Current role of surgery in Mycobacterium tuberculosis.

From January 1986 through December 1993, we operated on 59 patients with documented Mycobacterium tuberculosis infection. Indications for operation were as follows: multidrug-resistant tuberculosis (MDRTB) in 19 patients; bronchopleural fistula secondary to Mycobacterium tuberculosis infection in 12; massive hemoptysis in 5; destroyed lung in 7; solitary nodule in 7; trapped lung in 3; complicated cavity in 4; and empyema in 2. Sixty-five operative procedures were performed: pneumonectomy with latissimus muscle flap in 15 patients; pneumonectomy in 3; lobectomy in 16; segmental or wedge resection in 11; decortication in 5; window thoracostomy in 3; thoracoplasty with myoplasty in 4; tube thoracostomy in 4; return to operating room for bleeding in 2; Clagett procedure in 1; and drainage of a cold abscess in 1. There were no operative deaths. Major postoperative complications occurred in 5 patients. The two late deaths were in patients with MDRTB: 1 with progressive disease and massive hemoptysis and the other with a relapse of MDRTB. Of the patients operated on as part of their therapeutic regimen for MDRTB, 17 (89%) of 19 have remained culture negative. We conclude that (1) surgery still plays an important role in the management of patients with Mycobacterium tuberculosis infection; (2) surgical intervention can be performed with acceptable mortality and morbidity; (3) a variety of procedures are needed to effect cure; and (4) encouraging results in patients with MDRTB support surgical therapy in this difficult group of patients.

Production of tumor necrosis factor-alpha and interleukin-1 by alveolar macrophages from HIV-1-infected persons.

Tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1) are potent immunomodulatory cytokines which are produced principally by cells of the macrophage-monocyte lineage. We conducted an investigation to assess the secretion of these cytokines by bronchoalveolar macrophages from patients with progressive stages of human immunodeficiency virus (HIV-1) infection. The mean level of TNF-alpha produced by macrophages from 9 patients with AIDS was significantly reduced compared with the responses of macrophages from 6 healthy HIV-1-seronegative persons, 6 patients with either asymptomatic HIV-1 infection or persistent generalized lymphadenopathy, and 6 patients with AIDS-related complex (ARC). The four study groups did not differ in their mean IL-1 beta responses. However, within the HIV-1-infected patient population, macrophages from 4 patients, 3 of whom had AIDS and 1 with ARC, failed to secrete detectable levels of IL-1 beta. All 4 patients were also nonresponsive in assays for TNF-alpha. These data establish that advanced HIV-1 infection may result in a pronounced dysfunction in the cytokine responses of alveolar macrophages.

Unrecognized intraoperative torsion of the lung.

A case is presented of clockwise torsion of the entire left lung on its bronchovascular pedicle during intraoperative manipulations for a nonpulmonary procedure. The grave consequences are presented as well as a discussion of the mechanism of injury and a review of the pertinent literature. To our knowledge, this is the first such case reported.

A complication of direct right atrial catheterization for total parenteral nutrition.

A markedly malnourished man with Crohn's disease and superior vena cava thrombosis required direct right atrial catheterization for total parenteral nutrition. After 3 wk the catheter had migrated to the right pleural space, necessitating removal. An inferior vena cava line via the left saphenous vein was then utilized until the patient's death 10 wk later from pneumonitis. Technical suggestions for avoiding this complication and alternative venous access sites are discussed.

A simplified method of ligation of patent ductus arteriosus in premature infants.

A clip technique for ligation of the ductus arteriosus in premature infants is presented.

Celestin tube intubation for advanced esophageal carcinoma.

Nine patients with advanced esophageal carcinoma underwent intubation with Celestin tubes between July 1973 and May 1975. Our indications for intubation were inability to swallow liquids or handle secretions and tracheoesophageal fistula resulting from advanced carcinoma involving the esophagus. Eight patients received adequate palliation; one died of continuing aspiration from a tracheoesophageal fistula. Major complications were noted in two survivors. The operative technic is discussed in detail.

A comparison between propranolol and hypothermia in preventing ischemic contracture of the left ventricle (stone heart).

