Surgical and long-term outcome of graft replacement of aneurysms of the descending thoracic aorta. Analysis of 28 consecutive cases.

A consecutive series of 28 patients operated on at the Oulu University Hospital during the years 1974-1994 for aneurysms of the descending thoracic aorta is presented. Twenty-five cases were elective and three were operated on as emergencies. Their mean age was 58 years. During the aortic cross-clamp, circulatory support of the lower body, was used in 27 cases as follows: a direct aorto-femoral shunt without a pump (12/28), left-heart bypass (11/28) or femoro-femoral perfusion (4/28). Hospital mortality was 14% (4/28). One patient with a ruptured aneurysm died of renal failure, but there were no other renal complications. None had paraplegia postoperatively. Three had symptoms of paraparesis, but only one of them had a slight permanent discomfort while walking. The mean follow-up time was 100 months, range 2-242 months. Late actuarial survival including hospital mortality, was 65% at 5 years and 41% at 10 years, reflecting the generalized aortic disease with a high risk of very late rupture (4) and other manifestations of atherosclerosis with myocardial infarction (6) or cerebral atherosclerosis (1), the remaining late deaths being unrelated. The efficacy of lower body circulatory support in avoiding peroperative renal and spinal cord ischaemic complications is demonstrated.

Repair of an aneurysm of the left main coronary artery.

Coronary artery aneurysms are rare, especially in the left main coronary artery. Coronary artery aneurysms may rupture or cause myocardial infarction. There are only a few reports of coronary artery aneurysms of the left main coronary artery treated surgically. We report a case in which an arterial graft from the internal iliac (hypogastric) artery was used for the reconstruction of a congenital coronary artery aneurysm of the left main coronary artery. After a follow-up of 5 years, the patient is well and in good condition.

Cerebral haemorrhage after carotid endarterectomy.

Cerebral stroke is a serious complication related to carotid endarterectomy (CEA), being most frequently caused by thromboembolic events and less frequently on account of cerebral haemorrhage. The present series comprised five out of 857 (0.6%) patients who had undergone CEA at Oulu University Hospital between the years 1974 and 1993 and suffered a postoperative stroke four to 13 days after surgery due to intracerebral haemorrhage (IH). Preoperatively, all these patients were neurologically intact, with transient ischaemic attacked (TIA) as the main indication for CEA. All five patients had a history of arterial hypertension treated adequately preoperatively, and one patient had high blood pressure levels after surgery. Critical ipsilateral stenosis of the internal carotid artery (> 90%) was detected in the preoperative angiogram in all five cases. The primary outcome after CEA was uneventful in every case, without any signs of neurological deficiency. The symptoms, comprising severe headache, convulsions and/or hemiparesis occurred suddenly four to 13 days (mean seven days) after CEA. The diagnosis of IH was based on computed tomography (CT) findings. All five patients were treated conservatively. Three of them died. We conclude that even normotensive, neurologically intact patients without demonstrable cerebral infarction or postoperative hypertension may suffer cerebral haemorrhage after the relief of high-grade carotid stenosis. The role of possible insufficiency of the autoregulatory mechanisms of the cerebral vasculature on account of long-standing critical stenosis of the internal carotid artery and subsequent uncontrolled hyperperfusion following CEA are discussed.

De Vega's annuloplasty for tricuspid regurgitation.

A total of 337 patients underwent a mitral or combined mitral and aortic valve operation at the Oulu University Hospital between 1986 and 1992. Of these, 30 (8.9%) patients had De Vega's semicircular annuloplasty performed because of tricuspid regurgitation (TR) which was considered functional in nature. There were five (16.6%) early and seven (23.3%) late deaths during the follow-up period of 10 to 71 months. The preoperative mean New York Heart Association (NYHA) functional class was 3.4, and at follow-up 13 (76.5%) of the survivors were in NYHA CLass I or II. The actuarial survival rate was 37.6% at five years. All the survivors were evaluated echocardiographically and the TR was considered mild in 56.3%, moderate in 25.0% and severe in 18.7% of the cases. Tricuspid annuloplasty using De Vega's semicircular suture technique is a simple and effective procedure in patients with mild to moderate regurgitation. In patients with massive regurgitation, which is usually associated with a massively dilated tricuspid annulus and pulmonary hypertension, annuloplasty should be reinforced using a ring technique. Tricuspid valve replacement is hardly ever needed in the treatment of functional tricuspid regurgitation.

