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A 75-year-old woman with mild elevation of liver function test results was found to have an asymptomatic mass localized to the gallbladder by computed tomographic scan and ultrasonography. Endoscopic retrograde cholangiopancreatography revealed a fixed 2 x 4 cm filling defect in the gallbladder wall, consistent with a gallbladder neoplasm. The gallbladder and intramural neoplasm were excised successfully by use of uncomplicated laparoscopic cholecystectomy. Pathologic analysis revealed a carcinoid tumor of the gallbladder. All previously reported gallbladder carcinoid tumors in the Western literature are reviewed. Laparoscopic cholecystectomy has potential for application for the treatment of selected gallbladder neoplasms, with special preoperative assessment and intraoperative considerations being important.

A nonoperative approach to venous stasis ulceration of the lower extremity, consisting of initial bedrest, ulcer cleansing, dressing changes, and ambulatory elastic compression stocking therapy, has been maintained for over 15 years. All patients had class III, severe chronic venous insufficiency. One hundred five of 113 patients (93%) experienced complete ulcer healing in a mean of 5.3 months. One hundred two patients were compliant with elastic compression stockings, and 11 patients were noncompliant. Complete ulcer healing occurred in 99 of 102 patients (97%) who were compliant versus six of 11 patients (55%) who were noncompliant (p less than 0.0001). The influence of noncompliance, previous venous ulceration, previous venous surgery, previous known deep venous thrombosis, peripheral arterial insufficiency (ankle brachial systolic blood pressure index less than or equal to 0.60), pretreatment ulcer duration, ulcer size, age, sex, diabetes, smoking, and photoplethysmography venous refill time on ulcer healing was determined by logistic regression analysis. Only noncompliance with elastic compression stockings (p less than 0.0001) and a pretreatment ulcer duration of more than 9 months (p = 0.02) significantly decreased initial ulcer healing. Posthealing follow-up was available in 73 patients for a mean of 30 months. Fifty-eight patients (79%) continued to be compliant with stockings; 15 patients were noncompliant. Total ulcer recurrence in patients who were compliant was 16%. Five-year lifetable recurrence was 29%. All patients who were noncompliant had recurrent ulceration by 36 months. Previous ulceration, previous venous surgery, and peripheral arterial insufficiency had no effect on ulcer recurrence (p greater than 0.05).

Increasing numbers of patients with aortoiliac disease are seen with contraindications to standard infrarenal aortofemoral reconstruction. Although axillofemoral bypass is possible in these patients, the decreased patency rate associated with this operation makes alternate procedures desirable. This report details our experience with prosthetic bypass from the supraceliac aorta to the femoral arteries in seven patients with limb-threatening ischemia of the lower extremity, all of whom had undergone multiple previous aortic operations. The operations were performed through thoracoabdominal or flank incision, and the preferred graft configuration consisted of a single Dacron tube from the aorta to the left groin with a standard subcutaneous femorofemoral graft to the right groin. No surgical deaths occurred. At 3 1/2 years' mean follow-up, there has been one graft limb occlusion that resulted in amputation for an overall life table patency and limb salvage rate of 93%. We conclude that supraceliac to femoral artery bypass is a useful procedure for the treatment of patients who have had multiple previous aortic reconstructions fail.

Twenty-six patients with severe short-distance claudication underwent a 24-week, randomized, double-blind, parallel-group evaluation of the efficacy of pentoxifylline in the treatment of intermittent claudication. The primary variables analyzed were the initial and absolute claudication distances as determined by standardized treadmill walking. A statistically significant improvement in both parameters was present in the pentoxifylline-treated patients. Nausea was the only drug side effect noted.

A number of experimental and clinical studies have shown that early regional surgical sympathectomy decreases tissue loss following frostbite, presumably by relieving vasospasm and increasing blood flow. This study was performed to determine if a decrease in tissue loss following a standard cold injury could be obtained following a regional "medical sympathectomy" achieved by the intra-arterial administration of sympathetic blocking drugs. A standard cold injury was produced in rabbits and the animals were divided into nine treatment groups. Various treatment modalities were evaluated, including rapid rewarming, intra-arterial reserpine and tolazoline, and intravenous low molecular weight dextran. In the slowly rewarmed animals, the usual clinic situation, the regional intra-arterial administration of reserpine and tolazoline significantly reduced tissue loss, equalling the results obtained in the rapidly rewarmed group. These results indicate that the early achievement of a regional "medical sympathectomy" may be of benefit in reducing tissue loss following frostbite in patients, especially in those in whom rapid rewarming cannot be performed.

