Coronary artery bypass grafting in patients with transplanted livers.

Coronary artery bypass grafting was performed on 3 patients for refractory angina pectoris 48, 5, and 40 months after orthotopic liver transplantation. At the time of the cardiac operation, all 3 patients had drug-induced moderate renal dysfunction, and 1 of the 3 exhibited mild chronic rejection of the graft. Maintenance immunosuppressive therapy was continued during the cardiac operation and the perioperative period. Stress-dose steroids and standard prophylactic antibiotics were also employed. All 3 patients tolerated the cardiac surgical procedure without hepatic decompensation, excessive bleeding, infection, impaired wound healing, and other complications related to the transplanted organ or to the immunosuppressive therapy. Early postoperative liver function test results showed mild transient deterioration. One patient experienced a brief psychotic episode and massive upper gastrointestinal bleeding. Both complications were attributed to the steroids used in immunosuppressive therapy. Follow-up ranging from 2 to 24 months after coronary artery bypass grafting revealed that the patients were active and had no cardiac symptoms or manifestations of hepatic decompensation. It appears from this limited experience that cardiac operations can be performed safely in patients who have previously undergone liver transplantation.

Heparin resistance after preoperative heparin therapy or intraaortic balloon pumping.

Heparin resistance, defined as failure of 500 IU per kilogram of body weight of heparin to prolong the activated clotting time (ACT) to 480 seconds or longer, was noted during 949 of 4,280 (22%) consecutive open heart surgical procedures performed on adults between 1986 and 1991. The total population was divided into the following four groups: group 1, preoperative intraaortic balloon support without concomitant heparin therapy (n = 138 patients); group 2, preoperative intravenous heparin therapy (n = 741 patients); group 3, intraaortic balloon support with concomitant intravenous heparin therapy (n = 137 patients); and group 4, controls, not receiving preoperatively the therapy given groups 1, 2, or 3 (n = 3,264 patients). The ACT response to an initial dose of 500 IU/kg of heparin and the incidence of heparin resistance were 596 +/- 203 seconds and 30% in group 1; 506 +/- 149 seconds and 50% in group 2; 520 +/- 159 seconds and 53% in group 3; and 705 +/- 234 seconds and 14% in group 4, respectively. These results indicate that preoperative intravenous therapy and intraaortic balloon support are associated with a decreased ACT response to intraoperative heparin. Baseline ACT levels and preoperative platelet counts were not predictive of heparin resistance. A reduced ACT response to the initial dose of heparin was associated with increased requirements for supplementary anticoagulant therapy during the ensuing period on cardiopulmonary bypass, indicating that the decreased sensitivity to heparin extends beyond the initial episode of heparinization.(ABSTRACT TRUNCATED AT 250 WORDS)

Pack and close approach to persistent postcardiopulmonary bypass bleeding.

Persistent intraoperative hemorrhage after cardiopulmonary bypass was managed in three patients by packing the suspected bleeding sites with surgical sponges, leaving the packs in place and closing all layers of the sternal wound. The maneuver reduced the rate of bleeding to acceptable levels. The day after the primary operation the wounds were reopened and the surgical sponges were removed. Bleeding had ceased and the operative field remained dry in all three patients. Definitive closure of the sternotomy incisions was then performed. The method is proposed as a simpler alternative to the commonly used approach of leaving the mediastinum open for days and closing the wound after the bleeding stopped.

Replacement of the thoracic aorta with intraluminal sutureless prosthesis.

