The effect of subtalar joint posting on patellar glide position in subjects with excessive rearfoot pronation.

It has been postulated that patellar position is influenced by subtalar joint mechanics. The purpose of this study was to compare the patellar alignment observed by radiographic analysis in subjects with excessive rearfoot pronation, both pre- and post-placement of semirigid rearfoot posting. Sixteen asymptomatic patellofemoral joints were contributed from 12 female subjects (four bilaterally). The amount of subtalar joint posting each subject received was related to the amount of rearfoot pronation present. The subjects' patellofemoral joints were radiographed in full weight-bearing, tangential view, both pre- (resting calcaneal stance position) and post- (neutral calcaneal stance position) placement of the posting material. The paired t test revealed a statistically significant change in patellar positioning (medial glide) after placement of semirigid posting (p < or = .05). This finding has structural implications for utilization of orthotics in the treatment of patients with patellofemoral pain syndrome with requisite excessive rearfoot pronation.

Home heparin therapy used in a pregnant patient with a mechanical heart valve prosthesis.

The optimal anticoagulation therapy for pregnant patients with a mechanical valve prosthesis is uncertain, but teratogenic effects and the high incidence of fetal loss associated with dicumarol derivatives limit the use of these agents as anticoagulants in this setting. A patient with a mechanical valve prosthesis, in the first trimester of pregnancy, stopped taking her warfarin because of personal fears about teratogenicity. Prosthetic valve thrombosis developed, and she required redo mitral valve replacement. Another mechanical prosthesis was inserted without maternal or fetal injury. The patient was maintained on continuous home, intravenous, high-dose heparin therapy for the remainder of her pregnancy. This therapy resulted in a successful pregnancy and delivery without valve thrombosis, hemorrhagic events, or maternal or fetal compromise.

Resection of aortic arch aneurysms using an external shunt.

Surgical treatment of aneurysms of the thoracic aorta had its beginnings in the early 1950s. At that time, thoracic aneurysms were usually due to syphilitic infection and were usually fatal. Before the development of the heart-lung machine, it was realized that external shunts could facilitate the repair of these aneurysms. In 1954, Dr Ralph Alley and his colleagues at Albany Medical Center reported 2 patients who had surgical correction of thoracic aortic aneurysms using external vascular shunts. Both bovine aortic heterograft and human aortic homograft were used as aortic substitutes. These patients were presented at the Thirty-fourth Annual Meeting of the American Association for Thoracic Surgery in Montreal, Quebec, in May 1954, and case reports were subsequently published in the Journal of Thoracic Surgery in 1955. These presentations served as the stimulus for subsequent clinical studies and laboratory research, eventually leading to a better understanding of the physiologic principles involved in clamping the thoracic aorta. Doctor Alley's article is a classic in the field of cardiothoracic surgery and is now reviewed 39 years after its publication.

Traumatic thoracobiliary fistula.

Thoracobiliary fistulas are a commonly reported complication of subphrenic or liver abscesses and biliary tract obstruction. However, they are a rare and unusual complication of traumatic thoracoabdominal wounds. Due to their rarity, the experience of any one surgeon is minimal, and there is a paucity of information available in the literature regarding their treatment. We describe a case of a traumatic thoracobiliary fistula, review the existing literature, and discuss the proper management of this potentially lethal sequela of trauma.

Comparison of blood reinfusion techniques used during coronary artery bypass grafting.

A comparison of intraoperative autologous blood conservation techniques was carried out in 100 patients undergoing coronary artery bypass grafting. To facilitate comparisons of similar groups, patients were stratified into high-risk and low-risk groups based on the ratio of preoperative bleeding time to preoperative red blood cell volume. Our previous work suggested that patients with an elevated ratio have increased risk of excessive post-operative blood transfusion. We used this ratio to stratify the 100 patients to either the high-risk (39 patients) or low-risk (61 patients) strata. Within each stratum, patients were randomized to one of three groups: no intraoperative autologous blood conservation (control group), infusion of autologous platelet-rich plasma obtained from intraoperative plasmapheresis (PRP group), and infusion of autologous whole blood harvested immediately before cardiopulmonary bypass (whole blood group). Variables of postoperative blood loss and transfusion requirements were measured in each patient. Analysis of variance showed significant differences in blood product transfusions between groups. Patients in the high-risk stratum required significantly more blood product transfusions than those in the low-risk stratum (5.4 +/- 0.7 versus 2.0 +/- 0.6 units per patient; p < 0.001). In the high-risk stratum, PRP patients required significantly less postoperative blood transfusion compared with patients in the high-risk control group (2.9 +/- 2.1 versus 8.1 +/- 2.2 units per patient; p = 0.05). In the low-risk stratum, no intraoperative blood infusion method resulted in significant improvement in postoperative blood use.(ABSTRACT TRUNCATED AT 250 WORDS)

Pericardial closure without pericardial substitute.

