Clinical considerations of hormonal receptors in breast cancer.
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Biomedical subjects
Publications and source records attributed to S W Gray.
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The topographic anatomy of the submandibular triangle and its contents are described in terms of four surgical planes, with considerations of the anatomic complications during surgery. Attention is called to the importance of identifying and sparing five nerves in this triangle--the mandibular and cervical branches of the facial nerve, the hypoglossal nerve, the lingual nerve, and the chorda tympani.
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Two cases of supravesical hernia are described. One was a rare posterior internal supravesical hernia discovered only at exploratory laparotomy after exhaustive but fruitless diagnostic procedures. The surgical anatomy of anterior and posterior internal supravesical hernia is discussed and a simplified terminology is proposed.
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Ten cases of vascular compression of the duodenum are presented, and 125 cases in the literature since 1962 are reviewed. More common in women than in men, the lesion may result from supine immobilization, wearing body cast, or a rapid weight loss. In about one third of the patients, no predisposing factor can be found. Diagnosis is best made by cinefluoroscopy. Although conservative measures will provide relief in a few patients, most will require surgery. Section of the suspensory muscle and relocation of the duodenojejunal junction will relieve the symptoms in many patients. Duodenojejunostomy will be required in some others. Complete relief can be expected in all but a very few patients. Those who have developed neurotic eating habits from years of discomfort may not show immediate improvement. Untreated vascular compression of the duodenum may be chronic or may become acute with fatal results.
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The surgeon planning a thyroidectomy must be prepared to find variations in three important structures in the neck. He must be prepared to find ectopic thyroid nodules above, below or lateral to the normally located thyroid gland. Any unattached nodule should be considered malignant until proved otherwise. He must identify and preserve parathyroid glands that may not lie in the typical location. He must be prepared to encounter recurrent laryngeal nerves that do not recur. The surgeon who remembers the embryology of the structures in the neck may occasionally be astonished, but never surprised.
Nonrecurrence and variations in the ascending course of the recurrent laryngeal nerves make it essential to identify the nerve to avoid injury to it during thyroidectomy. We believe that visual identification of the nerve without undue handling is all that is necessary. The recurrent nerve is no more delicate than other similar nerves. Unilateral injury to the recurrent nerve may result in temporary hoarseness which will improve with time. Some restriction of the airway during exertion may be present. Bilateral injury to the recurrent nerves may produce initially a loss of voice without airway constriction. Later the voice may return, accompanied by serious respiratory embarrassment on exertion.
Injury to the internal (sensory) branch of the superior laryngeal nerve during thyroidectomy is unlikely. Signs of injury are loss of sensation in the upper larynx, resulting in choking and aspiration of swallowed fluids. Injury to the external (motor) branch of the superior laryngeal nerve produces no problem of respiration, but may result in changes in the quality of the voice or even voicelessness. Injury to the external branch can be avoided if the anatomical variations are kept in mind during ligation of upper pole vessels.
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