Management of the patient with emphysema,coronary artery disease,and lung cancer

Coronary artery disease, emphysema, and lung cancer often occur together and have cigarette smoking as a common etiologic contributor. The management of the patient with lung cancer, coronary artery disease, and emphysema is complex. The patient with significant coronary artery disease should undergo coronary artery bypass before or concurrently with pulmonary resection. Only proven carcinomas should be resected at the time of coronary artery bypass grafting because immunosuppression secondary to cardiopulmonary bypass can result in the life-threatening spread of fungal or other infections if biopsy is performed at the time of cardiopulmonary bypass. The risk of pulmonary resection is increased in the patient with emphysema because of decreased efficiency of the lungs and chest wall. Likewise, emphysema results in greater risk in the patient with coronary artery disease because of increased demands on the heart.     

The role of limited resection in carcinoma of the lung

Thirty years ago lobectomy was considered inadequate excision for carcinoma of the lung. In 1982 we are at the same point in comparing lobectomy with lesser resections. Limited pulmonary reserve and second carcinomas, as well as evidence of control by wedge and segmental resection, indicate that the need for lobectomy should be reappraised in carcinomas limited to smaller portions of the lungs.     

Should aortography be used routinely in the elective management of abdominal aortic aneurysm?

Until recently aortography was performed routinely for elective abdominal aortic aneurysm at our institution. A death resulting from this procedure prompted us to evaluate this policy by a retrospective study of 105 elective aneurysm patients. These studies identified 21 renal artery stenoses, 2 renal artery aneurysms, 2 cases of multiple renal arteries, 8 celiac stenoses, 6 superior mesenteric artery stenoses or occlusions, and a number of peripheral occlusive processes and associated iliac aneurysms. However, the impact of these findings on surgical management was limited to six renal artery reconstructions: one for reimplantation of a renal artery arising from the aneurysm, one for serious hypertension, and four in normotensive patients with severe arterial stenosis. No celiac or mesenteric reconstructions were undertaken, and no visceral complications ensued. In only one patient, the one with renal artery reimplantation, was the angiographic information unsuspected and significant for operative management. This did not appear to justify the risk and expense involved in routine preoperative aortography.     

Altered helper and suppressor lymphocyte populations in surgical patients: A measure of postoperative immunosuppression

Although a wealth of evidence has suggested that cell-mediated immunity is suppressed after simple surgical trauma, there have been contradictory results using stimulation assays of lymphocyte function. We quantitated T-lymphocyte subsets in 11 patients undergoing routine cholecystectomy by immunofluorescence microscopy using specific monoclonal antibodies. T-helper to T-suppressor cell ratios were calculated on the preoperative day and the first postoperative day in all patients, and on the third or fourth postoperative day in five patients. Helper to suppressor ratios decreased in all patients on the first postoperative day (p > 0.01), but returned to within normal limits on subsequent days. Changes were due more to decreases in helper cells than to increases in suppressor cells, although changes in both populations were statistically significant.The measurement of T-cell subsets by antibodyspecific labeling and immunofluorescence microscopy may prove to be a more sensitive, quantifiable, and reproducible assay of immune function in surgical or traumatized patients than use of stimulation assays. Measurements of specific helper and suppressor lymphocyte populations may prove useful in predicting morbidity and mortality, and may also help in studying the effect of immunomodulating agents on the immune response.     

Drainage of intraabdominal abscesses: Tactics and choices

The experience in treating 44 intraabdominal abscesses in 30 patients using percutaneous or surgical drainage was analyzed. Ultrasonography or computerized tomography-guided percutaneous drainage was highly satisfactory for the definitive treatment of single, accessible collections. Complex, multilocular, and phlegmonous lesions can also be treated by percutaneous drainage as a temporizing measure. Abscesses that are inaccessible, contain large amounts of necrotic material or are ill-defined, as well as those that have not responded to percutaneous drainage, require surgical exploration. Using these principles, there was only one death from sepsis in this series and three significant complications.     

Computed tomography in lung cancer

Computer-assisted tomography produces a cross-sectional image of the body using x-ray absorption measurements. Density differences are much more apparent than on conventional radiographs, although spatial resolution is not so fine. Lung cancer can be evaluated accurately with regard to size, location, and whether regional or mediastinal lymph nodes are enlarged. Although enlarged granulomatous nodes generally tend to be dense, histologic specificity is not available.Computed tomography is recommended as a screening technique in lung cancer staging for patients whose routine radiographs are normal but whose primary lesions fulfill criteria for mediastinoscopy. If findings on computed tomography are normal, thoracotomy should then be performed; if enlarged nodes are detected, then a biopsy is needed to exclude operability. This strategy presumes that computed tomography has high sensitivity, although it remains to be proven by further experience whether the false-negative rate of computed tomography is an acceptable 10 to 15 percent. Computed tomography has been shown to be of considerable value in optimizing radiation therapy of lung cancer, and in diagnosing pleural complications of the cancer or its treatment.     

An autopsy study of traumatic deaths: San Diego County, 1979

All traumatic deaths in San Diego County were analyzed for the year of 1979. Death certificates, coroner's reports, and autopsy data served as the basis for this review. A total of 177 deaths were studied, of which 94 were associated with CNS injury and 83 were not. Sixteen (20 percent) of the deaths not CNS-associated and four (5 percent) of the CNS-associated deaths were classified as preventable. One hundred seventeen deaths were due to motor vehicle accidents, of which 11 of 35 (31 percent; all not CNS-associated) were deemed preventable. Preventable causes of death included hemorrhage, unrecognized hemopneumothorax, and unrecognized epidural hematoma.     

