Intraoperative measurement of adrenocorticotropin (ACTH) during removal of ACTH-secreting bronchial carcinoid tumors.

The optimal treatment for ectopic ACTH syndrome is the complete removal of the tumor secreting ACTH. These tumors are often occult, with their location suggested but not proven with imaging techniques. The intraoperative measurement of ACTH by immunoradiometric assay in five patients with the occult ectopic ACTH syndrome during removal of suspicious intrapulmonary lesions is reported. A significant ACTH gradient was detected in the pulmonary veins of the affected lobes in two patients. ACTH had decreased significantly in all five patients by 10 and 15 min after tumor removal. All five patients had histologically proven ACTH-secreting bronchial carcinoid tumors, suppressed plasma ACTH by 24 h after tumor removal, and subsequent secondary adrenal insufficiency indicating successful surgical therapy (five of five true-positive). In one patient, previous surgery was not curative and did not result in a decrease in intraoperative measurement of ACTH (one of one true-negative). It was demonstrated that a rapid ACTH immunochemiluminescence assay with a 15-min incubation time has sufficient sensitivity and precision to detect decreases in ACTH described above. These results demonstrate that complete removal of ACTH-secreting bronchial carcinoid tumors can be detected intraoperatively by a decrease in arterial ACTH by 15 min. The modification of the ACTH immunochemiluminescence assay to 15 min incubation allows the documentation of a successful tumor removal in the operating room. It may also be used to locate the tumor intraoperatively by selective pulmonary vein sampling. This protocol may be applicable to the intraoperative measurement of ACTH during pituitary microadenomectomy for Cushing's disease.

Combined median sternotomy and video-assisted thoracoscopic resection of pulmonary metastases.

Median sternotomy has been a common approach for resection of bilateral pulmonary metastases. It provides good exposure and quick accessibility to most lesions in the lung. The retrocardiac left lower lobe may at times be a problematic area for resection of metastases. We have used a simultaneous median sternotomy and left video-assisted thoracoscopic approach to remove three such lesions in two patients, with satisfactory results.

Thoracoscopic stapled resection for spontaneous pneumothorax.

Video-assisted thoracoscopy has recently evolved as an alternative to thoracotomy for several thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. Stapling of apical blebs and pleurodesis or pleurectomy can now be performed thoracoscopically in a fashion identical to the standard operation done through a lateral or axillary thoracotomy. We compared our results with thoracoscopic management of spontaneous pneumothorax in 26 patients (group I) with a group of 20 patients previously subjected to axillary thoracotomy (group II). Indications for operation, sex distribution, and average age (group I, 32.3 years; group II, 33.7 years) were comparable. Hospital stay was less in group I (2.88 +/- 0.99 days versus 4.47 +/- 1.07 days; p = 0.07), as was the use of parenteral narcotics after 48 hours (2/26 = 7.7% versus 14/20 = 70%; p = 0.01). There have been no recurrences to date (mean follow-up, 8 months) in the thoracoscopic group. Video-assisted thoracoscopic management of spontaneous pneumothorax allows performance of the standard surgical procedure while avoiding the thoracotomy incision. Video-assisted thoracoscopic management is safe and offers the potential benefits of shorter hospital stays and less pain.

Preoperative and postoperative comparison of patients with univentricular and biventricular support with the thoratec ventricular assist device as a bridge to cardiac transplantation.

OBJECTIVES: The goal of this study was to determine whether there are differences in populations of patients with heart failure who require univentricular or biventricular circulatory support. METHODS: Two hundred thirteen patients who were in imminent risk of dying before donor heart procurement and who received Thoratec left (LVAD) and right (RVAD) ventricular assist devices at 35 hospitals were divided into three groups: group 1 (n = 74), patients adequately supported with isolated LVADs; group 2 (n = 37), patients initially receiving an LVAD and later requiring an RVAD; and group 3 (n = 102), patients who received biventricular assistance (BiVAD) from the beginning. RESULTS: There were no significant differences in any preoperative factors between the two BiVAD groups. In the combined BiVAD groups, pre-VAD cardiac index (BiVAD, 1.4 +/- 0.6 L/min per square meter, vs LVAD, 1.6 +/- 0.6 L/min per square meter) and pulmonary capillary wedge pressure (BiVAD, 27 +/- 8 mm Hg, vs LVAD, 30 +/- 8 mm Hg) were significantly lower than those in the LVAD group, and pre-VAD creatinine levels were significantly higher (BiVAD, 1.9 +/- 1.1 mg/dl, vs LVAD, 1.4 +/- 0.6 mg/dl). In addition, greater proportions of patients in the BiVAD groups required mechanical ventilation before VAD placement (60% vs 35%) and were implanted under emergency conditions than in the LVAD group (22% vs 9%). The survival of patients through heart transplantation was significantly better in patients who had an LVAD (74%) than in those who had BiVADs (58%). However, there were no significant differences in posttransplantation survival through hospital discharge (LVAD, 89%; BiVAD, 81%). CONCLUSION: Patients who received LVADs were less severely ill before the operation and consequently were more likely to survive after the operation. As the severity of illness increases, patients are more likely to require biventricular support.

