Alcohol use following liver transplantation for alcoholic cirrhosis.

Due to the significant increase in the number of patients with alcoholic liver cirrhosis being referred for liver transplantation, studies to determine recidivism rates and influential factors affecting those rates have become increasingly crucial. Between 12/85 and 12/91, 67 patients diagnosed with alcohol related end-stage liver disease underwent orthotopic liver transplantation at Baylor University Medical Center. A 3-8 year follow-up study was conducted wherein surviving patients were contacted by phone to evaluate subsequent alcohol consumption following transplantation (with the exception of two patients whose primary physicians were contacted). Of the 67 patients transplanted, 18 had expired, 7 were alive but unavailable, and 1 had been lost to follow-up. Of the remaining 41 patients interviewed, 21 had remained abstinent, while the other 20 had returned to some form of drinking. Of patients with less than 6 months of pretransplant abstinence, only 30% remained abstinent, while the other 70% had resumed drinking. Regarding patients with at least 6 months of pretransplant abstinence, 58% had remained abstinent, while the other 42% had resumed drinking. In both groups, nearly 1/3 of those who had admitted to posttransplant drinking reported themselves as again abstinent and recommitted to sobriety when interviewed. In conclusion, 49% of patients interviewed had resumed some type of drinking following transplantation-- however, this appears not to have affected compliance or survival potential. Only 2 (4.8%) of the 41 patients interviewed had returned to excessive drinking. Thus, our findings support the use of orthotopic liver transplantation for patients with alcohol related end-stage liver disease.

New approaches to Pancoast and chest wall tumors.

Superior pulmonary sulcus carcinoma, or Pancoast's tumor, was first identified in 1932 by H. K. Pancoast, who described a small tumor at the apex of the lung producing a characteristic pain pattern and rapid, universal mortality. Despite early indications that this type of carcinoma was amenable to neither radiation nor surgery, the current treatment approach calls for irradiation therapy (3,000 rad over 2 to 3 weeks) followed by surgical resection of the chest wall, lower brachial plexus, and en bloc resection of the lung. In selected patients with negative mediastinal nodes, this approach has been associated with a 34% 5-year and a 29% 10-year survival.

Revascularization of the stenotic left main coronary artery and impaired left ventricle.

The high mortality rate associated with revascularization for stenosis of the left main coronary artery and impairment of the left ventricle (classes III and IV) has been significantly reduced by a twofold approach: combating hypotension during induction of anesthesia and preventing ischemia resulting from anoxic arrest, often needed to facilitate the insertion of the left coronary anastomoses. These two goals have been successfully achieved by (1) a readiness to institute circulatory assist by means of femoral-to-femoral cardiopulmonary bypass and (2) augmentation of coronary flow through immediate insertion of a vein graft between the aorta and right coronary artery, if the anatomy permits.

Management of concomitant occlusive disease of the carotid and coronary arteries.

With the advent of direct coronary artery revascularization, the high mortality rate from cardiac disease associated with carotid endarterectomy can be favorably altered by simultaneous or staged revascularization for combined lesions. The choice for combined or sequential procedures is determined by the severity of the disease both clinically and anatomically in each system. Review of 32 patients with both severe coronary and carotid occlusive disease established that selective surgical intervention has been successful, with no deaths and only minimal morbidity. Simultaneous revascularization was carried out in 8 patients with preinfarctional angina, significant left main lesion or triple vessel disease producing a functional lesion of the left main coronary artery, and tight carotid lesion. Staged operations were performed in the remaining 24 patients. Priority of staging was determined by the extent of disease in each system.

Operative transluminal balloon angioplasty. Adjunct to coronary bypass for extended myocardial revascularization of more than 3000 lesions in 1000 patients.

