An alternate method of ventricular venting--the pulmonary artery sump.

The need for venting the heart during cardiopulmonary bypass has been the topic of continued debate. Potential disadvantages and drawbacks have been noted with traditional modes for venting. A technique for venting the heart is presented using a pulmonary artery catheter. The relative advantages and merits of this approach are discussed.

Rupture of the left main-stem bronchus with a polyvinylchloride double-lumen tube.

Double-lumen tubes have proved to be a useful adjunct in thoracic surgery. Their use has become quite commonplace, particularly since the introduction of the softer polyvinylchloride (PVC) tubes, which are technically easier to use and may carry less risk for serious complications. Any such tube, however, can cause life-threatening complications. We present a case with such a complication related to the use of a PVC double-lumen tube and make recommendations regarding the use of these tubes to minimize the risk of serious intraoperative complications.

Comparative efficacy of positron emission tomography with fluorodeoxyglucose in evaluation of small (<1 cm), intermediate (1 to 3 cm), and large (>3 cm) lymph node lesions.

PURPOSE: Our objective was to determine if positron emission tomography (PET) with fluorodeoxyglucose (FDG; PET-FDG) imaging is equally efficacious in detection of metastases in small and large mediastinal lymph nodes as compared to CT scanning. MATERIALS AND METHODS: PET-FDG imaging, CT scanning, and histology results of sampled mediastinal lymph nodes were compared in 54 patients of total 118 patients studied. Efficacy of PET and CT was determined and compared in small (< 1 cm), intermediate (1 to 3 cm), and large (> 3 cm) mediastinal lesions. RESULTS: PET was accurate in 94% of patients in characterizing "N" disease as compared to 61% with CT. Overall, sensitivity, specificity, and accuracy of PET for staging mediastinal lymph nodes (n = 168 in 54 patients) was 96, 93, and 94%, as compared to 68, 65, and 66% with CT. Positive and negative predictive value of PET in detecting mediastinal adenopathy was 86% and 98%, as compared to 47% and 82% with CT, respectively. PET was also highly reliable and accurate for detecting lymph nodes < 1 cm, 1 to 3 cm, and > 3 cm in size with superior efficacy than CT. Sensitivity, specificity, and accuracy of PET for detecting malignancy in lymph node lesions < 1 cm in size was 97, 82, and 95%, respectively. CONCLUSION: PET-FDG imaging is equally reliable and accurate for detecting disease in small and large lymph node lesions in patients with suspected or proven lung cancer with better efficacy than CT.

Wounds traversing two or more cardiac chambers. Case presentation of two survivors and review of the literature.

A review of the literature on patients who have survived wounds traversing two or more cardiac chambers is presented and two further cases are documented. The inital management of the patient should be directed toward control of hemorrhage or treatment of cardica tamponade or both. Cardiopulmonary bypass is helpful in repair of many intracardiac defects but is not absolutely essential for survival. Surface myocardial wounds should be sutured during the initial procedure to allow for immediate survival. A subsequent procedure may be indicated to correct intracardiac defects. Repair of injuries to the mitral and aortic valves should be directed at an attempt to reconstruct the damaged valve. If this is impossible, a prosthetic valve should be inserted. Injuries to the tricuspid and pulmonic valves probably warrant a conservative approach. Septal defects can be treated easily with Dacron patches or primary suture closure. Postoperative complications include all of those commonly seen with thoracic procedures, but infection is less prominent than one would anticipate, even when prostheses have been implanted. With early, aggressive management it is anticipated that more survivors of these serious wounds will be recorded.

Thoracoscopic resection of bilateral metastatic sarcomas causing spontaneous pneumothorax.

Pulmonary metastases from soft tissue sarcomas may present with spontaneous pneumothorax. Metastatectomy via thoracotomy or median sternotomy has been the procedure of choice. We present a patient with bilateral spontaneous pneumothorax secondary to metastatic angiosarcoma where staged video-assisted thoracic surgery using the thoracoscope was used to successfully resect the tumors.

Positron emission tomographic imaging with fluorodeoxyglucose isefficacious in evaluating malignant pulmonary disease.

