Faculty Bibliography

Because of the theoretic benefits of autologous vein we undertook an investigation to evaluate cervical veins (facial, external jugular) as patch material after carotid endarterectomy. A device that stimulated both circumferential fixation by sutures and radial tension exerted on in vivo patches was constructed to measure burst strength of tissue. Mean bursting pressure for groin saphenous vein (n = 10) was 94.5 +/- 15.1 pounds per square inch (psi), 75.5 +/- 8.9 psi for ankle saphenous vein (n = 10), 83.3 +/- 14.5 psi for everted (double layer) cervical vein (n = 5) and 10 +/- 3.3 psi for single layer cervical vein (n = 5). No significant differences between saphenous vein at any level and everted (double layer) cervical vein, but all were significantly different from single layer cervical vein (p less than 0.05). From June 1987 through November 1989, 19 patients underwent 21 carotid endarterectomies complemented with adjunctive everted cervical vein patch angioplasty. Indications for surgery were asymptomatic stenosis (53%), transient ischemic attack (29%), and cerebrovascular accident with recovery (18%). All patients were studied after surgery with duplex scanning. Asymptomatic recurrent stenosis was observed in one patient. Transient hypoglossal nerve dysfunction occurred in one other patient. One postoperative death occurred as a result of massive aspiration. These results indicate that everted cervical vein is comparable to the saphenous vein in resistance to bursting and can yield similar results as patch material after carotid endarterectomy. Accordingly, saphenous vein can be spared and lower extremity incisions avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Infection with Mycobacterium tuberculosis is frequently found in patients with acquired immunodeficiency syndrome and can result in diffuse lymphadenopathy from disseminated disease. A case is presented of esophageal erosion and perforation secondary to mediastinal lymph node enlargement from Mycobacterium tuberculosis in a patient positive for human immunodeficiency virus. Emergent surgical intervention required resection of the perforated esophagus, end-cervical esophagostomy, gastrostomy, and feeding jejunostomy. Long-term prognosis is poor owing to acquired immunodeficiency syndrome, therefore, reconstruction at a later date is uncertain

A primary fistula between the abdominal aorta and the duodenum is rare and usually fatal. Computed tomography in a symptomatic but stable patient enabled preoperative evaluation and even diagnosis of abnormal communications, real or incipient, between the vascular and enteric system. This case demonstrated the effectiveness, ease, and low cost of documenting a primary aortoduodenal fistula. Surgical results were ultimately improved by initiating early intervention and aggressive management. Therapeutic principles included early intervention with aneurysmectomy, duodenorrhaphy, and extra-anatomic bypass. Anatomic graft placement may be acceptable in selected cases.

Although synchronous intrauterine and ectopic pregnancies associated with the use of clomiphene citrate for infertility are rare, the actual incidence might, in fact, be considerably higher than previously thought. The cornerstone for ruling out an extrauterine gestation is the presence of sonographic evidence of an intrauterine pregnancy, as the possibility of concomitant intrauterine and extrauterine gestation is perceived to be statistically rare. This has resulted in an unacceptably high incidence of negative ultrasound interpretations. During a recent 12 month period, four women treated with clomiphene citrate for infertility were diagnosed as having concomitant intrauterine and ectopic pregnancies. Three had pelvic sonograms that were erroneous for the extrauterine component. However, successful evacuation of the products of ectopic gestation was performed in each, despite an immediate preoperative false-negative ultrasound report. Three of the women delivered healthy normal infants at full term, and the fourth woman spontaneously aborted the products of the concomitant intrauterine gestation. All four did well postoperatively, and no gross complications were encountered. Reassessment of ultrasound diagnostic criteria and the use of more sensitive methods, such as endovaginal ultrasound in high risk patients, are indicated for any symptomatic patient using clomiphene citrate for infertility. Awareness of the prevalence of this entity and the limitations of ultrasound will lead to prompt intervention and improved survival rates.