The effects of preoperative irradiation on primary tracheal anastomosis.

Preoperative radiotherapy was used in the management of selected patients with cancer of the lung or trachea who might subsequently require segmental resection of bronchus or trachea and reconstruction by primary anastomosis. This study was designed to determine the effects of varying dosages of preoperative irradiation on anastomotic healing. Two rings were resected from the cervical trachea of 20 dogs following irradiation with varying doses of cesium. There were no important adverse effects on healing of the trachea or adjacent organs in dogs receiving up to 3,500 rads. All dogs receiving a higher dose than this developed some anastomotic stenosis, which was severe in 6 of 8 animals. Similar adverse effects were observed in 2 patients managed by preoperative radiotherapy (4,000 rads in three weeks) and tracheal resection with primary anastomosis.     

Use of Mediastinoscopy in Selection of Patients for Lung Cancer Operations

We performed diagnostic pleuroscopy in 66 patients with pleural effusion and in 14 with pleural masses. The findings were diagnostic in 76 patients (95%). Pleural metastases were found in 63 patients, primary pleural or lung tumor in 5, and less common findings in the remainder. Only 1 minor complication occurred, and there were no deaths.Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 31 of 35 patients. Talc also was used with equal success and without complications in management of recurrent pneumothorax.We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure. It is simple and well tolerated, has a diagnostic yield of 95%, and is virtually free from complications. It provides the best way of insufflating talc for pleurodesis.     

Innominate Artery Rupture: A Major Complication of Tracheal Surgery

Innominate artery rupture is a life-threatening complication of tracheal reconstructive surgery. Early postoperative rupture of the innominate artery occurred in 8 of 100 consecutive patients undergoing tracheal resection and reconstruction (93, end-to-end anastomosis; 7, Marlex prosthesis). A premonitory transient hemoptysis occurred in 4 of the 8 patients. This sign may permit early diagnosis and effective treatment. When massive hemorrhage occurs, prompt arterial compression, control of the airway, and subsequent ligation of the artery may be lifesaving. Direct repair of the arterial defect is not recommended. If the innominate artery lies in direct contact with the suture line following primary anastomosis, soft tissue interposition is recommended.     

A Technique for Preclotting Vascular Grafts

Porous vascular grafts can be safely and securely sealed prior to use by a thirty-minute soak in cryoprecipitate followed by a ten-minute immersion in topical thrombin. This technique does not use the patient's blood and works in a patient fully anticoagulated with heparin. It has provided absolute graft competence in a series of 12 patients with valve conduits and 6 with patch enlargement of the ascending aorta.     

Criteria for operability and reduction of surgical mortality in patients with severe left ventricular ischemia and dysfunction.

A series of 188 patients who were operated on for left ventricular ischemia and dysfunction is presented. Angina was a prominent symptom in all patients, and a history of congestive heart failure could be elicited in 20%. Mean ejection fraction for the series was 0.35, with 67% having an ejection fraction of 0.35 or less 24%, 0.20 or less. Complete revascularization was accomplished whenever possible; more than 70% of the patients had triple-vessel disease, and single bypass was performed infrequently (5%). Factors thought to be important in achieving a low operative mortality (2.1%) were: precise prebypass monitoring, particularly with the V5 precordial lead; maintaining a low rate-pressure product (less than 12,000) prior to bypass; myocardial preservation with cold hyperkalemic or hyperkalemic-hyperosmolar solution; and careful titration of inotropic and vasodilator drugs. Inotropic drugs and intraaortic balloon pumping were used frequently in this series. The late mortality was 4.3%. Angina was completely relieved or improved in 94% of the patients. Those having a history of congestive heart failure had an increased late mortality rate, four times that of the entire series.     

Primary disordered motor activity of the esophagus (diffuse spasm). Diagnosis and treatment

Primary disordered motor activity (PDMA) of the esophagus is characterized by abnormal motor activity in the lower two-thirds of the esophagus. Twenty-one patients with this syndrome were studied by history, roentgenography, endoscopy, manometry, and at operation. The results of a new and more radical approach to esophageal myotomy are evaluated.Pain, dysphagia, and weight loss are characteristic of PDMA. Motor spasm is seen roentgenographically, the esophageal wall is thickened, and with longstanding disease a retention esophagus develops. Manometry showed a very severe motor disorder in the lower two-thirds of the esophagus. Postoperative manometric studies were of value in distinguishing PDMA from achalasia, as proximal esophageal peristalsis was more recognizable. At operation muscle hyperplasia and spasm were found. A myotomy from the stomach to 10 cm. above the aortic arch was done, and it was found necessary to add a Collis gastroplasty to control reflux. With this approach all patients have had relief of pain and dysphagia.     