OBJECTIVE: Positron emission tomography (PET), when used with the intravenously administered radiopharmaceutical F-18 fluorodeoxyglucose (FDG), has the potential to help in the evaluation of patients with lung cancer because the radiopharmaceutical is concentrated by metabolically active cells. We conducted a retrospective study of PET-FDG in 96 patients evaluated at our institution over the past 2 years for suspected primary pulmonary neoplasms. PET-FDG results were compared with the findings of computed tomographic scans on the same patients. All patients underwent surgical exploration with or without resection of the malignant tumors. Sites of potential malignancy were subjected to biopsy and/or excision, with subsequent pathologic evaluation. RESULTS: A total of 96 patients with suspected or proven primary pulmonary malignant disease were evaluated. Sixty-six patients had histologically confirmed malignant tumors, and 30 had benign masses histologically. PET-FDG had an accuracy of detecting malignancy in pulmonary lesions of 92% (sensitivity 97%; specificity 89%). A total of 111 surgically sampled sites were from lymph nodes. PET-FDG was accurate in predicting the malignancy of nodes in 91% of instances, whereas computed tomography was correct in 64%. The sensitivity, specificity, and predictive accuracy of PET in detecting metastatic lymphadenopathy in mediastinal lymph nodes were 98%, 94%, and 95%, respectively. PET-FDG also changed the M stage in 8 (12%) patients (6 with and 2 without metastases). The 6 malignant (positive) lesions were correctly identified by PET-FDG, and the 2 without tumor were accurately predicted as benign (negative). CONCLUSION: These initial results suggest that PET-FDG is highly accurate in identifying and staging lung cancer. PET-FDG also appears to be more accurate in detecting metastatic mediastinal lymphadenopathy than computed tomographic scan.

Coronary artery bypass grafting in young patients under 36 years of age.

Results of coronary artery bypass graft (CABG) surgery in patients under age 36 who were operated upon between 1970 and 1980 at two large medical centers were compared to matched control patients, age 45 to 59 years, and 60 years and over. Patient follow-up ranged from one to 13 years (average five years). Event-free survival was significantly worse in the young group (37 percent) vs the middle aged group (61 percent, p less than 0.01) and vs the elderly group (59 percent, p less than 0.02). Failure of the operation was due to failure to improve or worsening of Canadian Cardiovascular Society anginal class, need for reoperation, subsequent myocardial infarction, or death due to cardiac causes. Risk of failure of CABG surgery in young patients was increased with the presence of cardiac risk factors. Because of the high rate of long-term failure of CABG surgery in young patients, its use in this group needs to be reevaluated relative to current aggressive medical therapy for angina.

Surgical implications of intraoperative postinfarction ventricular rupture.

This case report documents that ventricular myocardial rupture after acute infarction may seal with clot, only to rupture again with potentially lethal consequences. At exploration, the clot over a fresh rupture was intact. As closure was started, the clot disrupted, causing severe hemorrhage. Rupture was successfully repaired and the patient survived.

Acute diverticulitis following cardiac surgery.

Gastrointestinal complications requiring surgical correction following cardiopulmonary bypass most frequently involve the upper gastrointestinal tract. Surgical diseases of the colon are quite unusual in this setting. We recently performed cardiac surgery on three patients who developed acute diverticulitis requiring laparotomy in the early postoperative period. The presentation and management of this disorder after open heart surgery are discussed.

Bayesian statistical theory in the preoperative diagnosis of pulmonary lesions.

We used a computerized Bayesian algorithm to assist in the preoperative diagnosis of pulmonary lesions. One hundred consecutive patients who were undergoing exploratory thoracotomy for newly discovered pulmonary lesions were prospectively evaluated. The Bayesian model used a total of 44 preoperative clinical and roentgenographic factors to categorize the lesions as benign or malignant. The Bayesian algorithm correctly categorized 96 of the 100 lesions, thereby providing an accuracy of 96 percent. The sensitivity of the model was 98 percent and the specificity was 87 percent. All but two of the 85 malignant lesions were correctly categorized and 13 of the 15 benign lesions were correctly analyzed by the model. These results indicate that computer-assisted diagnosis using the Theorem of Bayes may provide valuable preoperative information for the management of selected patients.

Cystic lesion of the thymus. An occasionally malignant cervical and/or anterior mediastinal mass.