Outcome of thoracoabdominal aortic aneurysm surgery. Analysis of 27 consecutive cases.

Twenty seven patients underwent repair of a thoracoabdominal aortic aneurysm at our hospital during 1978-1993. Sixteen were elective and 11 emergencies. We used a temporary shunt and transsection of the proximal aorta between vascular clamps, so that the whole distal aorta with its branches was perfused through the shunt during suturing of the proximal anastomosis. The aortic branch arteries were revascularized by the step by step technique. Hospital mortality was 6/27 (22%) and two and five-year cumulative survival rates 74% and 52%. Late deaths were not related to aneurysm disease. Paraplegia developed in two patients. Distal aortic perfusion was used as a means of spinal cord preservation.

Acute type A aortic dissection--diagnostic aspects and surgical experience.

Acute type A aortic dissection was surgically treated in 33 patients aged 20-65 years, all critically ill on admission to hospital. Transthoracic echocardiography revealed pericardiac tamponade in eight cases of extreme emergency, indicating surgery without need of additional imaging. Transesophageal echocardiography provided a definitive diagnosis in 16 cases, with excellent reliability and no false positive findings. Composite graft replacement with button technique was used in 24 patients and other methods of repair in nine. The perioperative mortality was 12% (4/33) and the late mortality 7% (2/29). The actuarial 5-year survival rate was 73%. No aortic root reoperation was required during follow-up for a mean of 4 years. Transesophageal echocardiography proved to be an accurate tool for speedy diagnosis of acute type A aortic dissection and open composite graft replacement with button technique highly satisfactory treatment, avoiding late aortic root problems.

Assessing resectability of lung cancer: the role of computed tomography of the mediastinum, upper abdomen and head.

In order to assess the value of computed tomography (CT) of the mediastinum, upper abdomen and head in the assessment of resectability of lung cancer, the CT findings of 262 patients, of whom 198 underwent thoracotomy, were analyzed retrospectively and the stagings obtained at CT and thoracotomy were compared. Mediastinal CT reliably predicted resectability when there was no evidence of mediastinal involvement. However, it was often impossible to determine whether tumour with apparent mediastinal infiltration on CT was resectable or not. The sole finding of lymph node enlargement did not permit differentiation of benign from malignant lymphadenopathy when the lymph node diameter was less than 25 mm and the lymphadenopathy was confined to one lymph node station. Upper abdominal metastases were found in 6.1% and brain metastases in 4.6% of patients and neither the histological type nor other features of the tumour were found to be useful predictors of their presence. The large number of non-specific findings decreased the utility of abdominal CT. The appropriate strategy for the pre-operative evaluation of patients with lung cancer is discussed.

Computed tomography and mediastinoscopy in the assessment of resectability of lung cancer.

In order to assess the potential of computed tomography (CT) of the mediastinum and mediastinoscopy in the staging of lung cancer, 125 patients were examined. Of these, 104 underwent thoracotomy, at which there was no evidence of mediastinal tumour involvement in 79 while 25 patients had signs of tumour spread. The sensitivity and specificity of CT were 87.0 per cent and 95.8 per cent, respectively, in the detection of direct tumour extension with a mediastinal mass. When lymph node enlargement was the sole finding, CT did not provide any differentiation between benign and malignant lymphadenopathy. The mediastinal involvement was inaccessible on mediastinoscopy in 18 cases (72%). Despite the surperior sensitivity of CT it was often difficult to determine whether direct tumour infiltration of mediastinal structures had occurred. It was concluded that CT is necessary for screening the entire mediastinum and, when it reveals no evidence of mediastinal tumour spread, mediastinoscopy will yield no further information. Mediastinoscopy will help to correctly identify accessible mediastinal lymph node involvement of the superior mediastinum and to define the mediastinal tumour invasion in doubtful cases.

Surgery of thoracoabdominal aneurysms.

