The treatment of pleuropulmonary amebiasis with metronidazole.

One hundred forty patients with pleuropulmonary amebiasis were classified radiographically in order to rationalize therapy based on the use of metronidazole. Amebic testing with gel diffusion, serial chest x-ray films, and observation of the patient's response to treatment have dominated management of the patients, 135 of whom made a successful recovery. Five patients died. Sixty percent of the surviving patients have been reviewed at a follow-up clinic, and there has been no instance of recurrence of amebiasis.

Surgical management of prosthetic valve endocarditis.

Operative mortality in patients with prosthetic valve endocarditis (PVE), who already have severe hemodynamic failure, is extremely high (35% to 84%). Over a period of 10 years, between 1972 and 1981, fourteen consecutive urgent operations were performed for PVE in 12 patients. On thirteen occasions the patients were in severe hemodynamic failure (NYHA Functional Class IV), and five of them had early PVE (within 60 days of previous operation). In all patients at least two of the other recognized risk factors, such as presence of non-streptococcal organisms, detachment of the prosthesis, and myocardial invasion, were present. All of the patients but one were operated upon within 48 hours of their hemodynamic deterioration, and there was one postoperative death (operative mortality 7%). Our results indicate that an acceptable surgical mortality in patients with intractable heart failure due to early and late PVE can be achieved by prompt surgical intervention despite the presence of multiple risk factors.

Primary small-cell cancer of the esophagus.

Primary small-cell cancer of the esophagus is a rare tumor that disseminates early with a uniformly poor prognosis if untreated. Sixteen patients with malignant dysphagia referred to the Thoracic Surgical Unit, City Hospital, Edinburgh, within a 10-year period had a diagnosis of primary small-cell cancer of the esophagus. Seven patients underwent subtotal esophagectomy or esophagogastrectomy, either alone or with adjuvant chemotherapy or radiotherapy, with a mean survival of 20 months (standard deviation 35.4 months, range 2 weeks to 96 months). The remaining nine patients had disseminated disease when they were first seen and were treated symptomatically by intubation alone (1 patient), intubation and palliative chemotherapy or radiotherapy (3 patients), palliative chemotherapy (2 patients), palliative radiotherapy (1 patient), or no therapy (2 patients), with a mean survival of 4.8 months (standard deviation 2.6 months, range 2 to 9 months). Patients seen with this aggressive tumor should be assessed urgently for evidence of metastatic spread and then offered resection in combination with chemotherapy if they are otherwise fit for operation. This treatment regimen has given us one long-term survivor (96 months) who, we believe, is the only patient to have been cured of this condition. Patients seen with disseminated disease should have symptomatic treatment of the dysphagia combined with palliative chemotherapy.

Prognostic significance of tumor deoxyribonucleic acid content in surgically resected small-cell carcinoma of lung.

The prognostic role of deoxyribonucleic acid flow cytometry was investigated in 53 cases of surgically resected small-cell lung cancer. Deoxyribonucleic acid aneuploidy was detected in 26 patients (49.1%), the remaining tumors being either diploid or tetraploid. Patients with aneuploid tumors had a significantly reduced 2-year survival (38.5%) when compared with patients with diploid or tetraploid tumors (70.3%; p less than 0.05). This finding was independent of tumor stage on multiple logistic regression analysis. Diploid or tetraploid deoxyribonucleic acid content was associated with a particularly good 2-year survival (85%) in N0 or N1 disease. Tumor deoxyribonucleic acid ploidy should be taken into account in planning of management and assessment of prognosis in small-cell lung cancer.

A comparison of cobalt (57Co) bleomycin scanning and contrast-enhanced CT scanning for assessment of the mediastinum in lung cancer.