Between 1965 and 1982, we treated 46 patients with cystic lesions of the thymus. Thirty patients had anterior mediastinal cysts, nine had cysts which were large enough to be both cervical and mediastinal, and seven had cervical cysts. The majority (40/46) presented with asymptomatic masses. Six patients presented with distinct complaints: dysphagia (four patients), hoarseness owing to vocal cord paralysis (one patient), and cervical pain (one patient). All six had benign thymic cysts. The diagnosis of a cystic mass was established prior to operation by ultrasonography and computed axial tomography in our last three patients. These two techniques delineated the capsule and the central fluid in those three cases. All 46 patients had the mass resected without mortality or significant morbidity, except for resection of the phrenic nerve in one patient with malignant cystic thymoma. Cervical cysts were excised through cervical incisions. Cysts located in the anterior mediastinum and cervical-mediastinal cysts required median sternotomy or right thoracotomy for successful resection. Pathological examination showed that 39 patients had benign thymic cysts, three had benign cystic thymoma, two had malignant thymoma, one had a seminoma arising in the thymus, and one had a lymphoblastoma. We believe that a cystic thymic mass which can be detected by ultrasonography and computed tomography, although usually benign, does not eliminate the possibility of malignancy, and resection, therefore, is indicated.

Creatine kinase and lactate dehydrogenase in the muscles encountered during median sternotomy and in the myocardium of the cardiac chambers.

The validity of using creatine kinase MB and lactate dehydrogenase serum isoenzymes to confirm the diagnosis of perioperative myocardial infarction in patients who have had cardiac operations has been questioned, since both have been detected in skeletal muscles. Little is known concerning the concentration of either isoenzyme in the muscles routinely encountered during median sternotomy. Since we have previously shown that the dog is an adequate model in which to study creatine kinase and lactate dehydrogenase isoenzymes, eight healthy dogs were placed under general anesthesia and 1 gm blocks were resected from selected muscles (intercostals, rectus abdominis, diaphragm, and sternothyroid) and from the walls of all four cardiac chambers. Each 1 gm block was homogenized individually in Ringer's lactate, centrifuged, and the supernatants were analyzed for total creatine kinase and lactate dehydrogenase activity by spectrophotometry. Isoenzymes were determined by agarose gel electrophoresis. The study shows that the chest wall muscles and atrial myocardium have appreciable quantities of creatine kinase MB. Hence, serum creatine kinase MB bands in the perioperative period can be generated by manipulation of chest wall muscles and the atrial wall as well as by infarction of the ventricular myocardium.

A comparison of patients with endoscopic esophageal perforations and patients with Boerhaave's syndrome.

A review was conducted to ascertain whether patients who suffered spontaneous postemetic esophageal rupture (Boerhaave's syndrome) experienced higher morbidity and mortality than patients who had endoscopic iatrogenic esophageal perforations. Review of the records of three medical centers from 1960 to 1985 identified 11 patients with Boerhaave's syndrome (group B) and 19 with iatrogenic perforations (group E). In group B, four patients were diagnosed greater than 24 h after perforation. Nine were treated surgically; of these one died. Two group B patients who were treated conservatively survived. In group E, only four patients were diagnosed greater than 24 h after perforation. Of 19 patients, 15 were treated surgically and four, medically. In group E, three patients died (one surgically and two conservatively treated). This study suggests that there is little difference in mortality between the two groups of patients as long as the diagnosis is made early and therapy is instituted promptly.

Changes in serum creatine kinase and lactate dehydrogenase caused by acute perioperative myocardial infarction and by transatrial cardiac surgical procedures.

