Surgical treatment of active and sequelar forms of pulmonary tuberculosis.

BACKGROUND: The incidence of tuberculosis has risen since 1990, and in some countries, the resistant forms are becoming more and more frequent. Surgical treatment is once again needed to manage these problems. The purpose of this study was to analyze the indications and results of resection, which we performed for pulmonary tuberculosis. METHODS: From 1980 to 1997, 477 patients were operated on for thoracic or intrathoracic tuberculosis in Laennec Hospital, Paris (259 suffered lung diseases). There were 165 women and 94 men, aged 25 to 86 years (mean 46 years), from Europe (n = 148), North Africa (n = 65), Subsaharian Africa (n = 34), Asia (n = 7), and the West Indies (n = 5). This population was reviewed concerning the lung tuberculosis (sequelae or active lesions), the indications of lung resection, the type of resections performed, and the results at 1, 6, and 12 months. RESULTS: Active lesions were present in 97 cases and sequelae in 162. Surgery was performed for a therapeutic purpose in 104 patients with sequelae, and in 10 patients with active tuberculosis (pneumonectomy, n = 19; pleuropneumonectomy, n = 19; lobectomy, n = 54; and segmentectomy, n = 22). Surgery was performed for a diagnostic purpose in 54 patients with sequelae, and in 87 patients with active lesions (lobectomy, n = 32; segmentectomy, n = 19; wedge resection, n = 94, of which 11 performed by video-assisted thoracoscopy since 1991). One patient died after pleuropneumonectomy. We observed 25 complications: empyema, n = 7; hemothorax, n = 2; prolonged air leaks, n = 14; and pneumopathy, n = 2. All patients with active lesions subsequently were given antitubercular drugs. Follow-up was 100% at 1 month, 57% (n = 92) and 77% (n = 75) at 6 months for patients with sequelae and for patients with active lesions, respectively. All were asymptomatic with a normal chest roentgenogram. The number of operations for active lesions is increasing over the years, while it is decreasing for sequelar lesions. CONCLUSIONS: In our department, surgery is being performed more frequently to make a diagnosis in cases of active tuberculosis, and to treat complicated lesions in case of sequelae. Lung resection for active tuberculosis evolving under treatment or for drug resistance was rare. However, our study confirms the good results commonly obtained by surgery and supports the idea that surgery may help eradicate tuberculosis when social and economic circumstances render its medical management difficult or hazardous.

[Recovery evaluation in a pediatric heart surgery unit using the AP-DRG classification system (All Patient Diagnosis Related Groups)]. / Valutazione dell'attività di ricovero in cardiochirurgia pediatrica mediante il sistema di classificazione AP-DRG (All Patient Diagnosis Related Groups).

The evaluation of Health Care activities, particularly of those concerning hospitals, is one of the most important aims for the National Health Service for a "fair" resource allocation. In the recent past a great bulk of research has been directed to methods for patient classifications in relation to resource needs. Diagnosis Related Groups (DRG) is one of the most important patient classification systems related to resource allocation which has been developed in the U.S. Medicare Program (HCFA-DRGs) during the eighties and more recently adopted all over Europe, Italy included. Wide experimentation has been developed during the recent past concerning DRGs confirming its validity, but also has disclosed its limits, mostly concerning applicability outside U.S., identification of specific patient subgroups (like the pediatric patient population) and capability in distinguishing patients with apparently similar resource needs, but different clinical severity conditions. In order to overcome such limits, DRGs have been subjected to some important modification: All patient DRG (AP-DRG) is a system which should pay more attention to some patient subgroups, such as the pediatric one. Research is still looking for methods, easily extensible to the whole hospital informative system concerning the possibility of distinguishing patients with different level of severity condition. With the double aim of experiment the actual utility in the use of AP-DRG, more than HCFA-DRG in a pediatric population and find further indexes for complexity and/or severity characterization of the hospital case-mix, the 1992 in-patients hospital files of the pediatric cardiosurgery hospital CREAS-IFC-CNR was reviewed. Results confirm that some increase in the identification of the case-mix do occur by using the AP-DRG system, even if a better clinical characterization could be possible (i.e. AP-DRG 108). Of particular interest is the fact that descriptive statistical analysis of position and variability parameters do confirm the importance of the length of stay as a brief index for hospital efficiency evaluation and its organizative model characterization.