Sixty patients with histologically proven lung cancer who had been accepted for mediastinoscopy or thoracotomy were prospectively entered into a study to evaluate computed tomographic (CT) scanning, 57Co-bleomycin scanning, and barium swallow in preoperative assessment of mediastinal lymph node metastasis. Fifty-six patients had thoracotomy at which all accessible lymph nodes were sampled. Twenty-four patients were found to have mediastinal tumor on histologic analysis of the resected mediastinal lymph nodes. Neither 57Co-bleomycin scanning nor barium swallow were clinically useful, with sensitivities of 21 percent and 11 percent respectively, whereas CT scanning was helpful. However, there was no clear cutoff point of node size to optimize sensitivity and specificity for CT scanning. When nodes greater than or equal to 15 mm were taken to indicate likely malignancy, the sensitivity was 58 percent and the specificity was 87 percent and when greater than or equal to 10 mm was used the sensitivity was 80 percent but the specificity was only 55 percent. There was no clear relationship between the size of the largest resected lymph node in each patient and the presence of malignant lymph nodes. Only 42 percent of patients with resected nodes greater than or equal to 2 cm had histologic evidence of metastases. We conclude that CT scanning should be used to indicate the presence and site of mediastinal lymph nodes, which, when visualized, should always be sampled and histologically examined prior to resection of primary tumor.

Repair of pulmonary vein rupture after deceleration injury.

Injuries to the major pulmonary vessels are uncommon and are extremely difficult to manage. We report a case of an isolated pulmonary vein injury following a road traffic accident that was repaired successfully.

Hufnagel revisited: a descending thoracic aortic valve to treat prosthetic valve insufficiency.

In 1953 Hufnagel and Harvey reported their successful treatment of aortic valve insufficiency by the implantation of a ball-valve prosthesis into the descending thoracic aorta. Since then, great advances in technology, surgery, and anesthesia have made aortic valve replacement a more common procedure with relatively low mortality. This remains true for the vast majority of prosthetic valve replacements. However, cases requiring reoperation can be difficult, leading to a much higher degree of morbidity and mortality. In selected patients who require repeated approaches to the aortic root we propose that Hufnagel's original idea may still be of value to reduce the severity of aortic insufficiency. We report our experience in 4 cases of aortic prosthetic incompetence, all of which were improved by two New York Heart Association functional classes after a modification of Hufnagel's procedure.

Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: results of therapeutic and prophylactic use.

In the period 1984 to 1988, 2,448 patients underwent major thoracic operations in our unit. Of these patients, 144 (5.9%) underwent percutaneous cricothyroidostomy (minitracheostomy) using a 20F pediatric silver tracheostomy tube. Minitracheostomies were performed for the treatment of sputum retention in 81 patients, prophylactically in 62 patients, and as a route for high-frequency jet ventilation in 1 patient. Minitracheostomy tubes remained in situ a median of four days. Suction function was satisfactory in 99% of patients, with only 2 patients requiring subsequent suction bronchoscopy and no occurrence of tube blockage. Ninety-four percent of minitracheostomies performed were entirely uneventful. Bleeding was the most common complication (3.5%), and no instances of subglottic stenosis have occurred. During the review period, there was a significant increase in the percentage of patients requiring major operations undergoing prophylactic, but not therapeutic, minitracheostomy (p less than 0.001). This was associated with a significant decrease in the percentage of patients requiring suction bronchoscopy (p less than 0.001). We conclude that prophylactic minitracheostomy with the 20F pediatric silver tracheostomy tube is a safe and effective procedure in the prevention of postoperative sputum retention.

A pedunculated intraluminal foregut reduplication cyst of the proximal esophagus.

A 66-year-old woman with a 3-month history of progressive dysphagia underwent transoral excision of a pedunculated cyst arising in the proximal esophagus. Histologic examination confirmed a pedunculated intraluminal foregut reduplication cyst. She remains well 1 year after excision with no recurrence of dysphagia.

Esophagectomy for carcinoma in the octogenarian.