A survey of the collective experience reveals that between 1976 and 1990, a sutureless intraluminal prosthesis was used to replace the ascending thoracic aorta, arch, and descending thoracic aorta in 122, 14, and 81 patients, respectively. During these 217 operations, at least 364 of the 434 anastomoses were performed by sutureless fixation. The underlying disease processes consisted of acute and chronic dissections; atherosclerotic, Marfan's, and mycotic aneurysms; and intraoperative disruptions of the ascending aorta. The data in the literature suggest that sutureless fixation shortens aortic cross-clamp time and reduces blood loss. Early graft-related complications were few and probably can be further reduced by improving surgical techniques. The incidence of paraplegia and renal failure after descending aortic grafting was identical at 2.5%. The operative mortality rate for ascending aortic, arch, and descending aortic replacement was 13.1%, 42.9%, and 14.8%, respectively. Long-term follow-up of 143 patients revealed satisfactory graft function with three possible device-related deaths and no other known complications attributable to the prosthesis. There are, however, anecdotal references to late complications from the intraluminal prosthesis. Most of these relate to faulty implantation techniques, but some could be due to flaws inherent in the concept of sutureless grafting. The collective experience suggests that grafting of the thoracic aorta is less hazardous with the sutureless than with the conventional sutured anastomosis technique. The implications of the anecdotal accounts about late complications remain to be determined.

Thoracic surgery and the war against smoking: Richard H. Overholt, MD.

Richard H. Overholt was born at the beginning of the twentieth century when thoracic surgery hardly existed. During the first 20 years of his life progress in the field was slow. The next 20 years, which coincided with Overholt's surgical training and his early years as a thoracic surgeon, saw a rapid and almost explosive growth. Overholt's contributions were legion. They included the world's first successful right pneumonectomy, advancements in surgical treatment of tuberculosis, development of segmental resection, and introduction of the prone operative position. He was a bold and creative pioneer thoracic surgeon with consumate technical skills. Sixty years ago, when Overholt started his career as a thoracic surgeon, the hazards of smoking were not appreciated, the habit was fashionable, and consumption of tobacco was rapidly rising. In the early 1930s Overholt was among the very few physicians who recognized the perils of smoking and initiated a long but initially unrewarding antismoking crusade. By the early 1950s evidence about the ill effects of tobacco use began to accumulate. Organized medicine, voluntary health groups, and governmental agencies joined in a concerted effort to educate and to contain smoking. During the ensuing 30 years the antismoking movement achieved ever-increasing success. Today, it is widely recognized that smoking is a major health hazard and tobacco consumption is on the decline. Richard Overholt issued the first warning signals about the perils of tobacco and served as an indefatigable leader of the antismoking crusade throughout his professional career.

Resection of cavoatrial renal cell carcinoma employing total circulatory arrest.

Intracaval extension of renal cell carcinoma to the right atrium is a life-threatening presentation that may result in fatal tricuspid valve obstruction or pulmonary embolization. From 1981 to 1989 we treated 10 patients with such extension of tumor, the last 7 of whom underwent resection in which hypothermic circulatory arrest was used. No postoperative deaths, myocardial infarctions, or strokes occurred. Four patients were alive with no evidence of disease at 4, 10, 16, and 39 months after resection, and 1 patient was alive with pulmonary and spine metastases at 34 months after resection. Two patients died of metastatic disease at 7 and 12 months. In the absence of diffuse metastatic disease, lymph-node involvement, or invasion of contiguous organs, radical resection of cavoatrial hypernephroma may result in excellent palliation and possibly a cure.

Benign lesions mimicking malignant tumors of the esophagus.

Three cases of benign lesions which mimicked malignant tumors of the esophagus are described. In all three cases, two inflammatory pseudotumors and one case of diffuse leiomyomatosis, the clinical presentations, radiologic features, and gross pathologic findings led to the mistaken diagnosis of carcinoma at thoracotomy. The benign nature of the processes was recognizable only on microscopic examination. Although most benign tumors of the esophagus are localized solitary lesions that are easily distinguished from carcinoma, occasionally benign conditions may present as infiltrative, ulcerated mass lesions. Inflammatory pseudotumor and diffuse leiomyomatosis should be included in the differential diagnosis of esophageal malignancies.

Complications of the Nissen fundoplication.

