Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula.

Postpneumonectomy empyema, with or without bronchopleural fistula, remains an infrequent but serious complication of pulmonary resection. We reviewed our experience with the Clagett procedure in 31 patients with postpneumonectomy empyema. Seven had empyema alone and 24 had empyema with bronchopleural fistula. Ten patients died of metastatic disease without attempted closure of the thoracostomy window. In eight patients the total Clagett procedure was completed; window closure was permanent in two patients, but the remaining six had recurrence of empyema (four of whom had persistent occult fistulas). In eight further patients, persistent infection prevented attempted closure of the window. Five patients refused further surgical procedures. In only two of 31 patients were we able to achieve permanent closure of the thoracostomy window. Based on this experience, we conclude that open window thoracostomy provides adequate drainage and an excellent interim or permanent treatment of the infected pneumonectomy space. However, the presence of persistent bronchopleural fistula prevents successful completion of the total Clagett procedure. In our series, there were no deaths related to empyema or the surgical procedures performed for it.

The source of coronary perfusion during partial bypass for extracorporeal membrane oxygenation (ECMO).

The proper siting of cannulas to return oxygenated blood to patients on long-term membrane oxygenator support is as yet undecided. This experimental study on adult sheep shows the problems of obtaining perfusion of the coronary arterial tree when blood is returned to the ascending aorta. Our 11 experiments demonstrate that the coronary arterial tree is perfused with blood ejected from the left ventricle except during very high bypass flows (85% bypass) or when the aortic valve is rendered incompetent.

A modified Sugiura procedure.

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose-fundal wrap. Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, ad coagulopathy, died in the postoperative period. Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.

Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods.

After 28 patients, studied prospectively, underwent percutaneous endoscopic gastrostomy (PEG) by the Ponsky "pull" technique, another 28 patients underwent PEG by the Russell "introducer" method. These two groups were compared retrospectively with 28 patients who had previously undergone Stamm gastrostomy as an independent operation performed by the same group of surgeons. All procedures were done within a 5-year period. The major indication for gastrostomy was the inability to swallow due to neurologic diseases; a similar number of patients in each group also had pharyngeal blockage, cachexia, respiratory failure and inhalation burns. Percutaneous endoscopic gastrostomy could be done most appropriately under local anesthesia, the "introducer" method requiring less time than the "pull" method, which in turn required less time than the Stamm gastrostomy. Feeding was generally instituted successfully 24 hours after PEG compared with 3 days after Stamm gastrostomy. "Introducer" PEG was not associated with peristomal infection, and the authors postulate that the peristomal infections in the "pull" PEG group were due to oropharyngeal bacteria brought through the abdominal wall by that technique.

Technique for cardiopulmonary bypass in the goat.

The goat is an ideal animal for intracardiac surgical investigation. The animal is docile and easy to care for; it has an ideal heart size, a high cardiac output and a long life expectancy. The animal tolerates cardiopulmonary bypass well and does not require blood transfusion. Anoxic cardiac arrest is tolerated for up to 35 minutes. Initial experience in 36 animals with operations on the right side of the heart resulted in a 72% long-term survival.

Quantitative analysis of p53 protein in non-small cell lung cancer and its prognostic value.

Accumulation of mutant p53 protein occurs frequently in human malignancies, including 40-60% of non-small cell lung carcinomas. The implications of such p53 over-expression, usually assessed by immunohistochemical techniques, for the prognosis of lung cancer patients remain undetermined. In this study, we used a time-resolved immunofluorometric assay to measure p53 protein concentrations in extracts prepared from 86 primary non-small cell lung tumours and examined the associations between p53 protein levels (corrected for total protein) and other clinico-pathologic variables, including post-surgical disease-free and overall survival. Contingency tables analysed by chi2 tests revealed no significant relationships between p53 status, defined by a median cut-off point, and patient gender, age, disease stage, histologic grade and type, lymph node extension, smoking history and administration of adjuvant chemotherapy or radiation. However, multivariate Cox proportional hazard regression analysis demonstrated a dose-response relationship between p53 concentration, expressed as a 4-level, quartile-divided variable, and increased risk of relapse (p = 0.010) and death (p = 0.016). Patients whose tumours contained p53 concentrations exceeding the median value had over 3-fold higher risk of relapse (p = 0.002) and death (p = 0.007) than those whose tumours had lower p53 concentrations. We also provide evidence suggesting that the impact of p53 on survival is greater in patients with squamous cell carcinoma than in those with adenocarcinoma. Although the latter finding needs confirmation, our results suggest that application of an immunoassay of p53 protein on non-small cell lung tumour extracts may identify patients at increased risk of unfavourable outcome.