Management of aortocaval fistula due to abdominal aortic aneurysm.

Anasarca and intractable congestive heart failure were the presenting signs of an abdominal aortic aneurysm with aortocaval fistula. Management with careful monitoring of cardiovascular function using a Swan-Ganz catheter before, during, and after surgery resulted in an uneventful recovery.     

Long-term survival of patients with multiple myeloma and acute renal failure at presentation

Eight patients presented with simultaneous multiple myeloma and acute renal failure requiring hemodialysis. Patients had no known pre-existing renal disease nor exposure to nephrotoxic agents or x-ray contrast dye. Renal failure was attributed to light chain nephropathy in all cases. In 4 of these patients the diagnosis of myeloma was initially unsuspected. Renal biopsies in 3 of these patients, and post-mortem material in a fourth revealed the changes of "myeloma kidney." No patient regained renal function and all required chronic hemodialysis. Among these eight patients, three survived for periods greater than 21 months.     

Facilitation of exchange transfusions with Scribner shunts in Reye's syndrome

Scribner shunts were placed in nine patients, who had clinical and laboratory evidence of Reye's syndrome and ranged in age from four to fifteen years, to facilitate repeated, rapid exchanges of large volumes of blood. A method of inserting the Scribner shunt is described. Over a period of 30 to 90 minutes, 3 to 8 units of blood were easily exchanged without hemodynamic or mechanical difficulties. There were no infections; all shunts were removed from survivors after four to eight days without permanent sequelae.     

Results of complete repair of tetralogy of Fallot in 156 consecutive patients.

Between 1958 and 1974 156 patients underwent repair of tetralogy of Fallot, with a 6 per cent mortality since 1969. Our experience indicates that Waterston shunts should be reserved for infants less than four months of age, Blalock-Taussig shunts should be used in patients from four months to three years of age, and correction should be carried out in patients older than three years.     

Neoadjuvant Treatment Is Associated With Superior Outcomes in T4 Lung Cancers With Local Extension

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Symptomatic histoplasmosis in children

Symptomatic histoplasmosis in children is rare and presents difficulties both in differentiation from neoplasm and in the mode of therapy. Thirty-two children with an average age of 8.3 years were studied over a 10-year period for this disease. The most frequent symptoms were chronic fever (25 of the 32 patients), malaise (18 patients), significant weight loss (9 patients), and chest pain (6 patients). While physical evidence of a pneumonic process was present in 11 children, 19 had lymphadenopathy and 10 had hepatic or splenic enlargement or both. Chest roentgenograms demonstrated noncalcified masses and infiltrates in 29 children. Nine patients required operation, primarily for a presumptive diagnosis of neoplasm, including six thoracotomies, one liver abscess drainage, and two pericardiectomies. No operative deaths or morbidity occurred. Six children suffered significant morbidity from the disease.Unlike the chronic process in adults, histoplasmosis in children may strongly mimic neoplasm. Skin and serological testing, while beneficial, are of limited usefulness in endemic regions. Operative intervention is justified when careful patient evaluation cannot confirm the diagnosis.     

The free internal mammary artery bypass graft. Use of the IMA in the aorta-to-coronary artery position

Transposition of the internal mammary artery (IMA) into the aorta-to-coronary artery position is described, and 4 patients who underwent this operation are reported. Currently, this type of bypass graft is reserved for those patients who have unsuitable or stripped saphenous veins. The free IMA grafts can be connected to any of the major coronary vessels, and in most instances optical assistance is not necessary. There was no significant difference in recorded blood flow between these free grafts and a large group of in situ IMA-to-coronary artery bypass grafts.     

A metal ring marker for the proximal end of an aorta-to-coronary artery graft

A metal ring encircling an aorta-to-coronary artery saphenous vein graft can facilitate the assessment of graft patency at postoperative cardiac catheterization.     

Internal mammary--coronary artery anastomosis. "No-touch" technique.

A simple technique for internal mammary--coronary artery anastomosis that can be applied to all branches of the coronary circulation is described. The anastomosis can be constructed in 10 to 15 minutes. This technique eliminates pinching of the internal mammary artery by forceps.     