A more astute selection of patients and greater attention to technical details will preclude most complications. The first step is standardizing the technique, with avoidance of unnecessary ancillary maneuvers. Equally important is a thorough preoperative evaluation. With these considerations in mind, the authors believe that Nissen fundoplication is the preferred method of treatment for patients with uncomplicated gastroesophageal reflux refractory to medical therapy.

Reoperation for complications of the Nissen fundoplication.

Case histories of 25 patients are reported in whom complications after a Nissen fundoplication were sufficiently severe to require reoperation. Patients were classified by complications as having postoperative dysphagia (14), recurrent reflux (seven), "gas bloat" syndrome (two), and paraesophageal hernia (two). Six of the 14 patients with dysphagia had no esophageal peristalsis, one had a panmural fibrous stricture, and had a "slipped" Nissen, and in six the wrap was presumed to have been fashioned too tightly. Too tight a wrap was also responsible for the seven instances of recurrent reflux and the two of "gas bloat" syndrome. Revision of the fundoplication relieved the symptoms in the 15 patients in whom it was done. A variety of surgical procedures were performed on the other 10, all but one of whom experienced a good result. Proper selection of patients for operation coupled with attention to certain technical surgical details will ensure good results in 90% of patients after a Nissen fundoplication.

Dysphagia due to aortic arch anomaly: diagnostic and therapeutic considerations.

An unusual aortic arch anomaly produced dysphagia in a previously healthy man. Aortography performed simultaneously with a barium esophagogram disclosed a right aortic arch and right descending aorta. Esophageal compression was caused by a retroesophageal aortic diverticulum that emerged from the descending aorta and gave rise to the left subclavian artery. A left ligamentum arteriosum connected the proximal left subclavian artery and the left pulmonary artery, thus completing a vascular ring encircling the esophagus. Surgical correction was accomplished using a left thoracotomy. Division of the ligamentum as well as the junction of the aortic diverticulum and left subclavian artery freed the esophagus from its circumferential constrictions and relieved the patient's dysphagia.

Surgical management of chest wall tumors.

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.

Bilateral pulmonary resection for bronchiectasis: a 40-year experience.

Ninety-nine patients underwent bilateral pulmonary resection for severe multisegmental bilateral bronchiectasis at the Overholt Thoracic Clinic during the period 1937 to 1977. A total of 216 operations were performed, and 20 patients underwent three or more procedures. The operative mortality was 1.4% and the incidence of severe complications, 7%. Follow-up ranged from 1 to 30 years (average 10.2 years). Only 1 patient was lost to follow-up. Improvement in pulmonary symptoms was achieved in 83 patients; there was no improvement in 9 patients; and 4 patients were worse following resection. The results suggest that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection.

Tracheobronchial mucoepidermoid carcinoma. Clinicopathological features and results of treatment.

Mucoepidermoid carcinomas of the tracheobronchial tree are extremely uncommon and, as a result, opinions regarding their natural history are conflicting. In an effort to determine whether the tumors are aggressive or relatively benign, we have collected seven well-documented, previously unreported cases from among 4,250 primary pulmonary carcinomas and 116 bronchial adenomas. The two tracheal and five endobronchial lesions presented here include one high-grade and six low-grade tumors. Curative resections were performed, including segmental tracheal resections in two patients, lobectomy in three patients, and pneumonectomy in two patients, and the follow-up is complete to the time of this report. Long-term survivals ranging from 5 to 23 years, averaging 12.8 years, have been achieved in the six patients with a low-grade carcinoma. The one high-grade variant proved fatal within 28 months of diagnosis despite two surgical attempts at control and radiotherapy. It is concluded that these tumors exhibit a spectrum of virulence with low-grade lesions amenable to long-term surgical cure. The optimum treatment of high-grade lesions remains problematical.

Surgery for short esophagus with stricture: an experimental and clinical manometric study.