Primary closure of the native pericardium is recommended whenever possible, and pericardial substitutes are advocated when primary closure is not feasible. To avoid foreign material, we have employed a unique method of dissection to allow mediastinal coverage without tension.

Alternative conduits for coronary revascularization: a novel approach for harvest of the lesser saphenous vein.

Previous use of the greater saphenous vein limits the subsequent availability of conduit for coronary artery bypass grafting (CABG). One readily available alternative conduit is the lesser saphenous vein (LSV). During a 4-year period, 34 LSVs were explored in 23 patients using a novel surgical approach. The incision used for LSV harvest was carried through and deep into the muscular fascia, posterior to the tibia, along the length of the leg, developing a fascial-cutaneous flap. The LSV in all patients was imaged before operation by venous duplex scanning. Important anatomic details were mapped on the patient's leg before surgery using indelible ink. Findings at operation correlated well with the duplex imaging results. Of the 34 LSVs explored 31 were judged usable by the operating surgeon. In eight patients bilateral LSVs were used and in two this vein was the only conduit available. Among patients undergoing LSV harvest there was no operative mortality and minimal operative morbidity related to harvesting. Only one wound infection developed at the incision site. There were no documented cases of deep vein thrombosis. A case-control study was performed in which a control group of 25 patients undergoing CABG without use of the LSV were compared with the 23 who had LSVs harvested; patients in both groups underwent preoperative venous duplex studies. There were no significant differences in operative mortality or morbidity rate between groups (statistical power > 0.8 for these negative observations), suggesting that harvest of the LSV is usually successful when used in conjunction with preoperative venous duplex scanning.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiologic assessment and surgical management of diffuse esophageal spasm.

The physiologic abnormalities and management of patients with diffuse esophageal spasm are controversial. We evaluated the symptomatic and functional results of surgical therapy in 19 patients with diffuse esophageal spasm who were incapacitated with dysphagia and chest pain and unresponsive to conservative management. A long esophageal myotomy with an antireflux procedure was performed in 15 patients, and four patients with multiple previous esophageal procedures had an esophagectomy. Eleven patients had increased esophageal exposure to gastric juice on preoperative 24-hour esophageal pH monitoring. The severity of dysphagia, chest pain, regurgitation, and heartburn was scored on a scale of 0 to 3 before and a mean of 24 months (range 8 months to 13 years) after the operation. After myotomy, each of these symptoms and the overall symptom score improved significantly (p < 0.01). The improvement in the symptom scores in the patients who had esophagectomy were comparable with the improvement after myotomy. On self-assessment, 90% of the patients would have the operation again if again faced with the decision. Standard and ambulatory 24-hour manometry showed a significant reduction in the amplitude of the esophageal body contractions, a decrease in the frequency of simultaneous contractions, and the elimination of multi-peaked waves after the myotomy. Despite the addition of an antireflux procedure, lower esophageal sphincter pressure, overall length, and abdominal length were reduced markedly after the myotomy. This was associated with persistent or emerging heartburn or regurgitation in four patients. These data indicate that a long esophageal myotomy is a valid treatment alternative in appropriately selected patients with diffuse esophageal spasm. Esophagectomy and colon interposition is the procedure of choice in patients with multiple previously failed myotomies.

Transesophageal echocardiography in the surgical management of renal cell carcinoma with intracardiac extension.

Renal cell carcinomas may extend into the vena cava and the tumor thrombus occasionally involves the right atrium. The operative approach depends upon precise preoperative and intraoperative staging and thrombus localization. We report a case of renal cell carcinoma with complete inferior vena caval and hepatic vein occlusion with tumor extension into the right atrium. Preoperatively, transesophageal echocardiography provided superior images of the tumor and its extension, and intraoperatively allowed continuous monitoring of cardiac function and the removal of tumor from the atrium and inferior vena cava. Its use obviated the need for more costly and invasive preoperative and intraoperative procedures.

Ambulatory 24-hour esophageal manometry in the evaluation of esophageal motor disorders and noncardiac chest pain.

Standard manometry is currently considered the gold standard for the classification of esophageal motor disorders. We compared the new technique of ambulatory 24-hour esophageal motility monitoring to standard manometry in 108 patients thought to have a primary esophageal motor disorder, assessed the esophageal motor pattern associated with spontaneous noncardiac chest pain, and studied the effect of long esophageal myotomy on circadian esophageal motor function. Standard manometry was found to frequently overestimate and underestimate the severity of esophageal motor abnormalities as compared to 24-hour monitoring. Ambulatory manometry showed a direct correlation of abnormal esophageal motor activity with episodes of noncardiac chest pain in 13 of 26 patients who experienced the symptom during the monitoring period. The abnormal motor activity immediately preceding the pain episodes in these patients was characterized by an increased frequency of simultaneous, double and triple-peaked, high amplitude, and long duration contractions (p less than 0.01). Long esophageal myotomy markedly reduced or eliminated the ability of the esophagus to produce these abnormal contractions (p less than 0.01). These data suggest that ambulatory esophageal motility monitoring allows more precise classification of esophageal motor disorders than standard manometry and identifies abnormal esophageal motor activity associated with noncardiac chest pain that can be abated by long esophageal myotomy.

