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For decades, tropical peatlands in Indonesia have been deforested and converted to other land uses, mainly oil palm plantations which now cover one-fourth of the degraded peatland area. Given that the capacity for peatland ecosystems to store carbon depends largely on hydrology, there is a growing interest in rewetting degraded peatlands to shift them back to a carbon sink. Recent estimates suggest that peatland rewetting may contribute up to 13 % of Indonesia's total mitigation potential from natural climate solutions. In this study, we measured CO 2 and CH 4 fluxes, soil temperature, and water table level (WTL) for drained oil palm plantations, rewetted oil palm plantations, and secondary forests located in the Mempawah and Kubu Raya Regencies of West Kalimantan, Indonesia. We found that peatland rewetting significantly reduced peat CO 2 emissions, though CH 4 uptake was not significantly different in rewetted peatland compared to drained peatland. Rewetting drained peatlands on oil palm plantations reduced heterotrophic respiration by 34 % and total respiration by 20 %. Our results suggest that rewetting drained oil palm plantations will not achieve low CO 2 emissions as observed in secondary forests due to differences in vegetation or land management. However, extrapolating our results to the areas of degraded oil palm plantations in West Kalimantan suggests that successful peatland rewetting could still reduce emissions by 3.9 MtCO 2 yr -1 . This result confirms that rewetting oil palm plantations in tropical peatlands is an effective natural climate solution for achieving national emission reduction targets., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nisa Novita reports financial support was provided by Bezos Earth Fund and The Jeremy and Hannelore Grantham Environmental Trust. Nisa Novita reports a relationship with Yayasan Konservasi Alam Nusantara that includes: funding grants. No conflict of interest. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Tropical wetlands and freshwaters are major contributors to the growing atmospheric methane (CH 4 ) burden. Extensive peatland drainage has lowered CH 4 emissions from peat soils in Southeast Asia, but the canals draining these peatlands may be hotspots of CH 4 emissions. Alternatively, CH 4 oxidation (consumption) by methanotrophic microorganisms may attenuate emissions. Here, we used laboratory experiments and a synoptic survey of the isotopic composition of CH 4 in 34 canals across West Kalimantan, Indonesia to quantify the proportion of CH 4 that is consumed and therefore not emitted to the atmosphere. We find that CH 4 oxidation mitigates 76.4 ± 12.0% of potential canal emissions, reducing emissions by ~70 mg CH 4 m -2 d -1 . Methane consumption also significantly impacts the stable isotopic fingerprint of canal CH 4 emissions. As canals drain over 65% of peatlands in Southeast Asia, our results suggest that CH 4 oxidation significantly influences landscape-scale CH 4 emissions from these ecosystems., Competing Interests: Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Water-logged peatlands store tremendous amounts of soil carbon (C) globally, accumulating C over millennia. As peatlands become disturbed by human activity, these long-term C stores are getting destabilized and ultimately released as greenhouse gases that may exacerbate climate change. Oxidation of the dissolved organic carbon (DOC) mobilized from disturbed soils to streams and canals may be one avenue for the transfer of previously stored, millennia-aged C to the atmosphere. However, it remains unknown whether aged peat-derived DOC undergoes oxidation to carbon dioxide (CO 2 ) following disturbance. Here, we use a new approach to measure the radiocarbon content of CO 2 produced from the oxidation of DOC in canals overlying peatland soils that have undergone widespread disturbance in Indonesia. This work shows for the first time that aged DOC mobilized from drained and burned peatland soils is susceptible to oxidation by both microbial respiration and photomineralization over aquatic travel times for DOC. The bulk radiocarbon age of CO 2 produced during canal oxidation ranged from modern to ~1300 years before present. These ages for CO 2 were most strongly influenced by canal water depth, which was proportional to the water table level where DOC is mobilized from disturbed soils to canals. Canal microbes preferentially respired older or younger organic C pools to CO 2 , and this may have been facilitated by the use of a small particulate organic C pool over the dissolved pool. Given that high densities of canals are generally associated with lower water tables and higher fire risk, our findings suggest that peatland areas with high canal density may be a hotspot for the loss of aged C on the landscape. Taken together, the results of this study show how and why aquatic processing of organic C on the landscape can enhance the transfer of long-term peat C stores to the atmosphere following disturbance., (© 2024 John Wiley & Sons Ltd.)

