Resectional operations and long-term results in carcinoma of the esophagus.

The 5 year survival rate after resectional operations for carcinoma of the esophagus is still very low. Many factors have been identified as contributing to these poor long-term results. The main factor found in this study, comprising 102 patients undergoing resection out of 125 patients operated upon during a 10 year period, was nonradical resection. The main cause of nonradical resection was invasion of the tumor into the mediastinum, which was observed in 80% of the patients. In 43 of the 102 patients undergoing resection, the penetration of the carcinoma into the tissue surrounding the esophagus was observed only histologically. Thirty-three of the 38 hospital survivors in this group died within 2 years of the operation of recurrence of carcinoma. Fourteen of 17 survivors after resectional operations in whom the tumor growth was still limited to the esophagus were alive from 2 to 9 years (mean 6 years) after the operation, without evidence of recurrence.

Prognostic value of malignant cells in pleural lavage at thoracotomy for bronchial carcinoma.

Despite seemingly radical surgery many patients operated on for bronchial carcinoma will die from their disease. Some patients might benefit from postoperative treatment and a prognostic factor that could identify those with an increased risk for tumor relapse would be of great clinical importance. One possible such factor is the occurrence of malignant cells in pleural lavage performed at operation. To test this hypothesis 224 consecutive patients who had been operated on due to verified or strongly suspected bronchial carcinoma, preoperatively staged as stage I or II, were investigated. After opening the thorax and before manipulation or palpation of the lungs, 300 ml of physiological saline solution was installed into the pleura. After excluding patients who were not radically operated, there remained 138 patients with histologically confirmed lung cancer (carcinoids excluded) and 12.3% showed tumour cells in the washings. Two of 18 patients with metastatic lung disease ( 11%) and one of ten patients with carcinoid tumor also showed malignant cells in the lavage. The patients with lung cancer have been followed for 3 years or until death. After three years 60.2% of those without malignant cells in the pleural lavage were still alive, while this figure was 41.2% in the other group. The difference was not statistically significant. Other factors, such as spread to local lymph nodes, size of tumor, etc. were related to the occurrence of malignant cells in the pleura, and these factors were also better prognostic ones. We conclude that the clinical use of pleural lavage cytology is limited.

Half-dose aprotinin preserves hemostatic function in patients undergoing bypass operations.

High-dose aprotinin reduces bleeding in cardiac operations but with potential side-effects and increased cost. It is therefore mandatory that the effectiveness of a low dose be investigated. Half of the Hammersmith regimen was studied in cardiac surgical patients to find out how it could reduce bleeding. Blood fibrinolysis parameters were studied in 40 elective patients undergoing coronary artery bypass grafting in a double-blind, placebo-controlled study design. The plasma activities of tissue plasminogen activator, plasminogen activator inhibitor, alpha 2-antiplasmin, plasminogen, fibrinogen, and D-dimer as well as platelet number, bleeding times, activated clotting time, and aprotinin plasma concentrations were assessed before, during, and after the operation. Fibrinolysis was inhibited by aprotinin as evidenced by decreased D-dimer (p = 0.0001) and tissue plasminogen activator (p = 0.0432) levels and increased plasminogen activator inhibitor (p = 0.0105) and alpha 2-antiplasmin (p = 0.0002) levels during the operation. A postoperative abnormal bleeding time occurred 38% more frequently in the placebo group (p < 0.05). Aprotinin plasma concentrations reached adequate levels to inhibit plasmin and plasma kallikrein. This study showed that half-dose aprotinin significantly inhibits fibrinolysis and prevents postoperative abnormal bleeding time in cardiac surgical patients.

Half-dose aprotinin does not affect haemorheological properties in patients undergoing bypass surgery.

OBJECTIVE: To investigate haemorheological changes in patients undergoing coronary artery bypass grafting and to determine whether the protective effect on haemorheology of high-dose aprotinin also exists under a half-dose regimen. METHODS: Forty patients were studied in a double-blind, placebo-controlled study design. Patients in the aprotinin group received half of the standard high dose of aprotinin during surgery. Erythrocyte and white-cell clogging rates as well as whole blood and plasma viscosity were measured. Viscosity results were expressed as a ratio to the viscosity of saline. RESULTS: Erythrocyte and white-cell clogging rates were increased significantly, whereas whole blood and plasma viscosity were decreased significantly during cardiopulmonary bypass. The reduction in viscosity had a strong correlation to haemodilution. There was no significant difference in any of the measured variables between the aprotinin and the placebo groups. CONCLUSION: This study showed that blood cell damage occurred during cardiopulmonary bypass surgery, as measured by a raised clogging rate. This tendency was the same in both groups and therefore no increased potential for microthrombi could be attributed to aprotinin haemorheologically. However, half-dose aprotinin did not show any preserving effect in haemorheology when the blood-cell clogging rate and blood viscosity were studied.

Easy pleurectomy with winding up of pleural flaps.

The authors describe an effective method of performing apical pleurectomy by winding up large pleural flaps on the thoracoscopic forceps after delineating the borders of the pleurectomy with electrocautery. The method is preferred by the authors compared to abrasio of the parietal pleura or stripping the pleura in small pieces and is in their hands easier and quicker than the other methods.

Long-term follow-up of operative treatment for pulmonary metastases.

