Accentuated cyclic activation of peritoneal macrophages in patients with endometriosis

Peritoneal fluid was collected from 107 women undergoing laparoscopic sterilization or diagnostic laparoscopy for evaluation of infertility. Cells consisting mainly of macrophages were separated and subjected to sophisticated flow fluorocytometric analysis. In this way more detailed information was obtained about activational characteristics of the pelvic macrophage population during the menstrual cycle. In normal women the macrophages, as compared to peripheral monocytes, showed evidence of elevated baseline activation, and a gradual increase in several markers occurred during the menstrual cycle. Cells increased in size, lost their ability to stain for myeloperoxidase, and increased in activity of both endoenzymes and ectoenzymes. These results suggest that female peritoneal macrophages are continuously responding to stimuli. The macrophage irritation was much more pronounced in women with mild endometriosis. This accentuated cyclic activation may represent an inflammatory response to bleeding from ectopic implants or retrograde menstruation or may be a consequence of some defect in the cell-mediated immune response in endometriosis.     

Circular myotomy as an aid to resection and end-to-end anastomosis of the esophagus.

Segments ranging from 40 to 70% of the thoracic esophagus were resected in 80 mongrel dogs. End-to-end anastomosis was effected after circular myotomy either proximal or distal, or both proximal and distal, to the anastomosis. Among dogs undergoing resection of 60% of the esophagus, distal myotomy enabled 6 of 8 animals to survive, and combined proximal and distal myotomy permitted 8 of 10 to survive. Cineesophagography was performed in a majority of the 50 surviving animals and showed no appreciable delay of peristalsis at the myotomy sites. When these sites were examined at postmortem examination up to 13 months after operation, 1 dog showed a small diverticulum but none showed dilatation or stricture. It is concluded that circular myotomy holds real promise as a means of extending the clinical application of esophageal resection with end-to-end anastomosis.     

Pericardial Window for Malignant Pericardial Effusion

Seventeen patients with malignant pericardial effusion were treated by the creation of a pericardial window. This was done through a subxiphoid approach in 13 patients and through limited anterior thoracotomy or sternotomy incisions in 4.There were no deaths and no major complications attributable to the operation. In all patients, relief of the cardiac compression caused by the effusion was immediate and complete. No patient showed a clinically significant recurrence of the effusion, although 1 patient who had received irradiation required pericardiectomy for constriction 5 months later.Survival was determined principally by the extent of the primary malignancy. Six patients died of the primary tumors within 30 days, but 6 survived 3 to 12 months and 2 are alive at 8 and 21 months.It is concluded that creation of a pericardial window, preferably by the subxiphoid approach, is the treatment of choice for malignant pericardial effusion. The procedure provides an accurate diagnosis, carries virtually no mortality or morbidity, and affords immediate and long-lasting relief of cardiac compression.     

Palliation of esophageal carcinoma with intraluminal tubes: experience with 30 patients.

Between 1968 and 1978, 26 patients with carcinomas of the thoracic esophagus and 4 with adenocarcinomas involving the esophagogastric junction were treated by the insertion of indwelling intraluminal (endoesophageal) tubes. Four different types of tube were inserted by the pull-through technique. Thirteen of the 30 patients died in the hospital within 30 days. However, among the 20 patients who did not have neoplasms of the upper third of the thoracic esophagus or who had not had a prior resection, only 5 died. The principal cause of death was aspiration pneumonia. Survival averaged 2.5 months. Four patients survived 5 to 7 months. Deglutition was adequate in most patients but was not as satisfactory as after esophagogastrectomy. Our best results were obtained in patients with carcinoma of the middle or lower third of the esophagus, with or without an esophagorespiratory fistula, who had not had a previous resection.     