Conservation of undrained tropical peatland ecosystems is critical for climate change mitigation as they store a tremendous amount of soil carbon that is preserved under anoxic water-logged conditions. Unfortunately, there are too few measurements of carbon fluxes from these ecosystems to estimate the climate change mitigation potential from such conservation efforts. Here, we measured carbon dioxide (CO 2 ) and methane (CH 4 ) fluxes as well as fluvial organic carbon export over the peat swamp forest within an undrained tropical peatland landscape in East Kalimantan, Indonesia. Our measurements throughout one year (Oct 2022-Sep 2023) showed that despite its water-logged condition, peat and water overlying the swamp forest on average emits 11.02 ± 0.49 MgCO 2 ha -1  yr -1 of CO 2 and 0.58 ± 0.04 MgCO 2 e ha -1  yr -1 of CH 4 . Further, the fluvial organic carbon export contributes to additional carbon loss of 1.68 ± 0.06 MgCO 2 e ha -1  yr -1 . Our results help improve the accuracy of carbon accounting from undrained tropical peatlands, where we estimated a total carbon loss of 13.28 ± 0.50 MgCO 2 e ha -1  yr -1 . Nevertheless, the total carbon loss reported from our sites is about half than what is reported from the drained peatland landscapes in the region and resulted in a larger onsite carbon sink potential estimate compared to other undrained peat swamp forests. Together, these findings indicate that conserving the remaining undrained peatland ecosystems in Indonesia from drainage and degradation is a promising natural climate solution strategy that avoids significant carbon emissions., (© 2024. The Author(s).)

Chromophoric dissolved organic matter (CDOM) optical properties were measured in surface and pore waters as a function of depth and distance from an oil well in a southern California salt marsh. Higher fluorescence and absorbances in pore vs. surface waters suggest soil pore water is a reservoir of CDOM in the marsh. Protein-like fluorophores in pore waters at distinct depths corresponded to variations in sulfate depletion and Fe(II) concentrations from anaerobic microbial activity. These variations were supported by fluorescence indexes and are consistent with differences in optical molecular weight and aromaticity indicators. Fluorescence indices were consistent with autochthonous material of aquatic origin in surface waters, with more terrestrial, humified allochthonous material in deeper pore waters. CDOM optical properties were consistent with significantly enhanced microbial activity in regions closest to the oil well, along with a three-dimensional excitation/emission matrix fluorescence spectrum peak attributable to oil, suggesting anaerobic microbial degradation of oil., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Gastrointestinal angiodysplasia (GIAD) of the jejunum is a rare cause of acute upper and lower gastrointestinal bleeding in the paediatric population. This is the case of a previously well 10-year-old girl who presented with acute rectal haemorrhage, haematemesis and syncope. Despite an exploratory laparotomy, the cause of bleeding remained unknown. A computerized tomography angiogram was performed once she was haemodynamically stable. It indicated bleeding in the jejunum. Repeat laparotomy was performed including enterotomy, copious small bowel washout and visualization of the whole small bowel. The lesion was identified at approximately 100 cm from the duodenojejunal flexure and confirmed by isolating the lesion and testing for bleeding. A 30 cm length of jejunum was resected and primary anastomosis performed. She recovered well and was discharged three days postoperatively. She remained well at six-month follow-up. This case highlights the importance of considering upper GIAD in an acute paediatric gastrointestinal bleed and the way in which surgical management can prevent a potentially fatal outcome.