Seventeen patients with thoracoabdominal aneurysms, including 5 ruptured aneurysms, were operated upon using a left diaphragm-splitting thoracoabdominal incision and the retroperitoneal route. A temporary shunt was used in 13 patients, femorofemoral perfusion in 1 and cold perfusion cooling of the kidneys in 3 patients. The step-by-step reattachment technique into ready-made limbs or holes in the Dacron graft ensured that visceral and renal ischaemic times remained within acceptable limits. The mean renal and proximal clamping times were 44 and 77 min, respectively. One patient with a ruptured aneurysm (6%) died of diffuse bleeding. The others recovered without paraplegic, renal or other severe complications. During the follow-up period, mean 44 months and range 10-116 months, 3 patients died of lung cancer and 2 of coronary disease giving a late mortality of 29%. The remaining 11 patients are alive and well. The cumulative 2- and 5-year survival is 87% and 62% respectively. The patency rate of the grafts was 100% and that of the 30 individually revascularised arteries 80%. We recommend elective surgery for thoracoabdominal aneurysms using a temporary shunt or cold perfusion cooling of the kidneys as a protective measure against perioperative ischaemia.

Survival after surgical treatment of lung cancer.

All 205 patients operated on for primary pulmonary cancer at Oulu University Hospital in 1975-1977 were followed up for 10 years to evaluate the prognostic influence of factors such as lymph-node invasion, size of tumour and histologic type. Preoperative mediastinoscopy was performed on 186 patients (91.2%), and revealed no mediastinal metastases in 182. Nevertheless N 2 (mediastinal) lymph nodes were found in 36 cases at operation and N 1 (perihilar or ipsilateral) nodes in 42. Despite lobectomy or pneumonectomy, all 32 patients (17.2%) with false-negative mediastinoscopy died within a year (mean 7.2 months) of operation. Pneumonectomy was performed in 67 cases (29 right, 38 left), lobectomy or bilobectomy in 125 and exploratory thoracotomy in the remainder. Most of the tumours were epidermoid carcinoma (53.7%). Adenocarcinoma was present in 20%, and large-cell carcinoma and oat-cell carcinoma each in 11.7%. Survival rates were significantly higher in patients without vs. those with lymph-node metastases and in epidermoid or adenocarcinoma vs. small-cell carcinoma.

Infection prophylaxis in pulmonary surgery: a randomized prospective study.

A prospective randomized study to evaluate the efficacy of antibiotic prophylaxis against postoperative infections was carried out on 120 patients undergoing pulmonary operations. The patients were randomized into two groups of 60 patients each. One group received doxycycline (deoxytetracycline) prophylaxis for five days, and the other received cefuroxime (a second-generation cephalosporin) for one day. The groups were comparable with regard to age, sex, common risk factors, diagnosis, and operative procedures. A reduction in the infection rate was noted in the cefuroxime group (10/60) compared with the doxycycline group (19/60), but the difference was not statistically significant (p = 0.055). In major infections (empyema and pneumonia) there was no difference between the groups (4/60 in the cefuroxime group and 5/60 in the doxycycline group), but a significant (p less than 0.05) reduction was noted in minor infections (6/56 and 14/55, respectively) such as lower respiratory tract infections and prolonged fever. There were no wound infections in the two study groups. There were significantly (p less than 0.05) fewer postoperative fever reactions (axillary temperature greater than 37.5 degrees C) in the cefuroxime group (30/60) compared with the doxycycline group (44/60). Both antibiotics were effective in preventing wound infections, but cefuroxime may also be beneficial in preventing minor respiratory infections. The bactericidal effect of cefuroxime may explain this finding.

Delayed left ventricular rupture after mitral valve replacement.

Posterior left ventricular rupture (LVR) is a serious complication following mitral valve replacement (MVR), especially if occurring postoperatively with the chest already closed or the patient in the intensive care unit. Only one of the patients with this delayed type of LVR reported earlier has been treated successfully. Our experience consists of 4 such complications among 161 MVR patients, the incidence being 2.5%. Two of these patients survived. Mechanical factors seem to constitute the most important etiologic causes for this complication. Immediate reoperation must be performed, and extracorporeal circulation is generally mandatory for successful repair. The reconstruction of the ruptured posterior left ventricular wall in both surviving patients was performed from the epicardial surface of the heart using pledget sutures. The auricle of the left atrium was used to cover the site of the tear when bleeding was not stopped with pledget sutures. It usually seems possible to avoid this complication if all mechanical etiologic factors are taken into consideration. After successful correction, a pseudoaneurysm may arise and, for that reason, a cardiac echo sonography follow-up is recommended.

Candida immunity in patients undergoing surgical treatment for heart valve disease.