Evolving Indications for Preoperative Intraaortic Balloon Pump Assistance

Over a two-year period about 1,000 operations were performed with cardiopulmonary bypass. Intraaortic balloon pump assistance (IABP) was employed on 150 occasions, and a review of these has permitted clarification of the indications for its use.Sixty patients had IABP for cardiogenic shock either after infarction or after cardiotomy, and 37 (62%) survived. Preoperative IABP in 90 high-risk patients resulted in survival for 79 (88%). The indications for prophylactic IABP included: (1) relief of severe pain, which occurred in 42 patients with acute coronary insufficiency, (2) improvement in the coronary perfusion pressure, which was accomplished in 20 patients with significant left main coronary artery occlusion or its equivalent, and (3) protection of left ventricular function, which was carried out in 28 patients with an LV ejection fraction of less than 0.40. The significance of the preoperative endocardial viability ratio (EVR) in relation to prophylactic IABP was also assessed: an EVR below 0.70 appears to be an indication for preoperative IABP.     

Giant left atrial V-waves in post-myocardial infarction ventricular septal defect.

A 54-year-old man developed a post-myocardial infarction ventricular septal defect with a 4:1 shunt. The first cardiac catheterization showed left atrial V-waves of 70 mm Hg. Assessment of the presence or absence of mitral regurgitation was not possible because of ventricular irritability and rapid runoff from left ventricle to right ventricle. At the second catheterization two months later, the left atrial V-waves had fallen to 34 mm Hg. The absence of mitral regurgitation was shown by observing the time difference in appearance of indocyanine green in the right ventricle and the left atrium after left ventricular injection. The defect was repaired by right ventriculotomy with subsequent normalization of left atrial V-waves. This case shows that very large left atrial V-waves may occur in postinfarction ventricular septal defects without mitral regurgitation and that these V-waves may decrease with time, probably reflecting increased left atrial compliance.     

The Value of Adjuvant Radiotherapy in Pulmonary and Chest Wall Resection for Bronchogenic Carcinoma

Thirty-five patients, 29 men and 6 women, underwent pulmonary and chest wall resection for treatment of bronchogenic cancer which had extended into the chest wall. Anterior chest wall resection was performed in 6 patients, lateral resection in 2, and posterior resection in 27. Marlex mesh was employed as a prosthetic material in 13 patients. Radiotherapy was given as part of the planned therapeutic regimen in 13 patients.Three patients (8.5%) died in the postoperative period. There were 21 late deaths. Eleven patients are alive 7 months to 12 years after resection. The overall actuarial survival, including operative mortality, is 38% at 5 years. Actuarial survival of the 13 irradiated patients is 56% at 2 and 5 years.We believe that bronchogenic carcinoma with chest wall involvement is not hopeless, and that resection of the lung and chest wall can be performed with an acceptable mortality rate.     

Subannular Mitral Prosthesis in Aortic Position

Björk-Shiley subannular mitral prostheses have been used in the aortic position in 36 patients with calcific aortic annulus. We believe that the flange in the sewing ring of these prostheses offers added protection against perivalvular leakage; over an 18-month period there have been no instances of periprosthetic leakage in these patients.     

Gastroesophageal Reflux: Medical and Surgical Management

The assessment of gastroesophageal reflux requires a carefully taken history and appropriate selection of the relevant diagnostic tests from among the many such tests available. Gastroesophageal reflux is generally produced by an imbalance between the intragastric pressure on the one hand and the degree of competence of the lower esophageal sphincter on the other. Medical management incorporates measures designed to promote gastric emptying, augment the resting tone of the lower esophageal sphincter, and favorably alter the nature of the refluxed material by dietary and pharmacological means.The surgical techniques commonly applied for the prevention of gastroesophageal reflux aim to restore an intraabdominal segment of esophagus and to augment sphincter competence by either a partial or complete fundoplication. Comparison of results obtained with various operations is difficult, as assessment is often imprecise, subjective, and partisan. Development of a uniform method of postoperative assessment, free from observer bias, would be a major advance.     

