Improved survival in esophageal cancer in the period 1978 to 1983.

The outcome of therapy of adenocarcinomas and squamous-cell carcinomas of the esophagus is so poor that the results of new approaches to therapy, such as the addition of radiotherapy or chemotherapy, are often compared with those achieved in historical controls. To determine the validity of this approach in cancers with a poor outcome, the results of therapy were analyzed at our institution from Jan 11, 1978 to Aug 9, 1981 (77 patients) and compared with the results achieved in the period from Aug 14, 1981 to Feb 19, 1984 (77 patients). The patients were evenly matched for prognostic factors. It was found that the median survival of the first group of patients (4 months) was significantly less (P less than .01) than that of the recently treated group (10 months). This was due to the better median survival of patients treated surgically from 4 months in the early group to 29 months at present (P less than .01). There was no change in the survival of the other patients. The major improvement in the outcome of surgery was due to the reduction of the perioperative mortality rate to less than 5%. There was no detectable change in patient selection for surgery. The results indicate that even in tumors with a very poor outcome, such as esophageal cancer, large changes in results can occur without a specific change in therapy, and that historical controls may be misleading.

The fate of internal mammary arterial implants and bypass conduits for myocardial revascularization. Experimental angiographic, histologic, and ultrastructural observations.

Experimental angiographic, histologic, and ultrastructural observations were obtained from dogs to determine the fate of internal mammary artery (IMA) implants and aorta-coronary bypass (ACB) conduits in the 3 month postoperative period. Angiographic implant patency and evidence of implants forming collaterals with the coronary circulation did not accurately reflect anatomic luminal narrowing. Subendothelial fibrocellular proliferation similar to that described in saphenous vein grafts occurred with regularity in all IMA implants and ACB conduits. The intimal changes were much more severe in the IMA implants as compared to the ACB conduits: There was 25 to 95 per cent liminal narrowing in the IMA implants, whereas the ACB conduits rarely showed greater than 25 per cent luminal narrowing. Both reduced flow and surgical trauma appeared to be influential determining factors of the intimal proliferative process, whereas devascularization alone seemed less important.

Epicardial tumor-like angiofibromatous proliferative lesion. An unusual complication of coronary bypass surgery.

The first report of an unusual complication of coronary bypass surgery for myocardial revascularization is presented. In a dog used for experimental studies of internal mammary artery (IMA)-coronary bypass and killed three months later, the postmortem examination of the heart showed a tumor-like epicardial angiofibromatous nodule at the site of the IMA-left anterior descending (LAD) coronary artery anastomosis. The lesion, consisting of plexiform vascular channels in a fibrocollagenous stroma, measured 2 by 1.5 by 1 cm. This was the only lesion found in the animal. It was speculated that the lesion might have arisen from a hematoma developing at the site of arterial anastomosis.

Fibrosing mediastinitis with coronary artery involvement.

This case report describes a patient with chronic fibrosing mediastinitis involving the entire intrapericardial aorta, innominate artery, and the base of the heart with involvement of the proximal segments of the coronary arteries. This finding was unsuspected before emergency coronary artery bypass grafting. Coronary stenosis due to fibrosing mediastinitis is a rare complication of fibrosing mediastinitis. Owing to the extensive fibrosis, the normal bypass, cardiac preservation, and revascularization techniques required alteration and are discussed.

Empyema thoracis: 14-year experience in a teaching center.

One hundred two patients with empyema thoracis were managed at the Royal Melbourne Hospital between 1976 and 1989. Fifty-five cases of empyema thoracis were postpneumonic, 8 followed esophageal rupture, and 5 were associated with thoracic trauma. Some form of systemic illness was a major contributing factor in the presentation of 29 patients. A single causal organism was found in 53 patients (the most common being Staphylococcus aureus), multiple organisms in 36, and no growth in 13. During the years 1983 to 1989 there was an increased incidence of empyemas caused by multiple or antibiotic-resistant organisms. Operative drainage was required in 90 patients and 12 were managed by thoracentesis or intercostal tube drainage alone. The in-hospital mortality rate for patients managed nonoperatively was 58% (7 of 12 patients); it was 16% (14 of 90 patients) for those receiving operative drainage. There were seven late deaths, four empyema related and three nonrelated. Early adequate operative drainage is recommended for patients with empyema thoracis.

Recognition and management of catheter-induced pulmonary artery rupture.

