Diaphragmatic pedicle flap for treatment of Boerhaave's syndrome.

A case of spontaneous perforation of the esophagus is described, which was managed by thoracotomy, primary closure, and reinforcement of the suture line with as diaphragmatic pedicle flap. The advantages of this technique are discussed.

Myocardial protection with methylprednisolone. Evaluation of viability of hearts subjected to warm ischemia before transplantation.

Methylprednisolone was given at different intervals before warm ischemia of the heart (37 degrees C. for 60 minutes), and viability of these hearts was evaluated after transplantation into the abdomen of another dog. Animals were divided into four groups: Group 1 received no methylprednisolone: Groups II, III, and IV received 30 mg. of methylprednisolone per kilogram 10 minutes, 60 minutes, and 120 minutes before warm ischemia. In all parameters measured, the animals of Group IV performed better than the other groups. It is concluded that methylprednisolone, when given 2 hours before warm ischemia, exerts a protective effect on the ischemic myocardium.

Surgical implications of pulmonary actinomycosis.

Four cases of pulmonary actinomycosis are presented. Resection was necessary in three cases before the diagnosis was established. A high index of suspicion for this disease is advised for the thoracic surgeon involved in the treatment of lung masses.

Operative experience with infective endocarditis and intracerebral mycotic aneurysm.

The surgical management of eight patients with infective endocarditis and intracerebral mycotic aneurysm is presented. Three patients had craniotomy before valve replacement and four patients had valve replacement before craniotomy. There were no deaths related to the valve replacement or craniotomy. Two of the eight patients died in the hospital of continuing sepsis resulting from undrained foci of infection. It is concluded that the drug-addicted patient with a mycotic aneurysm and hemodynamic decompensation from endocarditis can be successfully treated by staging the operations according to the more severe problem.

The infected pacemaker pocket.

Between January, 1963, and September, 1978, a total of 1,789 pacemakers were implanted at Henry Ford Hospital. Infection at the site of implantation developed in 19 instances for an incidence of 1.06 percent. The most common organism cultured was Staphylococcus epidermidis, and conservative treatment was successful with these patients. In all patients with organisms other than Staphylococcus epidermidis, reimplantation of a new unit in a new, clean site was required.

The role of surgery in primary osteomyelitis of the chest wall.

Seven patients with primary osteomyelitis of the chest wall are described. All patients presented with pain at the site of infection, and four patients had a tumor-like mass that could easily be confused with a neoplastic process. All were heroin addicted and pseudomonas was the most common organism cultured. Conservative management with antibiotics for a minimum of 4 weeks is recommended with operation assuming a secondary role, namely, to assist in the initial diagnosis or in the form of limited resection of residual sinuses. Primary wide resection is discouraged.

Complications of attempted central venous injections performed by drug abusers.

Intravenous abuse of drugs has become an integral part of various subcultures within American communities. The continued use of peripheral veins in this setting eventually leads to their obliteration through a sclerotic or infectious process. Inveterate drug abusers often turn to using larger veins in the groin and neck. Some real or imagined technical aspects of subclavian and internal jugular venous injections are well known to drug abusers in many locales. Undoubtedly as these skills are passed from one user to another, the fine points of anatomy and needle positioning are distorted with resultant mishaps. Twelve patients have been seen with complications arising from attempted supra- or subclavicular injections of drugs in the "street" setting: unilateral pneumothorax, six cases; bilateral pneumothorax, one case; mycotic subclavian carotid artery aneurysm, two cases; neck abscesses, three cases (one also listed under pneumothorax); and paraplegia, one case. Since this type of injury may occur in greater frequency due to increasing drug abuse, recognition and proper treatment of these potentially life-threatening problems may prevent mortality and reduce morbidity.

Long-term results of esophagomyotomy for achalasia of esophagus.

Modified Heller's esophagomyotomy for achalasia of the esophagus was done in 145 patients at Henry Ford Hospital, Detroit, from 1951 to 1977. Information on current symptoms was obtained for 121 patients from a detailed questionnaire that was sent to all patients, from personal interviews, or from data obtained from patients' clinical records. Average period of follow-up was 85 months. Actuarial analysis of postoperative symptoms showed an incidence of reflux of 24% after one year and 48% after ten years; incidence of relief of dysphagia was 89% of all patients after one year and 81% after ten years. Continual surveillance of patients after esophagomyotomy must be stressed. Dissatisfaction with the results of this procedure prompted us to recommend that an antireflux operation be performed at the time of the initial procedure.

