Serosal onlay repair of common duct stricture

Repair of experimental stricture of the common bile duct was carried out by applying a patch of jejunal serosa to the reopened common bile duct. The method was successful in restoring patency of the biliary system. Liver function test results returned to normal limits postoperatively and deposition of periportal fibrous tissue did not progress. Histologic examination of the serosal patch repairs demonstrated regeneration of normal biliary epithelium over the serosa.     

Noncoronary Collateral Distribution in Coronary Artery Disease

Noncoronary collateral flow is a potential hazard when cold cardioplegia is used for myocardial protection. In this study, noncoronary collateral flow was observed during coronary revascularization in 58 patients. It was distributed significantly (p < 0.005) toward arteries demonstrating intercoronary collateral flow angiographically—10 of 35 with and 12 of 121 without. Preponderance of coronary collateral flow in hearts with more extensive disease may complicate cardioplegic myocardial protection for such patients.     

A method of outflow tract reconstruction in tetralogy of Fallot with anomalous anterior descending coronary artery.

An anomalous anterior descending coronary artery that arises from the right coronary and crosses the right ventricle outflow tract can compromise corrective operations for tetralogy of Fallot. The only safe method of outflow tract reconstruction reported until now is the use of a tubular graft from the right ventricle to the pulmonary artery. We report successful reconstruction of the outflow tract by placing a standard fabric path under the mobilized anomalous coronary artery. This technique should avoid the late complications of tubular conduits by preserving the natural posterior wall of the outflow tract for growth.     

Direct Ascending Aortic Insertion of the “Percutaneous” Intraaortic Balloon Catheter in the Open Chest: Advantages and Precautions

When intraoperative balloon pump support is needed for patients who cannot be weaned from cardiopulmonary bypass and when the balloon catheter will not pass retrograde into the aorta from the femoral artery, the catheter must be inserted into the ascending aorta directly. We have found that the new Datascope “percutaneous” balloon catheter offers many advantages for direct insertion into the ascending aorta, but certain precautions are necessary to prevent cerebral emboli when the percutaneous balloon catheter is used this way.     

Simplified insertion of left atrial pressure monitoring catheter

A simplified, safe, and reliable technique is described for intraoperative insertion of a left atrial monitoring catheter using modified, currently marketed plastic intravenous catheters.     

Ventricular venting during coronary revascularization: assessment of benefit by intraoperative ventricular function curves.

Although the physiological benefits of left ventricular venting during cardiopulmonary bypass have been documented experimentally, air embolus is still a concern clinically, and surgeons, therefore, continue to debate whether or not to vent routinely during coronary revascularization. In this study, 10 patients vented during revascularization and 10 not vented were studied immediately before and after cardiopulmonary bypass using Sarnoff ventricular function curves to assess changes in ventricular performance. Stroke work index by each patient before and after bypass was compared at common left atrial pressures and concomitant similar systemic resistances. In patients who were vented, there was overall no change in function (98 +/- 7% of control; range, 146--73%). In patients who were not vented, there was overall significant depression of function (67 +/- 5% of control; range, 91--45%, p less than 0.01). The overall absence of depression in patients who were vented, several of whom had very poor ventricles before bypass, strongly supports venting for coronary revascularization.     

Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch

Banked blood transfusion, with its attendant hazards, may be avoided in certain instances. A search for an acceptable plasma substitute was made. A randomized prospective trial of hydroxyethyl starch (HES) versus plasma for postoperative volume replacement is described. Ninety patients undergoing operations for coronary artery disease were studied over a six-month period. Ten received banked blood in the immediate postoperative period and were excluded from the study. The remaining 80 were randomized into two groups. Group 1 received plasma, and Group 2 received HES. All patients initially had autologous blood transfusion, and in 7 patients this sufficed; these patients were excluded from the study except for regression analysis. Postoperative blood loss and urine output did not differ between groups, but Group 2 patients required significantly more volume replacement (p less than 0.02). In a total of 27 patients drawn from both groups, coagulation factors and colloid osmotic pressure were investigated. There were no significant differences in fibrinogen titer and prothrombin time between groups, but return to normal values was significantly delayed in the HES group (p less than 0.01). Activated clotting time and partial thromboplastin time were unaffected. Colloid osmotic pressure was significantly higher at one week in the HES group (p less than 0.001) and was correlated with the volume of HES given (r = 0.525; p less than 0.01). There were no untoward effects attributable to HES. It is concluded that HES is a safe, cheap, and effective plasma substitute for volume replacement following cardiac surgical procedures.     

Technical considerations in saphenous vein bypass grafts to the right coronary artery.

Measurement of the proper length for saphenous vein bypass grafts to the right coronary artery can be complicated by the increase in cardiac volume that takes place when extracorporeal circulation is discontinued. Inadequate or excessive allowance for this increase can cause undue tension on the grafts or troublesome kinking. This report describes an improved method of orienting vein bypass grafts to the right coronary artery which eliminates problems of incorrect measurement.     