The appearance of Candida antigen (Latex agglutination method), Candida antibodies (indirect immunofluorescence) and positive fungal cultures as well as the lymphocyte transformation response to Candida antigen "in vitro" was studied in a series of 37 successive patients before and after heart valve replacement. The Candida antigen test was positive preoperatively in 11/36 (31%) and postoperatively in 14/36 (39%) of the patients and in 2/200 (1%) of the controls (blood donors). The differences in the frequencies of positive tests between the patient group and the control group are significant (p less than 0.001). The lymphocyte response to Oidiomycin (Candida albicans) preoperatively was greater than the mean control value in 6/11 (54.5%) of the patients showing a positive Candida antigen test, but only in 4/25 (16.0%) of the patients who were Candida antigen negative. The total number of lymphocytes and the number of ANAE positive (T) cells as well as the lymphocyte response to Oidiomycin (OID), tuberculoprotein (PPD) and phytohaemagglutinin (PHA) decreased markedly postoperatively. Candida antibody titres were positive (greater than or equal to 1:128) in 3/37 (8%) of the postoperative patients and in 2/84 (2.4%) of the controls. This difference is not significant. Positive Candida antibody titres were found postoperatively in 15/37 (41%) of the patients, which is a significantly higher frequency than that seen preoperatively (p less than 0.005). More positive fungal cultures from throat specimens (p less than 0.005) were found in the patient group before surgery than in the control group (hospital personnel). After surgery the number of positive fungal cultures in these cases decreased (p less than 0.001) due to the use of oral antifungal prophylaxis with nystatin tablets.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of surgery, radiation therapy, and combined radiation therapy and chemotherapy on immunocompetence in patients with lung carcinoma.

The immunologic status of 59 patients with lung carcinoma was determined by analysis of peripheral venous blood samples. The following tests were performed: total leucocyte and lymphocyte counts, the number of acid alpha-naphthyl acetate esterase (ANAE) positive cells (T-cells), and phytohaemagglutinin (PHA) and tuberculin (PPD) transformation tests. The patients were divided into three treatment groups: a surgery group (S), a radiation therapy group (R), and a combined cytostatic and radiation therapy group (C). A follow-up was carried out 4 to 6 months after treatment. The therapeutic measures, resection, irradiation, and chemotherapy, produced a decrease in the total leucocyte and lymphocyte counts, in the number of T-cells, and in the leucocyte transformation response to PPD. In the surgically treated group the decrease was transient. In the groups treated with radiation therapy and combined cytostatic and radiation therapy the values remained low throughout the follow-up. The lymphocyte response to PHA was not altered in any of the groups during initial treatment or follow-up. The results did not suggest a correlation between the immunologic parameters used and the stage and histologic type of lung cancer. The tests were of no clinical value in the determination of the individual prognosis.

Repair of ruptured oesophagus. A case report.

Oesophageal perforation or rupture is a serious condition. Delayed diagnosis is associated with high mortality rate. A method of repair is described, used to cover a lower oesophageal tear with high gastric fundoplication in three cases with delayed diagnosis (greater than 12 h), two of which survived.

One turn more: threshold superiority of 3-turn versus 2-turn screw-in myocardial electrodes.

Epicardial electrodes are an alternative for patients in whom the transvenous approach presents technical difficulties. We have had clinical experience with two types of myocardial sutureless electrodes inserted in the anterior left ventricular wall: the 3-turn screw-in electrode (Medtronic 6917) was used in 209 patients from 1974 to 1977 and the 2-turn screw-in lead (Medtronic 6917 A) was used in 61 patients from 1978 to 1981. The initial threshold was equal and acceptable with both types of electrodes. During a follow-up period (up to 48 months), critical elevation of the pacing threshold resulting in exit block was found in 12% (25) of the patients with the 3-turn screw-in electrode and in 20% (12) of the patients with the 2-turn electrode (p less than 0.05). Elevation of the pacing threshold developed fairly early, usually within 6 months, with the 2-turn screw-in electrode, but much later, within 2-4 years, with the 3-turn electrode. During a longer follow-up time of up to 96 months the frequency of exit block increased up to 16% with the 3-turn electrode. Our results indicate that late critical elevation of the pacing threshold is surprisingly frequent with screw-in electrodes inserted into the left ventricular myocardium, and it is especially common with the 2-turn screw-in electrode.