BACKGROUND: Esophageal carcinoma is predominantly a disease of the elderly, a group often only considered for palliative therapies. METHODS: A case note review identified 31 octogenarians undergoing resection for carcinoma of the esophagus or gastric cardia over a 12-year period ending December 1994. RESULTS: Nineteen patients made either an uncomplicated postoperative recovery (n = 12) or suffered minor complications (n = 7). Of the 12 patients who suffered moderate or severe complications, 5 died (in-hospital mortality, 16%). The deaths included 2 of 3 patients who underwent emergency operation for esophageal perforation and 3 of 28 patients who underwent elective esophagectomy (elective mortality rate, 10.7%). Nineteen of the 26 survivors (73%) experienced no further dysphagia. The 5-year survival rate was 17%. CONCLUSIONS: Elective esophageal resection can be performed safety in selected octogenarians who have no or few coexisting medical problems and present with a localized carcinoma that is technically easy to resect. Patients undergoing emergency operations or in whom moderate or severe postoperative complications develop often have poor physiologic reserve and are therefore at risk of early postoperative death.

Comparison of ventricular septal surgery and mitral valve replacement for hypertrophic obstructive cardiomyopathy.

We have reviewed the results of two different forms of surgical management of hypertrophic obstructive cardiomyopathy refractory to medical therapy. Twenty-one patients were treated with 22 procedures between 1963 and 1987. Eleven underwent a ventricular septal procedure by myotomy with or without myectomy, and 11 underwent mitral valve replacement (MVR), 1 of whom had previously undergone a ventricular septal procedure. The groups were comparable with respect to severity and duration of symptoms, age range, electrocardiographic features, and hemodynamic changes. Mitral valve replacement produced a greater and more consistent reduction in the left ventricular outflow tract pressure gradient than a ventricular septal procedure (MVR, 68.3 mm Hg preoperatively and 2.5 mm Hg postoperatively; ventricular septal procedure, 60.1 mm Hg preoperatively and 13.4 mm Hg postoperatively). This was associated with better postoperative ventricular configuration in diastole and more apparent loss of midcavity narrowing in systole. Ejection fraction did not fall after a ventricular septal procedure but decreased significantly from a mean of 79% to a mean of 61% after MVR. Similarly, left ventricular end-diastolic pressure remained unchanged after a ventricular septal procedure but fell from a mean of 26.6 mm Hg to 17 mm Hg after MVR. Although both groups experienced a generally satisfactory symptomatic result, this appeared more reliable with MVR. We suggest that MVR offers a more predictable improvement than a ventricular septal procedure and may be the procedure of choice for units with limited experience with ventricular septal procedures.

Effect of blood transfusion on survival after esophagogastrectomy for carcinoma.

BACKGROUND: There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious. METHODS: The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period. RESULTS: The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged. CONCLUSIONS: Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.

Pneumonectomy for bronchogenic carcinoma in the elderly.

We have reviewed 70 consecutive elderly patients (70 years or older) who underwent pneumonectomy for bronchogenic carcinoma, in order to evaluate morbidity, mortality, and long-term survival. The majority of the patients had stage II (n = 32) or III (n = 25) disease. Fifteen deaths occurred in the peri-operative period (21%). Pre-operative factors associated with peri-operative death included a history of ischaemic heart disease (P = 0.001) and right-sided tumour (peri-operative mortality for right pneumonectomy = 37%, left pneumonectomy = 6%, P = 0.001). Poor lung function (as assessed by pre-operative spirometry), peripheral vascular disease, cerebrovascular disease, diabetes mellitus, and hypertension were not significant risk factors for peri-operative death. Post-operatively, the requirement for ventilation, or the development of post-operative myocardial infarction, adult respiratory distress syndrome and respiratory failure were significantly associated with peri-operative death. Over 60% of the patients developed one or more complications. The absolute survival rates for operative survivors were 51% and 27% at 1 and 5 years, respectively (stage I, 60% and 40%; stage II, 63% and 33%; stage III 33% and 14%). The absolute overall survival rates were 40% and 21% at 1 and 5 years, respectively. We conclude that pneumonectomy is justified in elderly patients but right-sided lesions and ischaemic heart disease should be considered as relative contra-indications.

