No abstract

To visualize intracoronary lesions in patients with different clinical expressions of coronary disease, we performed coronary angioscopy during coronary-artery bypass surgery in 10 patients with unstable angina and 10 patients with stable coronary disease. We examined a total of 32 vessels, using flexible fiberoptic angioscopes. Twenty-two vessels had no acute intimal lesion; three had complex plaques, six had thrombi, and one had both. Coronary angiography correctly identified the absence of complex plaque and thrombus in 22 vessels, but it detected only one of four complex plaques and one of seven thrombi. On angioscopy, none of the 17 arteries in the patients with stable coronary disease had either a complex plaque or thrombus. In the "offending" arteries of the patients with unstable angina, all three patients with accelerated angina had complex plaques and all seven with angina at rest had thrombi. We conclude that angioscopy frequently reveals complex plaques or thrombi not detected by coronary angiography. Our observations suggest that anginal syndromes that are refractory to medical treatment can be caused by unstable pathologic processes in the intima. Ulceration of plaques may increase the frequency and severity of effort angina, and the subsequent development of partially occlusive thrombi may cause unstable rest angina.

Records of 1200 consecutive open cholecystectomies, performed by a teaching service of a large, urban hospital in the years immediately preceding the laparoscopic era, were reviewed for morbidity and mortality rates. The mortality rate in this series was 1.8%, chiefly in the older age groups. Only two ductal injuries were incurred. A review of published series from 1952 through 1990 revealed a mean mortality rate of 1.53%. These recent observations on the morbidity and mortality after open operation should provide a useful standard of comparison with ongoing similar studies of laparoscopic cholecystectomy.

Splenic tumors are uncommon lesions that can be divided into two main categories: nonlymphoid and lymphoid. The most common nonlymphoid tumors are the vascular tumors, which include benign and malignant hemangiomas, lymphangiomas, and hemangioendotheliomas. The remaining nonlymphoid tumors, such as fibrosarcoma and lipoma, are so uncommon as to be only anecdotally reported. Of the lymphoid tumors, Hodgkin's lymphoma may rarely occur as a primary splenic tumor, but more commonly is seen as part of disseminated disease. The same is true of histiocytic lymphoma and plasmacytoma. Rare benign lymphoid lesions may simulate lymphoid tumors. Of the metastatic tumors to the spleen, melanoma, breast, and lung are the principal lesions, but metastases from many other neoplasms occur. Metastases to spleen are less common than to other parenchymatous organs for reasons yet unknown. The surgical approach to splenic tumors should conform to the principles of good tumor surgery with good access, extirpation without rupture, and correct handling of tissue for study. Partial splenectomy is an acceptable procedure for benign splenic cysts, and possibly for polar hamartomas.