Esophageal adenocarcinoma after laparoscopic gastric band placement for obesity.

Obesity is a risk factor for the development of esophageal malignancy. We report a case of the development of esophageal adenocarcinoma after placement of an adjustable gastric band for obesity. A 66-year-old male was referred to our clinic for findings of an obstructing mass at the gastroesophageal junction after previously undergoing a laparoscopic adjustable gastric band placement. Investigations confirmed a locally advanced poorly differentiated esophageal adenocarcinoma. The patient underwent chemotherapy and gastric band removal with improvement of his dysphagia. However, his disease progressed and he died of metastatic disease. We discuss the diagnosis of esophageal carcinoma after gastric banding procedure.

Cervical and thoracic components of multiorgan lymphangiomatosis managed surgically.

We report a patient who presented for management of suspected metastatic carcinoma of unknown origin. The lesions proved to be lymphangiomatosis involving multiple organ systems. Surgical management of the thoracic and cervical components of this rare condition is described.

Fractured occluder disc: a previously unrecognized complication of the Starr-Edwards disc prosthesis.

Fracture of the occluder disc of a low-profile Starr-Edwards prosthesis is a hitherto unrecognized complication. We describe a patient who presented with right heart failure and severe pulmonary hypertension 27 years after mitral valve replacement with a model 6520 caged-disc prosthesis. At surgery, there was a longitudinal split in the occluder disc, and organized thrombus was lodged between the split segments. This case offers a unique opportunity to study the long-term effects of wear on the polyethylene poppet and Stellite cage.

Multiple lung abscesses due to Ochroconis gallopavum, a dematiaceous fungus, in a nonimmunocompromised wood pulp worker.

An occurrence of multiple chronic lung abscesses managed by lobectomy is described. These abscesses were present for 13 years in the patient, a nonimmunocompromised wood pulp worker. The patient had hemoptysis at presentation. The organism isolated was Ochroconis gallopavum, a dematiaceous fungus known to cause disease in immunocompromised patients and epidemic encephalitis in poultry. The fungus is typically found in warm environments and in decaying compost; for this reason, we postulate that his illness was occupationally acquired.

Techniques of pneumonectomy. Pneumonectomy through an empyema.

The practical management of the patient with a destroyed lung in association with a preexisting empyema, based on considerable experiences, is discussed. Control of infection before proceeding with pneumonectomy by adequate drainage of the empyema and control of tuberculosis and pneumonia, particularly on the opposite side, is stressed. Pneumonectomy is undertaken through the empyema and usually in the intrapleural plane.

Superior vena cava syndrome caused by chronic hemodialysis catheters: autologous reconstruction with a pericardial tube graft.

Superior vena cava (SVC) syndrome caused by long-term use of indwelling catheters is an infrequent but increasingly common complication. Because collateralization often is sufficient, surgical treatment rarely is indicated. We present a case of a patient with severe symptomatic SVC syndrome as a result of the long-term use of indwelling hemodialysis catheters. The SVC was reconstructed with a pericardial tube graft. Magnetic resonance angiography performed 13 months after the operation showed patency of the graft. The patient continues to be free of symptoms.

Aortic valve replacement after previous coronary artery bypass grafting.

BACKGROUND: As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. METHODS: Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years. RESULTS: In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time. CONCLUSIONS: Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.

Thoracoscopic obliteration of the left atrial appendage: potential for stroke reduction?

BACKGROUND: In a review of all relevant articles describing the site of left atrial thrombus in patients with atrial fibrillation, the thrombus was localized to the left atrial appendage in 43% of patients with rheumatic heart disease and in 91% of patients with nonrheumatic atrial fibrillation. This study was designed to test the feasibility of thoracoscopic obliteration of the left atrial appendage as a means of reducing thromboembolic stroke. METHODS: Thoracoscopic obliteration of the left atrial appendage was undertaken in 10 dogs, 5 with staples and 5 with an endoloop. Obliteration also was attempted in 8 fresh human cadavers. RESULTS: In all dogs, the appendage was rapidly obliterated (21.3 +/- 7.6 minutes) and confirmed at euthanasia at 11 weeks. In 3 cadavers, anatomic and disease factors prevented visualization of the left atrial appendage; in 1 the appendage tore, and in the remainder the appendage was obliterated. CONCLUSIONS: Obliteration of the left atrial appendage is feasible and may be considered as an additional surgical procedure to reduce stroke. The group of patients in whom it offers the greatest potential are those with atrial fibrillation deemed ineligible for warfarin, those without atrial thrombus and with a free pericardial and pleural space.

Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.

BACKGROUND: Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures. METHODS: To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation. RESULTS: Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001). CONCLUSIONS: These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

Early results of a simplified method of mitral valve annuloplasty.