Influence of obesity on the early and long term results of surgery for coronary artery disease.

In order to determine the effect of obesity on the results of coronary artery bypass graft (CABG) surgery, we compared 250 obese patients undergoing CABG procedures between 1984 and 1987 with 250 age- and sex-matched controls of normal body mass index (BMI) undergoing CABG in the same period. The obese group had a greater incidence of diabetes mellitus (p less than 0.02), hypertension (p less than 0.05), hyperlipidaemia (p less than 0.05), and left main stem coronary artery disease (p less than 0.001). No differences were identified in the surgery performed, but obesity was associated with prolonged total bypass time (p less than 0.05). Operative mortality was 0.8% in both groups. Multivariate analysis demonstrated obesity to be an independent risk factor for perioperative morbidity (p less than 0.05). Univariate: respiratory (p less than 0.01); leg wound (p less than 0.001); myocardial infarction (p less than 0.02); arrhythmias (p less than 0.02); sternal dehiscence (p less than 0.02). At a mean follow-up time of 36.9 months obese patients exhibited a greater incidence of significant recurrent angina (p less than 0.01), which was associated with further weight gain (mean 12.2 kg; linear correlation: p less than 0.001, r = 0.891). Although in CABG surgery operative mortality is not increased in obese patients, aggressive pre- and postoperative weight control is indicated to reduce both perioperative morbidity and the incidence of recurrent angina.

Retention of bioprosthetic valve annulus in mitral prosthetic replacement.

Mitral valve prosthetic replacement carries high mortality rates by modern standards, and mitral bioprostheses are particularly prone to degeneration. Bioprosthetic replacement may be technically difficult when there is calcification of the tissue ingrowth, strut incorporation, or valve-to-annulus size mismatch at the primary operation. A "valve-in-valve" technique is described where the mechanical prosthesis is implanted in the bioprosthetic annulus in order to avoid such difficulties. The results in the first eight patients are presented, showing post-operative Doppler-derived transvalvar mean gradients between 3.9 mmHg and 7.5 mmHg, and estimated valve areas between 1.9 cm2 and 3.5 cm2. All patients are alive at between 20 and 30 months (mean 23.6 months) after operation, they are without serious post-operative morbidity and are in functional class I or II (NYHA classification).

Immediate and long-term results of mitral prosthetic replacement using a right thoracotomy beating heart technique.

OBJECTIVE: Repeat median sternotomy is a potentially dangerous technique providing variable but mainly poor access to the mitral valve. Right thoracotomy is an alternative route previously used to access the mitral valve in the early years of cardiac surgery that offers the advantage of a fresh surgical field in the context of redo surgery. We have reviewed our experience with mitral prosthetic replacement undertaken via a right thoracotomy in order to determine the immediate and long-term results obtained with this approach. METHODS: The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta. Arterial inflow was achieved via the femoral artery or ascending aorta and venous drainage with bi-caval cannulae. Pre-, intra- and postoperative data were documented from case note review. Long-term follow-up was established from the UK Heart Valve Registry, referring Cardiologist, direct patient contact and the Scottish Registry for births and deaths. Statistical analysis was undertaken using a desktop computer package. RESULTS: One hundred and twenty-five patients (mean age 63 years) underwent mitral prosthetic replacement by this technique. One hundred and eleven patients (86%) were in NYHA grades III or IV preoperatively. Twenty-two patients (16.6%) had also undergone previous CABG. Thirty-five patients (28%) had undergone two or more sternotomies. Mean bypass time was 83.6 min (SD 43.1). Postoperatively, mean duration of ventilation was 44 h; mean ITU stay was 4 days (SD 5.3) and mean inpatient total stay was 12 days. Thirty-six patients (28.8%) required inotropic support postoperatively. Complication rates were low: pleuro-pulmonary, 30 patients (24%), re-operation for bleeding, four patients (3.2%) and CVA, two patients (1.6%). Eight patients (6.4%) died within 30 days. Ten-year survival figures (Kaplan-Meier) were: 47% for all causes of mortality and 82.9% when only valve related causes of death were considered. Most of the patients (97.5%) had not required re-operation at 10 years. CONCLUSION: Mitral prosthetic replacement via a right thoracotomy on beating heart under normothermic bypass offers a safe alternative to redo median sternotomy in this high-risk group. Operative access is facilitated and procedural time reduced. Complication rates are low and perioperative mortality is lower than that generally reported with conventional surgery.

