Belsey Mark IV antireflux procedure for complicated gastroesophageal reflux disease.

BACKGROUND: Over the past 20 years, medical management of gastroesophageal reflux disease has met with increasing success, but a proportion of patients continue to have symptoms or complications requiring surgical treatment. The variety of operations available attests to the general lack of satisfaction with any single procedure. METHODS: A retrospective study was conducted of 276 patients who underwent the Belsey Mark IV antireflux procedure at our institution between 1979 and 1995. The indication for operation was gastroesophageal reflux disease refractory to medical therapy in 137 patients, gastroesophageal reflux disease with symptomatic stricture or Schatzki's ring in 36, achalasia or epiphrenic diverticulum in 74, paraesophageal hernia in 27, and esophageal mass in 2. Fifteen patients (5.4%) had undergone prior antireflux operations. RESULTS: There was one perioperative death (0.4%) resulting from an apparent myocardial infarction in an 87-year-old woman who underwent operation for paraesophageal hernia with volvulus. Two patients had contained leaks diagnosed by routine postoperative contrast studies; both were managed successfully without operation. Two patients required early reoperation for recurrent symptoms: 1 underwent a repeated Belsey Mark IV procedure and the other underwent an esophagogastrectomy. An additional 7 patients experienced late recurrence of symptoms requiring surgical management. The overall complication rate was 10.1%, with minor pulmonary complications (2.1%) and atrial arrhythmias (1.8%) occurring most commonly. CONCLUSIONS: The Belsey Mark IV procedure is a safe and effective operation for the management of gastroesophageal reflux disease with complications, and it compares favorably with other antireflux procedures.

Video-assisted removal of left ventricular mass.

The use of endoscopic technology, widely accepted in general surgery and general thoracic surgery, has recently gained popularity in cardiac surgery, as witnessed by the development of minimally invasive cardiac surgery. Intracardiac employment of this technology, however, has largely been limited to enhanced fiberoptic visualization in anecdotal cases. We present a case employing thoracoscopic instruments in the removal of a benign intracavitary lesion using cardiopulmonary bypass.

Diagnosis and management of malignant pleural effusions.

Approximately half of all patients with metastatic cancer develop malignant pleural effusions. Because the patients are already terminally ill, these effusions can present significant diagnostic and therapeutic challenges. Symptoms are either present at the time of diagnosis or develop subsequently in virtually all cases. The diagnosis is based on chest radiography followed by thoracentesis or thoracoscopy. Most malignant effusions are exudative and about one third are bloody. Cytology is positive for cancer cells in the initial pleural fluid specimens from 60% of patients who are ultimately shown to have malignant effusions. The remaining 40% require a repeat thoracentesis, pleural biopsy, thoracoscopy, or multiple procedures to prove the presence of cancer. Because the average life expectancy of a patient with a malignant pleural effusion is about 6 months, it is important to obtain a diagnosis expeditiously and formulate a treatment plan that optimizes quality of life. Tube thoracostomy with chemical pleurodesis using doxycycline or bleomycin is the mainstay of current treatment and is about 85% effective.

Inhibition of the fetal stress response improves cardiac output and gas exchange after fetal cardiac bypass.

Cardiac bypass in late-gestation fetal lambs causes severe placental vasoconstriction, which leads to fetal death from hypoxemia and respiratory acidosis. This response can be blocked by the administration of indomethacin; however, a fatal metabolic acidosis then gradually develops in the fetus. Because the fetus is known to mount an intensive catecholamine response to stress, and because the fetal myocardium is particularly sensitive to increased afterload, we hypothesized that elevated afterload as a result of fetal stress contributes to diminished cardiac output after bypass. Twenty fetal lambs at 80% gestation underwent 30 minutes of normothermic cardiac bypass at flow rates of 200 to 500 ml/kg per minute. All ewes received general anesthesia with ketamine. In 10 fetuses general anesthesia was specifically designed not to inhibit the release of stress-related catechols (ketamine); the remaining 10 fetuses received a "high" (cisterna magna) total spinal anesthetic with tetracaine, to block the fetal stress response. In each anesthetic group, 5 of the 10 lambs received indomethacin. During operation, normal hemodynamics were preserved in the spinal anesthetic group. Cardiac output, placental blood flow, and arterial carbon dioxide tension were all improved relative to results in the ketamine group. When spinal anesthesia and indomethacin are both given, hemodynamics also approach normal after bypass, and gas exchange is further improved. These data suggest that the inhibition of the stress response by spinal anesthesia improves the hemodynamic status of the fetus during operation and, in combination with indomethacin, allows maintenance of near-normal placental function after fetal cardiac bypass. Similar responses may also be possible in human fetuses with use of a high-dose narcotic technique.