Suction rectal biopsy (SRB) may not include sufficient submucosa for histological diagnosis of Hirschsprung's disease (HD) and a repeat biopsy is required. Substitution of the conventional syringe for sustained suction from a machine or wall suction unit could provide a more consistently adequate tissue biopsy. This study was conducted to compare the adequacy of SRB specimens using a conventional method of syringe suction (SSRB) with those taken by wall or machine suction (WSRB). Hospital records of patients who had a SRB between 2002 and 2004 were studied retrospectively. The biopsy was considered inadequate if there was insufficient submucosa and a repeat specimen was requested. SSRB were taken using the conventional SSRB technique. WSRB were taken with the same Noblett forceps but with suction from wall suction or from a portable suction machine. Ninety-five infants had 103 SRB, 24 had WSRB and all (100%) were adequate for histopathological diagnosis or exclusion of HD. Seventy nine conventional SSRB were undertaken in 71 infants of which 64 (81.02%) were adequate. The difference in adequacy between WSRB and SSRB was statistically significant (P = 0.02). There were no instances of haemorrhage or bowel perforation in either subgroup. WSRB with the Noblett biopsy forceps is more likely to produce an adequate specimen and to reduce the incidence of repeat biopsies.

Congenital duodenal obstruction (DO) has a well-known association with Down syndrome (DS) and other congenital malformations. Previously reported series on DO have not examined the influence of DS on associated congenital malformations and postoperative morbidity and mortality. We report on a retrospective study of all children born with DO over an 11-year period to investigate this. A total of 79 patients with DO were studied: group 1 consisted of 51 (64.6%) children without DS, and group 2 consisted of 28 (35.4%) children with DS. There was no significant difference in mean gestational age and birth weight between groups 1 and 2. A coexisting congenital malformation was found in 68% of patients. Gastrointestinal malformations were the most common in group 1 (71.1%), and cardiac malformations were the most common in group 2 (81.5%). The mean time to reach full intragastric feeds was 12 days, with no significant difference between the two groups ( p=0.383). Seven (8.9%) patients developed a postoperative complication, with no significant difference between both groups ( p=0.853). A total of 11 patients died: six (12%) in group 1 and five (28%) in group 2, with no significant difference between the groups ( p=0.454). DS does not influence the morbidity and mortality of DO but does carry a higher incidence of congenital cardiac abnormalities. Delayed mortality was a result of coexisting congenital cardiac and respiratory disease.

A case of traumatic rectovesical fistula in a 14-year-old boy is presented. A transvesical approach was employed to access the defect. This approach provided excellent exposure, ease of surgery, and an uncomplicated post-operative course. The operative procedure is described, and aspects of the case are discussed.

Objective: To review the outcome of cholecystectomy after heart transplant., Summary Background Data: The optimal timing for gallbladder surgery in heart transplant patients is controversial., Methods: Between April 1985 and October 2000, 518 cardiac transplants were performed at Ochsner Foundation Hospital. Data gathered included ultrasound reports, cholecystectomy operative reports, gallbladder pathologic reports, complications, and deaths., Results: Charts were available for 509 patients (98%), 68 (13%) of whom underwent cholecystectomy before transplantation. Of the 509, 53 (10%) had serial ultrasound examinations and 29 of the 53 (55%) developed gallstones. After transplant, 47 (9%) underwent cholecystectomy. Five cholecystectomies were performed during the immediate postoperative course. Two patients who underwent cholecystectomy had acalculous cholecystitis; one was incidental. Four patients died (one with rejection and three with sepsis). After discharge, 42 cholecystectomies were performed: 16 for biliary colic (no deaths, three patients with complications), 19 for acute cholecystitis (one death, nine patients with complications), 5 for biliary pancreatitis (1 death, 1 patient with complications), and 2 others., Conclusions: The risk of morbidity and mortality from gallstone disease is high in cardiac transplant patients, particularly immediately posttransplant. Posttransplant patients require annual ultrasound examinations to detect the onset of gallstone disease, and this risk is higher than in the general population. Gallstones alone are an indication for cholecystectomy in the cardiac transplant patient. Pretransplant cholecystectomy should be considered in clinically stable patients with gallstones.

Background: The purpose of this study was to determine the significant factors contributing to the difference between men and women in anaerobic power (AP) generation. METHODS., Participants: College men (n = 113) and women (n = 175) were randomly selected for evaluation from a fitness class prior to training., Measures: AP was determined from the Margaria-Kalamen stair run. Dynamic strength was evaluated from the 1-RM single-leg extension. Body composition was estimated from gender-specific skinfold prediction equations., Results: Discriminant analysis identified %fat, fat-free mass (FFM), and leg extension strength as significant components differentiating between men and women and allowed proper gender classification in 99% of the cases. When both strength and body composition variables were held constant by covariance, there was no significant difference between men and women in AP (F = 1.25). A multiple regression equation using %fat, FFM, and leg extension strength predicted AP (R = 0.91) with an error of 150 W. When the multiple regression equations was applied to a cross-validation sample, AP could be accurately predicted (r = 0.91, t = 0.17) with an average error of 3% +/- 21%., Conclusions: Body size and dynamic strength are the major factors explaining the explosive leg power difference between men and women without a specific or unique gender quality.