Protective effect of hyaluronidase after long-term aortic cross-clamping: initial experimental observations.

This work studies the effect of hyaluronidase on myocardium subjected to long-term aortic cross-clamping (three hours) and moderate hypothermia (28 degrees C). Animals receiving hyaluronidase (1,00o U per liter) through the root of the aorta with a procaine-potassium chloride-lasmalyte cardioplegic solution showed better functional, electrical, and morphological response than the untreated animals. These findings, although preliminary, appear to be promising for potential clinical application.

Auxiliary heart transplantation.

At the present time, the major obstacles in the successful clinical application of heart transplantation are the immunological attack on the allograft, the treatment of complications resulting from immunosuppression, and the supply of transplantable hearts. Recently, auxiliary heart transplantation has been proved to be a successful technique for treatment of end-stage myocardial failure in humans. Here we review the experimental work in auxiliary heart transplantation leading to the present technique used in humans.

Spontaneous degeneration of porcine bioprosthetic valves.

From October, 1971, to October, 1979, 490 patients with 560 porcine bioprosthetic valves were discharged from the hospital. During these 8 years, 23 valves were removed because of failure due to spontaneous degeneration. Bioprosthetic valve survival without degeneration was at 4 years, 98.9% +/- 86 (standard error); at 5 years, 96.4% +/- 1.3; at 6 years, 90.8% +/- 2.4; and at 7 years, 84.2% +/- 3.7. There was no difference in degeneration observed with regard to sex, valve position, or whether the valves were rinsed with antibiotics prior to implantation. There was an increase in degeneration in patients 35 years old and younger compared with those more than 35 years old (p = 0.0001). Valve failure was gradual, and valve changes were noted by echocardiogram and phonocardiogram prior to actual failure. Specific factors leading to degeneration require further investigation.

Management of tricuspid valve insufficiency. Replacement with Hancock bioprosthesis or suture annuloplasty.

Forty-seven patients who underwent tricuspid valve replacement (TVR) or tricuspid annuloplasty (TA) combined with aortic (AVR) or mitral valve replacement (MVR) at Henry Ford Hospital, from 1971 to 1977 are reviewed. Thirty-three patients underwent TVR with a Hancock valve combined with MVR or AVR; hospital mortality was 30% (10 to 33) and was higher at the beginning of the series when smaller valves were used. No valve dysfunction has been seen with mean follow-up time of 36.7 months, ranging from 4 to 60 months. Good functional improvement was accomplished in all patients. Fourteen patients underwent TA; hospital mortality was 21% (3 of 14) with one late mortality (9%); good functional improvement was accomplished in all patients. However, one patient presented 11 months following surgery with tricuspid insufficiency after a period of improvement. For patients with severely deformed valves a large size Hancock valve is recommended. For insufficiency alone tricuspid annuloplasty is recommended.

Intrathecal morphine for off-pump coronary artery bypass patients.

Due to the fact that patients have increased mental alertness following off-pump coronary artery bypass (OPCAB), pain management in the immediate postoperative period is a major concern. Thirty-two patients underwent OPCAB grafting, 20 received 5 mcg/kg morphine sulfate intrathecally. This group was compared with 12 patients who did not receive intrathecal morphine. All patients were verbally evaluated for pain using the Wong-Baker Visual Analog Scale at eight, 12 and 24 hours. All the scores were highly statistically significant in favor of the intrathecal group. No significant complications were seen in this group of patients. It is concluded that intrathecal morphine at 5 mcg/kg is effective and safe in maintaining comfort for OPCAB patients in the immediate postoperative period.

Lung water accumulation with and without left ventricular venting during cardiopulmonary bypass.

The effect of venting on left atrial pressure and lung water accumulation was studied after prolonged aortic cross-clamping (90 min) and cardiopulmonary bypass in mongrel dogs. Two groups of animals, one with and one without venting, were studied. Left atrial pressure rose significantly (p less than 0.05) in the non-vented animals. This increase, however, did not allow for lung water accumulation or morphological evidence of pulmonary edema. These results appear to indicate that venting is only necessary if a normal left atrial pressure is sought during prolonged aortic cross-clamping. Since the increase in left atrial pressure did not have any detrimental effect on lung morphology or water accumulation, the role of venting under our experimental setting becomes more theoretical than necessary.