Blood loss and factors affecting pulmonary antibacterial defenses

Since impaired intrapulmonary bacterial inactivation of staphylococcus aureus has been described in rats during the first 15 hr after blood loss, the effect of phlebotomy on several factors known to influence host responses to bacteria in the lung were studied.Significant hypotension was present during the first hour after phlebotomy, but arterial pressure was normal during the next 14 hr. Respiratory alkalosis was present at one, but not at 4 or 15 hr after blood loss. Fractional lung water content was increased at both 4 and 15 hr. Alveolar bubble stability was depressed at both 4 and 15 hr. Phlebotomy had no effect on the alveolar macrophage when it was studied in vitro. Sham and experimental rats had similar number, cell viability, oxygen consumption and enzyme content of recovered macrophages at 4 and 15 hr.Since in vitro studies have demonstrated the need of normal surfactant fraction for maximal bactericidal activity of the alveolar macrophage, the abnormal surface lining material with blood loss may have contributed to impaired in vivo host defenses. Study of humoral and immunological influences on the alveolar macrophage after blood loss is needed to further evaluate mechanisms of intrapulmonary bacterial inactivation.     

Multiple circumscribed pulmonary hematomas masquerading as metastatic carcinoma

A 23-year-old patient presented with multiple circumscribed pulmonary densities two months following a motorcycle accident. A history of mediastinal irradiation as an infant and a thyroid lobectomy for adenoma when a teenager reinforced an initial diagnostic impression of metastatic carcinoma. The clinical picture was further clouded by the obvious nonunion of a clavicular fracture, giving the impression of a metastatic deposit. Ultimately, when all other diagnostic studies had failed, an exploratory thoracotomy revealed multiple pulmonary hematomas which have since regressed.     

Bypass grafts for recurrent or complex coarctations of the aorta.

Twenty-three patients aged 5 to 53 years with recurrent or complex coarctations of the aorta were successfully operated upon using bypass grafts. This technique of repair was selected for 5 patients with recurrent coarctation, 11 with long-segment coarctation with or without hypoplasia of the transverse aortic arch, and 7 with inadequate collateral circulation. Nineteen patients had bypass grafts from the left subclavian artery to the distal descending thoracic aorta. The other 4 had a combined approach through a left thoractomy and median sternotomy with grafts between the ascending and descending thoracic aorta. All patients survived the operative procedure. One patient were reexplored for a hemothorax and 5 developed transient postoperative hypertension. There were no instances of abdominal vasculitis or lower extremity paralysis. These patients have been followed from 3 months to 11 years postoperatively, and all but 1 are alive and well. Twenty-two are normotensive, and none have the sequelae of hypertensive disease. Gradients up to only 15 mm Hg exist between upper and lower extremity blood pressures. Five patients have undergone postoperative catheterization and aortography, and all have patent grafts. This procedure is a useful and adjunct in difficult coarctations of the aorta and can be safely performed with excellent reproducible long-term results.     

Peroral esophageal intubation for obstructive carcinoma of the esophagus

Seventeen patients with advanced obstructive carcinoma of the esophagus were treated by peroral esophageal dilation and intubation using a latex tube reinforced with a stainless-steel coil (Haering tube). The procedure has produced excellent benefits in this debilitated group of patients in the terminal stages of disease.All 17 patients had dysphagia, which was relieved in 13 after intubation. Twelve of these 13 patients had aspiration pneumonitis that promptly resolved. In 2 cases, patients previously debilitated from obstructive carcinoma of the esophagus improved so significantly following Haering tube insertion that a subsequent curative resection was performed.No death was attributed directly to the operative procedure. One patient died from a myocardial infarction 24 hours after operation, however. The only perforation occurred during dilation of a gastric carcinoma invading the esophagus. This was treated by plication, and recovery was uneventful. In no instance was there late tube migration, perforation, or hemorrhage. The average period of survival following placement of a Haering tube was 5½ months; during this time all patients who had had successful tube placement were able to eat solid foods. One patient with a tracheoesophageal fistula and aspiration pneumonia survived 4 months following occlusion of the fistula by a Haering tube.     

Pulmonary Artery Pressure and Lung Water During Extracorporeal Circulation in Experimental Pulmonary Insufficiency

Use of the membrane oxygenator has been advocated in the management of severe respiratory insufficiency. We have compared this method to conventional therapy in an experimental model in which 23 dogs were subjected to aspiration with 0.1 N HCl and 18 were supported with a volume respirator and positive end-expiratory pressure or placed on partial bypass using a membrane oxygenator for 12 to 24 hours. Adequate oxygenation (PO₂ > 100 mm Hg) was achieved with the membrane oxygenator. The increase in lung weight during conventional therapy was significantly greater than during membrane oxygenator support.Extracorporeal support during recovery from severe pulmonary injury allows pulmonary artery pressure to be controlled and reduces the expected increase in lung water.     

Interstitial irradiation for unresectable carcinoma of the lung.