A prospective clinical study was conducted to ascertain if a patient's postoperative elevation in serum creatine kinase MB isoenzyme coupled with determination of the lactate dehydrogenase1/lactate dehydrogenase2 ratio could differentiate whether atrial or ventricular myocardium was the source of these changes. Animal studies have shown that atrial myocardium is as rich a source of creatine kinase MB as is ventricular myocardium. Atrial myocardium has a lactate dehydrogenase1/lactate dehydrogenase2 ratio less than 1.00, whereas in ventricular myocardium the ratio is greater than 1.00. Sixty-four patients were assigned to six groups on the basis of serial electrocardiograms and vectorcardiograms by a cardiologist who was unaware of their clinical courses. The control group (Group 1) consisted of 16 patients admitted to the coronary care unit who had no electrocardiographic changes. Three surgical groups without electrocardiographic or vectorcardiographic evidence of perioperative myocardial infarction were studied: 10 patients undergoing routine coronary artery bypass procedures (Group 2), six adults undergoing repair of secundum atrial septal defect (Group 3), and 13 patients having mitral valve replacement (Group 4). Two groups of surgical patients who had acute perioperative transmural myocardial infarctions confirmed by serial electrocardiograms and vectorcardiograms were studied: 15 patients (Group 5) who had elective coronary artery bypass procedures and four (Group 6) who had mitral valve replacement. This study suggests that serum creatine kinase MB levels in excess of 50 IU/L on the postoperative day 1 and day 2 samples coupled with serum lactate dehydrogenase1/lactate dehydrogenase2 ratios greater than 1.00 on the postoperative day 2 and day 3 samples support the diagnosis of acute myocardial infarction. Patient groups undergoing procedures necessitating atriotomies had average elevations in serum creatine kinase MB and in the lactate dehydrogenase1/lactate dehydrogenase2 ratio, but these were significantly less than those seen when acute perioperative myocardial infarction had occurred.

The use of computed tomography in the evaluation of mediastinal masses.

A retrospective analysis was conducted to ascertain whether computed tomography had increased diagnostic accuracy while decreasing the number of tests needed in the preoperative assessment of patients with mediastinal masses. A total of 42 patients were entered into the study: Fifteen patients were evaluated before the advent of computed tomography (No CT) and 27 patients had computed tomography during their evaluation (CT). The No CT group comprised 10 male and five female patients (2:1 ratio); the age range was 8 months to 61 years. The CT group included 15 male and 12 female patients (1.25:1.0 ratio), the age range being 21 to 70 years. In each group, both invasive and noninvasive studies were done. Although the CT group had 40 noninvasive tests, 27 were computed tomographic scans. The additional 13 noninvasive tests and the five invasive tests added no significant diagnostic information. In the No CT group, preoperative evaluation as to the cystic or solid nature of the mass was correct only four of 13 times (31%). In the CT group, 22 of 25 patients had accurate assessment as to the cystic or solid nature of the lesions (88%). In addition, extension of the mass into other structures, consistent with malignancy, was correctly diagnosed preoperatively in nine of the patients in the CT group. Two had extension of the mass at operation not preoperatively diagnosed (82% accuracy). None of the No CT group was given an assessment of possible mass extension preoperatively. The results suggest that mediastinal masses can be evaluated by computed tomography with a high degree of accuracy for predicting the nature, size, location, and involvement of other organs by the mass. The use of other tests before resection generally yields little additional information.

Randomized clinical trial of preoperative and postoperative adjuvant chemotherapy with cisplatin, vindesine, and bleomycin for carcinoma of the esophagus.

Thirty-nine patients with potentially resectable cancer of the middle or lower esophagus who had not previously been treated were randomly assigned to receive either immediate operation (n = 20) or operation plus preoperative and postoperative therapy with cisplatin, vindesine, and bleomycin (n = 19). Patients were stratified by tumor size and location and by sex, with no significant differences appearing between the two treatment groups. Median follow-up for both groups was 30 months. The preoperative response rate to chemotherapy was 47%. The postoperative complication rate for patients in the operation-only group was 47%; it was 29% for patients receiving chemotherapy. The overall resectability rates were similar for the two groups. Patients responding to chemotherapy preoperatively had significantly prolonged survival (median greater than 20 months) when compared with either nonresponders (median 6.2 months) or patients receiving only operation (median 8.6 months). A highly significant correlation was noted between a weight loss of less than 10% and response to chemotherapy, which suggested that responses occurred in patients with less advanced disease. We conclude that preoperative and postoperative cisplatin, vindesine, and bleomycin chemotherapy has acceptable toxicity and does not increase the incidence of postoperative complications. The natural history of epidermoid carcinoma of the esophagus is altered and overall survival is prolonged for patients responding to preoperative chemotherapy. Potential responding patients can be identified by the degree of preoperative weight loss.

