Resection of pulmonary metastatic choriocarcinoma in 43 drug-resistant patients

A regimen of multiple intermittent intensive doses of chemotherapy (chiefly 5-fluorouracil) was used in a series of 806 women with choriocarcinoma and malignant mole. The rate of complete remission of choriocarcinoma was 78.6%, and approximately 85% of the patients survived for more than 5 years. From 1962 through 1982, pulmonary metastatic choriocarcinoma was found to be resistant to chemotherapeutic agents in 43 of these patients; they subsequently underwent lung resection. There were no postoperative deaths, and the 5-year survival was 50%. These are relatively good results for patients with long-standing and widely disseminated choriocarcinoma. Human chorionic gonadotropin titer in urine and blood and variations of lung shadows are important criteria in selecting candidates for lung resection. For preservation of lung function, simple lobectomy is the first choice. Better long-term survival was obtained in patients who had a solitary lung lesion on admission without other major organ metastases and in those in whom the lung lesion was well encapsulated and became necrotic after chemotherapy.     

Bronchogenic carcinoma: a study of patients treated at Capital Hospital, Peking, China

From 1961 to 1972, 123 patients with lung cancer underwent operations at Capital Hospital, Peking, China. Ninety-six patients had resectable lesions and 27 did not, a resectability rate of 78%. Four patients (4.2%) died immediately postoperatively. Complications occurred in 8 (8.3%) patients. Five-year survival in this group of 92 survivors was 26 (28.3%). Ten-year survival among 49 patients was 10 (20.4%). Among the 92 five-year survivors, 41.2% had squamous cell carcinoma, 25% had adenocarcinoma, and 16% had undifferentiated carcinoma. Patients with squamous cell carcinoma had a much longer survival than the others. Six factors appear to influence survival after resection: cell type, presence of lymph node metastases, presence of tumor emboli in blood vessels, sex, age, and location. Men about 50 years of age, with a peripherally located squamous cell tumor and with no tumor emboli or lymph node metastases, have a good chance of surviving a pulmonary resection for ten years.     

Surgical Treatment of the Ruptured Aneurysm of the Aortic Sinuses

Over the past 11 years, 51 patients (36 male, 15 female) underwent operation to correct ruptured sinus of Valsalva at the Shanghai Chest Hospital. Associated lesions were present in 36 patients. All patients had cardiac enlargement, pulmonary plethora, and prominence of the main pulmonary arterial trunk. Preoperative arterial pressure averaged 135/46 mm Hg (range, 200–96/95–0 mm Hg).At operation the cardiac chamber into which the ruptured aneurysm emptied was opened. The projecting aneurysmal sac was resected at its base, leaving a fringe of 2 to 3 mm for suturing. A double-layer suture closure was used, first a row of figure-of-eight sutures, followed by a row of buttressed mattress sutures.Forty-five patients survived operation; 6 died shortly after operation, a perioperative mortality of 11.8%. Follow-up averaged 4 years 8 months. Thirty-eight patients were symptom free and working; 7 had returned to part-time work. There were no late deaths. A grade II systolic murmur persists in 2 patients, and in 1 of them a loud continuous murmur and thrill were both noted. All patients who survived have shown remarkable reduction in cardiothoracic ratio and improvement in symptoms. These results justify early surgical intervention.     

Chondroma of the Trachea: Report of a Case and Review of the Literature

Chondroma of the trachea is an extremely rare neoplasm. A patient is described who required surgical treatment for this abnormality on three separate occasions over a nineteen-year period. The last two instances represent either local recurrence or new primary growths. The most recent presentation was that of a very large mediastinal mass causing tracheal compression, dysphagia, and superior vena caval obstruction. The clinical and pathological features of chondromas of the tracheobronchial tree are discussed. Because of its recognized potential for local recurrence, a localized chondroma of the trachea is best managed by tracheal resection.     