Background: Cholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure., Methods: Between 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA < 4 who were living < 2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions., Results: Since 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained approximately 60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed > 1 day (range, 2-20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided., Conclusion: Successful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

Background and Purpose: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned., Methods: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed., Results: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy., Conclusion: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.

In the last decade, laparoscopy has been the most innovative surgical movement in general surgery. Minimally invasive surgery performed through a few small incisions, laparoscopy is the standard of care for the treatment of gallbladder disease and the gold standard for the treatment of reflux disease. The indications for a laparoscopic approach to abdominal disease continue to increase, and many diseases may be treated with laparoscopic techniques. At Ochsner, laparoscopic techniques have demonstrated better cosmetic results, shorter recovery times, and an earlier return to normal activity compared with open surgery.

Objective: This experiment evaluated enterally administered low molecular weight heparin (LMWH) combined with sodium N-[10-(2-hydroxybenzoyl)amino] decanoate (SNAD) for the treatment of induced venous thrombosis., Summary Background Data: SNAD is a delivery agent that potentiates the gastrointestinal absorption of LMWH., Methods: Forty female pigs were equally assigned to four groups: control (saline); enteral LMWH, 2,000 IU/kg; enteral SNAD, 50 mg/kg; and enteral LMWH, 2,000 IU/kg and SNAD, 50 mg/kg. Under fluoroscopic guidance, the infrarenal vena cava was occluded with a balloon catheter. Two milliliters of ethanol was injected into the distal vena cava. The inflated balloon catheter remained in situ for 5 days, at which time animals angiographically exhibiting thrombus were randomly assigned to the four groups. Study medications were dosed at 12-hour intervals by means of a gastrostomy tube placed previously. After 7 days of treatment, thrombus was extracted. A separate group of 10 animals was used to measure plasma antifactor Xa levels for 6 hours after enteral dosing of LMWH/SNAD., Results: The amount of residual thrombus after treatment with enteral LMWH/SNAD was significantly decreased. Antifactor Xa levels were significantly elevated in the LMWH/SNAD group versus baseline., Conclusion: The combination of enterally administered LMWH and SNAD given for 7 days appeared to decrease caval thrombosis in this model of deep vein thrombosis. Enteral LMWH/SNAD effected an increase in plasma levels of antifactor Xa.

Purpose: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution., Methods: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls., Results: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05)., Conclusion: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.

Laparoscopic procedures have achieved results equivalent to their open counterparts, with shorter hospital stays and less incisional morbidity. These procedures should be performed by surgeons trained in minimally invasive techniques. Overall, patient satisfaction with regard to symptom response is excellent.

Patients with clinical features of intestinal obstruction without a history of prior laparotomy or physical evidence of a hernia can be a diagnostic challenge. We attempted to evaluate our preoperative diagnostic accuracy, to assess the effectiveness of our diagnostic tools, and to determine the incidence of various causes of intestinal obstruction in this select group. Medical records of all patients admitted to our institution and taken to surgery with a diagnosis of intestinal obstruction from 1975 through 1995 were reviewed. Patients with a history of prior laparotomy, evidence of hernia, or emergent indications for surgery on admission were excluded. The most common cause of intestinal obstruction in this select group of patients was malignancy. The ability to detect malignancy preoperatively is significantly better than the ability to detect benign causes of obstruction (Pearson Chi square = 4.09 with a P value of 0.04). Preoperative detection of malignancy in these patients is critical for optimal treatment planning and counseling for patients and their families.

