Simple method of elongating a colonic segment for esophageal replacement

Occasionally the surgeon is confronted with a major problem that can be solved easily if he has been alerted to an applicable and simple maneuver. Several years ago Najafi and Beattie¹ employed such a maneuver in elongating a piece of colon to bridge a gap in an adult with extensive stricture of the esophagus. Although their technique would not seem feasible with the colon of an infant, they did call attention to the fact that the teniae coli, rather than the blood supply, limited the stretching of the colonic segment. It is this point that deserves emphasis and justifies the following report.     

Corrected transposition. Surgical treatment of associated anomalies

From 1958 through September, 1972, 25 Mayo Clinic patients underwent repair or palliation of one or more cardiac anomalies associated with corrected transposition. Their ages ranged from 7 months to 45 years (median 5 years). The most common associated anomalies were ventricular septal defect and insufficiency of the systemic atrioventricular valve. Four patients underwent cardiac operations without the use of extracorporeal circulation, and the anomalies in the remaining 21 patients were repaired by open-heart surgery. There were 11 deaths within 30 days after operation and 2 late deaths. Approximately half of the patients are alive with a satisfactory late result at the time of this report. Anatomical and technical considerations in the repair of anomalies associated with corrected transposition are discussed.     

Anesthesia for Prolonged Bronchoscopy

At the Mayo Clinic, experience with 22 patients undergoing bronchoscopy on 29 occasions has shown that prolonged operative manipulation in the airway can be carried out safely and satisfactorily using general anesthesia. Requisites for this procedure include a period of apneic oxygenation, an adequate-sized endotracheal tube, hyperventilation of the patient during operative manipulation, and careful attention to management of postoperative bronchospasm. Prolonged bronchoscopy under general anesthesia has permitted localization of occult bronchogenic carcinoma at an earlier stage than has been possible up to this point.     

Open-heart surgery in patients more than 65 years old

At the Mayo Clinic from 1968 to 1973, 305 open-heart operations were performed on patients more than 65 years old. The overall operative mortality rate was 15.7%. Of the various types of operations, aortic valve replacement was associated with a mortality of 10.6%; mitral valve replacement, 20.0%; multiple valve replacements, 42.4%; coronary artery grafting, 3.7%; coronary grafting plus valve replacement, 23.1%; and miscellaneous procedures, 8.3%. Advanced disease, inability to achieve good coronary perfusion during operation, intraoperative ventricular fibrillation, postoperative myocardial infarction, and low cardiac output were factors in mortality. Open-heart operations can be done in patients more than 65 years old with an acceptable operative mortality.     

An expanded indication for coronary surgery

In the first 48 hours following open-heart operation, 33 patients in rotation had an infusion of (1) 2 liters of 10% glucose in water, 80 units of regular insulin, and 160 mEq of potassium (GIK), (2) the same solution without insulin (GK), or (3) 5% glucose in water (a control group). The three groups were matched: in each, 8 patients had Functional Class III or IV disease by New York Heart Association criteria, and 8 had valves replaced. Anesthesia and perfusion techniques and supportive care before and after operation were identical in all groups. During infusion, mean arterial levels of the following were significantly lower in the GIK group than in the two other groups: osmolality, sodium, glucose, lactate, fatty acids, and total ketone bodies. Arterial oxygenation, acid-base balance, and pyruvate, growth hormone, calcium, and insulin levels did not differ among groups. Mean plasma potassium levels were the same during infusion in all groups, but 1 patient in the GIK group, 4 in the GK group, and 4 in the control group had ventricular arrhythmias requiring treatment. The only death was in the GK group. For patients with Functional Class III or IV disease, cardiac output (left atrial-to-thoracic aorta dye curve) was significantly higher both days in the GIK group than in the other groups. The GIK solution promoted aerobic carbohydrate metabolism over lipid metabolism, more hemodilution, and better cardiac output than did GK. The GIK solution may be effective in controlling ventricular hyperirritability.     

Reoperation after insertion of aortic homograft as a right ventricular outflow tract

Three patients who developed pseudoaneurysm or stenosis of the right ventricular outflow tract after insertion of an aortic homograft between the right ventricle and the pulmonary artery presented the technical problems at reoperation of intimate adherence of the homograft to the sternum. Successful replacement of the defective aortic homograft was accomplished by sequentially employing peripheral venous and arterial cannulation, heart-lung bypass, hypothermia, circulatory arrest, sternotomy, right atrial cannulation, and resumption of bypass.     