From 1963 to 1971, 105 patients with histologically proved cancer of the lung were explored at Memorial Hospital and underwent interstitial implantation using encapsulated sources of radon 222 (53 patients) or iodine 125 (52 patients). These lung cancers were considered unresectable because of extension of the disease into the mediastinum with fixation or invasion of the major vessels, trachea, and esophagus or chest wall involvement. No apical lesions, which have a better prognosis, are included in this review. Sixty-nine patients had epidermoid cancer, 24 had adenocarcinoma, and the remaining 12 had various other histological types. All patients were staged according to the criteria proposed by the American Joint Committee using the TNM definitions (standing for tumor, nodes, and metastasis). Local control was obtained in 8 of 10 patients (80% with clinical Stage I and II unresectable cancers of the lung and in 44 of the 95 (46%) with clinical Stage III lung cancer. The two-year survival was 50% for Stages I and II and 7% for Stage III. Five patients have survived for five years or more. The complications, disease-free interval, local recurrences, distant metastases, and survival are presented and indications for this type of therapy outlined.     

The changing role of surgery for pulmonary metastases.

From 1960 to 1977, 663 resections for pulmonary metastases were performed in 448 patients, 202 with a sarcoma and 246 with a carcinoma. The majority of the patients (70%) had wedge resection or segmentectomy. Operative mortality was 1.0% (7 patients in 663 thoracotomies). With the increased effectiveness of chemotherapy in some specific areas--osteogenic sarcoma and carcinoma of the testis, breast, and colon--the role of surgery is changing. Surgery is now indicated to establish the histology of a solitary lesion, resect metastases unresponsive to chemotherapy, and to reclassify lesions that stabilize but do not disappear totally with chemotherapy.     

Tube Milking Device

A new milking device for tubing is described. Two rollers built into a stainless-steel spring clip both compress the tube and discharge the intraluminal debris. Threading the tube through the device automatically orients it for proper function and prevents it from accidentally falling off. While this device was designed primarily for chest tubes, it may be used in many drainage tube systems in which intraluminal blockage may cause malfunction. A few of its other applications would be for clearing operating room suction lines, nephrostomy tubes, tube cecostomy, and urinary drainage tubes.     

Diagnosis and reversal of rejection in experimental and clinical lung allografts

Experience in our patients and dogs with lung transplants has provided reliable criteria for diagnosing rejection and distinguishing it from other pathological processes such as pneumonia and ischemic injury. These criteria include fever; dyspnea; malaise; increased sputum production; decreased arterial oxygen tension; and, most importantly, the rapid development (often within hours) of a roentgenographic alveolar infiltrate without any change in the sputum bacteriology.Using these criteria we have identified multiple rejection episodes in 2 patients and in comparably immunosuppressed dogs. In almost every instance all acute manifestations of rejection, including the roentgenographic infiltrates, have been completely reversed by three to seven large intravenous doses of methylprednisolone given at 12- to 24-hour intervals. In the dogs, reversal of rejection has also been confirmed by gross and microscopical examination of the allograft. These findings show that acute rejection in lung allografts can be reliably identified by noninvasive criteria and successfully reversed.     

Immediate Reconstruction of Full-Thickness Chest Wall Defects

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible.     

New Trends in Skeletal Reconstruction after Resection of Chest Wall Tumors

Involvement of the chest wall in malignant tumors, either primary or resulting from contiguous or metastatic spread, occurs in less than 5% of thoracic malignancies. From 1963 through 1978, 155 patients had chest wall resection in continuity with the tumor. Eighty-five tumors were carcinomas, and 70 were sarcomas.Since 1973 reconstruction of chest wall defects in 12 patients has included the use of a composite of Marlex mesh and methyl methacrylate. It provides an excellent replacement both physiologically and esthetically. Such a reconstructed chest wall has obviated the need for postoperative respiratory support.The overall mortality was 4.5% (7 out of 155). The 5-year survival in this varied group of patients is 20%. We believe excellent palliation can be achieved even in patients who are not potentially curable.     

Occult Carcinomas of the Lung

In 1974, we reported 26 patients with roentgenographically occult lung carcinomas. In 13 (50%) of them, the tumor was localized and treated by resection while the disease was still early (Stage I). These patients have done well, and the median survival has reached 8 years. We have added 21 patients to the series since our last report. Localization was by fiberoptic bronchoscopy in all 21. Fourteen of these patients had Stage I disease and were treated by resection.Of a total of 27 patients with early disease treated by resection, none has had recurrence after follow-up extending from 2 months to 20 years. However, in 21 of the entire 47 patients (45%) a second carcinoma developed, 15 (71%) of which were second lung carcinomas.     

Maintenance of Distal Aortic Perfusion by a Heparin-bonded Shunt during Repair of Coarctation of the Aorta with Minimal Collateral Circulation

A heparin-bonded shunt was used to maintain distal aortic perfusion during repair of a coarctation of the aorta in a child who showed evidence of minimal collateral circulation preoperatively. This method is quite simple and obviates the technical difficulties inherent in previously described methods designed to maintain distal perfusion while the proximal thoracic aorta is occluded. The technique proved quite effective, and the patient had an uncomplicated postoperative course.     