The Edinburgh Cardiac Surgery Score survival prediction in the long-stay ICU cardiac surgical patient.

Predictors of outcome in long-stay patients following cardiac surgery have hitherto been ill defined. The aims of this study were to test the Parsonnet pre-operative scoring system and to define a scoring system for inhospital mortality applicable post-operatively to strengthen the clinical decision-making process. Following case note review of 262 consecutive patients who stayed 7 days or more in intensive care, a total of 110 pre-, intra- and post-operative factors were documented. In this long-stay group the Parsonnet score was confirmed to be predictive of 30 day mortality. Univariate analysis identified significant association between mortality in the Intensive Care Unit (ICU) and the following: inotrope days, (defined as number of inotropes times number of days) ventilation, units of platelets (P = < 0.00001), chest reopening, fresh frozen plasma units (P < 0.002), total parenteral nutrition, noradrenaline, Parsonnet score (P = 0.005), dopamine, bypass time, vasodilators, intra-aortic balloon counterpulsation, enteral nutrition and other major surgery (P < 0.05). Stepwise logistic regression on these significant factors was used to produce the Edinburgh Cardiac Surgery Score (ECS) applicable from Day 10 onwards in the intensive care unit: ECS Score = (Inotrope days) +2 (Ventilation) + (Platelets) + (Parsonnet) -3. The ECS score may be a useful predictor of ICU mortality probability for cardiac surgical patients requiring 10 days or more intensive care and is presently undergoing prospective evaluation in our centre.

Pregnancy after uterine artery embolization to control haemorrhage from gestational trophoblastic tumour.

Gestational trophoblastic tumour (GTT) of the uterus can cause severe and even life threatening haemorrhage in patients who may be contemplating future pregnancy. Three cases of successful pregnancy after uterine artery embolization to control severe haemorrhage from uterine GTT are reported. Both uterine arteries had been selectively catheterized and embolized in these patients. The areas of pathological circulation measured on the pre- and post-embolization films had been reduced by over 80%. Embolization failed to control haemorrhage in another four patients in whom the uterine arteries had not been selectively catheterized and embolized and where the embolization procedures had reduced the areas of pathological circulation by less than 65%. The conclusions are that control of severe haemorrhage from uterine GTT is likely if both uterine arteries are selectively catheterized and embolized. Patients thus treated can become pregnant.

Gastrobronchial fistula in untreated lymphoma.

A 48-year-old man with B-cell lymphoma of the stomach was seen with recurrent pneumonia, weight loss, and anorexia. A barium study revealed a large malignant gastric ulcer with a gastrobronchial fistula. A computed tomography (CT) scan of the abdomen showed a gastric neoplasm invading the left lower lobe of the lung and the spleen.

Pulmonary capillary hemangiomatosis: radiographic appearance.

Pulmonary capillary hemangiomatosis is a rare disorder that is characterized pathologically by formation of capillaries along alveolar walls that may ultimately invade the pulmonary parenchyma and pulmonary arteries. The clinic presentation overlaps that of primary pulmonary hypertension, but the natural history of pulmonary capillary hemangiomatosis is one of rapid deterioration. The typical radiographic appearance is a diffuse bilateral reticulonodular pattern associated with enlarged central pulmonary arteries.