BACKGROUND: Catheter-induced pulmonary artery rupture is a well-recognized complication of invasive monitoring, but the risk has not diminished. Although commonly associated with cardiopulmonary bypass, injuries also occur in intensive care. Definitive proof requires pulmonary angiography or autopsy. Many cases are never reported, and lesser injuries are probably under-diagnosed. METHODS: Seven cases fulfilling accepted diagnostic criteria discovered over 2 years are described in four groups illustrating the common modes of presentation: hemoptysis with hypoxemia, exsanguination, delayed recurrent hemorrhage, and bleeding with cardiopulmonary bypass. RESULTS: One patient had a planned elective operation deferred. Four patients were being monitored in intensive care. Two of them died of pulmonary artery rupture. Two other patients had bleeding on weaning from cardiopulmonary bypass. One settled with conservative treatment, the other survived after extracorporeal life support. Recognition and management are discussed, emphasizing means of avoiding pulmonary resection. CONCLUSIONS: Catheter-induced pulmonary artery rupture is unavoidable. Constant awareness is essential. A plan of management is presented. Extracorporeal life support may help to avoid pulmonary resection. Early pulmonary angiography is advocated for accurate diagnosis and to enable treatment by embolization.

Bleeding as a complication of fine needle lung biopsy.

Two patients in whom bleeding into the pleural space was a major complication of fine needle biopsy of the lung are described. Both had a pleural effusion before biopsy.

Psychiatric aspects of coronary artery surgery. A prospective study.

A psychiatric assessment was carried out before operation, and at three months and 12 months after operation, in 77 men undergoing coronary artery bypass graft surgery. Neither psychiatric assessment before the operation nor perioperative surgical assessment could predict the physical outcome of surgery. The physical results of surgery were good, but there was a 20% decrease in the number of patients who were in employment after the operation. Abnormally high scores on measures of anxiety and depression were present in about 50% of patients before the operation, and in about one-third of patients after the operation. Impairment in various aspects of personality-functioning since surgery was reported by 7%-29% of patients. These complaints were not correlated with the surgical result. Attention is drawn to this area of persisting postoperative morbidity.

Excellent long-term results of cardiac valve replacement with the St Jude Medical valve prosthesis.

BACKGROUND: A retrospective review of the performance of the St Jude Medical valve prosthesis over a 12-year period was undertaken. METHODS AND RESULTS: Between 1978 and 1990, 696 St Jude Medical valve prostheses (351 isolated aortic, 191 isolated mitral, 64 double aortic/mitral) were implanted into 616 patients (mean age, 55 years). Concomitant coronary artery graft surgery was performed in 18%. During mid-1991, follow-up was conducted, yielding a 97% completion (16 lost), for a total of 3075 cumulative patient-years (mean, 5.0 years). Early (30-day) mortality rates were 3.1%, 5.2%, and 6.4% after aortic, mitral, and double valve replacements, respectively. The 5-year actuarial survival rates were 94.1 +/- 1.3%, 85.8 +/- 2.7%, and 86.3 +/- 4.6% and those for 10 years were 89.6 +/- 1.9%, 72.9 +/- 6.1%, and 83.0 +/- 5.4%, respectively. There were no structural valve failures. Anticoagulant-related hemorrhage was the most common valve-related complication (28 events, 0.9% per patient-year), with three being fatal. Thromboembolism (13 events) occurred at a rate of 0.5% per patient-year (0.6% aortic, 0.3% mitral, 0.3% double). All of the nonstructural deteriorations (10 events, 0.3% per patient-year) were paravalvular leaks, including 3 aortic valve replacements in patients who developed hemolytic anemia. There was 1 valve thrombosis (0.03% per patient-year). Patients undergoing coronary artery graft surgery had lower survival and higher complication rates than patients without coronary artery graft surgery. There was a significant improvement (P < .001) in New York Heart Association functional class for the entire patient population. CONCLUSIONS: The St Jude Medical valve prosthesis has performed well in all positions over a 12-year period, with an acceptably low incidence of valve-related complications.

Alveolar proteinosis treated with a single bronchial lavage.

An acute febrile illness with respiratory failure and pulmonary infiltrates is a recognized accompaniment of many infective and inflammatory diseases. We report a case of pulmonary alveolar proteinosis, with secondary bacterial infection, that responded to a single pulmonary lavage and the elimination of occupational exposure to dust. In contrast to other interstitial lung diseases, therapy with corticosteroid or antibiotic agents alone was not appropriate. This report underlines the need for early, active intervention in diffuse lung diseases, and emphasizes the importance of obtaining a specific diagnosis in directing subsequent therapy.

Surgery for unstable angina.

A series of 84 patients with unstable angina, treated surgically by grafting procedures between October 1970 and September 1976, have been reviewed. The study indicates that extensive coronary artery disease is common in these patients, and suggests that operation may favourably influence mortality, both immediate and delayed, but does not reduce the risk of myocardial infarction. Eighty per cent of the patients were relieved of angina and able to lead a reasonably normal existence.