Anatomic spectrum of abnormal ventriculoarterial connections: surgical implications.

To clarify the salient anatomic features of surgical significance, we investigated 33 specimens representing the spectrum of abnormal ventriculoarterial connections. In those with tetralogy of Fallot or double-outlet right ventricle with subaortic ventricular septal defect, the muscular outlet septum separating the subarterial outflow tracts was always inserted into (or in front of) the anterior limb of the septomarginal trabeculation (septal band). In those having double-outlet right ventricle with doubly committed ventricular septal defect, the outlet septum was lacking. When the ventricular septal defect was in subpulmonary position, with either double-outlet or discordant ventriculoarterial connections, the outlet septum was attached to the posterior limb of the septomarginal trabeculation. The outlet septum was deviated into the subpulmonary outlet in hearts with discordant ventriculoarterial connections and pulmonary stenosis. It is the interrelations between the septomarginal trabeculation, the outlet septum, and the ventriculoinfundibular fold that hold the key to the understanding of surgical anatomy and determine the optimal choice of procedure for definitive biventricular repair.

[Stress myocardial scintigraphy in the pre- and postoperative diagnosis of ischemic cardiopathy. The correlations between the clinical aspects and the coronary angiographic picture]. / La scintigrafia miocardica da sforzo nella diagnostica pre- e postoperatoria della cardiopatia ischemia. Correlazioni tra aspetti clinici e quadri coronarografici.

With radioisotopes it is possible to study the heart obtaining complementary or substitutive informations to those provided by the most common noninvasive methods of myocardial assessment and by coronarography. This paper aim is to report experience with thallium 201 and 99mTc isonitrile in the diagnosis and followup of ischemic heart disease, in particular correlating clinical, coronarographic and scintigraphic findings. MATERIAL AND METHODS. During the biennium 1989-91 we have used the myocardial perfusion imaging with thallium 201 in 29 patients (20 male age ranging from 40 to 60 years) injecting 2 mCi at exercise peak with immediate planar mapping, followed by a second registration at rest 4 hours later (thallium 201). Imaging with 99mTc SESTAMIBI has been carried out in 6 patients (two of whom previously studied with thallium 201) injecting 20-22 mCi both at stress peak and at rest, with SPECT mapping 60'-90' later. All these patients presented specific problems for the diagnosis of myocardial ischemia. The exercise testing has been performed by a bicycle ergometer and with a standardized procedure increasing every two minutes the workload to the maximum tolerated according to the clinical conditions and to the response. All antianginal treatments were discontinued for at least 48 hours before testing and the patients were fasted for 6 hours. The images were obtained using a small field scintillation camera with a low-energy general purpose collimator. We divided the patients in 4 groups: Group A. Six patients who had an open heart operation: in 5 coronary revascularization was carried out (plus left ventricular aneurysmectomy in one and plus aortic valve replacement in another); in 1 patient an aortic valve replacement was performed on. Group B. Six patients have been evaluated after coronary angiography. Group C. Seventeen patients with doubtful diagnosis of myocardial ischemia on the base of the symptoms and/or non invasive testing as rest or stress electrocardiogram (ECG). Group D. In 6 more patients (2 of those previously studied with thallium 201) the myocardium has been assessed with SESTAMIBI. RESULTS. In one patient of the group A the thallium 201 images detected silent ischemia; in 5 removed the diagnostic doubts of the ECG findings owing to left ventricular overload or to old infarctions in 2 patients and to electrolytes disturbances or pharmacological effects in 3 patients. In group B patients the thallium 201 further on could assess the extent of ischemic and necrotic areas suggesting the final indications to angioplasty in 3 patients, medical treatment in 2 and surgery in 1. We could not find correlations between the extent of the disease predicted by the coronarography and the findings of the thallium 201 images. In the diagnosis of myocardial ischemia, group C, the Thallium 201 has been very useful and specific excluding an ischemic origin in 4 patients with arrhythmias, in 2 patients without symptoms of angina but with doubts at rest and exercise ECG findings and in 4 with atypical thoracoalgia and doubtful ECG. On the contrary, this test could give the final diagnosis of ischemia in 6 patients displaying its sensitivity in detecting coronary artery disease. Among the patients assessed with SESTAMIBI, in 2 this test has been essential in evaluating the myocardial contractility and the segmental wall motion. DISCUSSION. The usefulness of Thallium 201 imaging, as a very sensitive mean in detecting coronary artery disease and in the assessment of myocardial viability, is well known. Although the most common indications of this technique are well standardized, in the clinical practice there are many situations in which the thallium 201 can contribute to the diagnosis and to the management. (ABSTRACT TRUNCATED)

Pulmonary atresia with intact ventricular septum: surgical management based on right ventricular infundibulum.

