Mitral valve replacement in the first 5 years of life.

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results.

Pleomorphic adenoma of the cervical esophagus: a rare tumor.

Pleomorphic adenoma of the esophagus is a rare tumor: less than 10 cases have been reported. These pleomorphic neoplasms are sessile and arise in the submucosal glands of the esophagus. Described in this report is the long-term follow-up of an additional case, in which the resection was reinforced with a pectoralis major muscle wrap.

Experimental evaluation of staple lines in gastric surgery.

This study was designed to evaluate the bursting pressure, tensile strength, and healing of staple lines in the dog stomach. Pavlov pouches were created in 30 dogs using a single, double, or triple application of a stapler loaded with 4.8-mm staples. Staple lines were assessed immediately in half of the animals and after 21 days in the remaining animals. Acutely, reinforcing a single staple line with a second or third application of the stapler resulted in an anastomosis more resistant to leakage and disruption. Satisfactory healing occurred by 21 days and contributed to staple line strength in the pouches using a single and double application of the stapler. The orientation of collagen deposition in the anastomosis was related to the number of staples used. The degree of collagen deposition across the muscularis mucosa correlated with the healed staple line strength. Although healing occurred when a triple application of the stapler was utilized, the orientation of the fibroconnective tissue was parallel to the anastomosis and did not contribute to staple line integrity.

Duplication of the appendix mimicking adenocarcinoma of the colon.

Duplication of the appendix is a rare anomaly that has been reported fewer than 60 times. Three anatomic types of appendiceal duplications have been described--each the result of a different embryologic occurrence. A unique case of appendiceal duplication is presented, in which the duplication caused a constricting lesion of the colon and mimicked carcinoma. The anomalous appendix in this patient was not compatible with any of the previously described types of appendiceal duplications.

Esophageal carcinoma. Improved quality of survival with resection.

Twenty years ago the experience with carcinoma of the esophagus at Vanderbilt University and affiliated hospitals was reported in 263 patients. Overall 5-year survival was 2 per cent. Esophagectomy was possible in 89 patients (34%) and was associated with a 32 per cent mortality. This study updates the authors' experience with squamous cell carcinoma of the esophagus in 311 patients seen from 1966 to 1985. Overall 5-year survival has increased to 6 per cent. Esophageal resection was accomplished in 104 patients (33%), with a 10 per cent operative mortality and 41 per cent complication rate. Multi-variant analysis disclosed that smoking, alcohol use, sex, race, and site of tumor did not influence survival. Actuarial survival rates following esophageal resection were 51 per cent at 1 year, 21 per cent at 2 years, and 13 per cent at 5 years. These survival rates were not influenced by adjuvant radiotherapy. Radiation therapy was used for attempted cure in 83 patients. Actuarial survival rates following curative doses of radiation were 29 per cent at 1 year, 15 per cent at 2 years, and 4 per cent at 5 years. These survival rates were significantly (P less than 0.001) lower than survival rates following esophagectomy. The quality of life following treatment was good or fair in 83 per cent of patients undergoing esophagectomy and good or fair in 64 per cent of patients receiving "curative" doses of radiation. The results of this review demonstrate that esophageal resection using the Lewis operation or transhiatal esophagectomy can be done with an acceptable operative mortality, results in prolonged survival, and improves the quality of life.

Combined computerized tomography and angiography in evaluation of hemorrhage into pancreatic pseudocysts.

Hemorrhage into a pancreatic pseudocyst is a rare but frequently lethal complication of pancreatitis, which remains a diagnostic and therapeutic challenge. Angiography alone or in combination with ultrasonography and radionuclide perfusion scans will occasionally fail to identify adequately the source of bleeding. We have presented a case illustrating the superiority of dynamic computerized tomography and angiography in the preoperative evaluation of a patient with pancreatic disease and upper gastrointestinal hemorrhage.

Aboral changes in D-glucose transport by human intestinal brush-border membrane vesicles.

