Management of ascites with hydrothorax.

Hydrothorax occurs in 5.3 percent of ascitic patients. Our experience with 22 cases forms the basis of this report. Of the 22 cases, 21 were spontaneous and 1 was due to transdiaphragmatic incision. Eighteen occurred on the right side. Usually fluid enters the chest through tiny defects in the diaphragm. These defects are often covered by pleuroperitoneum, but the high abdominal pressure raises a bleb on the superior surface of the diaphragm. Rupture produces hydrothorax. The ascites is often relieved with the onset of the hydrothorax. Blockage of the thoracic duct has produced chylous ascites. The thoracoabdominal communication is immediately confirmed by a scan of the chest and abdomen after intraperitoneal injection of technetium-99 colloid. Fluid is tapped from the chest immediately before intraperitoneal injection. The rate at which the technetium-99 enters the chest is related to the size of the defect in the diaphragm. A significant transfer should occur within 12 hours. Immediate transfer occurs with large defects. The ruptured blister on the diaphragm forms a one-way valve. Intrathoracic injection does not migrate into the peritoneal cavity. The valvular characteristics of the leak force ascitic fluid into the thorax because the differential pressure between the abdominal and pleural cavities is intensified by inspiration. If tension hydrothorax has occurred, urgent thoracocentesis and paracentesis may be required. A chest tube should not be introduced. The main principle of surgery is to supply a low resistance pathway for the return of fluid to the venous system and to eliminate the diaphragmatic defect by obliteration of the pleural space. A LeVeen peritoneovenous shunt is performed after emptying the abdomen of its fluid load. After completion of the shunt operation, the chest is emptied of fluid, and a sclerosing agent (tetracycline or nitrogen mustard) is injected into the pleural cavity. Closure of the defect is verified by technetium-99 labeled scans which also confirm shunt patency. With this regime, the defect closed or was rendered insignificant in 18 of 22 patients. One patient had a post-transdiaphragmatic surgical defect which was too extensive to be closed by the aforementioned procedures. One patient remained well but did not have closure of the defect, one patient with a ruptured hiatal hernia did not have closure, and one patient who had previous placement of a chest tube could not be closed. Therefore, 18 of 22 patients were successfully treated.

Limb salvage by inverted "Y" grafts to below knee arteries.

(1) An inverted Y graft to the proximal tibial arteries is described, and the limited clinical experience with this type of graft is presented. (2) The inverted Y graft provides a low-resistance high-low situation, which theoretically favors graft patency. (3) This clinical series confirms the value of bypass procedures to small, below-knee arteries in limb salvage situations. An excellent rate of success can be accomplished if meticulous surgical technique is used to implement the principles of small vessel surgery.

The distribution patterns of biatrial myxomas.

Biatrial myxomas are extremely rare, and by 1970 only three of eight attempts at removal had been successful. Another successful removal, the difficulty of establishing the biatrial nature of a myxoma by echocardiography, and a summary of the distribution patterns of biatrial myxomas are presented here. In more than 50% of patients, both pedicles grew into separate atrial chambers from a common location in the atrial septum. The surgical implications are discussed.

Prehepatic hyperalimentation.

A technique for prehepatic infusion of parenteral nutrients is described. Portal vein hyperalimentation allows hepatic modification and control of the infused nutrients before delivery of these substances into the general circulation and theoretically should reduce the incidence of metabolic complications of hyperalimentation. The clinical experience with prehepatic infusions is reported and the metabolic investigations are described. Transumbilical catheters provided prehepatic delivery of parenteral nutrients for 1 month after esophagogastrectomy for esophageal malignancy without serious infection or portal vein thrombosis. Close surveillance of blood glucose and serum osmolarity demonstrated metabolic stability during the infusion period. Nitrogen balance studies showed better nitrogen economy than is achieved by infusion of similar solutions into the central systemic circulation. Indirect calorimetry indicated that the nitrogen used for production of energy was less than the amount supplied by prehepatic infusions. The same basic liver function abnormalities encountered with systemic infusion of hyperalimentation solutions were noted. The patients gained weight after esophagogastrectomy and did not experience the attrition from malnutrition which usually occurs in the first several months after esophageal resection.

Esophagogastrectomy for carcinoma of the middle third of the esophagus.

Elective esophagogastrectomy and reconstruction by esophagogastrostomy were performed on 55 patients with malignant tumors of the midesophagus, despite invasion of contiguous structures in 60% and regional lymph node involvement in 75%. The operations were invariably palliative. Two patients died within thirty days of operation. Dysphagia was relieved and oral alimentation resumed in the other 53. Twenty-nine patients who had experienced painful swallowing and 16 who had vomiting obtained relief. Survival curves show no improvement from previous decades for patients with malignancies of the middle third of the esophagus. The mean survival was 10.4 months. Mean survival of patients with liver metastases was 3.5 months.

Reappraisal of esophagogastrectomy for esophageal malignancy.