Effect of thermal injury and subsequent therapy on serum protein concentrations

We have measured the quantities of serum IgG, IgA, IgM, complement C′3, and alpha₂ macroglobulin in 43 patients divided into four groups according to severity of injury and comorbidity factors. We have been careful to select patients not receiving drugs which are known to alter serum protein production. We have compared serum protein concentrations 1 day, and 1, 2, 3 and 4 weeks post burn with age- and sex-adjusted normal means, and correlated serum protein changes with the occurrence of serum immunosuppressive activity, as measured by the effect of serum additions on the PHA responses of normal human lymphocytes in vitro. In general, it appears that IgG and IgA concentrations are initially depressed followed by elevated quantities circulating 2–3 weeks post burn. IgM and C′3 concentrations were elevated throughout the period of study with no initial depression, while alpha₂ macroglobulin concentrations were depressed throughout the period of study. There was no correlation between the occurrence of serum mediated immunosuppression and serum protein concentrations. Significantly, Ig concentrations were found to be normal or supranormal at times of maximum serum suppressive activity. The implications of these changes in serum protein concentrations are discussed.     

Ultrasonic imaging of the carotid arterial system

The ability of a B-mode, real-time, high frequency ultrasonic imager to diagnose carotid arterial disease was evaluated in 81 carotid arteries. The imager was relatively sensitive in detecting the presence of significant stenosis but was relatively insensitive in its ability to quantitate the degree of stenosis. The imager was unable to detect the presence of ulcerations. The oculoplethysmograph had a greater sensitivity, specificity and accuracy than the ultrasonic imager in diagnosing carotid arterial stenosis in the same group of patients. Ultrasonic imaging appears to be useful as a screening test of cerebrovascular disease when used in combination with the oculoplethysmographic test.     

Technic of bilateral renal transplantation in the rat

A microvascular surgical technic applied to perfect bilateral renal transplantation in the rat is described. Utilizing segments of the donor aorta and inferior vena cava with the renal vessels, one is readily able to anastomose these vessels to the host's aorta and inferior vena cava. The bladder to bladder anastomosis is then performed. Multiple biopsies can be performed.     

Counterfeit cholecystitis, a common diagnostic dilemma.

Of 238 patients hospitalized with a diagnosis of acute cholecystitis, 20 per cent were ultimately found to have other conditions, namely, renal/ureteral problems most often, followed by diseases of the liver, pancreas, appendix, and thorax. Discriminant factors are discussed. Operations based on misdiagnoses occurred only in the patients undergoing early operation. Painstaking preoperative study and interval cholecystectomy, whenever possible, are recommended.     

Radiation therapy, local tumor control, and prognosis in bronchogenic carcinoma: current status and future prospects

While the overall prognosis for cure of bronchogenic carcinoma remains poor for most patients, there is a growing body of evidence suggesting that rationally optimized local therapy may benefit a significant subset of patients. Local therapy in this context includes any systemic therapy (such as chemotherapy or immunotherapy) that enhances local tumor control in the chest. Compared with many other human epithelial cancers, the total local tumor burden is large for many nonresectable lung cancers and not within the tolerance for control by radiation alone. Thus there is growing evidence that combined surgery and radiation treatment will improve results, especially in the differentiated tumors. Proper selection of patients is important and must include histologic stratification in addition to conventional TNM staging. It is projected that much useful research can be conducted during this decade using clinical tools now available and those that are being tested in early clinical trials throughout the world. Likely candidates for such improvements are both oxic and hypoxic radiosensitizing drugs that should decrease the death rate from uncontrolled local cancer in the chest.     

Changing patterns in the management of small bowel fistulas.

Forty-seven patients were treated for infraduodenal small bowel fistulas over the past nine years. Thirty-four of these fistulas occurred postoperatively; the others followed trauma or radiation or were secondary to inflammatory bowel disease. A progressive diminution of operative rates (to close fistulas) was evident in each of three three-year groups, from 59 to 38 to 24 per cent (p <0.05). Four deaths occurred from intercurrent complications in the two earlier time periods.Management of these fistulas has changed from a transient reliance on hyperalimentation to prepare patients for operation, to expectation of healing during hyperalimentation. Numerous advances have made this change possible: the availability of hyperalimentation solutions which do not require central venous lines; the development of elemental diets combined with the administration of these by long slim tubes distal to the fistula; and great advances in stoma care which have essentially eliminated skin complications. Equally important has been a growing understanding of the necessity for a clear-cut therapeutic plan; time goals regarding diminution of output, closure of fistula, and adequate oral intake must be defined in prospect and followed if success is to be maximized and morbidity minimized.Using these principles, the average time for which these patients required hospitalization was reduced from fifty-two days in the first three-year period to thirty-nine days in the last period, and nonoperative closure rates more than doubled.     

Diagnosis of acute cholecystitis using hepatobiliary scan with technetium-99m PIPIDA

Sixty patients were evaluated for acute abdominal pain using technetium-99m PIPIDA hepatobiliary imaging. The sensitivity of the test was 90.6 percent in all patients and the accuracy was 93.3 percent. In the evaluation of acutely ill patients with right upper quadrant pain, fever, nausea and vomiting, hepatobiliary imaging with PIPIDA is the preferred test for diagnosing acute cholecystitis. If the test is positive, disease of the gallbladder and probably acute cholecystitis are present. Early operation can proceed if desirable. If the test is negative and the bilirubin level is less than 5.0 mg/dl, acute cholecystitis is not present. In such cases conservative treatment is appropriate, and follow-up tests should be performed to evaluate the possibility of chronic cholecystitis. When the bilirubin level exceeds 5.0 mg/dl, the test is often indeterminate.