Cystic and bullous lung disease.

One of the most difficult problems facing clinicians is the evaluation and management of patients with dyspnea whose chest roentgenogram shows single or multiple large cystic spaces. This is made more difficult when underlying lung disease is present. The dilemma focuses on whether the obliteration or removal of the cystic areas will benefit or cause further deterioration of the patient's condition. The pathophysiology of the problem is not completely understood, but accumulated clinical experience has shown that surgical therapy can be beneficial but requires proper patient selection.

Traumatic hemipelvectomy.

Traumatic hemipelvectomy is an uncommon and devastating injury with few patients alive when they reach the hospital. There are only 19 reported survivors of this injury. This group includes 17 males and 2 females. All had severe, associated injuries. The mechanism of injury involved motorcycle, automobile, pedestrian/motor vehicle, or heavy machinery accidents. All surviving patients are young (10-34 years of age). Most suffered from a variety of postoperative complications. Two interesting patients with traumatic hemipelvectomy are reported. One involves a new mechanism of injury, the propellor of a motorboat. The management of these 2 patients is explained, the experience of others with similar injuries is reviewed, and the benefit of reconstruction with the gluteus myocutaneous flap is discussed.

Extension of renal cell carcinoma into the vena cava with concomitant coronary artery disease: surgical considerations.

Surgical removal of renal cell carcinoma with extension into the inferior vena cava can be a difficult operation. Cardiopulmonary bypass and circulatory arrest have been used to assist in resection of tumors that extend into the vena cava above the level of the hepatic veins. Coronary artery disease is a common problem and may present together with renal cell tumors. A patient with left main coronary artery disease and a renal cell carcinoma extending into the vena cava provides a management challenge. We present such a case and discuss the surgical options.

Cardiopulmonary bypass.

There has been a recent renewed interest in certain aspects of cardiopulmonary bypass employing extracorporeal circulation. Several areas have received special attention. Among these is the institution of extracorporeal circulation using a percutaneous technique for circulatory assistance during high-risk percutaneous transluminal coronary angioplasty. A national registry has been established to review and monitor results using this percutaneous technique. Several recent developments in the delivery of cardioplegia during ischemic arrest have stimulated investigative efforts. In particular, the delivery of cardioplegia in a retrograde manner through the coronary sinus has proved an effective and useful adjunct to myocardial protection during cardiopulmonary bypass with extracorporeal circulation. A newer investigative technique employing only warm cardioplegia delivered primarily through the retrograde coronary sinus route seems to offer some promise in providing optimal myocardial protection while minimizing hemorrhagic complications and other cold-induced myocardial injury. Because of concerns regarding blood transfusion-related communicable disease (eg, acquired immune deficiency syndrome and non-A, non-B hepatitis), there has been increasing research effort into postoperative hemorrhage related to cardiopulmonary bypass with extracorporeal circulation. Specifically, various drugs that may serve as hemostatic adjuncts have been investigated extensively. These drugs include aprotinin and desmopressin acetate. Likewise, several studies have evaluated other drugs (mainly aspirin) that have a negative influence on postoperative hemostasis. Additionally, there has been continued research interest in the activation of the inflammatory system during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical approach to non-small cell lung cancer stage I and II.

No patient with a potentially curable lung cancer should be denied the opportunity for a curative resection. Solitary pulmonary nodules should be approached as though they were malignant until proven otherwise, either by definitive histologic or extremely convincing circumstantial clinical evidence. Consequently, thoracotomy should be performed, assuming that the patient is physiologically able, if cancer cannot be definitely excluded. The evaluation of patients with synchronous lung nodules is complex owing to the possible causes of the two nodules but should be pursued because of its important effect on therapeutic outcome. The major factor influencing survival is the extent of the tumor at the time of resection. When metastatic lymph nodes are found at the time of surgery, regardless of the location, the survival rate is significantly lower. Lobectomy for patients with stage I disease is usually sufficient treatment, but when the tumor is large (exceeding 4 cm) or centrally located or when hilar lymph nodes are involved, a pneumonectomy must be considered in order to eradicate local disease. Those patients with N1 disease can obtain improved survival when resection is combined with adjuvant radiation and chemotherapy.

Basal cell burn carcinoma.

Postburn malignant degeneration into squamous cell carcinoma is unusual but well described. Much rarer is malignant degeneration of a burn into basal cell carcinoma. Recently a well-documented case was seen. The cause was postulated to be injury to the more superficial hair follicles and sweat glands. A brief report is given.