Esophagogastrectomy performed in eighty-three patients with a thirty day mortality of 7 per cent, a resectability rate of 93 per cent, and no anastomotic leakage, provided dependable relief of malignant obstruction and restored oral alimentation in all surviving patients. Long-term survival was unchanged. The successful resection of all midthird lesions with a 3.9 per cent mortality reflects the capability of current surgery and suggests that surgical palliation of midthird esophageal tumors is preferable to radiotherapy alone.

Preserved saphenous vein allografts for vascular access.

Preserved venous allografts were used as an alternate access procedure in 70 patients receiving dialysis during a three year period. The clinical experience with allograft fistulas revealed an extremely high initial patency rate; absence of infection postoperatively and during three years of dialysis; suitability for dialysis a week after implantation, thus greatly obviating the need for Silastic shunts; a low long term thrombosis rate and the weakly antigenic allograft veins produced no accelerated rejection of subsequently transplanted kidneys. Surviving patients average 172 dialysis treatments per allograft. Allograft fistulas constituted 45 per cent of the last 100 vascular procedures, an indication of the extent of usage. Microscopic examination of grafts retrieved from patients who died during the late follow-up period demonstrated that structural components of the wall of the vein were still identifiable. Allograft venous fistulas offer dependable, safe vascular access, especially in the infection prone patient with diabetes who is receiving dialysis treatment. The clinical results of allograft fistulas suggests a major role for this technique in vascular access operations.

Limb salvage by inverted Y vein grafts to below-knee arteries.

Distal Y branches to other below-knee arteries were added to standard femorotibial bypass grafts to increase runoff, more effectively perfuse the ischemic limb, and improve limb salvage rate. Y grafts were performed in 16 lower limbs in 15 patients. Flow through the graft was increased significantly with each additional Y limb. Preoperative angiograms demonstrated filling of the distal vessels. Surgical indications were gangrenous toes or ischemic ulcers in 12 patients, and 13 limbs were saved. Three patients received bypass grafts for acute ischemic changes, limbs were salvaged in two of the three patients. Two Y grafts performed in 1971 and in 1974 remain patent. Between 1971 and 1977, forty standard femorotibial bypasses were done, with a long-term patency rate of 54%. During the past two years, 13 more Y grafts were performed, with an overall initial patency of 94%. Late results of the Y grafts have been surprisingly good, with no subsequent loss of grafts or limbs.

Brachial artery to brachial vein preserved vein allograft fistulas for hemodialysis.

Vein allografts were obtained from varicose vein patients in whom stripping and ligation was indicated. Proximal 30 cms of the long saphenous vein was removed and stored at -30 degrees C. A-V fistulas were constructed in the upper arm between brachial artery and the brachial or cephalic vein in dialysis patients. All these allograft vein recipients had major blood groups identical to the donors. Clinical experience over a two year period revealed a 100% long term patency. Complications including early graft thrombosis, superficial wound infection, hematoma formation and local edema were few and easily managed. Allograft rejection was not a problem in this series of patients. The large diameter grafts in upper arm position function well. They are convenient for the patient and preferred by dialysis personnel as a direct site for venepuncture. An initial experience suggests that preserved vein allografts may become the preferred material for arteriovenous fistulas.

Primary extramedullary esophageal plasmacytoma: First case report.

Solitary extramedullary plasmacytomas are rare tumors, reported to occur most commonly in the upper respiratory passages, but which also are rarely seen in the middle and lower gastrointestinal system. This report documents the first primary plasmacytoma of the esophagus. A 67-year-old Caucasian man complained of dysphagia and weight loss. Preoperative diagnosis, based on functional inquiry, radiology, and biopsy, was undifferentiated carcinoma involving the lower third of esophagus. The patient was treated by esophagogastrectomy. The pathology specimen revealed the typical histology of plasmacytoma. The extramedullary nature of the tumor was established postoperatively on the basis of the following criteria: 1) Absence of Bence-Jones proteinurea; 2) normal serum electrophoresis; 3) normal bone marrow biopsy; and 4) absence of distant metastases on liver scan and bone survey.

Preserved allografts of dilated saphenous vein for vascular access in hemodialysis: an initial experience.

Arteriovenous fistulas constructed from preserved (frozen) allograft veins provided vascular access for maintenance hemodialysis in 14 patients with inadequate vasculature for conventional autogenous fistulas. Electromagnetic flows ranged from 200 to 250 cc/min. Dialysis flow of 200 cc/min were accomplished consistently. The allografts were useable for dialysis much earlier than autogenous A-V fistulas. Arteriography demonstrated a wide vasculature channel very suitable for dialysis needles. Allografts seemed superior to bovine heterografts in both patency and susceptibility to infection. Scanning electron microscopy revealed smoother initimal surfaces if the donor received small amounts of heparin systemically while the veins were being removed. Allograft veins appear to be a useful alternative means of vascular access for hemodialysis.