Background: To evaluate the economic impact of performing carotid endarterectomy based only on a diagnosis of duplex scanning, we evaluated a cohort of patients treated at our institution during 1 calendar year., Methods: Ninety-seven patients were evaluated and divided into two groups: those with and without arteriogram prior to their operation. Duplex scan and arteriogram results were reviewed to determine their effect on the operative plan. Hospital charges and physician fees were assessed for each patient admission. Operative results, complications, and total charges were compared between the two groups., Results: There was one operative stroke in each group for a stroke rate of 2%. Angiographic complications included one stroke and one femoral artery thrombosis. Two arteriograms led to a change in the operative plan. The hospital charges for patients without an arteriogram was $10,292 verses $13,906 for patients with an arteriogram (P < 0.01). Physician charges for patients without an arteriogram were $3,882, with angiograms and $6,297. The total charges related to the endarterectomy were $14,174 and $20,203, respectively. Arteriograms accounted for an increase of 43% in total charges., Conclusion: Nonroutine use of angiography does not increase operative risk or postoperative length of stay, and preoperative angiography increases total charges by 43% ($6,029) per patient.

A case of endovascular treatment of abdominal aortic aneurysm is discussed along with a review of the literature. This recently introduced Food and Drug Administration Phase II treatment modality may have a significant impact on the approach to the treatment of aneurysmal disease. This discussion details the treatment of one typical patient and reviews the current status of endovascular therapy as it applies to infrarenal abdominal aortic aneurysms.

Purpose: The intraaortic balloon pump (IABP) is useful in the treatment of failing hearts. Although most experience with IABPs has been with acute short-term use, the safe duration of therapy and possible complications of long-term IABP use are uncertain. We evaluated the feasibility, management, and complications associated with long-term IABP therapy., Methods: Fifty consecutive patients with 87 IABPs were evaluated retrospectively. All patients had IABP support for greater than 72 hours. Results and complications were evaluated., Results: The mean duration of IABP support was 23.2 days. There were 21 IABP-related complications in 16 patients: (16 ischemic, three infections, two hemorrhage). The rate of complications was 0.13 per patient-week of support. Significant predictors of complications were total days of IABP support (p < 0.0001), use of multiple IABPs (p < 0.0001), and attempted but unsuccessful percutaneous insertions (p < 0.001). Complications led to 14 vascular procedures (five patch angioplasties, four bypass procedures, two major amputations, one fasciotomy, one groin exploration for hemorrhage, and one removal of an infected Dacron patch). Percutaneous removals had a 14% complication rate compared with none after operative removal (p = 0.02). Thirty-two patients survived (64%). Of the survivors, 27 underwent transplant., Conclusions: Prolonged IABP therapy is feasible and is associated with an acceptable rate of complications. Operative removal is superior to percutaneous removal. Percutaneous removal should be limited to short-term therapy. There is no need for mandatory removal or site rotation based solely on indwelling time.

A 67-year-old man had symptoms of peripheral vascular disease and was noted to have a carotid bruit. Duplex ultrasound examination of the neck demonstrated a short segmental occlusion of the proximal internal carotid artery (ICA) with antegrade flow distal to the occlusion maintained by an anomalous branch of the ICA. Angiography confirmed the findings and suggested that the branch was from the distribution of the occipital artery. The ICA findings were surgically proved, and endarterectomy was successfully performed without complication. This case reinforces the usefulness of duplex ultrasonography of the carotid arteries and is a rare situation in which a completely occluded ICA can be repaired with a good clinical outcome.

Objective: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported., Summary Background Data: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published., Methods: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported., Results: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities., Conclusions: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Objective: The authors determined whether carotid endarterectomy in patients with recurrent stenosis could provide durable stroke prevention with acceptable perioperative risk., Summary Background Data: Balloon angioplasty and stenting are being advocated for recurrent stenosis because of the presumption that reoperation is unsafe with poor results., Methods: The authors retrospectively reviewed their experience with 67 patients undergoing 74 operations for recurrent stenosis in a recent 11-year period. This represented 8.4% of 883 endarterectomies performed during the same period., Results: At original operation, 55% had primary closure and 45% were patched. Reoperation was performed for amaurosis fugax and transient ischemic attack (45%), post-stroke (7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%). Four patients (6%) undergoing simultaneous cardiac procedures were excluded from further analysis. Mean duration between primary and first redo operation was 78 months (range, 1-240 months). The 30-day combined mortality and stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality rates. Recurrent disease occurred predominantly (69%) in the previous endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2). Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral neurologic events and four late contralateral events occurred. Two patients required third ipsilateral reoperation. Life-table analysis shows the ipsilateral stroke-free rate at 5 years to be 93.6%, Conclusions: Recurrent stenosis occurs either proximal to or in the previous endarterectomy site in the majority of patients. Recurrent stenosis can be treated surgically with low morbidity and mortality and durable long-term stroke prevention. The presumption that results of redo carotid surgery are poor is disproved.