The effect on pulmonary ultrastructure of dacron-wool filtration during cardiopulmonary bypass

Pulmonary embolectomy for massive pulmonary embolism associated with refractory shock was performed in 17 patients with 13 long-term survivors. Three of the 4 deaths were not related to the procedure. Angiographic documentation of the diagnosis and the employment of preoperative circulatory support with a pump oxygenator were instrumental in obtaining a high success rate. Intraoperative pressure measurements and postoperative angiographic as well as hemodynamic studies suggest that embolectomy restores normal perfusion of the lung.     

A Rational Approach to Total Thymectomy in the Treatment of Myasthenia Gravis

Thymectomy is important in the treatment of myasthenia gravis. Total removal of the gland is considered indicated. Although median sternotomy has been the accepted surgical procedure, the transcervical approach has been advocated as a safer method of achieving total thymectomy.A surgical-anatomical study of the thymus was made in 22 patients. A high incidence of surgically important variations in thymic anatomy was found in the neck and in the mediastinum. We believe wide exposure by way of median sternotomy with direct vision is required to remove all of the extracapsular mediastinal thymus in many patients, and good cervical exposure is required to remove the anomalous tissue in the neck.If a total thymectomy is to be achieved, we recommend a median sternotomy and a cervical incision, using the meticulous dissection described.     

Operative treatment of massive hemoptysis

Fifty-five pulmonary resections have been performed at our institution for hemoptysis of 600 ml. or more in 24 hours. The overall mortality was 18% as compared with more than 75% in patients who bled 600 ml. or more in 16 hours and 54% in patients who bled 600 ml. or more in 48 hours, all of whom were managed conservatively. Mortality correlated with the rate of bleeding irrespective of the extent of resection. Nineteen patients were bleeding massively at the time of pulmonary resection and required single lung ventilation; of these, 7 (37%) died. Of the 36 patients in whom active bleeding had ceased at the time of pulmonary resection, 3 (8%) died. In 2 patients with extensive bilateral disease, cavernostomy and packing of bleeding cavities was employed. The most common cause of death was respiratory insufficiency. Our experience indicates that operative treatment of massive hemoptysis offers a reduced mortality as compared with conservative management.     

Surgical correction of pulmonary atresia with multiple large systemic-pulmonary collaterals.

A young patient in whom the pulmonary blood flow was supplied completely by five systemic-pulmonary collaterals underwent reconstruction of the pulmonary outflow tract by a new technique. This consisted of the insertion of a valve-bearing conduit between the right ventricle and an isolated segment of the descending aorta, which gave rise to three of the collaterals. Although the patient had a hypoplastic pulmonary artery confluence, other factors mitigated against its use as the sole conduit for right ventricular output.     

A comparative study of the direct internal mammary-to-coronary artery anastomosis and the aortocoronary vein bypass graft

In a comparative follow-up study of the direct internal mammary-to-coronary artery anastomosis and the aortocoronary saphenous vein bypass graft, 202 dogs were observed for periods of up to 48 months. The 311 flow studies in the direct internal mammary-to-coronary artery anastomosis group showed 264 patent grafts. The average flow rates were 18.3 ml. in the right internal mammary-to-right coronary artery anastomosis group and 32.2 ml. in the left internal mammary-to-left circumflex coronary artery anastomosis group.No significant degenerative changes were detected in the internal mammary arterial wall during the four-year period; however, subintimal fibrous hyperplasia was observed in the vein wall within the 3-month postoperative period.     

Cerebrovascular blockade associated with thoracotomy and its prevention with a platelet inhibitor.

Dogs subjected to a thoracotomy in which a rib-spreading retractor was employed developed filling defects in the cerebral microcirculation attributable to obstruction by microemboli. These changes were not observed in control groups and could be prevented in the experimental group by pretreatment with RA233, a platelet inhibitor. It is possible that microembolic-related complications of operations and trauma, such as pulmonary insufficiency, might be ameliorated by the use of platelet inhibitors.     

A comparative study of cardiopulmonary bypass with nonblood and blood prime

A prospective study of cardiopulmonary bypass in adult cardiac surgical patients undergoing similar types of operations compared 50 consecutive perfusions utilizing a clear, balanced, electrolyte-protein prime with 50 consecutive perfusions utilizing a solution containing 1,000 ml. of blood. Significant findings were: The oxygenation and perfusion capabilities during bypass were similar and satisfactory in both groups. The postoperative coagulation studies were essentially the same. The postoperative plasma hemoglobin was 83 mg. per 100 ml. with nonblood prime and 138 mg. per 100 ml. with blood prime; and 12 hour postoperative blood loss was 353 ml. with nonblood prime and 455 ml. with blood prime—22% less in the nonblood prime group. Total blood requirements during hospitalization averaged 1,500 ml. in the nonblood prime group and 3,500 ml. in the blood prime group.The use of nonblood prime and autotransfusions reduces postoperative blood loss, demands on blood bank facilities, risk of serum hepatitis, transfusion reactions, and coagulation abnormalities.