"Benign" giant cell tumor of bone metastasizing to lung

A case of “benign” metastasizing giant cell tumor is presented. Previous experience shows that this is a relatively favorable lesion not having the grave implications of sarcomatous disease, as evidenced by the good long-term results in our previously reported patient [14] and a number of others reported in the literature. An aggressive surgical approach to pulmonary metastasis of giant cell tumors is warranted because long-term control, if not permanent eradication, can be accomplished by that means.     

Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders

Traumatic subluxation and dislocation of the extensor digitorum tendons are uncommon in patients without rheumatoid disorders. Management of the acute injury is not well defined in the orthopedic literature. Two cases of traumatic dislocations of the extensor digitorum tendon were seen acutely in young persons without rheumatoid disease. These patients were successfully managed by early closed reduction and immobilization. This treatment had yielded good hand function to date, without recurrence of the dislocation. One of these cases was particularly unusual in that the direction of the tendon dislocation was radial. This particular injury has not been previously described.     

Bilateral teratoma of testis in an infant

Germ-cell tumors, which comprise more than 95% of testicular tumors, have an incidence of three per 100,000 of the male population.¹ These tumors are rare in infancy and childhood; they account for less than 5% of testicular tumors.^2,3 Nevertheless, among malignant diseases of pediatric patients, they rank seventh in frequency,⁴ with most occurring during the first 4 yr of life.²About 30% of the testicular tumors of germinal origin found in the prepubertal period are teratomas, which occur slightly less frequently than do embryonal carcinomas or orchioblastomas.⁵ In 1957, Phelan et al.⁶ reviewed 464 childhood testicular tumors reported between 1923 and 1955 and found 48 teratomas; none were bilateral. Since then an additional 60 childhood teratomas have been described. Houser et al.⁵ tabulated 14 of these; the remaining cases, with various degrees of documentation, are listed in Table 1. In only one case was the teratoma bilateral, but no details were provided.²The purpose of this report is to document a second case of bilateral testicular teratoma in a prepubertal child and to discuss the therapeutic problem posed by this rare situation.     

Reconstructive surgery of roller injuries of the hand.

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.     

Ventricular septal defect and aortic insufficiency: surgical considerations and results of operation

Ventricular septal defect (VSD) is uncommonly associated with valvular aortic insufficiency (AI). From 1957 through 1971, 51 patients with this combination underwent operation at the Mayo Clinic; these patients made up 2.2% of all patients with VSD repaired during that period. The most frequent aortic valve abnormality was a prolapsing right cusp. Surgical management of AI consisted of: (1) no procedure on the aortic valve in 25 patients, (2) plastic repair of the aortic valve in 13 patients, and (3) partial or total replacement of the aortic valve in 13 patients; in the group with severe AI prior to operation, those treated by replacement did better than those treated by repair. Early closure is indicated for VSD associated with mild AI. With severe AI, VSD closure and valve plication are preferred, although valve replacement may be necessary either at the primary operation or at some future date. In adults, replacement with a prosthesis is indicated for severe AI.     

Opposition of the thumb: an anatomic and biomechanical study of tendon transfers

Tendon transfers for opposition of the thumb were anatomically and biomechanically studied to help determine the optimal criteria for selecting the best motor unit for a transfer. Forearm and hand muscle volume, mean fiber length, and cross-sectional area were measured in eight fresh specimens of the upper extremity to determine which muscles best replace lost thenar muscle strength. In a separate group of 18 specimens, the effective moment arms for abduction and flexion of the first metacarpal were calculated in vitro and from biplanar radiographic techniques to determine the effect of eight different opposition transfers on thumb abduction, rotation, and strength. Results of these studies demonstrate that the transfers of flexor digitorum superficialis (FDS) of the long finger and extensor carpi ulnaris best replaced lost thenar muscle strength and provided maximal abduction and near full thumb rotation. The transfers of the extensor carpi radialis longus and the FDS of the ring finger replaced 60% and 40% of required thenar muscle strength, respectively. The palmaris longus was the least effective transfer, having good abduction but weak flexion and opposition. Motion, balance, and strength of tendon transfers must be considered for effective thumb opposition.