Endoscopic abdominoplasty is feasible, safe, and effective in the proper surgical candidate. Excellent results can be expected when proper patient selection criteria are followed. With future refinements in technique and equipment, this procedure may be extended safely to those patients with more severe deformities.

Vaccines which successfully protect against virus infections usually need to induce a broadly reactive immune response which includes the induction of cytotoxic T lymphocytes (CTL). In this study, we have used a convenient in vitro approach to investigate if plasmid DNAs encoding proteins of herpes simplex virus (HSV) are capable of inducing primary CD8+ CTL. Dendritic cells or macrophages were transfected with either plasmid DNA encoding glycoprotein B or DNA encoding the immediate-early protein ICP27. These antigen-presenting cells (APC) were then used to stimulate enriched populations of naive T cells in microcultures for 5 days in vitro. Antigen-specific CD8+ CTL which reacted both with specific protein-expressing targets and with syngeneic targets infected with HSV could be demonstrated. Dendritic cells, as APC, generated the maximal responses, but such cells needed to be transfected with DNA in the presence of a cationic lipid. However, macrophages could act as APC when they were exposed to purified DNA. HSV-primed splenocytes were also shown to generate specific CTL responses when they were stimulated with purified DNA encoding ICP27. The novel approach described in this paper promises to be extremely useful, since defining immunogenicity profiles and identifying epitopes on viral proteins should be easier and more convenient when working with DNA and investigating variables in vitro. This is particularly the case with complex viruses such as HSV, most of whose encoded proteins have yet to be isolated in sufficient quantity or purity to perform in vivo immunological studies.

Cholera toxin (CT) is a strong systemic and mucosal adjuvant that greatly enhances IgG and IgA immune responses, but its adjuvant effects for cellular immunity, particularly class I-restricted cytotoxic T lymphocyte (CTL) responses, are less well understood. In the present report, CT and the purified non-toxic B component (CTB) were assessed for their ability to facilitate class I-restricted CTL induction to soluble proteins as well as to permit sensitization of target cells for CTL-mediated lysis. Priming for ovalbumin (OVA)-specific CTL occurred following oral exposure to a combination of OVA with CT plus CTB. In addition, CTB mixed with soluble proteins and administered intravenously primed mice for antigen-specific class I-restricted CTL. Target cells could also be sensitized for CTL-mediated killing following their exposure to soluble antigen and CTB in vitro. These results indicate that combinations of CT and CTB not only enhance antibody responses, but also have an immunomodulating effect to allow sensitization and priming for antigen-specific class I-restricted CTL.

After a decade of effort to develop a minimalist alternative to standard cholecystectomy as the treatment for gallstone disease, laparoscopic cholecystectomy (LC) has emerged as the treatment of choice. Gallstone dissolution and lithotripsy failed to meet the tests of applicability and reliability. In fact, lithotripsy was denied approval by the US Food and Drug Administration in 1989. LC achieves the benchmark of treatment--removal of the diseased gallbladder and its stones--with less pain, disability, and disfigurement than standard surgery. The procedure is applicable in more than 90% of cases, being limited primarily by the severity of inflammation and the surgeon's experience. During the past 3 years, the special instrumentation has improved and operative techniques have been standardized resulting in fewer complications. For these reasons, laparoscopic surgical techniques are now being applied to a widening array of procedures including hernia repairs, bowel resections, antireflux procedures, common bile duct stone removal, lymph node dissections, and peptide ulcer disease treatment.