Current management of esophageal impactions.

We analyzed our experience at a university medical center from 1977 to 1990 to assess our success in using esophagoscopy and related treatments for removing esophageal impactions. There were 157 episodes of impaction in 150 patients, consisting of 39 pediatric and 111 adult patients. In the pediatric cases, foreign bodies were most often the cause of impaction, while adult cases were usually caused by food or bones. Esophagoscopy was performed successfully in 32 of 34 pediatric patients in which it was attempted; there was only one complication. Other forms of therapy that were infrequently tried met with variable results. Esophagoscopy was successful in removing the impaction in 104 of 109 attempts in adults. Two perforations occurred, with one resulting in death. Various other methods achieved success in the remaining patients. The data suggest that esophageal impaction can be treated successfully by endoscopy with very low morbidity and mortality.

Management of patients with malignant thymoma.

This report documents the results of therapy in 23 patients treated for malignant thymoma between 1944 and 1979. Of the group, 22 patients had neoplasms which invaded mediastinal structures; six had distant metastases. Four patients had myasthenia gravis and one had erythroid hypoplasia associated with collagen vascular disease. No deaths were associated with primary therapy, which included an operative procedure in all cases. Follow-up ranged from 4 months to 18 years (mean 5.63 +/- 1.03 years, SEM). Fifteen patients died, with postoperative survival times ranging from 4 months to 18 years (mean 3.8 +/- 1.27 years). Five patients were alive without recurrence from 3 to 11 years postoperatively (mean 6.8 +/- 1.36 years), and three patients were alive with recurrence or distant metastases from 4 to 17 years postoperatively (mean 10.75 +/- 2.66 years). Differences in survival on the basis of tumor cell type were not statistically significant. Therapeutic groups were analyzed for 5 year survivors, tumor deaths within 5 years of therapy, deaths due to other causes, deaths due to tumor after 5 years, those presently alive, and longest known survivor. The data suggest that complete surgical excision offers the best chance of long-term survival when compared to partial resection plus irradiation (p less than 0.05). No statistical significance could be demonstrated between the groups who had complete resection with versus without postoperative irradiation. There also was no statistically significant difference between the group of patients receiving irradiation following partial excision of most of their tumor and the group receiving irradiation following only biopsy of the lesion. This observation suggests there is no value in so-called "debulking procedures" and suggests that irradiation may be of value in local control of thymoma. Perpetual surveillance is necessary since late recurrence is common.

Alterations in serum creatine kinase and lactate dehydrogenase. Association with abdominal aortic surgery, myocardial infarction and bowel necrosis.

Experimental studies have shown that peripheral serum creatine kinase and lactate dehydrogenase change with bowel infarction. Some clinical reports have suggested that similar changes occur in patients. This prospective study documents the changes in these enzymes associated with acute myocardial infarction, acute bowel necrosis (MES INF), and uncomplicated abdominal aortic reconstruction. Analysis of 15 patients with AMI, 13 patients undergoing major AAS, and eight patients with MES INF has shown that these conditions may be differentiated by analysis of serum CK and LD isoenzymes. The study suggests that in the absence of electrocardiographic changes, a patient with epigastric distress with elevated levels of serum CK and either CK-MB or CK-BB bands present may well have a mesenteric rather than a myocardial infarction. Acute myocardial infarction can be ruled out further through analysis of serum LD1/LD2 ratios.

Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis.

Enterostomal varices have been recognized as a cause of serious recurrent hemorrhage in patients with portal hypertension secondary to cirrhosis. Most often the varices at the mucocutaneous junction are the source of the hemorrhage. Three patients--two with hemorrhages from ileostomies and one with hemorrhages from a colostomy--are presented. Local measures have proved successful in controlling hemorrhages. Occasionally direct pressure alone will prove sufficient; more often the bleeding varix will need ligation. Complete revision of the enterostomy under local anesthesia can effect total disruption of the protal-systemic shunt and temporarily can eliminate local hemorrhage. Surgically created portasystemic shunts may be considered in good risk patients in order to eliminate hemorrhage from the stomal varices. Palliative local measures, however, remain the treatment of choice in the high-risk, cirrhotic patient who is unlikely to survive a major operation.