Operative transluminal coronary artery balloon angioplasty has been used for over 3000 lesions in 1000 patients since 1980. Initially it was only used for distal stenoses not accessible to coronary bypass grafting in 200 patients. Recatheterization of patients who had intraoperative transluminal balloon angioplasty of the proximal left anterior descending, right, and circumflex coronary arteries 3 years previously revealed excellent patency of both the bypass grafts and the dilated native coronary arteries. This observation supports the thesis that with properly constructed bypass anastomoses competitive flow does not significantly mandate graft thrombosis. Subsequently, intraoperative balloon angioplasty has been performed for both proximal and distal stenoses in 800 patients to improve native coronary artery perfusion and maximize revascularization. Follow-up from 1 to 7 years revealed perioperative myocardial infarction in 21 patients (2.1%) and death in 19 patients (1.9%). Recatheterization from 1 to 7 years after the operation in 51 patients (41 with symptoms) revealed that patency was almost as prevalent in arteries subjected to angioplasty (82%; 137/167) as in bypass grafts (84%; 102/122). Intraoperative balloon angioplasty appears to improve coronary artery perfusion without detrimental competitive flow when used with bypass grafts.

Primary pulmonary hemangiopericytoma.

Hemangiopericytoma is a potentially malignant tumor of vascular origin. It usually is a solitary lesion and may arise in the chest or in extrathoracic areas. It is usually encapsulated. Microscopic features vary with the degree of differentiation of the individual tumor. The more differentiated variety exhibits abundant capillaries with open lumina surrounded by ovoid tumor cells; in the less differentiated tumors, the capillaries lack lumina and the tumor cells are spindle shaped. The prognostic significance of the microscopic pattern is controversial. However, prominent mitotic activity, necrosis, hemorrhage, and increased cellularity are ominous signs and are usually noticed in tumors that later exhibit malignant behavior. The larger the lesion, the more likely that it will be symptomatic. Treatment of choice is ample surgical resection.

Dorsal sympathectomy and management of thoracic outlet syndrome with VATS.

Dorsal sympathectomy and the management of the thoracic outlet syndrome have been considerably improved with the use of video assistance because it affords both magnification and an improved light system. Two techniques of video assistance were employed in the group of patients described here. One involved the sympathectomy done through three ports using standard video-assisted thoracic surgical methods. The second technique involved a transaxillary incision with removal of the first rib using video-assistance magnification and light, operating either directly or secondarily while visualizing the image on the television set. (The vast majority of cases have been performed using this latter technique.) Major indications for performing dorsal sympathectomy include (1) hyperhidrosis, (2) Raynaud's phenomenon, (3) Raynaud's disease, (4) causalgia, (5) reflex sympathetic dystrophy, and (6) vascular insufficiency of the upper extremity. Except for hyperhidrosis, all of the other indications require the usual diagnostic techniques, including cervical sympathetic blockade to assess whether the symptoms are relieved by temporary blockade of the sympathetic ganglia. In 326 patients, sympathectomy, performed either alone or in conjunction with first-rib removal for relief of the thoracic outlet syndrome, has been successful. In only 6 patients has sympathetic activity recurred in less than 6 months. Initially all of them were treated conservatively. Three of the 6 required a repeat sympathectomy. Postsympathectomy neuralgia occurred in only 2 of more than 326 patients. Both cases were managed successfully in a conservative fashion. Among the patients in whom a Horner's syndrome was not deliberately induced, the syndrome developed in 2. In both, the syndrome resolved spontaneously within several months.

Solo or partnership.

Reassessment of the managed care environment and restructuring of our practice will be accomplished by transitional short-term actions while we institute our long-range plan. In the short term we must develop appropriate relationships with hospitals and medical groups that interrelate to our specialty, and develop a "love our enemy" philosophy. We must establish operating organizational units that will be competitive. Reassessment of our own practice, our unique skills, our inadequacies, our competition, and our performance through outcome studies is essential to retake positions weakened by loss of contract inclusion. Long-term strategy must develop insurance coverage in conjunction with our patients in such a way that the middleman is eliminated and the profit currently extracted by managed care is reinvested in patient care, research, and education. Whoever controls payment determines the quality of medicine and how it is delivered.