Surgical therapy for venous stasis: results of a modified Linton operation.

Bipedicled flaps in the natural skin lines permit ligation of offending perforating and communicating veins of the postphlebitic leg with stasis change. This technic affords safer immediate postoperative healing and durable long-term results. The indications for operation have been extended to include more elderly patients as well as selected patients with ulcerations due to combined venous stasis and arterial insufficiency.     

Treatment of carcinoma of the esophagus and gastric cardia with concentrated preoperative irradiation followed by early operation. A progress report

Our experience in treating carcinoma of the esophagus and cardia of the stomach with a concentrated, abbreviated course of irradiation followed by early operation is reported. The treatment protocol consists of three consecutive 800 R cobalt 60 teletherapy treatments on successive days followed by esophagogastric resection in ten to fourteen days. This treatment was used routinely in 70 consecutive patients seen between 1964 and 1971. Seven patients are living; 5 have survived more than two years postoperatively. These 5 patients all had unusually favorable tumors with no involved lymph nodes found in the resected specimen. Since the only good results occurred in unusually favorable cases, it is difficult to substantiate significant benefit from the addition of this form of radiation therapy to surgical treatment. The routine use of preoperative irradiation has been discontinued.     

Myocardial performance in clinical septic shock: Effects of isoproterenol and glucose potassium insulin

Six patients with low-output septic shock were studied with Swan-Ganz pulmonary artery catheterization. The results indicate severe biventricular dysfunction. Inotropic therapy with isoproterenol produced improved ventricular performance but did not correct myocardial depression. Infusion of glucose/potassium/insulin dramatically improved myocardial performance and appeared to correct the myocardial abnormalities of low-output septic shock.     

Notice from The Society of Thoracic Surgeons

In a retrospective study, the serial electrocardiograms of all patients with surgically induced right bundle-branch block (RBBB) were reviewed. None of these patients had had RBBB prior to operation. Seven patients who had RBBB from 6 to 16 days after operation showed resolution in ECGs done 3 to 8 months later. Two patients are reported, with documentation by vectorcardiogram, in whom RBBB resolved by 3 and 12 years after operation. The origin of transient forms of RBBB may be different from the long-standing form. If RBBB of long duration is due to operative injury to the proximal right bundle, Purkinje fiber network, or distal branch or branches of the right bundle, or to combinations of these tracts, one may speculate about the possibility of regeneration of the right ventricular conduction system. Since no data are available concerning the long-term prognosis of RBBB and since a progressive conduction disturbance can occur, the resolution of RBBB after many years might carry a better prognosis than its persistence.     

Effect of excess iodine on thyroid and liver lysosomal enzymes

The lysosomal enzymes, cathepsin D and β-glucuronidase, were measured in subcellular fractions of rat thyroid and liver tissue after the rats were subjected to 3 days of excess iodine administration. Excess iodine resulted in a statistically significant reduction in the activity of both of these thyroid tissue lysosomal enzymes, as well as a redistribution of enzyme activity. The latency of isolated intact lysosomes from excess iodine-treated rats was also compared to that of lysosomes from untreated rats and those administered pharmacological doses of methylprednisolone. Lysosomal stabilization occurred in the methylprednisolone-treated rats, but not in those which received excess iodine. In addition, excess iodine was found to be organ specific in that it did not significantly change liver lysosomal enzyme activity or stabilize isolated liver lysosomes. Our data support the hypothesis that excess iodine may decrease thyroglobulin hydrolysis by reducing available lysosomal proteolytic enzymes. Iodine does not function by the mechanism of lysosomal membrane stabilization.     

Experimental hyperbilirubinemia: effect on glomerular filtration

The hyperbilirubinemia state, as shown in a canine shunt model producing bilirubin levels comparable to those high levels seen in clinical practice, was associated with a 54% decrease in renal creatinine clearance. The amount of deterioration in glomerular function was proportional to the extent of hyperbilirubinemia obtained. Plasma volume in the jaundiced animal was decreased 21% from control values. Decreased renal perfusion may have been responsible for the descreased glomerular filtration rate observed.