The contribution of anterior mediastinotomy in the diagnosis and evaluation of diseases of the mediastinum and lung.

Our experience with 62 consecutive patients who underwent anterior mediastinotomy is presented. A wide range of histological diagnoses was achieved. The highest yield was achieved for mediastinal masses. The overall diagnostic specificity was 64.5% and the diagnostic sensitivity was 98%. However, patient morbidity and mortality were 16.1% and 1.6%, respectively. Therefore, specific guidelines for the procedure are presented.

Fiberoptic bronchoscopy with general anesthesia using a transvector for ventilation.

A transvector, a highly efficient flow amplifier, until present in use only in industry, has been adapted to the ventilation of patients during fiberoptic bronchoscopy under intravenous general anesthesia. The transvector is connected directly to an endotracheal or tracheostomy tube and provides an open unobstructed passage of the instrument into the patient's airways. The method combines safety with ease of instrumentation and uniformly satisfactory ventilation has been obtained in 25 patients.

Thoracic wounds in Israeli battle casualties during the 1982 evacuation of wounded from Lebanon.

During the first 3 weeks of the operation "Peace for Galilee" (O.P.G.) 938 wounded soldiers were evacuated from Lebanon to the Rambam Medical Center in Haifa, Israel. Of these, 64 (6.8%) had chest wounds with or without other wounds. The characteristics of these wounds, the treatment given in the field and at the hospital and their results, are examined and a review of the literature of chest war wounds are summarized. A rapid and efficient in-field medical aid was the most important contributing factor to the low mortality and morbidity rates achieved. As far as we know, this is the first time computerized tomography was used in the diagnosis of war wounds of the chest.

Effects on respiratory patterns during bronchoscopy by the Sanders attachment technique.

The purpose of this study was to rationalize the choice of injector and bronchoscope sizes during bronchoscopy under general anesthesia using the Sanders attachment technique. Arterial Po2 and Pco2, FIo2, and peak inspiratory pressure at the tip of the bronchoscope were plotted against the ratio (RI/B) of the internal diameters of the injector and the bronchoscope in seven dogs undergoing bronchoscopy under general anesthesia. Peak inspiratory pressure, FIo2, and PaO2, increased, and PaCO2 decreased with an increase in RI/B. A working table is proposed to predict the optimal RI/B.

Transbronchial fine needle aspiration.

In a pilot study, 21 patients underwent transbronchial fine needle aspiration (TBFNA) using a 45 cm-22 gauge needle guided by means of a semi-rigid metal sleeve, which was introduced through a standard rigid bronchoscope. A total of 33 aspirations were performed from main carina (15), paratracheal (five), and lobar carinal (13) foci. Six aspirations yielded malignant cellular samples, 22 aspirations presented only normal cells, and in five no adequate cellular sample was obtained. Fifteen patients underwent surgical exploration (mediastinoscopy with or without thoracotomy). Four of the cytologically malignant cases were explored and in three the aspiration site was confirmed histologically. In the remaining patients where the site of aspiration was explored, no tumour was demonstrated in the cytologically negative or cytologically inadequate cases. There were no complications from TBFNA. We suggest that TBFNA is useful in determining mediastinal malignant involvement rapidly and with lesser invasion than with current techniques.

The value of cardiac catheterization and cineangiography in infantile lobar emphysema.

Lobar emphysema is an uncommon cause of respiratory distress in infancy. Congenital heart disease is seen in about 20% of the patients with infantile (congenital) lobar emphysema. We described six infants with lobar emphysema. In three of them a congenital heart disease was demonstrated by cardiac catheterization and cineangiography; two had a tetralogy of Fallot with right aortic arch and the third infant a ventricular septal defect. The pulmonary angiography showed stretching of the arteries with very poor filling of the peripheral arteries and a characteristic smaller pulmonary vein in the affected lobe. In all the six patients the pulmonary artery pressure was normal. All the patients underwent lobectomy with good results. We feel that a preoperative cardiac catheterization and cineangiography is of value in this very sick group of infants.

Complete heart block in an adult with corrected transposition of the great arteries treated with permanent pacemaker.

A 53-year-old patient with corrected transposition of the great arteries developed complete heart block with fainting episodes. After temporary pacing through the endocardium of the venous (anatomically left) ventricle, a permanent epicardial pacemaker was implanted. This case shows the progressive nature of the atrioventricular conduction disturbances, which are very common in association with this congenital cardiac anomaly.

Permanent right ventricular pacing through an anomalous left superior vena cava.

A persistent left superior vena cava can complicate the implantation of a transvenous pacemaker. In a patient who required a permanent pacemaker, this venous anomaly was discovered during the insertion of the electrode but it did not prevent long-term right ventricular pacing. This was achieved after the electrode had been manipulated through the coronary sinus and right atrium. A plan of management is proposed for dealing with this unexpected problem.

Myopotential inhibition of a bipolar pacemaker caused by electrode insulation defect.

A patient is described in whom myopotentials orginating from the anterior abdominal wall muscle suppressed the implanted demand pacemaker despite its bipolar mode of action. This phenomenon was shown by simultaneous recording of the electrocardiogram the electromyogram. At operation, a defect in the insulation of a previously repaired epicardial electrode was found lying in close proximity to these muscles. After repair of the insulation defect, normal pacemaker function was restored. It is suggested that the myopotentials leaked into the pacing system through the insulation defect, thereby suppressing the demand unit, which maintained its bipolar mode of pacing throughout.

Intermittent positive pressure inflation during fiberoptic bronchoscopy.

We describe a new technique for diagnostic fiberoptic bronchoscopic procedures under general anesthesia. The technique of inflation via nasotracheal catheter, which consists of using intermittent high inflating pressure for ventilation by passing a double catheter through the nose to the glottis and into the trachea, gave very satisfactory ventilaton, with high levels of oxygen in the blood. Intratracheal pressure was monitored continuously to guarantee safety, and pulmonary function was assessed before and after the procedure. Continuous electrocardiographic monitoring was used, and blood gas levels were determined at very frequent intervals. The use of infusions of methohexitone and succinylcholine (suxamethonium) provided adequate safe anesthesia and prompt recovery, with absence of recall of the procedure.

Long-term survival of elderly patients after pacemaker implatation.

The follow-up of 80 patients above the age of 70 years with implanted pacemakers is described. These patients were the most advanced in age from a total group of 150 with implanted pacemakers. Their ages ranged from 70 to 87 years, with an average of 75.4 years; 50 were male and 30 were female. An epicardial electrode was implanted in 13 patients and an endocardial electrode in 67. The pacemaker was implanted in 76 patients for symptomatic atrioventricular block and in four patients for sick-sinus syndrome. Two patients (2.5 per cent) died during the postoperative period and 19 patients within a period of 3 months to 6 years after the implantation. The survival rates were: 1 year, 90.0 per cent; 2 years, 82.1 per cent; 3 years, 74.1 per cent; 4 years, 67.2 per cent; 5 years, 58.3 percent. These survival rates were surprisingly similar, for the first 3 years of follow-up, to those of our and others' previous studies, which included all age groups. The survival rates in the most advanced age groups decreased in comparison only in fourth and fifth years after the implantation. There was no evidence of new episodes of myocardial infarction among this group of patients during the follow-up period. We conclude that even in patients of the most advanced age groups the implantation of an endocardial pacemaker significantly prolongs life, improves its quality, and this at a low operative risk.