D-Glucose transport was investigated in isolated brush-border membrane vesicles from human small intestine. Characteristics of D-glucose transport from the jejunum were compared with that in the mid and terminal ileum. Jejunal and mid-ileal D-glucose transport was Na+-dependent and electrogenic. The transient overshoot of jejunal D-glucose transport was significantly greater than corresponding values in mid-ileum. The terminal ileum did not exhibit Na+-dependent D-glucose transport, but did exhibit Na+-dependent taurocholate transport. Na+-glucose co-transport activity as measured by tracer-exchange experiments was greatest in the jejunum, and diminished aborally. We conclude that D-glucose transport in man is Na+-dependent and electrogenic in the proximal intestine and directly related to the activity of D-glucose-Na+ transporters present in the brush-border membranes. D-Glucose transport in the terminal ileum resembles colonic transport of D-glucose.

Comparison of automatic staplers in small bowel anastomoses.

Automatic stapling instruments have been used in gastrointestinal operations with increasing frequency. As a result, newer staplers have been developed which use more staples and compress the tissue to a greater degree. Our study was designed to compare one of the newer devices (GIA Premium) with a conventional device (ILA) in regard to tensile strength, bursting pressure, and histology. Functional end-to-end jejunal anastomoses were created in dogs and studied acutely and chronically. Acutely, the pressure needed to produce a staple line leak was greater with the GIA Premium; however, after healing no difference was noted. Total work required to disrupt a staple line was greater with the GIA Premium and remained so after healing. Fibroconnective tissue density was greater after healing in anastomoses created with the GIA Premium stapler. The data suggest a theoretical advantage in using the GIA Premium stapler, though both staplers produce an anastomosis adequate to resist the usual physiologic stress that may be encountered in man.

Management of penetrating hepatic injury. A review of 102 consecutive patients.

The records of 102 consecutively treated patients with penetrating hepatic injuries from 1972 through 1982 were reviewed. Fifty-five patients (54%) sustained gunshot wounds and 47 (46%) sustained knife wounds. The mean age was 29 years (range 3-71); 83 per cent were men. Hypovolemic shock was present in 39 per cent of all the patients, and 74 patients (73%) required perioperative transfusions. Major associated injuries were present in 65 patients (64%) with 30 patients having two or more other injuries. All patients received preoperative and postoperative antibiotics and 88 per cent were treated with intraabdominal drains. Fifteen patients were managed with a tamponade technique using multiple Penrose drains within the injury tract. Six patients (5.9%) required hepatic resection. Major vascular injuries were present in ten cases, and seven of these patients survived. Hospital stay ranged from 4 to 60 days with a mean of 14 days. Postoperative complications occurred in 42 per cent of the patients with over one-third of the complications being pulmonary related. Mortality was 2.9 per cent and all three deaths were secondary to bleeding from severe liver and associated vascular injuries. The low incidence of hepatic resection and mortality in this series of patients is attributed to the conservative management of liver injuries, adequate drainage, the use of a tamponade technique with multiple Penrose drains for through-and-through liver injuries and the expeditious repair of the vascular injuries. This paper includes a detailed description of the tamponade technique.

Simultaneous radioimmunoassay of thyrotropin and thyroxine in human serum.

The importance of early diagnois and treatment of congenital hypothyroidism has been well established, and several screening programs have been undertaken to detect neonates with this disorder by measurement of concentrations of thyrotropin or thyroxine in the serum. However, measurement of either hormone alone may fail to identify all affected patients. Accordingly, we have established a simultaneous double-antibody, dual-isotope radioimmunoassay for both. Sensitivity, slope, analytical recovery, and precision characteristics of the simultaneous assay do not differ from those of each assay performed separately. Values for the two analyses in the single and simultaneous assays correlate well (r = 0.951 for thyroxine, 0.983 for thyrotropin). This assay system permits determination of both hormones within 72 h after specimen collection and thus should allow more rapid evaluation, diagnosis, and treatment of infants with congenital hypothyroidism.