Vascular injuries in electrical burns —the pathologic basis for mechanism of injury

These studies present a more complete picture of the pathological changes in injured arteries obtained from patients with electrical injuries affecting the upper extremity. The specific characteristics of vascular injury by electric current proceed from relatively mild to severe in the order of the intima, adventitia and whole-thickness. Vascular injury by electricity is a thermal process extending from the interior to the exterior.     

Early Removal of Double-J Stents Decreases Urinary Tract Infections in Living Donor Renal Transplantation: A Prospective,Randomized Clinical Trial

Background

The optimal timing for stent removal after renal transplantation remains controversial. This article describes an interim analysis of a randomized, prospective, double-blind trial aimed at detecting differences in urological complications between early ureteral stent removal at 1 week and routine ureteral stent removal at 4 weeks.

A Modified Sternal Retractor for Exposure of the Internal Mammary Artery

This report describes the use of a modified chest wall rake retractor used to provide better exposure of the internal mammary artery (IMA). The instrument is easy to use and has been associated with minimal complications. It facilitates the harvesting of the IMA for use in coronary artery bypass grafting and provides better visualization of the retrosternal area for control of hemostasis.     

Diaphragm Pacing in Infants and Children: Report of a Simplified Technique and Review of Experience

Diaphragm pacing was used for treating 6 infants with congenital hypoventilation syndrome at the Children's Memorial Hospital, Chicago. All patients had inadequate sleep-related ventilation and absent ventilatory response to hypercarbia.A single incision was utilized to implant both the electrode and receiver. The phrenic nerve was isolated with a piece of pericardium to minimize injury. All infants required bilateral nerve pacing to obtain satisfactory ventilation (normal transcutaneous measurements of partial pressure of oxygen and end-tidal pressure of carbon dioxide).The technical details described here are helpful in achieving successful phrenic nerve pacing in infants with results comparable to those reported in adults.     

Disadvantages of prostacyclin infusion during cardiopulmonary bypass: a double-blind study of 50 patients having coronary revascularization

Prostacyclin (PGI2) has been suggested for use in cardiopulmonary bypass (CPB) because of its positive effects on platelet number and function. Fifty patients who underwent coronary artery bypass grafting using a bubble oxygenator received heparin, 3 mg per kilogram of body weight, and then were randomly assigned to receive PGI2, 25 ng/kg/min, beginning 5 minutes before and until the end of CPB (26 patients) or a placebo (24 patients). Both groups were similar in sex, age, heparin dose, protamine dose, and CPB time. During CPB, mean arterial pressure fell significantly with PGI2 (76 +/- 2 mm Hg to 53 +/- 2 mm Hg; p less than 0.05) and necessitated pressor substances. Platelet counts fell significantly in both groups with the start of CPB, but after 60 minutes were similar in both groups (118 +/- 9 X 10(3) versus 130 +/- 8 X 10(3); not significant [NS]) and were unchanged 3 hours after CPB. Total chest tube output was 647 +/- 51 ml (placebo group) versus 576 +/- 34 ml (PGI2 group) (NS); 18 of the patients given PGI2 required 26 transfusions compared with 16 transfusions in 8 of the patients given a placebo (p less than 0.05). In PGI2 patients, arterial oxygen tension on 100% oxygen fell from 281 +/- 18 mm Hg before CPB to 223 +/- 17 mm Hg immediately after CPB (p less than 0.05). The placebo patients did not show a change in this variable.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preferential Atherosclerosis at the Aortic Junction of the Ligamentum Arteriosum: Clinical Significance and Pathological Correlation

Clinical experience with 5 patients who had complications of atherosclerosis within the aorta at the site of the obliterated ductus arteriosus suggested the occurrence of clinically significant preferential atherosclerosis at this location. To examine this hypothesis, the clinical findings in these patients (4 with saccular aneurysm and 1 with systemic emboli from an ulcerated plaque at this location) were correlated with postmortem examination of the aortic isthmus in 40 consecutive cadavers.The point of ductal closure was the area of most severe atheromatous involvement in 32 of the 40 cadavers, and 25 of the 40 specimens demonstrated ulcerated plaques at this location. Microscopical examination consistently demonstrated intimal irregularity or disruption and thinning of the aortic media in this area. These studies indicate that preferential atherosclerosis occurs at the aortic end of the obliterated ductus arteriosus and that these atherosclerotic changes can be a clinically significant development.     