Upper plexus thoracic outlet syndrome: optimal therapy.

BACKGROUND: Previously, transaxillary first rib resection alone was not considered adequate therapy for "upper plexus" (median nerve) thoracic outlet syndrome. It was thought that the "combined" approach with upper plexus dissection through a supraclavicular incision in addition to the transaxillary approach was necessary. However, with better understanding of anatomy--that the median nerve receives fibers from C8 and T1 as well as the upper plexus and that muscles that compress the upper plexus attach to the first rib--it is now recognized that first rib removal alone will relieve upper plexus compression. METHODS: Assessment of 2,210 operations for thoracic outlet syndrome revealed 250 patients (11%) had symptoms and nerve conduction velocity slowing of the median nerve only (upper plexus), whereas 452 (20%) patients had both median and ulnar nerve compression (upper and lower), and 1,508 patients exhibited compression symptoms and nerve conduction velocity slowing of the ulnar nerve alone (lower plexus). RESULTS: Transaxillary first rib resection relieved symptoms of median nerve (upper plexus) compression as well as it did for ulnar nerve (lower plexus) compression. Treatment outcome comparisons of patients with median and ulnar compression show no significant differences. CONCLUSIONS: These data refute the need for supraclavicular or combined supraclavicular and transaxillary approaches to treat patients with upper plexus (median) thoracic outlet syndrome compression as previously recommended. The transaxillary approach alone is satisfactory.

The failed operation for thoracic outlet syndrome: the difficulty of diagnosis and management.

In 225 patients requiring reoperation for recurrent thoracic outlet syndrome, "pseudorecurrences" were noted in 43 patients not relieved of symptoms after the initial operation. Such recurrences were associated with technical errors at the initial operation including resection of the second rib instead of the first, resection of the first with a cervical rib left in place, or resection of a cervical rib with an abnormal first rib left. True recurrences occurred in 182 patients, 154 of whom had a substantial piece of rib remaining from the initial procedure. Indications for reoperation included persistent pain, ulnar nerve conduction velocity of 60 m/sec or less (normal, 72 to 82 m/sec), and failure of appropriate physical therapy. Reoperation involved neurolysis of the brachial plexus, decompression of the vessels, and dorsal sympathectomy performed through a posterior thoracoplasty incision. One hundred seventy-seven patients (79%) had improvement, 32 (14%) had moderate improvement, and 16 (7%) were either considered failures or had recurrent scarring.

Improved management of the Paget-Schroetter syndrome secondary to thoracic outlet compression.

For years, patients with "effort" thrombosis were treated by anticoagulants and conservative exercise; and if recurrent symptoms developed when they returned to work, they were considered for first-rib resection. Recently, use of thrombolytic agents with early surgical decompression of the neurovascular compression has markedly reduced morbidity, such as postphlebitic syndrome and the necessity for thrombectomy. A review of 67 patients seen over 25 years showed that 34 were initially treated with heparin sodium and then Coumadin (crystalline warfarin sodium). Recurrent symptoms developed in 21 after they returned to work and necessitated transaxillary first-rib resection to relieve symptoms. Eight also underwent thrombectomy. Recently, 33 patients were initially treated with thrombolytic agents and heparin, followed promptly by early first-rib resection. The evaluation and efficacy of this therapy have been established by frequent and repetitive venograms and careful follow-up of patients. Most of the patients showed improvement with thrombolytic agents. Remaining stenoses that suggested intravascular thrombosis were usually secondary to external compression of the vein by the clavicle, costoclavicular ligament, rib, or scalenus anterior muscle. Venous thrombectomy was necessary in only 4 patients in whom the clot was not controlled by thrombolytic therapy and operative release of compression. There were no deaths in the series.

"Collis-Belsey" fundoplication for uncomplicated hiatal hernia and gastroesophageal reflux.