Long-term survivors of fetal cardiac bypass in lambs.

The initial experience with cardiac bypass in fetal lambs resulted in early fetal death from placental insufficiency. Subsequent work in our laboratory indicated that vasoactive cyclooxygenase products were released as mediators of this response. The placental dysfunction could be blocked by the administration of indomethacin, allowing longer fetal survival. This unmasked a more subacute (but fatal) problem: fetal surgical stress resulted in diminished fetal cardiac output and progressive metabolic acidosis and contributed to the placental vasoconstriction. In acute studies, when indomethacin was given and the stress response was inhibited by the use of total spinal anesthesia, the fetus maintained normal blood gas levels, cardiac output, placental blood flow, and acid-base status for several hours after bypass. We hypothesized that beyond this point, no further fetal or placental compromise would occur and that this management technique would thus allow long-term fetal survival. With the use of total spinal anesthesia and sterile technique for long-term study, 12 fetal lambs at 120 days (80%) gestation underwent exposure, line placement, and cannulation for fetal cardiac bypass. Indomethacin was given intravenously on obtaining venous access. After 20 minutes of normothermic cardiac bypass at flow rates of 250 to 300 ml/kg/min, the fetus was weaned from bypass, the cannulas and lines were removed, the uterus and abdomen were closed, and the ewe and fetus were allowed to recover. There was one maternal death (pneumonia) and one early abortion (of twins); the remaining 10 ewes progressed to term. At term, five healthy lambs that had undergone fetal cardiac bypass were delivered (including one twin), four ewes delivered a mummified study fetus and one or two healthy siblings, and one delivered a dead term fetus. With the use of techniques that inhibit fetal stress and block placental vasoconstriction, cardiac bypass can be performed in single-gestation fetal lambs with a high degree of recovery and survival (80% in this study). The cause of the elevated abortion rate associated with twin gestation is unclear.

Total anomalous pulmonary venous drainage in newborns with visceral heterotaxy.

Children with visceral heterotaxy often present with total anomalous pulmonary venous drainage (TAPVD) associated with univentricular congenital heart disease. We reviewed our experience with the primary surgical management of this lesion under these circumstances. Over a recent 10-year span, 38 patients within the first 3 days of life were admitted to our institution and underwent primary palliation. Twenty-one of them had TAPVD, 18 to a systemic vein. Twelve (67%) of these 18 were seen with obstruction of the anomalous connection and underwent emergency operation. In 7 patients, repair of TAPVD was combined with a systemic-pulmonary artery shunt because of additional obstruction of the pulmonary blood supply, with two deaths. One patient had primary shunting and then repair of TAPVD. Four patients underwent repair of TAPVD alone. Two of them then showed signs of insufficient pulmonary blood flow, received a shunt in a second procedure, and subsequently died. Early mortality in the group with obstructed TAPVD was thus 4 (33%) of 12 patients. Statistical analysis of all 38 patients (univariate analysis, chi 2 testing) showed that neither the presence of TAPVD (p = 0.7) nor TAPVD repair alone (p = 0.8) or with shunting (p = 0.8) was a definite risk factor for early death. The performance of a shunt during the first operation, however, was associated with lower early mortality (p = 0.03). Total anomalous pulmonary venous drainage is a common finding in newborns with visceral heterotaxy. Its presence and its subsequent early repair (requiring cardiopulmonary bypass) do not increase the mortality risk. The need of a concomitant shunt in obstructed TAPVD can initially be underestimated.

Surgical repair of complete atrioventricular canal defects in infancy. Twenty-year trends.

