carotid arteriotomy after endarterectomy. It is useful for small arteries and reoperation but is probably not necessary as a routine maneuver.6 A variation of the standard carotid endarterectomy is eversion endarterectomy, used by some surgeons in an effort to reduce the incidence of postoperative neointimal hyperplasia.55As more and more vascular and neurosurgeons began to perform endarterectomy, it soon became clear that it was most effective for partially occlusive lesions rather than for total occlusions, in which restoration of flow was possible in only 40% of cases and in many of which operation was contraindicated because of the clinical presence of acute profound strokes, where operative mortality was reported to be from 20% to 60%.6It was also gradually realized that the principal role of carotid endarterectomy was one of stroke prevention in patients with TIAs, mild deficits, and asymptomatic stenoses, rather than treatment for completed or profound strokes, as in the early days of endarterectomy. Although a few early reports gave unacceptable outcomes for endarterectomy, most reported results in general were satisfactory.6The chief complication of carotid endarterectomy, apart from death, is the production or aggravation of neurological deficits. With proper selection of patients, arteriography by skilled radiologists, avoidance of surgery for those with acute profound and progressing strokes, meticulous operative techniques used by well-trained surgeons, and appropriate use of cerebral protection, results of operation have progressively improved.In a survey of 15 960 carotid endarterectomies, Hertzer found the overall average operative mortality rate to be 1.4% and the perioperative stroke rate to be 2.2%. In a number of individual series, the operative mortality is under 1% and the perioperative stroke rate less than 2%.6Considerable controversy has arisen over the years as to the effectiveness of carotid endarterectomy compared with best medical therapy in preventing stroke. An early randomized study, the Joint Study of Extracranial Arterial Occlusion, between 1959 and 1976, provided a tremendous amount of important information but showed no statistically significant difference in stroke rates between surgical and medical groups.3The surgeon's role in the treatment of cerebral ischemic syndromes by carotid endarterectomy has been substantiated by the recent reports of results of several multicenter randomized trials demonstrating the efficacy of surgery in preventing strokes in patients with high-grade carotid stenosis. In the NASCET study, the long-term stroke rate for surgical patients was 9% versus 26% for medical patients.56 In the ECST, it was 2.8% for surgical patients (excluding perioperative mortality and morbidity of 7.5%) and 16.8% for medical patients.57 In the VA symptomatic trial, stroke rate was 7.7% for the surgical group versus 19.4% for the medical patients.58In the VA asymptomatic trial, stroke plus TIA rate for surgery was 8% versus 20.6% for medical therapy.59 In the ACAS trial, stroke only in the surgical group was 5.1% versus 11% in the medical arm.60 Thus, endarterectomy is beneficial in certain groups of both symptomatic and asymptomatic patients with high-grade stenoses. Controversy now exists over the most appropriate method of measuring carotid stenosis.It is difficult, however, to document significant prolongation of survival after carotid endarterectomy, largely because of the prevalence of conco

Purpose: This study was undertaken to determine the safety and efficacy of percutaneous transluminal angioplasty (PTA) in the treatment of chronic mesenteric ischemia (CMI) in very high-risk surgical patients.Methods: Twenty-four focal mesenteric stenoses treated from 1984 to 1994 by PTA in 19 patients with CMI were reviewed. All 19 patients were considered poor surgical candidates. Seventeen patients had classic symptoms of CMI, and two patients had atypical abdominal complaints. Vessels dilated included the superior mesenteric artery (18), celiac artery (3), inferior mesenteric artery (1), aorta-superior mesenteric artery vein graft (1), and aorta-splenic artery vein graft (1). Complete follow-up was possible in all patients, with the exception of one patient who had no symptoms when last seen 17 months after the procedure.Results: PTA was technically successful in 18 of 19 patients (95%) and 23 of 24 stenoses (96%). The lone technical failure resulted in superior mesenteric artery dissection with thrombosis and bowel infarction; the patient died despite emergent laparotomy and revascularization (mortality rate, 5%). Complete symptomatic relief was attained in 15 patients (79%), with follow-up showing continued relief of symptoms for a mean of 39 months (range, 4 to 101 months). Partial symptomatic relief was attained in three patients. Recurrent symptoms developed in three patients (20%) ata mean interval of 28 months (range, 9 to 43 months). Repeat PTA performed in two patients provided good technical results and relief from clinical symptoms. One patient had a symptomatic axillary sheath hematoma that required surgical decompression.Conclusions: Mesenteric PTA is a valuable treatment option in patients who have CMI and are considered very high operative risks. The initial technical success rate is excellent, with the majority of patients having complete symptomatic improvement and continued relief of symptoms at short-term follow-up.

(1995). Cabeza de Vaca: The First Texas Surgeon. Baylor University Medical Center Proceedings: Vol. 8, No. 4, pp. 3-6.

BACKGROUND: Cecal leak or disruption after appendectomy for complicated appendicitis is a consequence of severity of disease and is related to residual abscess cavity, inflammation, phlegmon, and nonviable intestine. in an attempt to improve results, we have begun to resect the cecum and other localized infected tissue in instances of complicated appendicitis in which the viability of the appendiceal base and adjacent cecum is questionable.STUDY DESIGN: This is a prospective series of all patients who have undergone resectional therapy for complicated appendicitis in the last four years. Patients with other inflammatory conditions of the right colon have been specifically excluded.RESULTS: Seventeen patients have undergone resectional therapy for complicated appendicitis. Thirteen (76.5 percent) were men; the mean age was; 42.4 years. The mean temperature and leukocyte count were 37.8 degrees C and 16.1 X 10(9) per L, respectively. These patients presented with a mean of 6.8 days of abdominal pain. Nine had a palpable abdominal mass, and all had tenderness in the right lower quadrant. In ten patients an abscess was encountered at operation. While the extent of the resection varied, it generally included the cecum, part of the right colon, and 5 to 7 cm of terminal ileum. Fourteen patients had a primary anastomosis, while the other three had the creation of an ileostomy. Complications were encountered in only two patients: one wound infection and one pulmonary embolus. There were no instances of postoperative intra-abdominal abscess, intestinal obstruction, or fecal fistula. All patients had a benign postoperative course and were discharged on the average of 9.9 days postoperatively. The ileostomies in three patients have been closed and no complications have occurred on follow-up examination.CONCLUSIONS: We conclude that aggressive resectional therapy of the cecum during appendectomy in selected patients with complicated appendicitis is effective therapy and can be performed safely.

We reviewed the records of 32 adult patients with choledochal cysts (CDC) to determine the characteristics of the associated pancreatic disease. Eighteen patients (56%) had 30 documented episodes of pancreatitis with epigastric pain and elevated serum amylase levels. Three patients developed a prolonged course with a pancreatic phlegmon and one patient died secondary to a pancreatic abscess after endoscopic retrograde cholangi-opancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender, or race of the patient. There was an association with the size of the CDC: 90% of patients with CDC 3 5 cm developed pancreatitis compared with only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERCP was performed in 14 patients and demonstrated an abnormal pancreatico-biliary duct junction in eight (57%). All eight patients with an abnormal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.006). Patients under-going surgical bypass rather than resection also tended to have higher rates of pancreatitis (80 vs. 50%). One patient with a Type I CDC and chronic pancreatitis was treated with surgical resection of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal “common channel” within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecognized high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC. Diagnostic ERCP and surgical manipulations of the pancreas should be done with care to avoid precipitating pancreatitis. CDC resection is preferred to surgical bypass to avoid anastomotic stricture with cholangitis and to minimize the chance for ongoing pancreatitis.