Ischemic contracture of the left ventricle ("stone heart") was studied utilizing a previously described stone heart model. Our studies suggest that beta-adrenergic blockade is not quantitatively as important as hypothermia in protecting ischemic myocardium. On the basis of reduced fibrillatory activity and a slight protective effect shown by electron microscopy, it would appear that combining propranolol with hypothermia may be superior to either used singly.

Sodium nitroprusside and propranolol therapy for management of postcoarctectomy hypertension.

The cause of hypertension following satisfactory repair of coarctation of the aorta remains obscure. Most agree that significant elevation of the blood pressure after operation demands therapy. Previously the combination of trimethaphan and reserpine was utilized, but the incidence of adverse reactions was high. We recently have used the regimen of sodium nitroprusside and propranolol in six patients with gratifying results. This report reviews the problem as well as our use of nitroprusside and propranolol in managing hypertension following coarctation repair.

Bronchogenic cysts: problems in diagnosis and management.

Bronchogenic cysts usually are easily recognized and treated. On occasion they can present problems in diagnosis or management. We have experienced four such cases. A two month old infant whose cyst drained transbronchially during induction of anesthesia; a nine month old infant with preoperative respiratory obstructive signs; an adult with preoperative respiratory obstruction and acute severe respiratory distress during positioning for thoracotomy; and a newborn with an opacified hemithorax associated with retained fetal pulmonary fluid. Awareness of these unusual problems with bronchogenic cysts allows for promt and accurate management and avoids delays and possible complications.

Traumatic right coronary artery-right ventricular fistula with retained intramyocardial bullet.

A case of traumatic right coronary artery-right ventricular fistula secondary to a gunshot wound is presented. In addition, the bullet was retained within the interventricular septum. The diagnostic approach, surgical findings and operative procedure of this and other reported cases are discussed. Several key points are emphasized. First, extended follow-up is necessary after trauma to the heart since fistulas may develop years after the initial injury. Second, surgery is generally indicated for fistulas although some data are presented suggesting that small to moderate fistulas may be treated medically. Third, if surgery is undertaken, very careful operative technique must be utilized to locate and close the fistula. Surgical treatment of choice may be coronary arterial ligation with a distal bypass graft if necessary. Postoperative evaluation is mandatory because fistulas may recur. Indications for removal of a foreign body within the myocardium are also discussed.

A simple and effective left ventricular vent tube.

We have devised a simple, cheap, left ventricular vent that is relatively free from malfunction. It has further use in that it serves as a means of cooling the endocardium when hypothermic techniques are utilized.

Revascularization of the heart through the coronary veins.

Fifty-six dogs were used in a study to evaluate perfusion of the left anterior descending vein by the internal mammary artery in hearts with normal coronary arteries and those with ligated desending coronary arteries. Perfusion of the myocardium with arterial blood through the cardiac veins offers minimal immediate protection from infarction, as evidenced by light and electron microscopy studies. This protection is of short duration due to intimal fibrosis and luminal stenosis or obstruction of the perfused veins. Nineteen animals in which the coronary vein was perfused and the corresponding coronary artery was not ligated died within sixty hours from the time of operation. Pathological examination revealed patent grafts in all the animals. There was marked congestion of the myocardium with petechial hemorrhages over the surface of the heart. No evidence of myocardial infarction was found.

Pulmonary sequestration. A broad spectrum of bronchopulmonary foregut abnormalities.

We believe the broad clinical, embryological, and radiological spectrum of pulmonary sequestration has not been adequately emphasized. In order to gain clearer understanding of these foregut abnormalities, all cases from the files of three Army Medical Centers were reviewed. Thirty-two patients, the largest single series in the literature, met the criteria for a diagnosis of bronchopulmonary sequestration. Clinical manifestations varied from no symptoms to recurrent pulmonary infection, hemoptysis, and intrapleural hemorrhage. The presence of symptoms strongly correlated (23/32) with air-containing cystic sequestrations. The embryological and radiological spectra as well as appropriate operative therapy are reviewed.