Case histories of 301 patients with complete atrioventricular canal defect presenting to our institution in infancy between January 1972 and January 1992 were reviewed with the purpose of identifying the factors responsible for the observed improvement in perioperative mortality over this time period. A retrospective analysis of hospital records examined 46 patient-related, morphologic, procedure-related, and postoperative variables for associations with perioperative death and reoperation. Operative mortality decreased significantly over the period of the study from 25% before 1976 to 3% after 1987 (p < 0.0001). A number of the 46 variables examined showed trends over time that were similar to that for mortality. Palliative procedures decreased over time. Reoperation for most residual lesions also decreased to the degree that they were essentially eliminated in recent years. The exception to this was reoperation for postoperative left atrioventricular valve regurgitation, which also decreased but remained at 7% in recent years. Both technical and support-related procedural variables showed no trends over time, with the exception of the performance of left atrioventricular valve annuloplasty, which increased over time. Closure of the left-sided cleft was performed in 61% of the patients, with no trend over time. Annuloplasty and cleft closure were not associated with less postoperative left atrioventricular valve regurgitation, fewer reoperations, or lower mortality. Multivariate logistic regression analysis identified only earlier year of operation, the presence of double-orifice left atrioventricular valve, and postoperative residual regurgitation of the left atrioventricular valve as risk factors for death. Experience-related improvements in technical precision achieved over time best account for the reduction in the rate of reoperation for most types of residual lesions and also for the reduction in mortality. The only residual lesion that has not been essentially completely eliminated is left atrioventricular valve regurgitation, with reoperation for this lesion having been reduced in recent years, but not eliminated. Improved understanding of the structural and functional variability of the atrioventricular valve in this lesion may be necessary before postoperative dysfunction of this valve can be completely eliminated.

Fate of small homograft conduits after early repair of truncus arteriosus.

Neonatal repair of truncus arteriosus is being performed in a number of centers, often with the use of small homograft conduits. The fate of the homograft and the risk of replacement were the subjects of this study. Between January 1987 and October 1991, 43 infants aged less than 3 months (range, 3 to 90 days) underwent primary repair of truncus arteriosus including implantation of a valved homograft conduit (diameter, 7 to 12 mm). Twenty-nine had follow-up of more than 6 months (range, 6 to 65 months; mean, 21.9 months). After a mean period of 31 months (range, 8 to 65 months), 7 patients showed obstruction with right ventricular pressures at least 75% systemic and underwent either a conduit change (n = 5) or a patch augmentation (n = 2). Mean cardiopulmonary bypass time at reoperation was 99 minutes; mortality was zero. Five other children are known to have a right ventricular pressure of 50% to 60% systemic, 2 having undergone balloon dilation. Statistical comparison of the patients with conduit reoperation or high right ventricular pressure (n = 12) with the rest of the population (n = 17) revealed an elevated pulmonary artery to right ventricular pullback gradient on postoperative day 1 after the repair (7.7 versus 1.3 mm Hg; p = 0.001) and choice of an aortic over a pulmonary homograft (100% versus 64.7%; p = 0.065) as significant risk factors. Age and weight at repair, postoperative pulmonary artery pressure, length of follow-up, and size of the homograft showed no significant differences between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Exclusion of the placenta during fetal cardiac bypass augments systemic flow and provides important information about the mechanism of placental injury.

The in utero correction of congenital cardiac malformations requires the availability of fetal cardiac bypass. One difficulty with fetal cardiac bypass is that very high flow rates are necessary when the placenta is left in the bypass circuit; the placenta requires about 40% of fetal cardiac output, which results in a normal cardiac output of 400 ml/kg per minute. Previous attempts to perform fetal cardiac bypass failed to consistently achieve these high flow rates because of cannula size limitations. On the basis of previous work done in our laboratory with an isolated-placenta model, which demonstrated that at normothermia the placenta would tolerate at least 30 minutes of cessation of umbilical blood flow, we hypothesized that exclusion of the placenta from the fetal cardiac bypass circuit would reduce fetal cardiac output by one half and allow us to obtain better systemic perfusion without compromising placental function. Cardiac bypass was performed in 20 late-gestation fetal lambs. In 10 lambs, no drugs were given; 5 served as controls in which the placenta was perfused; in the last 5, the placenta was excluded by clamping the umbilical cord during bypass. The latter 10 lambs were treated with indomethacin, which is known to improve placental blood flow after fetal cardiac bypass. We measured blood gases and determined regional blood flow with radiolabeled microspheres to assess placental function after bypass. The 5 control fetuses experienced rapid hypercapnea and hypoxemia after bypass, in association with minimal placental blood flow; when the placenta was excluded, arterial carbon dioxide tension rose somewhat more slowly, and placental blood flow after bypass was significantly better. When indomethacin was given, arterial blood gases in both groups showed a mild increase in carbon dioxide tension and similar placental blood flows (about 30% of baseline) after bypass. Indomethacin is known to block the vasoconstrictive response of the placenta to fetal cardiac bypass, implicating the release of vasoactive cyclooxygenase products as the cause of the adverse effects. In this study, placental perfusion on bypass without indomethacin caused much more severe placental dysfunction than did bypass with the placenta excluded from the circuit. The use of indomethacin improved postbypass placental function in both groups, but this effect was much more dramatic in the placenta-perfused group.(ABSTRACT TRUNCATED AT 400 WORDS)