Noncardiogenic Pulmonary Edema and Peripheral Vascular Collapse Following Cardiopulmonary Bypass: Rare Protamine Reaction?

Four instances of severe anaphylactoid reaction occurring subsequent to cardiopulmonary bypass are described. These catastrophic reactions, from which 2 patients died, took place approximately an hour following administration of protamine and were characterized by marked peripheral vasodilatation, loss of capillary membrane integrity, and fulminant noncardiogenic pulmonary edema. Primary cardiac depression was not evident. We hypothesize that protamine was the causative agent in these unusually severe reactions. Differential diagnosis from other causes of acute cardiorespiratory dysfunction depended on early assessment of pulmonary artery and left ventricular filling pressures, cardiac output, respiratory mechanics, and arterial blood gases. Therapy was difficult; success in 1 of the patients seemed to have been effected in part by prompt administration of high-dose corticosteroids and maintenance of peripheral vascular tone with an alpha-adrenergic agonist.     

Management of sudden coronary death.

Twenty-three survivors of out-of-hospital sudden coronary death (SCD) have been followed subsequent to initial hospitalization, cardiac catheterization and coronary angiography, and ultimate coronary revascularization (11 patients) or medical treatment (12 patients). All were treated at the Milwaukee County Medical Center. History of previous myocardial infarction (10 patients) and predominance of triple coronary artery disease (20 patients) with associated ventricular dysfunction (21 patients) demonstrated advanced coronary disease in both groups. Selection for revascularization (mean, 3 grafts per patient) was not randomized, but was based on precarious coronary anatomy and was reinforced by post-SCD ventricular dysrhythmias and angina. During an average follow-up of 13 months, there were 2 perioperative surgical deaths (1 recurrent SCD) and 3 medical deaths (2 recurrent SCDs), giving a mortality rate of 22%. This is an improvement over reported post-SCD natural history and may support a policy of offering revascularization to all SCD patients who have precarious coronary anatomy.     

Fournier's syndrome: Synergistic gangrene of the scrotum

Progressive spread of necrosis in the skin and subcutaneous tissues of the scrotum is the key feature of idiopathic scrotal gangrene. The disease may present initially as an acute abdomen, but laparotomy should be avoided. Usually an anaerobic Streptococcus is found, acting in synergism with aerobic, frequently gram-negative, bacilli. As in other synergistic gangrenes, wide debridement with drainage of all sinus tracts is required.Although the testicles are frequently bared, they are usually not necrotic and should not be amputated. Once the infection has resolved, a surprising amount of skin coverage, including coverage of the testicles, can often be obtained from the scrotal remnants.     

Pancreaticogastrostomy:Clinical experience with a direct pancreatic-duct-to-gastric-mucosa anastomosis

The propensity for leakage and disruption at the site of the pancreaticojejunostomy is a major reason for morbidity and death after pancreaticoduodenal resection. Because it is less prone to leakage and disruption, pancreaticogastrostomy has been reintroduced as a possible alternative to pancreaticojejunostomy. Of four patients in whom the pancreas was simply implanted into the stomach and five patients in whom a direct pancreatic-duct-to-gastric-mucosa anastomosis was constructed, there was no morbidity or death related to the pancreatic anastomosis. Because of evidence that a direct pancreatic-duct-to-gastric-mucosa anastomosis has an increased incidence of patency and because it was successful in a clinical setting, it is recommended.     

The variability of estrogen receptors in metastatic breast cancer.

Estrogen receptor protein (ERP) concentrations were determined by the sucrose diffusion method in primary tumors and one or more metastases in twenty-nine patients with breast cancer. Concurrence of ERP concentrations between primaries and at least some metastases was found in 76 per cent of cases. Multiple metastases were assayed in ten cases, three of which demonstrated highly variable concentrations. It was concluded that clinically significant differences in ERP concentrations often exist between primary breast cancers and their metastases as well as between different metastases from the same tumor, accounting for the lack of responsiveness of some ERP-"positive" tumors and for mixed responses to hormonal or endocrine therapy. Assay of an isolated metastasis may be no more reliable in predicting overall patient benefit from therapy than assay of the primary itself.     

Glucagon,gastric inhibitory polypeptide and the gastrocolic response

Serosal bipolar electrodes and strain gauge force transducers were placed on the right and left colon in subhuman primates to record spike discharges and circular muscular contractions. The effect of glucagon on colonic motor and electrical activity were studied before and after meals. Serum concentration of gastric inhibitory polypeptide was measured simultaneously 15 minutes before and 45 minutes after eating. Serum levels of gastric inhibitory polypeptide increased in response to eating; pre- and postcibal concentrations were not altered by glucagon. The gastrocolic response of the colon to eating was demonstrated. Glucagon inhibited the intrinsic activity of the entire colon before meals and partly inhibited the right colon after meals. Postcibal left colon activity was not inhibited by glucagon. This indicates that a distinct mechanism accounts for the left colonic postcibal increase in contractile and electrical spike activity. A neural or humoral mechanism is implicated but is not specifically identified.