Successful double bridge to transplantation with the Thoratec ventricular assist device.

A 34-year-old woman was successfully bridged to heart transplantation after 5 days of biventricular support on the Thoratec system. Acute graft failure necessitated immediate replacement of biventricular support, which continued for 12 days until successful retransplantation occurred. Uneventful recovery led to discharge from the hospital on postoperative day 18.

Surgical repair of annular disruption following percutaneous balloon aortic valvuloplasty.

Percutaneous balloon aortic valvuloplasty for aortic stenosis is being performed with increasing frequency. Disruption-induced acute aortic insufficiency is an infrequent and unreported complication. We report one such case and describe its successful surgical repair.

Experience in 100 transthoracic balloon pumps.

We retrospectively reviewed our last 100 consecutive patients who had an intraaortic balloon pump (IABP) placed through the ascending aorta for postoperative cardiogenic shock. Eighty-one patients survived to have their IABP removed and were evaluated for complications. Complications that may have been related to the transthoracic route of IABP introduction included balloon rupture in 6.2% (5/81), cerebral vascular accident in 2.5% (2/81), transient ischemic attack in 1.2% (1/81), bleeding at the IABP arteriotomy site in 3.7% (3/81), and mediastinitis in 3.7% (3/81). Compared with expected rates of development of complications in this high-risk group of patients, it appeared that balloon rupture and mediastinal bleeding were increased because of the transthoracic placement of the IABP. The rates of neurologic events and mediastinal infection do not appear to be increased. Transthoracic IABP placement avoids ischemic problems in the lower extremities and has proved a useful route for IABP introduction.

Emergent applications of cardiopulmonary support: a multiinstitutional experience.

The use of emergent portable bypass systems is increasing. Because of limited patient use in any one institution, a combined experience can better determine the applicability of these systems. A total of 187 patients from 17 centers were analyzed. Causes leading to bypass initiation were cardiac arrest (125 patients), cardiogenic shock (44), profound hypothermia (7), pulmonary insufficiency (9), and miscellaneous (2). Weaning from bypass was successful in 30.5% (57 patients). Sixty-four patients (34.2%) were transferred to standard bypass or other modes of circulatory assist. Of the total population, 40 patients (21.4%) were alive greater than 30 days. There were no survivors of unwitnessed arrests. Major diagnostic or therapeutic interventions were carried out on bypass in 74.9% of all patients. In survivors, 77.1% (37/48) had major therapeutic interventions as compared with 50.0% (67/135) of nonsurvivors. Emergency portable bypass systems can successfully resuscitate and support cardiac hemodynamics, although the underlying causes necessitating bypass remain difficult to correct. When corrective intervention can be performed, there is an increased chance of survival. Unwitnessed arrest, prolonged cardiopulmonary resuscitation, and lack of treatment options are relative contraindications. Appropriate patient selection and early application of these systems should lead to improved survival.

Cost analysis for thoracoscopy: thoracoscopic wedge resection.

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracoscopic pericardiectomy for effusive pericardial disease.

Thoracoscopic techniques were used to perform a pericardiectomy in 35 patients with purely effusive pericardial disease after medical management and pericardiocentesis had failed to be effective. There were no intraoperative complications and postoperative complications were few. Two cases of dysrhythmia and 2 cases of pneumonia occurred postoperatively. Malignancy was identified as the cause in 18 patients and there were benign causes in the remaining 17. The hospital stay in the group with benign effusions was 4.6 days. There were no recurrences of pericardial effusions and no constrictive changes developed during a mean follow-up of 9 months. Fourteen (40%) patients had pleural or pulmonary abnormalities that were managed simultaneously thoracoscopically. These abnormalities included 2 pleural masses, 2 pulmonary nodules, and 12 pleural effusions. In 8 instances, the pericardiectomy was performed from the right pleural cavity in order to address the pleural or pulmonary problem. Thoracoscopic pericardial resection has proved safe and effective. It allows a wider pericardial resection than that usually permitted by the subxiphoid route, and should lessen the pain and the number of pulmonary complications, compared with open thoracotomy. An additional advantage is that it allows the visualization and management of simultaneous pleural and pulmonary abnormalities.

Myocardial revascularization in Jehovah Witnesses.

The refusal of certain patients to accept blood transfusions need not be a deterrent to surgery. We report on nine Jehovah's Witnesses who over a one-year period underwent myocardial revascularization without significant blood loss or decrease in hematocrit values.

Aortic annular tear after valvuloplasty: the role of aortic annulus echocardiographic measurement.

Following percutaneous transluminal aortic valvuloplasty, 2/100 patients (2%) developed significant aortic insufficiency as a result of an aortic annular tear. Both patients underwent emergency aortic valve replacement and survived the operation. One patient died 4 weeks postoperatively from sepsis and multiorgan failure, and the other patient had a benign postoperative course. In both cases, the balloon area significantly exceeded the aortic annular area and caused the complication. Review of the balloon area-aortic annular area ratio in our series showed that a value of less than 1.2 was not associated with this complication.