From 1954 onwards, 132 patients underwent 165 resections for pulmonary metastases. No other forms of therapy were adopted. The operative mortality was 7.6% (10 patients). After a minimum follow-up of 5 years, the overall survival rate was 20%. The 10- and 15-year survival rates were 6% and 3%, respectively. The major cause of late death was recurrence or spread of the primary disease in 102 patients (83.6%) while 5 patients died of reasons not related to cancer. Fifteen patients (12.3%) are still alive, 13 of whom have no clinical cancer. The presence of symptoms, the disease-free interval of less than 1 year and the number of metastases showed a statistically significant detrimental influence on survival (P less than 0.001, P less than 0.05 and P less than 0.046, respectively). The best 5-year survivals of 42%, 24%, 23% and 23% were noted for metastases from malignancies in the body of the uterus, kidney, bone and colon, respectively. Longterm survival or clinical cure can be achieved with surgery alone by an aggressive approach in selected malignancies.

Cerebral perfusion in dogs during pulsatile and non pulsatile extracorporeal circulation.

Eight dogs were cannulated for left heart bypass. Conventional roller pumps were used for bypass with one of the pump console modified to deliver pulsatile bypass. The experiments were performed at normothermia. Each dog was used as its own control. For measurement of cerebral blood flow (CBF) Xe133 was injected into vertebral artery and the gamma activity elimination over the skull was registered. In addition blood samples were withdrawn from the axillary artery and the sagittal sinus for measurement of blood gases. The CBF to the gray matter of the brain was significantly higher during the periods with pulsatile perfusion (P less than 0.01). This was probably due to decreased total cerebral vascular resistance (P less than 0.001). Mean aortic pressure also decreased when the mode of perfusion was changed from non pulsatile to pulsatile (P less than 0.05), indicating a general decrease of the peripheral vascular resistance. A good correlation was noted between the arteriovenous oxygen saturation difference (AV-O2 diff) across the brain and the CBF (R = -0.77, P less than 0.01).

Reduced per- and postoperative mortality following the use of urea during elective cardiopulmonary bypass. A proposed treatment for the prevention of reduced red cell deformability during open heart surgery.

The vital micro-rheological function of the red cells to deform was monitored during extracorporeal circulation in 75 patients undergoing open heart surgery. Red cell deformability was assessed in vitro by estimating red cell filtration rate (RFR). Urea was given to 32 patients during surgery and the remaining 43 acted as controls. After one hour on cardiopulmonary bypass (CPB) all patients showed a significant reduction of red cell filtration rate which continually worsened. In control patients where the RFR was severely altered there appeared to be more morbidity and mortality (11.6%). Using this simple method it is possible for the perfusionist to assess blood damage rapidly and possibly anticipate a difficult postoperative recovery. Urea administered during CPB reduced the decrease in RFR by a significant extent and in these patients the postoperative course was relatively uneventful and all survived.

High-dose aprotinin (trasylol) in reducing bleeding and protecting lung function in potential bleeders undergoing cardiopulmonary bypass.

Intraoperative high-dose aprotinin during cardiopulmonary bypass was used to investigate if high-risk bleeders could be changed to bleed normally or less as well as see if aprotinin could preserve lung function. Eleven matched controls were compared with eleven aprotinin patients taking warfarin or aspirin preoperatively. The mean (+/- SEM) 12-h and 24-h postoperative amount of bleeding, volume of blood product transfusion and hemoglobin reduction in the aprotinin group were 328 +/- 45 ml, 418 +/- 63 ml, 341 +/- 99 ml and 1.8 +/- 0.5 g% respectively, which were significantly lower than the respective values of 716 +/- 86 ml (P less than 0.01), 1,029 +/- 115 ml (P less than 0.01), 985 +/- 294 ml (P less than 0.05) and 4.1 +/- 0.4 g% (P less than 0.02) in the controls. There was a 65% blood-saving effect by aprotinin in this study. The hypercapnea rate was 45% in the treated patients, and 82% (P less than 0.05) in the controls reflecting better preservation of pulmonary diffusion function which is clinically important following major surgery.

[Use pleural drainage optimally! Current systems are quick and easy to manage]. / Använd pleuradränagen optimalt! Nutida system tysta och lättskötta.

Recent years have witnessed improvements in pleural drainage systems, especially in terms of emitted noise levels. Pleural drainage can now be performed without noise disturbance in the ward. It is recommended that a drainage system containing a water column manometer be used, to enable intrapleural pressure and pressure fluctuations to be monitored. Presence of increased fluctuation allows pneumothorax to be suspected, but a slight fluctuation is indicative of normal function of the drain. When active suction is terminated, the level of negative pressure obtained in the unit is preserved. Gradual dissipation of this negative pressure is indicative of a small continuing air leak from the patient, whereas preservation of the negative pressure level for several hours indicates the absence of such leakage (thus possibly obviating the need of a further x-ray before removal of chest tubes). The presence of an underwater seal is recommended, although there are systems that work without water. The systems may be used without active suction, e.g. for gravity drainage of fluid after pneumonectomy, and may temporarily function as portable Heimlich valves.

[Minidrainage in pneumothorax is expensive, but still beneficial. Considerate for the patient, reducing the number of hospitalization days]. / Minidränage vid pneumotorax dyrt, men ändå lönsamt. Skonsamt för patienten, reducerar antalet sjukhusdagar.

Initial tests (ten patients) are reported of a compact device, Tru-close, for the evacuation of pneumothorax. It consists of a small-bore plastic catheter combined with a small box containing a flutter-valve. Ease of insertion, safe function, stable fixation and painless removal were features found. Complications were pain on insertion in one patient and leakage of pleural fluid from the device in another. The unit is expensive, but in cases of simple pneumothorax without fluid it would seem possible to manage patients on an out-patient basis, thus saving several days' worth of hospitalization costs.