The case history is described of a man in his 73rd year who was one of the oldest surviving patients with uncorrected tetralogy of Fallot (ToF) before succumbing with renal failure. Factors contributing to his longevity included small pulmonary arteries and presumed slow development of subpulmonary obstruction together with moderate concentric left ventricular hypertrophy-features previously seen in long term survivors. Less than 3% of all patients with uncorrected ToF survive beyond their 40s but late operative repair is still a valuable option. Practicalities of renal dialysis in the presence of an intracardiac shunt are considered.T etralogy of Fallot (ToF), first described in 1888, comprises an interventricular septal defect, right ventricular outflow tract obstruction, an overriding aorta, and right ventricular hypertrophy (RVH).1 It is the most common form of cyanotic congenital heart disease (10% of all cases).2 This case describes a man in his 73rd year who was one of the oldest surviving patients with an uncorrected ToF before succumbing with renal failure. We review the factors contributing to his longevity and consider whether surgery in his 66th year would have been appropriate. CASE PRESENTATIONThe patient, described as having a weak heart in childhood, never attended school or played sports. Diagnosis of ToF was not made until the age of 31 (1961) but he defaulted from further investigations. In 1996 (aged 66 years) he was reassessed while being investigated for proteinuria (urea = 5.7 mmol/l; Cr = 98 mmol/l). He was asymptomatic. He was mildly cyanosed and clubbed with pectus carinatum. Blood pressure was 140/80 mm Hg. He had an ejection systolic murmur in the pulmonary area. Echocardiography disclosed a subaortic VSD with a left to right shunt of 1.94 m/s, minimal aortic override (diameter 3.76 cm), small volume, hypertrophied well contracting LV, RVH, dilated RA, bicuspid pulmonary valve with a small pulmonary artery (1.4 cm), subpulmonary stenosis with an RVOT gradient of 112 mm Hg, and moderate PR. Electocardiography confirmed sinus rhythym, voltage criteria for RVH; RBBB with a QRS duration of 100 ms. Chest radiography showed a right aortic arch. Holter monitoring disclosed one asymptomatic 4 beat burst of SVT. Exercise testing terminated at four minutes because of fatigue (O 2 saturation fell from 91% to 80%). The decision was made for medical management rather than surgical correction in view of his advanced age, asymptomatic status, and personal wishes. At the age of 69 the patient complained of regular fast palpitations and associated dyspnoea. The echocardiogram showed severely hypertrophied and impaired RV function, huge RA (6.868.2 cm), normal LV dimensions with moderate concentric hypertrophy as before, and a dilated LA (5.82 cm). Creatinine was 118 mmol/l. He was treated with frusemide, spironolactone, amiodarone, and aspirin. His renal function deteriorated in his 72nd year (urea = 18.5 mmol/l; Cr = 174 mmol/l), and he needed thyroxine for amiodarone induced hypothyroidism. He was n...

growth excited by chrOnic irritation that may have been falsely diagnosed. Therefore the urologist must be cautious in his treatment unless the means are at hand to establish his convictions by the microscope.

Precise staging of malignant disease is required to define the optimum therapeutic strategy. In spite of technical advances, the sensitivity of conventional imaging techniques is usually limited to defining lesions of at least 1 cm in size. Laparoscopy is a sensitive technique that is very valuable for visual inspection of the abdominal cavity and the identification of small surface lesions. However, non-superficial lesions may escape detection due to the lack of tactile sensitivity. As an adjunct to laparoscopy, this study, utilizing a young swine model, has analyzed the detectability of intra-abdominal lymph nodes by laparoscopic ultrasound (LU). Lymph nodes in and around the hepatoduodenal ligament, examined and measured by LU, were resected by subsequent open laparotomy in eight young, mixed-breed swine. The numbers and sizes of lymph nodes detected by LU and resected at laparotomy were compared and analyzed statistically. Forty-six lymph nodes were resected by laparotomy, while LU failed to detect 3 small nodes (sensitivity, 43/46 = 93.5%). The sizes of lymph nodes in the LU group correlated strongly with the sizes actually measured in the laparotomy group (r = 0.936, P < 0.001). Twenty-six small lymph nodes, which conventional extracorporeal imaging might have failed to diagnose, were detected accurately by LU (r = 0.877, P < 0.001). This new technology may not only be effective for staging intra-abdominal malignant disease, but adds the benefit of obtaining tissue samples under direct vision using minimally invasive techniques.

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ENLARGEMENTS of the mesenteric lymph nodes have been observed for a long time, especially those due to tuberculosis; but surgical attention has only recently been directed to chronic non-specific hyperplasia-a common and definite condition deserving careful consideration. It is met with quite frequently in laparotomies upon children and especially young adults (about 13 per cent. according to Guleke,11) although found often enough in those of middle age. Most surgeons, however, are r-t familiar with it and seldom consider it, either before or during operations. Even when detected it is not often properly evaluated, although it may represent the only discoverable lesion.Probably the first papers dealing with the surgical aspects of the subject were written by Carson,6 although Wilensky 25 published a paper in I920 dealing with the acute, inflammatory form limited to the ileocaecal angle. Three forms of enlargement of the mesenteric glands may be recognized: (i) The chronic, hyperplastic, non-specific, non-inflammatory; (2) the acute and chronic inflammatory; and (3) the specific (tuberculous, etc.). Undoubtedly the whole question has been much obscured by confusing these 618