BACKGROUND: We hypothesized that a simple, unmeasured posterior annuloplasty technique (two thirds of a 27-mm Duran ring) offered advantages of standardization and ease of insertion. METHODS AND RESULTS: A consecutive series of all patients (n = 418; median age, 67 years) having mitral valve repair performed by two surgeons was analyzed to determine the outcome of three different annuloplasty techniques: commissural annuloplasty (n = 124), complete ring annuloplasty (n = 113), and an unmeasured, posterior, partial ring annuloplasty (n = 181). Intraoperatively, before repair, severity of mitral regurgitation as measured by double sampling dye curves and transesophageal echocardiography was similar in all three groups; after mitral valve repair, intraoperative assessment showed a similar degree of reduction in regurgitation in the three annuloplasty groups. Before hospital dismissal, transthoracic echocardiography demonstrated that the mean mitral valve areas and gradients were similar in the three groups; more patients having commissural annuloplasty were classified as having grade II or greater regurgitation. Mortality (n = 7, 1.7%) and need for reoperation (n = 8, 1.9%) was low in all groups despite the fact that additional procedures were performed in 48.8% of patients. Durations of cardiopulmonary bypass and aortic cross-clamping were significantly less in patients having commissural or posterior annuloplasties compared with those receiving a complete ring annuloplasty. CONCLUSIONS: These early results indicate that the posterior annuloplasty method is reproducible and expeditious. Postoperative valve function as assessed by degree of regurgitation, transvalvular gradient, and valve area was similar to that obtained by measured, complete ring annuloplasty and superior to that found in patients having commissural annuloplasty.

Surgical repair in children with the Budd-Chiari syndrome.

Membranous obstruction of the inferior vena cava at the level of the diaphragm is a rare cause of Budd-Chiari syndrome in children. Medical therapy usually fails. Surgical intervention aims at reestablishing patency of the inferior vena cava and hepatic venous outflow to the right atrium. We report on the management of this condition in 19 children of whom 7 were treated surgically. Indications for operation were persistent ascites, deteriorating liver function, and hepatic and inferior vena caval obstruction without significant collateral circulation. Three pathologic types were identified by ultrasonography and cavography and were confirmed at operation. These were type I (4 cases), with a thin membrane occluding the inferior vena cava at the level of the diaphragm; type II (12 cases), with segmental fibrotic obstruction of the inferior vena cava with variable involvement of hepatic veins; and type III (3 cases), with complete absence or nonvisualization of the inferior vena cava. All procedures were done with an extended midline sternotomy incision, cardiopulmonary bypass, core cooling to 16 degrees to 20 degrees C, and periods of circulatory arrest. Type I lesions necessitated membranectomy; type II lesions necessitated transcaval resection of the occluded confluence of the inferior vena cava and the hepatic vein with repair of the defect with an autogenous pericardial patch. One type II lesion, in addition, called for use of a 14 cm polytetrafluoroethylene tube graft to restore inferior vena caval flow. After the operation, marked clinical improvement was observed with an immediate reduction in liver and spleen size and resolution of ascites. Repeat cavography 10 to 30 days after the operation revealed complete patency in four cases and residual stenosis, which required transiliac balloon angioplasty to normalize the inferior vena cava/right atrial pressure gradient, in 3 cases. Thus eventual relief of hepatic venous outflow obstruction and inferior vena caval flow was restored in all cases. We advocate transcardiac membranectomy and pericardial patch grafting for symptomatic and deteriorating membranous obstruction of the inferior vena cava in children.

Pacemaker induced superior vena cava obstruction: management by spiral vein graft.

A 35-year-old male developed superior vena cava (SVC) obstruction due to multiple retained pacemaker leads. This caused cyanosis and suffusion of the head and neck during arm exercise, with desaturation from 99%-90% demonstrated by ear oximetry. The SVC was bypassed using a spiral vein graft because of worsening symptoms. Dramatic improvement resulted, with desaturation no longer demonstrable.

Surgical repair and reconstruction of valvular lesions.

Thirty-six years have passed since the inception of mitral valve repair by Lillehei and McGoon. In the period presently under review it is apparent that mitral valve repair and the late results have become more predictable. Previously, repair was not attempted because of concern that valve replacement, with its attendant problems, might be necessary. This attitude appears to be slowly changing. The current issue is whether patients who have severe mitral regurgitation but are relatively asymptomatic should be referred for repair before ventricular function deteriorates or atrial fibrillation develops. Current evidence suggests that approximately 10% of asymptomatic patients will progress sufficiently each year to require surgical intervention. Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction, has, since the era of routine intraoperative transesophageal echocardiography, become a well-recognized occasional consequence of mitral valve repair. Numerous theories have been suggested as to its cause: the most plausible suggest that risk factors include the presence of excess valvular tissue, a bulging septum, a nondilated hyperdynamic left ventricle, and a narrow mitral-aortic angle. The fact that numerous annuloplasty techniques exist, each having its own proponent(s), suggests that different techniques or types of annuloplasty are equally effective. Reparative techniques for the aortic valve have lagged behind those for the mitral valve because of limited previous success. The type of valve pathology was recently classified in terms of repair and new techniques, which are briefly documented, have been tried.(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose aprotinin in cardiac surgery--a prospective, randomized study.

Fifty patients undergoing primary coronary artery bypass surgery and 50 patients undergoing valve surgery received either high-dose aprotinin (2 million units loading dose, 2 million units added to the CPB prime, and 500,000 units/hr maintenance infusion) or placebo. Mean postoperative blood loss in the first six hours was reduced from 321 ml in the placebo group to 172 ml in the aprotinin group (95% confidence interval (CI) for difference = 95 to 189 ml). Seven patients in the placebo group and 16 patients in the aprotinin group did not require transfusion with homologous blood. This study adds to the growing body of evidence that the administration of high-dose aprotinin reduces blood loss and blood transfusion requirements associated with primary cardiac surgery.