The optimal management of infants with pulmonary atresia with intact ventricular septum (PA.IVS) remains a controversy. Attempts have been made to base the surgical approach on various geometrical or morphological characteristics of the right ventricle (RV). However, the overall results remain poor when compared to other complex congenital heart defects. Forty-eight neonates with PA.IVS were admitted to our unit between 1980 and 1992. The management plan has evolved to be based entirely on the echocardiographic assessment of the state of development of the infundibulum of the RV. In neonates with a well-formed infundibulum (n = 31), the initial palliation consisted mainly of pulmonary valvotomy (without cardiopulmonary bypass) and PTFE shunt from the left subclavian artery to the main pulmonary artery. There was one death from initial palliation in this subgroup. If necessary, the RV cavity was later enlarged by excision of the hypertrophic muscle of both the trabecular and infundibular portions, before finally attempting biventricular repair. The actuarial probability of achieving a biventricular repair at 40 months of age was 60% (95% CL = 39.5% to 71.3%). Thirteen patients have undergone biventricular repairs with one late death over a total follow-up of 1,720 patient months. In one patient, the RV failed to grow satisfactorily, necessitating a Fontan procedure. Seventeen patients without a well-formed infundibulum were approached with a Fontan procedure in mind. The initial palliation in these patients consisted of a modified Blalock-Taussig shunt only. Ten have undergone a Fontan procedure so far and five are awaiting such repairs. In this group there were four operative deaths: two after initial palliation, and two after Fontan procedures. In patients with a well-developed infundibulum, the actuarial survival probability was 93% (95% CL = 74% to 98%) at 8 months with no further late deaths over 120 months follow-up, whereas in patients without a well-formed infundibulum it was 75% at 40 months (95% CL = 46% to 89%). The overall survival probability at 104 months was 77% (95% CL = 51% to 90%).

[The use of high-field magnetic resonance in the follow-up of patients with mechanic aortic valve prosthesis and composite aortic tubular prosthesis]. / L'impiego della risonanza magnetica ad alto campo nel controllo dei pazienti portatori di protesi valvolari aortiche meccaniche e di protesi tubulari aortiche composite.

Eleven patients who had undergone cardiac surgery were studied by means of high-field MR imaging (1.5 T). Six patients had had aortic root and valve replaced with a Björk-Shiley (BS) composite tubular aortic graft prosthesis for acute dissection of ascending aorta. In the other 5 patients with rheumatic calcific aortic disease, the valve had been replaced with a BS prosthesis. As a whole, MRI studies were 14. Previous evaluations of magnetic field effects had seem carried out ex vivo on both BS valves and BS composite prostheses, on surgical ligation clips (Tantalium and Stainless) and on stainless wires for sternal closure. In 4 patients (2 BS composite grafts and 2 BS valves) MRI diagnosed chronic dissection of both arch and descending aorta. In 1 of them, with a BS valve, associated localized acute dissection of ascending aorta was observed. In 3 patients with BS composite grafts, MRI revealed pseudo-aneurysms (including a thrombosed one) at the graft level. In one case MRI was repeated 4 times and was very helpful in monitoring the pseudo-aneurysm. MRI showed pericardial hematoma in 2 patients with BS grafts and paravalvular abscess in a case with BS valve. In one patient with BS valve fast-imaging MR revealed severe aortic regurgitation. No adverse reactions were demonstrated on MR images of prosthetic implants. MRI artifacts were insignificant with the spin-echo technique, while the fast-imaging technique showed clear image distortion at the valve level.

Experience with the modified Blalock-Taussig operation using polytetrafluoroethylene (Impra) grafts.