Pulsatile Sternal Tumor: Report of Three Cases and a Review of the Literature

At our institution, 3 patients with pulsatile sternal tumor have been seen. Although ascending aortic aneurysm frequently is high on the list of differential diagnoses, the likelihood that this tumor is metastatic from either a primary renal or thyroid neoplasm is overwhelming. Of the 15 patients reported, 11 had metastases from a primary renal cell carcinoma, including all 3 of our patients. There were 2 patients with primary myeloma, the only histologically proved primary pulsatile sternal tumor.From the surgical standpoint, only the patient with metastatic renal cell carcinoma has a chance of cure. With the recent report of 2 5-year survivors and our own experience of 1 patient with a long asymptomatic interval following resection of the primary kidney tumor and the secondary sternal metastasis, the attitude of hopelessness for these patients should be challenged and an aggressive approach considered.     

Bacteremia after Esophageal Dilation: A Clinical and Experimental Study

Patients with esophageal stricture caused by caustic ingestion, reflux esophagitis, or esophageal anastomosis often require repeated dilation. These patients frequently have a short febrile course after dilation. After development of brain abscess following esophageal dilation in 1 patient, positive blood cultures were obtained in 4 patients immediately following esophageal dilation. Caustic strictures were produced in cats and esophageal dilations performed. Blood cultures were positive at one minute after dilation in 6 cats and at five minutes in 2 of those cats. The organism responsible in all clinical and three of four experimental examples was Staphylococcus aureus. It is suggested on the basis of this clinical and experimental data that patients undergoing esophageal dilation should have prophylactic coverage if they are immunosuppressed, if endocarditis prophylaxis is necessary, if they are infants, if they are diabetic, or if they had severe bacteremia following dilation.     

An Appraisal of Blood Trauma and the Blood-Prosthetic Interface during Left Ventricular Bypass in the Calf and Humans

Mechanical circulatory support was accomplished in 20 calves (mean, 140 days) and in 5 patients following operation for acquired heart disease (range, 1 hour to 8 days) employing a pneumatically actuated xenograft-valved assist pump interposed between the left ventricular apex and aorta.Following pump implantation in calves, hematocrit and platelets decreased transiently and returned to normal within 14 days. Plasma hemoglobin and erythrocyte mechanical fragility values were elevated for 48 hours. Platelet survival was slightly reduced, but erythrocyte survival values were similar to controls. In patients who received assist pumps, plasma hemoglobin and erythrocyte mechanical fragility were transiently elevated, but rapidly decreased to normal. Thrombocytopenia occurred only in the presence of bleeding and renal failure requiring hemodialysis. Pump flow of the left ventricular assist device was maintained above 2.0 L/min/m² despite serious arrhythmias. Postmortem examination revealed no evidence of thromboemboli in the clinical patients although anticoagulant agents were not administered.     

Determinants of Operative Survival Following Combined Mitral Valve Replacement and Coronary Revascularization

To determine the operative survival rate following combined mitral valve replacement (MVR) and coronary artery bypass graft (CABG) operation, we evaluated 100 patients, who were seen consecutively at the Peter Bent Brigham and Brigham and Women's Hospital from 1972 to 1981. There were 63 men and 37 women; the mean age was 62 years. Thirty-six patients were in New York Heart Association (NYHA) Functional Class III, and 64 were in Functional Class IV. Mitral regurgitation was predominant in 76 patients; mitral stenosis, in 24. Emergency operations were performed in 15 patients, and elective or semielective operations were performed in 85.There were 18 operative deaths (18%): 9 in patients having elective operations (10.5%) and 9 in those having emergency operations (60%; p < 0.01). Significant preoperative factors related to operative death were NYHA functional class, increased pulmonary vascular resistance, lower cardiac index, and lower ejection fraction in the nonsurvivors. The rate of survival did not differ according to sex, age, or degree of coronary artery disease. In addition, myocardial protection with potassium cardioplegia and complete coronary revascularization significantly reduced operative mortality in the elective group of patients but did not alter the mortality in the emergency group.     

