Trends during 25 years of coronary artery bypass operation at St. Luke's Medical Center in Milwaukee, Wisconsin.

BACKGROUND: Most studies of changes in coronary artery bypass graft (CABG) operations are from major academic institutions. The present study evaluated changes in CABG operations since 1968 in a community hospital. METHODS: The data were from the St. Luke's Medical Center Cardiovascular Data Registry in Milwaukee, Wisconsin. Mortality rates, risk factors, overall patient risk, and surgical procedures were compared from 1968 to 1994. RESULTS: There was a dramatic decrease in 30-day mortality rates from 1968 to 1972. After 1976, mortality rates increased because of higher risk patients, but the mortality rate, adjusted for patient risk, continued to decline. Both internal mammary arteries and sequential grafts were widely used by 1972, followed by a decline in use until 1980, and then a steep increase in use from 1980 to the present. CONCLUSIONS: This study provided evidence from a community hospital that the skills of the surgical teams improved first dramatically then gradually. The pattern of adapting new surgical techniques suggested that these techniques were critically evaluated for several years after they were introduced.

Percutaneous transluminal aortic valvuloplasty--the acute outcome and follow-up of 149 patients who underwent the double balloon technique.

Double balloon percutaneous transluminal aortic valvuloplasty (PTAV) was performed on 149 patients (76 male (51%), mean age 76 +/- 11 years) whose symptoms included severe congestive heart failure in 127 cases (82%), syncope in 21 (14%) and angina in six (4%). Significant changes (P less than 0.05) in peak systolic (83 +/- 36 to 38 +/- 30 mmHg) and mean gradient (68 +/- 25 to 36 +/- 21 mmHg), and aortic valve area (0.6 +/- 0.2 to 1.0 +/- 0.4 cm2) were achieved in 130/149 patients (87%). Complications included an overall in-hospital mortality of 13%, (10.0% excluding the six deaths occurring in 18 moribund patients), a neurologic deficit incidence of 3%, and surgical arterial entry site repair 3.0% (14/47) of patients. Multivariate analysis identified congestive heart failure (NYHA Class IV), left ventricular ejection fraction, cardiac output and coronary artery disease as independent variables significantly affecting in-hospital mortality. Predictors of poor long-term survival were degree of heart failure, and coronary artery disease. The cumulative probability of survival at 24 months was 52 +/- 5% (excluding non-cardiac deaths, was 66 +/- 3%). Follow-up (mean time: 16 +/- 7 months) of 130 patients discharged alive revealed 41 late deaths (26 cardiac related). Sixty-two patients (70%) were symptomatically improved; 17 patients had symptom recurrence and underwent repeat valvuloplasty, and 10 patients valve replacement. Follow-up catheterization of 18 asymptomatic patients revealed that 11 patients had silently restenosed. These data indicate that aortic valvuloplasty is a palliative therapy for elderly patients, who are poor surgical candidates, with symptomatic calcific aortic stenosis with reasonable clinical success and long-term survival when considering their clinical status, but with a significant restenosis rate.

Coronary artery bypass surgery in patients over age 70 years: report from the Milwaukee Cardiovascular Data Registry.

Between 1972 and 1985, 674 coronary bypass patients greater than or equal to 70 years (70% male, mean age 73 years) were among 10,622 patients with both catheterization and operative data entered into the Milwaukee Cardiovascular Data Registry. These greater than or equal to 70 years patients were analyzed regarding the operative morbidity, the 30-day operative mortality and the operative mortality's relation to coronary artery disease and ventricular wall motion abnormalities. The operative mortality was not different for the 174 patients operated upon before and the 500 patients after 1980. A mean of 3.4 grafts were placed during surgery. The complications encountered included a 7.1% perioperative infarction rate, a 4.2% incidence of cerebrovascular accident, a 3.6% incidence of reoperation for bleeding, a 2.4% incidence of renal failure, and a 2.1% incidence of pulmonary embolism. The overall operative mortality was 7.4%. The extent of coronary artery disease was distributed among patients such that 8.4% had single-, 28.0% had double-, and 63.6% had triple-vessel disease. The operative mortality as related to the extent of coronary artery disease was 5.2% for single-, 8.9% for double-, and 7.0% for triple-vessel disease. The operative mortality was 6.7% with no and 7.9% with left ventricular wall motion abnormalities. The operative mortality was 1.9% with 1 segmental wall motion abnormality, and increased to 13.3% (p less than 0.05) with 4-6 segmental wall motion abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Perforation of the sigmoid colon simulating acute appendicitis.

Diverticulitis and carcinoma with abscess formation following perforation of the redundant sigmoid colon was erroneously diagnosed as acute appendicitis in nine patients over a period of five years. As te inflammatory process develops in the right lower quadrant of the abdomen, lack of previous colonic pathology may lead to a misdiagnosis, usually of acute appendicitis. It should be borne in mind, however, that acute appendicitis decreases with age, whereas diverticula and carcinomas increase, and that the sigmoid colon is often a redundant organ with a tendency to migrate to the right side of the abdomen. In elderly patients with acute right abdominal pathology, it is important to operate through a transrectal or paramedian incision. A two-stage operation is preferable to a three-stage one.