Between June 1978 and January 1982, 115 patients underwent 122 subclavian artery-pulmonary artery shunts using polytetrafluoroethylene (PTFE Impra) grafts. Forty-six of the patients had a ductus dependent pulmonary circulation, the patency of which was maintained by an infusion of prostaglandin E2 in 29 cases. There were nine hospital deaths, four of which were related to shunt failure. Five patients underwent a second shunt procedure within one week of the first. There were two cases of late graft occlusion. Twelve shunts were considered to have failed. The actuarial estimate of shunt patency was 90% (+/- 3%) at two years for all patients and 74% (+/- 10%) for neonates. There was no statistically significant difference in two year shunt patency between 4 mm grafts (88 +/- 5%) and 6 mm grafts (96 +/- 3%). The modified Blalock shunt using a PTFE graft is an effective pulmonary-systemic shunt with a good short term patency.

Atypical tamponade after cardiac operation in infants and children.

A state clinically indistinguishable from cardiac tamponade can occur after operation for congenital heart disease in the absence of intrapericardial blood or clot. We have employed a method of splinting the sides of the sternum apart in nine patterns in whom low-output states developed postoperatively, unresponsive to either inotropic drugs or vasodilator therapy. Blood pressure, heart rate, central venous pressure, urine output, toe temperature, and arterial PO2 immediately before and 90 minutes after the procedure were compared. Significant increases in blood pressure (p less than 0.02), urine output (p less than 0.001), and toe temperature (p less than 0.001) and a significant fall in central venous pressure (p less than 0.001) resulted. The figures indicate a marked improvement in cardiac output which occurred without alteration in inotropic support or after load reduction. We conclude that mechanical restriction of ventricular relaxation can occur in the absence of intrapericardial blood or clot, may contribute to low-output states, and can be successfully managed by sternal splintage.

Right lung agenesis. A case report.

This report describes a combination of a ventricular septal defect and partial anomalous pulmonary venous drainage in an infant with right lung agenesis. Unilateral agenesis of the lung has been rarely described. Although this condition is compatible with long survival, morbidity and mortality are increased by the associations with other malformations both intra- and extracardiac. In unilateral lung agenesis although there is a compensatory increase in volume of the single lung, there is a reduction in the number of branches of the pulmonary artery and the whole right ventricular output passes through a reduced vascular bed. In isolated unilateral agenesis of the lung, pulmonary hypertension is present in about 19% of cases, while in patients with additional left to right shunt the incidence is 88%. The basic condition of increased pulmonary blood flow (single lung) and the undiagnosed partial anomalous pulmonary venous drainage may explain why the early closure of the ventricular septal defect did not prevent the progressive pulmonary vascular disease. We discuss shortly Tolazoline as pulmonary vasodilator.

[Evaluation of K-canrenoate in post-surgical treatment of open heart paediatric surgery (author's transl)]. / Valutazione del "canrenoato di potassio" nel trattamento post-operatorio in chirurgia pediatrica a cuore aperto.

The variation of Aldosterone and its consequences on urinary Sodium and Potassium after cardiac surgical trauma are well known. We made a study on 2- pediatric patients operated by extracorporeal circulation (ECC). Ten patients were given an Aldosterone inhibitor (K-canrenoate), ten patients were the control group. The efficacy of treatment with the Aldosterone inhibitor drug is proved by: 1) progressive, significant drop of Natremia; 2) considerable heightening of Kaliemia; 3) significant higher ratio between Natriuria and Kaliuria. The importance of antialdosteronic treatment is demonstrated by: 1) diminished sodium retention implies a lessened water retention; 2) increased potassium retention protects from dangerous hypokaliemia in the early postoperative period; 3) possible inotropic and extrarenal activity. It's important to modify the dose of K-canrenoate in relation to the level of electrolytes. High levels of potassium may follow a dosage of 2,5 mg/Kg/24 h. In other cases higher dosage may be necessary.

[Treatment of coarctation of the aorta in paediatric age. Result of 7 years of experience (author's transl)]. / Risultati di 7 anni di esperienza nel trattamento della coartazione aortica in eta' pediatrica.

Results of 83 consecutive operations for coarctation of the aorta in the paediatric age group (0-20 years), performed in our Institution between September 1971 and May 1978 are presented. Mean age at operation was 7.04 years. All patients have been divided into two groups according to age under or over one year. Group one comprises 13 cases under one year of age. There were two death (15.23%). In group two there were 70 cases with two deaths (2.85%). The main post-operative complications are analyzed. Particular attention is paid to the incidence of postoperative hypertension in relation to age bracket and with this point in mind discussion is carried out on the opportunity of early operation before stable hypertension has set in.