Background: The occurrence of an intercarotid paraganglioma and a paraganglioma in an anatomic distribution away from the head and neck in the same patient is rare. We have treated a patient with this combination of tumors and report this unusual case with the purpose of reviewing the paraganglion system. We endeavor to clarify the confusion that exists by use of the terms chemodectoma, glomus tumors, nonchromaffin paragangliomas, and pheochromocytoma and to present a rational nomenclature based on their ontogeny., Methods: A computer-generated list of articles on this subject was obtained, and all articles relative to this rare combination of tumors were reviewed., Results: We found 31 other cases. Functional intercarotid paragangliomas are extremely rare, with only five cases having been reported., Conclusions: All hypertensive patients who are found to have an intercarotid paraganglioma should be investigated for a functional tumor. Family members should also be made aware of their probabilities of having these tumors because a familial trend has been documented in certain cases.

The infectivity, dissemination, and transmissibility of wild-type Sindbis (SIN) virus were studied in Aedes aegypti (L). There was an initial decline in the viral titer of whole mosquitoes for 3 d after ingestion of virus, followed by a gradual increase to a maximal level by day 6. Immunoperoxidase staining of Ae. aegypti for viral antigen showed infection of midgut epithelial cells on day 1, of the fat body by day 3, and of the brain by day 4. By day 5, there was infection of the foregut, hindgut, Malpighian tubules, ovariole sheaths, Johnston's organ, thoracic ganglia, ventral nerve cord, and salivary glands. Viral antigen was not detected in the flight muscles and was found only in ovariole sheaths of the ovaries; germinal tissue was not infected. The transmission rate from SIN-infected Ae. aegypti to neonatal mice was 40%. A comparison of Ae. aegypti infected with SIN and with a neuroadapted strain of Sindbis virus (NSIN), which is more neurovirulent than SIN to mice after intracerebral inoculation, did not reveal significant differences in infectivity, dissemination, or transmissibility. The important differences between SIN and NSIN in a mouse model were not reflected in the infection of Ae. aegypti by the oral route.

From January 1981 to December 1990, 55 consecutive patients underwent esophageal resection by either the transhiatal (THE, 26 patients) or transthoracic (TTE, 29 patients) approach. Patient age, tumor size, and tumor stage were similar in the two groups. THE patients had a significantly worse mean preoperative American Society of Anesthesiologists (ASA) risk class assigned by the anesthesiologist. Patients who underwent THE had a significantly lower operative mortality and rate of cardiopulmonary complications, significantly shorter intensive care unit and hospital length of stay, and a significantly better postoperative survival when operative deaths are included in the analysis. Operative deaths in the TTE group were concentrated among patients > 65 years of age (4 of 9 died), in an ASA risk class > or = III (3 of 7 died) or with moderate or severe cardiac or pulmonary impairment preoperatively (4 of 6 died).

In 1991, only symptomatic gallstones should be treated. The treatment of choice for all gallstones continues to be surgical removal. Except for stones in the common bile duct, which are amenable to removal by endoscopic papillotomy, nonsurgical treatment of gallstones should be investigated further before it can have widespread applicability. The major challenge in the future may be medical prevention of gallstone formation in susceptible individuals. Laparoscopic cholecystectomy seems to have moved to the forefront of surgical therapy in patients who are candidates for the procedure.

The mucosal route for the production of mucosal and systemic herpes simplex virus (HSV) antibodies was investigated using HSV1 subunit vaccine administered to guinea pigs. Groups of test animals (n = 13) were dosed, nasally or vaginally and compared with those injected subcutaneously (s.c.). The vaccines, in aqueous or gel form, were administered 5 and 3 weeks prior to vaginal challenge with HSV2 suspension. Control infected and non-infected animals were included for comparison. Animals which were vaccinated s.c. were shown to respond to subsequent infection with HSV by the production of serum HSV-specific IgG (and IgA) but negligible amounts of vaginal IgG and IgA. Control non-infected and infected-only groups produced none and only a small amount of vaginal HSV-specific antibodies, respectively. Substantial protection against HSV2 infection of the female guinea pig genital tract was provided by s.c. immunization with HSV vaccine. Protection was evaluated in terms of the reduction of histopathological lesions and clinical signs in vaccinated and control animals. The serum humoral response to nasal delivery in phosphate-buffered saline was comparable, and was superior for vaginal washes to that of parenteral vaccination. The nasally delivered free antigen gave significant (p < or = 0.05) reduction in the severity of the disease and higher levels of specific serum and vaginal immunoglobulin antibodies to HSV when compared with non-immunized infected-only controls, probably due to uptake of antigenically intact protein. Vaginal gel treatment slightly reduced the severity of the illness and gave higher humoral responses than those induced by vaginally delivered free antigen. Findings also indicate that these mucosal immune responses were produced at a site distant from the site of vaccination, suggesting a common immunological system.

