"Mini-sternotomy" for bilateral pulmonary wedge resections.

A mini-sternotomy is described that allows access to both thoracic cavities. This technique offers excellent exposure for lung resections from chest cavities without the invasiveness of a formal thoracotomy.

Four multiple primary malignant neoplasms of the aerodigestive tract.

Multiple primary cancers of the head, neck, and upper aerodigestive tract have been documented in patients previously treated for oropharyngeal cancer. There generally is no causal relationship established between the different tumors. Two synchronous or metachronous cancers are common, three are unusual, and four are very unusual. We describe the treatment of a patient with tonsillar and synchronous esophageal and pulmonary cancers followed by a tongue cancer over a 6-year period.

Early complications and long-term survival in severely obese coronary bypass patients.

Our objective was to describe the short-term morbidity of coronary artery bypass operations and the effect of surgery plus aggressive cardiac rehabilitation on the long-term prognosis of severely obese patients with coronary artery disease. We investigated an inception cohort of 28 consecutive severely obese patients with three-vessel coronary disease followed on average for 51 months. The patients' age, preoperative and postoperative weight, risk factors, and cholesterol were measured. We performed coronary artery bypass surgery, then began aggressive cardiac rehabilitation programs. We recorded intraoperative data, perioperative deaths, complications, readmissions, and lengths of stay. Also, New York Heart classifications and use of anti-anginal or cholesterol-lowering medications were noted. All patients were followed up. Despite high morbidity, long-term function and survival of severely obese CABG patients compares favorably with that of average patients. However, aggressive behavior modification fails to alter their postoperative weight or risk profile, placing them at risk for both second CABG procedures and continued obesity-related disease occurrences.

Surgical repair of esophageal perforation in cirrhotic patients with varices.

A 51-year-old woman, a known alcohol abuser, had sclerotherapy for esophageal varices from portal hypertension. A perforation of the distal esophagus, diagnosed several days later, could not be closed primarily at thoracotomy due to extensive bleeding. The method of "exclusion and diversion in continuity" was modified by ligation of the esophagogastric junction with absorbable suture over a tube stent. The perforation healed and patency of the esophageal lumen was demonstrated 2 weeks later. This alternative life-saving procedure may be useful in chronic esophageal perforation, especially in cirrhotic or otherwise debilitated patients.

Acute reaction to protamine. Its importance to surgeons.

Three open heart surgery patients developed noncardiogenic pulmonary edema after administration of protamine following cardiopulmonary bypass. A catastrophic series of events are characteristic of this reaction: 1) sudden onset; 2) severe bronchoconstriction with early extreme difficulty in ventilation; 3) hyperinflation of the lungs; 4) pulmonary hypertension with normal pulmonary wedge or left atrial pressures; 5) progression to fulminant noncardiogenic pulmonary edema; 6) significant mortality; and 7) ventilatory perfusion abnormalities in survivors. Review of the literature reveals three types of reactions to protamine injection of varying severity: 1) brief hypotension; 2) anaphylactoid generalized reaction; and 3) high protein noncardiogenic pulmonary edema with cardiopulmonary collapse. The severity of the reaction had no relation to the dose of protamine. Previous protamine exposure was documented in 14 of 35 cases. Awareness of this reaction is essential for prompt treatment if fulminant pulmonary edema occurs. Administration of epinephrine, steroids, vasopressors, and potassium replacement may be required. Needless use of protamine sulfate should be discouraged.

Clinical spectrum of radiation induced pericarditis.

A series of seven patients diagnosed as having radiation induced pericarditis were reviewed and compared to those reported in the literature. They constituted 6.8 per cent of all patients with the diagnosis of pericarditis seen in a five-year period. These patients had the diagnosis proven by autopsy or by the absence of tumor cells from the pericardial fluid and/or surgical biopsy. The echocardiogram and cardiac catheterization were found to be specific diagnostic tools. Recommendations are made for a therapeutic approach to these patients. The diagnosis of this condition depends on a high index of suspicion, and close follow-up of patients who have received intense radiotherapy to the chest. Recommendations are made for prophylaxis. We challenge the pessimistic approach towards the cancer patient who develops recurrent pericardial fluid or pleural effusion due to radiation induced pericarditis. We advocate an aggressive diagnostic approach and therapy which should be related to the degree of hemodynamic impairment.

Cardiac surgery in a small community: an eight-year experience.

Long-term results of 374 open-heart procedures performed over an eight-year period in a small community hospital are presented. Patients were followed up for an average of 49 months. The heart unit did not conform to the yearly volume of cases suggested by current national guidelines. Nonetheless, we obtained some interesting results. 1. The hospital mortality in nonemergency coronary artery bypass operations was 1.8%; in all types of bypass operation, 3.3%; and 5.1% for all types of cardiac operation. 2. The attrition rate was less than 1% per year for all types of patients with a total long-term survival of 92%. 3. Patients having coronary artery bypass had a yearly attrition rate of 0.66% and a total long-term survival of 94.2%. 4. The average hospital cost per patient having open-heart operation was $9,670 in 1978 and $11,073 in 1979. Case volume requirements for an open-heart-surgery unit in our area allowed an exception from the guidelines with emphasis on quality of results rather than quantity. This permitted comprehensive cardiac care especially for the poor and those with fixed incomes unable to afford the cost of traveling and associated expenses. Further similar reports may be valuable in the formulation of health policies for small communities that guarantee the health rights of all segments of the population.

Glycerol and methylprednisolone in lung contusion.

An experimental model was developed in dogs that quantifies the amount of pulmonary trauma produced. The severity of thoracic trauma is related to mortality and to a presence or absence of bilateral pulmonary injury. Bilateral injury represents severe trauma, consistently alters blood gases and is associated with significant mortality when untreated. Both methylprednisolone and glycerol exerted beneficial effects on mortality from bilateral pulmonary contusion, and glycerol altered the blood gas pattern towards normal. Glycerol has been utilized extensively clinically to reverse the adverse effects of cerebral edema. It may prove to be of similar value when pulmonary injury is an important factor.

Long-term survival of patients with carcinoma of the esophagus in Puerto Rico.

From 1950 to 1971 a total of 4,342 cases of carcinoma of the esophagus were reported to the Central Cancer Registry of the Puerto Rico Health Department. Fifty-eight patients with histologic proof of their diagnosis survived five or more years, for an absolute survival of 1.3 per cent. Neither location of the tumor or type of treatment made much difference in average survival. In fact, 20 of the 58 patients had metastasis or extension of the tumor to adjacent tissues at sometime in their clinical course.

Esophageal carcinoma. The value of staging in long-term survival.

A three-stage study of 177 patients in Puerto Rico who had esophageal carcinoma is presented. Those surviving five or more years over a twenty-one-year period were located. Next, the experience at the San Juan City Hospital from 1968 to 1973 was examined. The information obtained from those two groups led to the last stage, a prospective study in which treatment was based on objective staging of the extent of the disease. Only 27% of these patients are really potentially curable upon admission to the hospital, and they should have aggressive therapy. Adequate palliation can be obtained with radiotherapy and chemotherapy in the remainder. The findings that nearly half of the five-year survivors had metastases or tumor extension and that some patients survived for prolonged periods without treatment emphasize the need for individualized treatment and research in tumor immunology.