In response to specific stresses, such as a heat pulse or the sequence of hypoxia-reoxygenation, each isolated cell (prokaryotic and eukaryotic) that has been studied characteristically alters gene expression to synthesize a set of proteins (heat-shock proteins) that are important for intracellular homeostasis. To determine whether a corresponding response occurs within parenchymal cells in vivo when subjected to the complex stress of circulatory shock, liver biopsy specimens were obtained from a swine model of cardiogenic shock before and after shock/resuscitation. With use of complementary DNA prepared from post-shock/resuscitation messenger RNA, a library was constructed and screened for differential gene expression. Of 32/4000 clones initially screened as positive for induction after shock/resuscitation, six were confirmed positive by Northern blot analysis. The nucleotide sequences of two of these six have been determined, and one has been unambiguously identified as metallothionein.

A 10-year-old girl had bilateral, symmetrical swelling of the lower extremities, which had been present since the age of 1 year. Noninvasive vascular laboratory measurements of the ambulatory venous pressure, venous recovery time, and maximum venous outflow revealed profound bilateral lower extremity venous valvular incompetence. Duplex imaging of the veins of the lower extremities demonstrated no evidence of thrombosis, and no venous valves could be imaged. On phlebography, the patient was found to have no venous valves in the superficial and deep systems of the leg. We conclude that congenital absence of the venous valves of the lower extremities is almost certainly underdiagnosed and that the vascular laboratory can accurately and easily differentiate between lymphedema and venous valvular imcompetence. Such differentiation may have therapeutic implications.

This study was performed to determine the frequency of occurrence of associated autoimmune disease in a group of patients presenting with Raynaud's symptoms. A consecutive group of 100 patients presenting with Raynaud's syndrome underwent detailed prospective clinical and immunologic evaluation. Magnificantion hand arteriography was performed in certain patients. Based on current diagnostic criteria, the following autoimmune diseases were diagnosed or were suspected strongly: Raynaud's syndrome with scleroderma or CRST--28 patients; Raynaud's syndrome with lupus erythematosus--ten patients; Raynaud's syndrome with miscellaneous autoimmune disease--43 patients: Raynaud's syndrome without diagnosable autoimmune disease--19 patients. Fourteen of the 19 patients in the latter group had isolated serologic abnormalities. Arteriography showed combined organic arterial obstruction and vasospasm of the palmar and digital arteries in all patients. Patients with severe Raynaud's symptoms had more extensive arterial obstruction than did patients with mild or moderate Raynaud's symptoms. These results suggest that all patients with Raynaud's syndrome should be regarded as at high risk for having an associated autoimmune disease.

Twenty-five patients with Raynaud's phenomenon, including 20 with associated diseases and five with primary Raynaud's disease, were evaluated with sequential determinations of digital temperature recovery time after cold exposure and magnification hand arteriography before and after cold exposure and before and after intra-arterial reserpine. A variety of immunologic screening tests were performed, and the clinical response to oral guanethidine of phenoxybenzamine was determined. Temperature recovery time was prolonged in all but two patients with Raynaud's phenomenon before treatment. Arteriography revealed luminal obstruction of variable degree in all but two patients with Raynaud's phenomenon but not in those with Raynaud's disease. Radiographic vasospasm was noted in all patients. Patients with Raynaud's symptoms had a markedly greater vasospastic response to cold exposure than did three control patients without Raynaud's symptoms. Arteriography 48 hours after intra-arterial reserpine repeat revealed decreased vasospasm and a decreased vasospastic response to cold in most patients. A variety of serum protein and serologic aberrations were detected, with only eight patients being free of immunologic abnormalities, Nineteen patients were treated with guanethidine alone, three with guanethidine-phenoxybenzamine combination, and one with phenoxybenzamine alone. Good or excellent clinical results were noted in 19 of the 23 patients treated, with an average follow-up to date of 12 months.

The pathophysiologic basis for spastic Raynaud's syndrome remains undefined but may be related to altered adrenergic activity. The relationship between Raynaud's syndrome and alterations in adrenergic receptor populations was examined in the present study by evaluation of alpha 2-adrenergic receptors in platelets. Direct binding assays revealed 78 +/- 8 fm/mg protein of alpha 2-adrenergic receptors in the platelets from control subjects. Similar levels of alpha 2-adrenergic receptors were observed in patients with obstructive Raynaud's syndrome. In contrast, platelet alpha 2-adrenergic receptor levels were significantly elevated (182 +/- 15 fm/mg protein) in the platelets from patients with spastic Raynaud's syndrome. These results indicate the presence of an altered alpha 2-adrenergic receptor population in the platelets from patients with spastic Raynaud's syndrome, which may be related to the vasospasm experienced by these patients.

A 22-year-old-man with intermittent obstruction of the subclavian vein at the thoracic outlet was evaluated by a pullback venous pressure gradient measurement and phlebography. The use of venous pressure gradient measurement allowed precise definition of the site of venous obstruction in the thoracic outlet and guided appropriate surgical therapy. The gradient information is of potential importance as many normal individuals have positional phlebographic venous compression at the thoracic outlet. Early identification of subclavian compression syndromes may avoid venous thrombosis with its attendant morbidity.