Pericardial Graft for Intraoperative Balloon Pump Insertion

A technique that permits rapid insertion of an intraaortic balloon pump to support patients who cannot be successfully weaned from cardiopulmonary bypass is described. A pericardial patch is obtained while the sternum is still open, and is sutured to a common femoral arteriotomy. A 6-0 Prolene mattress stitch is inserted at the heel and continued along the sides. The ends are tied at the toe, and the same suture is used to construct a tube of pericardium over the balloon catheter. A single heavy silk suture is placed around the pericardial graft to prevent bleeding.The technique helps prevent thrombus and avoids infectious complications. It reduces the incidence of vascular complications and makes use of the Fogarty catheter after balloon removal unnecessary. We have used the method in 9 patients since November, 1979, without problems.     

Critical analysis of pulse generator replacement

A review of 633 pacemaker pulse generator replacements performed over 5.7 years revealed that the average life of pacemakers replaced electively (29.1%) was 24.9 months, while that of failed pacemakers (54.7%) averaged 21.6 months. Asynchronous pacers (169) lasted a mean 25.0 months and 301 demand pacers, 21.4 months. The average longevity of all pacemakers removed for all reasons was 20.7 months.Examining the evolution from (1) no clinic to (2) a routine pacemaker clinic to (3) a Pacemaker Evaluation Center with telephone analysis and peripheral clinic network, it is demonstrated that although the use of a clinic alone improved mean pacer longevity from 18.4 to 22.9 months, the evaluation center with telephone surveillance produced the greatest longevity of pacemaker units (25 units removed for failure, mean life 26.4 months). The number of electrode-related problems decreased from 15.2% to 10.7%, and the average life of pacemakers removed for these reasons increased from 5.4 to 16.7 months. Infection and erosion were also encountered less frequently (11.6% to 5.0%), and implant duration was increased (7.1 to 16.1 months). Emergency admissions decreased from 55% in 1968 to 10% in 1973, and similarly, return of symptoms dropped from 66% to 27%.We have found that a pacemaker clinic that uses a team approach reduces patient risk, alters the pattern of morbidity, and prolongs pacer longevity. Telephone surveillance may offer the greatest potential for longer pacemaker life but has numerous practical implications regarding increasing cost, time, and personnel.     

Angina PectorisAngina Pectoris, Oglesby Paul M.D. (Ed.), Medcom, New York (1974), p. 135, $17.50

Twenty-eight patients underwent open lung biopsy on an emergency basis. The clinical course in each case was deteriorating rapidly, and all were in respiratory failure. The correct diagnosis was established in 96% of the biopsies (27 of the 28 patients). The clinical diagnosis prior to biopsy was in error or incomplete in 15 (55%) of the patients. Specific therapy was lifesaving in 12 of the 28 patients.The value of the procedure outweighed the complications. Thrombocytopenia and positive end-expiratory pressure ventilation were not contraindications to biopsy.     

Upper Extremity Gangrene: A Complication of Subclavian Artery Division

Gangrene of the upper extremity is a rare complication following subclavian artery ligation. Two case reports from the 23-year experience at the Hospital for Sick Children are presented. If gangrene is to be eliminated in such cases, early recognition of inadequate limb perfusion is mandatory. A suspicion of inadequate perfusion justifies heparin therapy, and prompt revascularization and fasciotomy must be considered.     

Correlation of the changes in diastolic myocardial tissue pressure and regional coronary blood flow in hemorrhagic and endotoxic shock

The changes in systemic hemodynamics, in diastolic myocardial tissue pressure (MTP), and in regional coronary blood flow were observed during two stages of hemorrhagic or endotoxic shock in 17 dogs. Nine dogs were subjected to hemorrhagic shock at a mean arterial pressure of 50 mm Hg for 45 min and at 33 mm Hg for a further 15 min. Eight dogs were subjected to endotoxic shock for 1 hr.Both hemorrhagic and endotoxic shock led to a reduction in the magnitude of the normal diastolic MTP gradient from epicardium to endocardium. They also led to a reduction in the proportion of the left ventricular myocardial flow going to the subendocardial region. These changes occurred at a constant heart rate.It is suggested that the change in regional diastolic MTP is an important contributing factor to the inadequate subendocardial perfusion which can occur in both hemorrhagic and endotoxic shock.     