The surgical management of short esophagus with stricture has been simplified in recent years by the introduction of an esophageal lengthening procedure (Collis gastroplasty) combined with antireflux maneuvers, such as the Belsey and Nissen operations. This report compares the experimental and clinical manometric findings after these procedures. After myectomy of the lower esophageal sphincter (LES) in the cat, three experimental groups were developed including Collis gastroplasty, Collis-Belsey and Collis-Nissen. formation of a gastric tube did not provide protection against reflux while the Collis-Nissen procedure was more effective than the Collis-Belsey in raising pressures at the high pressure zone (HPZ) (26.0 +/- 3.5 cm H2O vs 15.0 +/- 2.7) and in preventing reflux (pH 6.3 +/- 0.5 vs 2.9 +/- 0.04). Of 20 patients with short esophagus and stricture, 11 underwent a Collis-Belsey procedure and nine a Collis-Nissen procedure. The latter procedure resulted in an HPZ of greater amplitude and length than the Collis-Belsey (18.7 +/- 2.3 mm Hg vs 11.6 +/- 1.7 and 3.9 +/- 0.4 cm vs 2.4 +/- 0.2). It also proved to be a more effective antireflux procedure, for no patient so treated had a positive pH reflux test after operation whereas after the Collis-Belsey procedure all but one patient had a positive pH reflux test. Short-term clinical results also support the superiority of the Collis-Nissen operation.

Diffuse spasm of the esophagus. Clinical manometric, and surgical considerations.

Extended esophagomyotomy was performed on 11 patients with diffuse spasm of the esophagus (DSE). Preoperative and postoperative clinical, manometric, and roentgenographic findings are reviewed. Preoperative manometry performed in all patients disclosed a mean deglutitive pressure of 70 mm. Hg in the diseases areas and indicated the required length of myotomy. The lower esophageal sphincter (LES) was within normal limits in most instances, with a mean amplitude of 20 mm. Hg, and its exclusion from the myotomy eliminated the need for additional antireflux procedures. Postoperative manometry in 10 patients disclosed a 70 percent reduction in deglutitive pressures in the myotomized segments, and the mean LES amplitude of 13 mm. Hg remained within the normal range (10 to 20 mm. Hg). Ten of the 11 patients were clinically improved, and postoperative reflux developed in only one patient. These results support the continued use of extended esophagomyotomy in selected patients with DSE and suggest that exclusion of the LES from the myotomy affords satisfactory antireflux protection without ancillary sphincter-enhancing maneuvers.

Experimental fundoplication: comparison of results of different techniques.

After the creation of a hypotensive lower esophageal sphincter (LES) by circular myectomy, several techniques of fundoplication were employed to assess the effect of variations in the degree and length of fundoesophageal encirclement on LES function. In series A, 360 degrees wraps were constructed around varying lengths of esophagus: group I, 1 cm; group II, 2 cm; and group III, 3 cm. In series B, 2 cm long fundoplications of varying circumference were performed: group I, 90 degrees; group II, 180 degrees; and group III, 360 degrees. LES evaluation included measurement of LES amplitude and length, the adaptive response of the LES to increased intragastric pressure, pH reflux testing, and LES response to parenterally administered pentagastrin. In series A, 2 and 3 cm wraps restored resting LES pressures to normal (18.8 +/- 0.5 and 20.7 +/- 0.3 cm H2O) in contrast to the 1 cm wrap (12.9 +/- 0.8 cm H2O), and both provided more effective protection against reflux when compared to the shorter variation (pH, 6.2 +/- 0.1 and 6.6 +/- 0.1 versus 4.2 +/- 0.1). In series B, the 360 degrees wrap proved to be more effective than partially encircling techniques. Fundoplication optimally restores normal LES function when it encircles the esophagus completely over a length equivalent to the normal high-pressure zone (1.8 +/- 0.1 cm in the cat).

Pulmonary dirofilariasis: report of a human case.

Dirofilaria immitis (dog heartworm) principally infests canine hosts. However, human pulmonary dirofilariasis is being reported with increasing frequency, and the following case illustrates essential features of the disease. It typically presents as a solitary pulmonary nodule without symptoms and invariably requires pulmonary resection to differentiate it from primary or secondary malignancy.