Second primary bronchogenic carcinoma: life-table analysis of surgical treatment.

Twelve patients had curative resection of primary bronchogenic carcinoma. Eleven to 84 months later, a second primary bronchogenic carcinoma was discovered and was operated on. Six patients underwent wedge resection, while the others had a lobectomy or pneumonectomy. There was no operative mortality. Two patients survived longer than 5 years. In addition to these patients, 26 patients who also had successive surgical resections for primary lung cancers were collected from the literature. Two operative deaths were related to respiratory insufficiency. Life-table analysis of this accumulated series of 38 patients revealed the survival rate 1 year after the resection of a second tumor to be 70%, and 2 and 3 years later, 55% and 27%, respectively. Thus, in patients in whom a second primary carcinoma of the lung develops, successive resections tailored to preserve respiratory reserve are compatible with low operative mortality and, in some instances, long-term survival.     

Bronchogenic carcinoma with a brain metastasis: a continuing challenge.

Twenty-three patients with carcinoma of the lung and a brain metastasis had both the primary and secondary tumors surgically removed (combined operation). Results revealed that 52% of the patients were unimproved and died during the first 6 months. Operation improved short-term survival in 26%. Five patients (22%) lived longer than 2 years, and 3 of them (13%) are alive and well 10 or more years following operation.     

Reflux Control Following Extended Myotomy in Primary Disordered Motor Activity (Diffuse Spasm) of the Esophagus

We have previously reported the results of extended esophageal myotomy and Belsey hiatal hernia repair in 21 patients. Reflux was considered to be a late complication of this operation, and gastroplasty has subsequently been added.Thirty-four patients have now been surgically treated, 17 with myotomy and Belsey repair and 17 with myotomy, gastroplasty, and Belsey repair. Eight of the 17 with Belsey repair developed clinical and roentgenographic signs of reflux 6 to 27 months following operation without evidence of hernia recurrence; 5 of the 8 patients have required further operation, with the addition of gastroplasty for reflux control. Seventeen patients were treated primarily by extended myotomy, gastroplasty, and Belsey repair. None of the patients who underwent gastroplasty have reflux symptoms, and only 1 shows a trace of reflux radiologically.     

Pulsatile perfusion: its effects on blood flow distribution in hypertrophied hearts.

Left ventricular hypertrophy was created in 15 pigs by banding the ascending aorta when they were young. The adult animals were placed on normothermic cardiopulmonary bypass and perfused with either nonpulsatile (two groups of pigs) or pulsatile (one group) flows. As long as the perfusion rate was maintained at 70 ml/kg/min, myocardial blood flow distribution as determined by radioactive microspheres, was identical in the hearts with normal sinus rhythm and those with ventricular fibrillation irrespective of the type of perfusion. At low flow rates, however, subendocardial ischemia developed in all three groups, but was most severe in the fibrillating hearts, and was not reversed by pulsatile perfusion.     

Diffuse Spasm of the Esophagus

During the past ten years 7 men and 15 women with diffuse esophageal spasm have been seen at the Duke University Medical Center. Dysphagia and severe substernal pain were the two characteristic symptoms. Eleven of the 22 patients were treated with a long esophageal myotomy. Two had a diverticulum of the lower esophagus excised in addition, while 6 had an associated sliding hiatal hernia repaired. Three patients in whom the diagnosis was made retrospectively all had an epiphrenic diverticulum excised without a myotomy; in 1 an esophageal leak occurred. These 3 patients still have mild symptoms of their diffuse esophageal spasm.The results of myotomy have been satisfactory. Although this operation does not correct the cause of the disorder, the improvement in symptoms makes it worthwhile in selected patients.