Urometrocolpos associated with retroiliac ureter.

We report on an 8-year-old girl who presented clinically with an acute abdomen. Examination revealed a left hypoplastic kidney with its ureter draining into the lower segment of the vagina, which was closed by an imperforate hymen. Initially, we thought that pressure by the urometrocolpos on the right ureter caused right hydronephrosis. Subsequently, it was found that the right ureter followed a retroiliac course and was compressed by a U-shaped iliac artery loop at the ureteral crossing. The iliac artery extended to the level of the second lumbar vertebra.

A comparative synchronous coronary surgery survival study.

Utilizing patient criteria published by the Veterans Administration Cooperative (VAC) Study, a cohort of 229 surgically treated patients was retrieved from the Milwaukee Cardiovascular Data Registry. These patients were all operated on by one surgeon during 1972 to 1974. Four-year survival of this group was compared with that of the medically treated cohort of 310 patients from the VAC Study. Operative mortality was included in all surgical groups. The cumulative 4-year survival of both groups revealed a 95 to 85% advantage for surgical therapy. In patients with three-vessel disease, the cumulative survival favored surgical therapy--94% compared with 80% in the medically terated cohort--and in patients with triple-vessel disease and a normal left ventricle, surgical therapy again showed better results: 100% compared with 88%. Patients with two-vessel disease and a normal left ventricle who underwent surgical intervention had slightly better 4-year survival than those who had medical treatment--100% versus 95%--and those with two-vessel disease and an abnormal left ventricle had a 93% survival after surgical treatment compared with 84% for those with medical treatment. For patients with single-vessel disease, there was no difference in survival between the surgical and medical cohorts.

Doppler flowmeter in the differential diagnosis of the acute scrotum in children.

A Doppler flowmeter was used to evaluate an acute scrotum in 23 children. A diminished or absent flow was noted in cases of torsion of the testis. Orchitis, epididymitis and torsion of the testicular appendix were accompanied with an increased blood flow. Inflammatory and ischemic lesions could be detected and in all operated cases the diagnosis proved to be correct. Unnecessary operations in cases of torsion of the testicular appendix can be avoided with this accurate non-invasive method.

Transomental strangulation.

A case of transomental strangulation in an 8-yr-old boy is presented with a review of the pertinent literature. The clinical presentation was that of an intestinal obstruction. A gastrografin study indicated the necessity of immediate surgery. Etiologic aspects and nomenclature controversies are briefly discussed.

The survival of inoperable breast cancer treated with radiotherapy and radiotherapy followed by mastectomy.

Forty-five patients with locally advanced breast carcinoma were treated by radiotherapy. Twelve of them became operable and were operated. After 3 and 4 years in comparable clinical stage the rate of metastases in the nonoperated group was 78.6% and in the operated 75%. The survival after 3 and 4 years in comparable clinical stages was similar. In more advanced stages the survival was worse. Considering the trauma of mastectomy and the similar survival obtained in our material, an international trial should be performed to decide whether inoperable breast cancer becoming operable after radiotherapy should be operated.

Intravenous hyperalimentation in the management of the critically ill patient, with special reference to abdominal fistulae.

The present paper described the technique of intravenous hyperalimentation applied to a group of 100 surgical patients. A specially prepared diet supplying a high amount of calories, using hypertonic glucose and supplying nitrogen, using polypeptides or aminoacid solutions, was infused into the superior vena cava. The inhibition of digestive secretions, during the period of hyperalimentation, was used in the management of 19 patients with intestinal and pancreatic fistulae. The general conclusion reached after wide clinical experience was that by supplying energy and nitrogen to a patient in a severe catabolic state, a significant and sometimes dramatic capacity could be developed which allowed him to overcome difficult conditions and even initiated a reversal of the metabolic balance in the direction of anabolism. The regimen should be adopted in the preoperative preparation of debilitated patients; in hypercatabolic states (post-trauma, post-surgery or burns); in gastrointestinal, granulomatous or infectious diseases; in acute pancreatitis; in digestive fistulae; in oncological conditions, and so on. The metabolic and infective complications can be pregressively decreased and eventually prevented by proper handling and strict metabolic monitoring. The use of this hyperalimentation was extremely encouraging, and on many occasions we had the impression that it was life saving.

Differential patterns of vasculature to liver tumours.

An angiographic study of the vasculature of Vx2 tumour deposits in the rabbit's liver is described.Tumours transplanted from donor rabbits within less than 2 weeks incubation, developed into an amorphic infiltrating tumour, characterized by a rich arterial network. Tumours harvested after 3 weeks growth in donors, became cystic and had a scanty arterial supply.In both groups there was no portal circulation to the tumours' deposits.It is suggested that prior to intra-arterial treatment of cancer in the liver, the morphology of the tumour should be assessed.