The combined Collis gastroplasty-Belsey Mark IV fundoplication was used in 86 patients with uncomplicated hiatal hernia followed for up to 8 years. Marked relief of symptoms was obtained, with no initial morbidity and mortality. Recurrence of hernia occurred in 1 patient. Minimal gastroesophageal reflux was observed in a few patients. Manometric and pH studies performed after operation showed a competent valve without notable esophageal reflux. The Collis gastroplasty creates a lesser curvature gastric tube that lengthens the so-called functional esophagus and eliminates tension at the suture line of the Belsey Mark IV fundoplication.

Median sternotomy as a standard approach for pulmonary resection.

Pulmonary resection was performed electively through a median sternotomy in 174 patients. The first 61 of these patients were compared with an equal number having pulmonary resection through a lateral thoracotomy. Both groups were similar in regard to sex, age, pathological condition, and type of resection. The patients undergoing median sternotomy had a shorter operative time and less postoperative pain, and were discharged from the hospital sooner than the patients having resection through a lateral thoracotomy. The cardinal technical essentials to expeditious pulmonary resection through a median sternotomy involve unilateral pulmonary ventilation with a double-lumen endotracheal tube, arterial pressure and gas monitoring, and proper lung packing and retraction. Two patients died, 1 of infection and 1 of bleeding; neither death was related to the incision. Certain pulmonary procedures are better performed through a lateral thoracotomy, and these include resection of a superior sulcus carcinoma, pulmonary resection with posterior chest wall extension, and left lower lobe resection in patients who demonstrate obesity, cardiomegaly, or an elevated diaphragm.

Paget-Schroetter syndrome: what is the best management?

BACKGROUND: The evaluation of 312 extremities in 294 patients with Paget-Schroetter syndrome (effort thrombosis of the axillary-subclavian vein) over 30 years provides the basis for optimal management determination. METHODS AND RESULTS: Group I (35 extremities) was initially treated with anticoagulants only. Twenty-one developed recurrent symptoms after returning to work, requiring transaxillary resection of the first rib. Thrombectomy was necessary in eight. Group II (36 extremities) was treated with thrombolytic agents initially, with 20 requiring subsequent rib resection after returning to work. Thrombectomy was necessary only in four. Of the most recent 241 extremities (group III), excellent results accrued using thrombolysis plus prompt first rib resection for those evaluated during the first month after occlusion (199). The results were only fair for those if seen later than 1 month (42). CONCLUSIONS: An early diagnosis (less than 1 month), expeditious thrombolytic therapy, and prompt first rib resection are critical for the best results.

Giant fibrovascular polyp of the esophagus.

A case of giant fibrovascular polyp of the esophagus with a review of the literature is presented. The lesion is benign and pedunculated and may attain giant proportions. Symptoms are related to esophageal obstruction. Death by asphyxia can occur. Small lesions can be removed endoscopically with a snare. Larger lesions should be excised using a formal surgical approach.

Coronary artery bypass occlusion second to postcardiotomy syndrome.

Postcardiotomy syndrome following coronary vein bypass procedures may cause graft occlusion as a result of the associated myxedematous hyperemic inflammation that later forms dense obliterative fibrosis. Variability of symptoms and onset make early recognition of postcardiotomy syndrome difficult. However, the presence of the classic triad of fever, chest pain, and pleuroericardial reactions along with leukocytosis and elevated sedimentation rate should suggest the diagnosis. Early recognition and prompt institution of steroid therapy offer relief of symptoms and regression of inflammation and probably reduce the incidence of graft occlusion. From early experience with 14 patients who developed postcardiotomy syndrome and received only symptomatic treatment, 12 developed graft occlusion, whereas in 31 subsequent patients with this syndrome who were treated with steroids, only 5 demonstrated graft occlusion.

Bypass grafting and aneurysmorrhaphy for aortic arch aneurysms.