Aspiration Needle Biopsy of Thoracic Lesions

We reviewed our experience with 2,114 percutaneous aspiration needle biopsies of intrathoracic lesions. Aspiration was performed for cytological diagnosis employing biplane fluoroscopy and a 20 gauge needle, 0.9 mm in outside diameter. A satisfactory specimen was obtained in 88% of biopsies, and the chance of obtaining a correct diagnosis of a malignant lesion was 81.5%. The false positive rate was 2.2%, and the cytologists could always distinguish between primary and secondary neoplasms. A false negative rate of 13.6% (36 patients) resulted in only three delayed thoracotomies and two instances of interval metastases discovered at mediastinoscopy. Cellular specificity in primary tumors was not sufficiently accurate to affect therapy. Pneumothoraces occurred frequently (31.9% of patients) but were generally small; 10.4% of patients required chest drainage. There were no recorded instances of tumor implantation in needle tracts. We conclude that a rapid and accurate diagnosis of intrathoracic pathology can be obtained by this technique. It is associated with an acceptable morbidity and may greatly expedite both patient care and investigation.     

Supradiaphragmatic Ligation of the Thoracic Duct in Intractable Chylous Fistula

Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml.Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation.High-output thoracic duct fistulas may be handled by supradiaphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.     

A comparison of nitroglycerin and nitroprusside: I. Treatment of postoperative hypertension

Nitroglycerin improves perfusion to ischemic myocardial regions and therefore has theoretical advantages over sodium nitroprusside to treat hypertension (mean arterial pressure [MAP] greater than 95 mm Hg) following coronary bypass operation. Thirty-three hypertensive patients were randomized to an initial infusion of either nitroglycerin or nitroprusside in a crossover trial designed to reduce MAP to 85 mm Hg. Thermodilution cardiac output measurements permitted calculation of left ventricular stroke work index (LVSWI), and nuclear ventriculograms permitted estimation of left ventricular ejection fraction, left ventricular end-diastolic volume index (LVEDVI), and left ventricular end-systolic volume index (LVESVI). Coronary sinus blood flow was measured by the continuous thermodilution technique, and arterial and coronary sinus lactate measurements permitted calculation of myocardial lactate flux (MVL). Both nitroglycerin and nitroprusside reduced MAP (-25 +/- 12 mm Hg and -20 +/- 10 mm Hg, respectively; not significant [NS]). Nitroglycerin reduced LVSWI more than did nitroprusside (-15 +/- 13 gm-m/m2 and -7 +/- 9 gm-m/m2, respectively; p less than 0.01). Both agents increased left ventricular ejection fraction (nitroglycerin, +8 +/- 8%, and nitroprusside, +10 +/- 7%; NS), and decreased LVEDVI (-20 +/- 22 ml/m2 and -11 +/- 17 ml/m2, respectively; NS) and LVESVI (-13 +/- 14 ml/m2 and -10 +/- 12 ml/m2, respectively; NS). Coronary sinus blood flow decreased with both drugs (NS), but MVL increased with nitroglycerin (+0.02 +/- 0.14 mmol/min) and decreased with nitroprusside (-0.02 +/- 0.02 mmol/min) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison of nitroglycerin and nitroprusside: II. The effects of volume loading

The treatment of postoperative hypertension with nitroglycerin or nitroprusside reduces cardiac filling, and volume loading is required to maintain hemodynamic and metabolic stability. Postoperative hypertension (mean arterial pressure greater than 95 mm Hg) developed in 33 patients who were randomized to an initial infusion of nitroglycerin or nitroprusside in a crossover trial. Volume loading (a rapid infusion of 250 to 500 ml of colloid to raise the left atrial pressure 2 to 4 mm Hg) was instituted prior to hypertension and again following the crossover trial during the infusion of nitroglycerin (11 patients) and nitroprusside (13 patients). Volume loading increased left ventricular end-diastolic volume index (LVEDVI) as documented by nuclear ventriculography, cardiac index (CI), and left ventricular stroke work index (LVSWI). Although CI was higher (p less than 0.01) with nitroprusside at any level of LVEDVI, myocardial performance (the relation between LVSWI and LVEDVI) was not different. Diastolic compliance (the relation between left atrial pressure and LVEDVI) was increased (p less than 0.01) with nitroglycerin. Myocardial metabolism was assessed by calculating myocardial lactate flux (MVL), the product of myocardial lactate extraction and coronary sinus blood flow by the thermodilution technique. Volume loading increased MVL during nitroglycerin therapy and decreased (p less than 0.01) MVL during nitroprusside therapy. Volume loading restored preload and increased CI with both nitroglycerin and nitroprusside. Only nitroglycerin improved myocardial lactate utilization. Nitroglycerin is the preferred vasodilator when ischemia is suspected after coronary bypass operations.