Occult rib fractures and brachial plexus injury following median sternotomy for open-heart operations

The incidence and the sites of rib fractures during open-heart operations through a median sternotomy incision were studied in 36 consecutive patients divided into two groups. In Group 1 (24 patients), a conventional Ankeney retractor was used to expose the heart, and in Group 2 (12 patients), a similar retractor was used but with its uppermost pair of blades removed. Thorough physical examinations and preoperative and postoperative chest roentgenograms were obtained, and postoperative bone scans were done in all patients. No rib fractures were detected on the routine chest roentgenograms in patients in either group. Bone scans, however, showed 44 rib fractures (15 of the first rib, 13 of the second rib, 4 of the third rib, 6 of the fourth rib, 3 of the fifth rib, and 3 of the sixth rib) in 16 patients in Group 1. Six patients in Group 2 had 9 rib fractures (2 of the first rib, 4 of the second rib, and 1 each of the third, fifth, and sixth ribs). None of the patients in Group 2 had brachial plexus injury and neither of the first rib fractures in this group were located posteriorly, whereas 3 patients in Group 1 had both brachial plexus injury and posterior first rib fractures.     

The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients

Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was combined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.     

Carcinoma of the esophagus: experience with a philosophy for palliation.

The preliminary results of a new therapeutic approach to carcinoma of the esophagus were reported in 1972. The primary objective of treatment should be palliation, with cure an important but secondary goal. Lesions in the upper third of the esophagus are treated by irradiation unless there is severe obstruction or tracheal involvement, in which case colon bypass is carried out. Limited resection and esophagogastrostomy is performed through a right thoractomy and midline laparotomy for middle-third lesions and through a left thoracotomy for lower-third carcinomas. Since 1969, 85 patients have been evaluated, of whom 65 (76%) have been treated according to the new protocol. Thirteen patients with upper-third carcinomas were treated primarily by radiation therapy and 6 by colon bypass. Resection was performed in 45 of the 46 patients with middle- and lower-third lesions. There were 5 operative deaths (9.8%). The quality and duration of palliation have been far superior to that achieved by previous methods of treatment and, perhaps surprisingly, survival rates have improved.     

Carcinoma of the esophagus: twelve years' experience with a philosophy for palliation

Twelve years of experience have now been gained with a new therapeutic approach to carcinoma of the esophagus. In this approach, the primary goal of treatment is palliation, with cure an important but secondary objective. Carcinomas in the upper third of the esophagus are treated by radiation therapy unless there is severe obstruction or tracheal invasion, in which case colon interposition is performed. Limited resection with esophagogastrostomy is performed through a right thoracotomy and midline laparotomy for neoplasms in the middle third of the esophagus and through a left thoracotomy for carcinomas in the lower third. Since 1969, 161 patients have been evaluated, of whom 107 (66%) have been managed according to the new protocol. Twenty patients with carcinomas of the upper third of the esophagus were treated primarily by radiotherapy and 7 by colon interposition. Resection was performed in 78 of the 80 patients with carcinomas of the middle and lower thirds. There were 9 operative deaths (10%). Palliation, of superior quality to that obtained by previous methods, was provided to 95 of the 107 patients. Survival also is at least on a par with that obtained before.     

Pulmonary Aspergillosis: An Analysis of 41 Patients

During the period 1969 to 1974, 41 patients having cultures positive for aspergillus were seen on the thoracic surgical services of the University of Maryland and Mt. Wilson State Hospitals. Intracavitary mycetoma was present in 36 patients. In 32 the underlying disease was chronic cavitary tuberculosis, 5 had decreased immunity due to other diseases, and in 3 no underlying disease was noted. One final patient developed a mycetoma following repair of tetralogy of Fallot.Hemoptysis, the predominant symptom, occurred in 23 patients, all of whom were from the group with intracavitary mycetoma. Hemoptysis was life-threatening in 8 patients, severe but not life-threatening in 12, and minimal in 3. Fifteen patients underwent pulmonary resection with 2 deaths. Both patients who died had undergone emergency resection for life-threatening hemoptysis; the fungus ball had developed following a previous resection for tuberculosis, and both had poor pulmonary reserve. Of 10 patients with hemoptysis who were not treated surgically, chiefly because they were poor operative risks, 4 died.This study suggests that pulmonary aspergillosis, particularly of the intracavitary type, is a potentially life-threatening disease. Because of the suddenness with which massive hemoptysis may occur, pulmonary resection is recommended for all patients with intracavitary mycetoma who do not constitute prohibitive operative risks.     

A temperature conversion nomogram for glycosylated hemoglobin analysis

Analysis of glycosylated hemoglobins by commercial mini-column methods was shown to vary linearly with the ambient temperature. However, the slopes of the temperature dependence lines for diabetic and healthy individuals was different. A method for temperature correction and a nomogram is proposed.