Spontaneous atheromatous visceral embolization from diffuse aortic atherosclerotic disease is an unusual and poorly understood entity. We have reviewed our experience with 88 patients who suffered atheromatous embolization from a "shaggy" aorta. Visceral embolization was evident in 36 patients (40.9%). Nine were treated nonoperatively with three patients dying within a week of presentation and an additional five patients dying within five years due to continuing renal and intestinal embolization. Surgical correction was undertaken 28 times in 27 patients. Endarterectomy or graft replacement of the aorta did not necessarily prevent visceral infarction or renal failure. Extra-anatomic bypass with ligation of the distal external iliac arteries appears to be associated with the lowest morbidity and mortality. Anticoagulation of these patients does not prevent embolization and may be contraindicated for long-term management.

We have reviewed our experience with 71 patients who had a femorofemoral bypass for unilateral iliac artery occlusion or stenosis. We analyzed morbidity, mortality, initial relief of symptoms, early patency, and long-term primary and secondary patency; and we attempted to identify the cause of graft failure. The overall hospital mortality after operative repair was 4%. One-year survival was 84% and 2-year survival was 81%. Early patency was 98.5% at 1 month, late patency was 91% at 1 year and 82% at 5 years. The major cause of graft failure was inadequate run-off and outflow disease progression.

A true pancreaticoduodenal artery (PDA) aneurysm (ie, one not associated with pancreatitis) is the second least common splanchnic artery aneurysm; it is usually situated in or near an area that is hard to dissect, and it has a distinct propensity to rupture. We reviewed a total of 36 cases of PDA aneurysm, including three from our institution, and we analyzed them in two time periods with relation to age, sex, method of diagnosis, morbidity, and mortality. Cases reported before 1970 were compared with those reported during or after 1970. The male-female ratio was 4:1 before 1970 and 1:1 after 1970, yet the mean age has stayed significantly lower for female populations (P less than .02). The use of angiography has increased significantly recently (P = .004). The overall mortality has not improved significantly (P = .08); however, if the initial diagnosis was made by angiography, the survival was significantly better (P less than .025). Surgical intervention remains the standard treatment, but preoperative angiography significantly improves operative results. Anecdotal reports suggest that selected high-risk cases may be successfully managed by therapeutic angiography with embolization.

Three cases of symptomatic cavernous hemangioma of the liver are reported. All three patients have normal angiograms. A review of the literature shows that the diagnosis of hemangioma may be made noninvasively with a high degree of accuracy. Technetium Tc 99m-labeled red blood cell scanning is very specific, while dynamic computed tomography may be more sensitive for small lesions. A combination of the two modalities makes the diagnosis in greater than 90% of cases. Magnetic resonance imaging is also sensitive and specific. Angiography, as shown in these cases, may not only be questionably indicated, but may be misleading. The treatment for symptomatic lesions is resection, and secondary alternatives are discussed.

The presentation, treatment, and outcome of 12 patients with high-grade neurogenic sarcoma (NS) of the extremity were compared with those of 21 patients with high-grade extremity soft-tissue sarcoma of nonneural origin in a retrospective study from January 1976 to January 1988. Pain and neurologic deficit were more common in the NS group. Limb-sparing surgery was carried out with equal frequency in both groups. Local recurrence was six times more frequent in the NS group at three-year follow-up (59% vs 10%). Width of resection margin was the dominant prognostic variable bearing on local control after limb-sparing surgery. Anatomic and functional constraints tended to limit resection margin in patients with NS arising from mixed motor-sensory or predominantly motor nerves.