The technique of permanent aortic arch bypass grafting combined with simultaneous aneurysmorrhaphy, excision or exclusion of the aneurysm without the use of systemic heparinization, cardiopulmonary bypass, or external bypass shunting has been used successfully in treating 5 patients with aneurysms of the aortic arch. There were no complicating cerebral vascular accidents, bleeding diatheses, or signs of distal embolization. There were 2 deaths; 1 patient died early (10 days postoperatively) of myocardial infarction, and the other died over one year later of unrelated causes. Follow-up has extended to an interval of seven years. The early death subsequent to myocardial infarction in 1 patient prompted the routine use of preoperative carotid and coronary angiography for assessment of these systems. Severe occlusive disease in these vessels requires a staged or simultaneous reconstruction prior to management of the aortic aneurysm.

Sclerosing mediastinitis: improved management with histoplasmosis titer and ketoconazole.

Recognition that many patients with benign sclerosing mediastinitis have smoldering disease responsible for failure of surgical procedures or for development of collateral circulation in patients with superior vena caval obstruction has markedly improved management of these difficult patients. Histoplasmosis complement fixation titers have been used to detect unsuspected subacute disease and to follow the therapeutic adjunctive management with ketoconazole, an oral antifungal agent. Twenty-two patients with benign sclerosing mediastinitis demonstrated a variety of symptoms relating to the area of compression: superior vena cava, 13; esophagus, 3; pulmonary artery and pericardium, 3; and trachea, 3. Histoplasmosis was documented in 12 patients. Operation is used initially for diagnosis, to rule out carcinoma, and to treat the complications: superior vena caval reconstruction, 6; tracheal decompression, 2; right middle lobectomy, 1; esophageal decompression, 2; division of tracheoesophageal fistula, 1; and release of pericardial effusion and cardiac tamponade, 1. Postcardiotomy syndrome occurred in 1 patient and wound infection in another. No deaths resulted. In 6 cases of histoplasmosis, symptoms recurred in 100% of patients and were successfully managed with ketoconazole treatment, and then clinical progress was monitored with serial histoplasmosis complement fixation studies. One patient had four superior vena caval reconstructions at an outside hospital, each 1 year apart, with symptoms recurring each time. With ketoconazole therapy alone, she has been asymptomatic for more than 2 years. Vigorous search for a fungal cause may even obviate the necessity for surgical intervention. If an operation is necessary, preoperative and postoperative use of ketoconazole has assured success.

Management of malignant esophagorespiratory fistula.

Esophagorespiratory communication developed in 46 patients among 570 with esophageal cancer. Therapy was basically palliative and aimed at mechanical interruption of the fistula, restoration of esophageal continuity, and avoidance of external tubes and appliances. Supportive therapy, gastrostomy, tracheostomy, and esophageal exclusion and diversion procedures resulted in little prolongation of life and poor palliation of the patient. Permanent endoesophageal intubation with tubes of the Celestin variety resulted in best palliation with minimal operative risk for most terminal patients. Colon bypass and occasional resection can accomplish the same goal and possibly provide long-term survival in good-risk, young patients with small tumors.

Reoperation for recurrent thoracic outlet syndrome.

Recurrent thoracic outlet syndrome that requires reoperation accounts for 1% of first rib resections. Symptoms in a series of 30 patients were mainly neurological and consisted of pain and paresthesia involving the neck, shoulder, arm, and hand and were severe and unrelenting. Recurrence of symptoms ensued from one month to seven years following initial rib resection, with the majority appearing within the first three months. Nerve conduction velocities were diminished to an average of 51 m per second, well below the normal of 72 m per second. Reoperation was required after a period of extensive physiotherapy and muscle relaxants. The high posterior thoracoplasty approach is recommended for all reoperations, as it gives better exposure to achieve safe neurolysis of the plexus and complete excision of the regenerated periosteum and posterior rib remnant, which were present in almost all patients. Results of reoperation were gratifying, and postoperative nerve conduction velocities were improved to an everage of 66 m per second.