Thoracic drainage.

The evacuation of empyemas first performed centuries ago, marked the beginning of thoracic drainage. The subsequent acquisition of a greater knowledge of the anatomy, physiology, and pathology of the pleural space directed the design of thoracic catheters and drainage systems and the development of the methods by which they are used. Furthermore, a better understanding of the physics of vacuum and air flow brought about improvements in the use of suction with drainage. Today, thoracic catheters, chest drainage systems, and most vacuum sources are well designed and well made and incorporate components needed to achieve the best care of the pleural-mediastinal space. This review covers the development and important considerations in the current use of thoracic drainage.

Primary angiosarcoma of the innominate vein: a case report with resection and long-term survival.

The first reported case of a primary angiosarcoma arising from the innominate vein is presented. This rare tumor was treated with surgical excision, and the patient is alive 8 years postoperatively.

Femoral artery infection complicating intraaortic balloon pumping.

Infection of the femoral artery (endarteritis) complicating intraaortic balloon pumping has not been reported. Most reports of complications with this pump have not emphasized wound infection. Whether the balloon is inserted by open or percutaneous technique, infection remains a problem. During the past 7 years, 32 of 50 patients (64 percent) who had intraaortic balloon pump insertion survived balloon removal. In four patients, wound infection of the groin developed with involvement of the femoral artery. Sepsis was due to P. aeruginosa in three patients and E. cloacae in one. All patients required variable degrees of resection of the infected femoral artery wall. One had successful arterial reconstruction with vein patch angioplasty alone after debridement of the vessel wall. In a second patient, resection of the common femoral artery with interposition of a saphenous vein that had been reconstructed to enhance its diameter to that of the femoral artery was accomplished. Dehiscence of a vein patch angioplasty occurred in the remaining two patients with resultant hemorrhage. Further resection of the femoral artery was required with femoro-femoral saphenous vein grafting in one patient and iliofemoral vein grafting in another. Tissue coverage of the reconstructed vessel was best accomplished using a tensor fascis lata myocutaneous flap. All patients survived the infection without amputation.

Left ventricular decompression by sump drainage.

Decompression of the left ventricle during cardiopulmonary bypass is a useful adjunct to open-heart operation, primarily to preserve myocardial tissue and also to improve the exposure of the operative field. The addition of sump drainage to left ventricular decompression systems enhances the usefulness of this established technique. Technical aspects of this sump drainage are detailed.

Dysphagia lusoria: current surgical approach.

The presence of an anomalous right subclavian artery in a patient was a cause of dysphagia and ill-defined upper back pain. Her problem was ideally managed by the median sternotomy approach. With this exposure, the artery is divided and its origin from the aortic arch oversewn. Relocating the artery into the right upper mediastinum and anastomosis with or without a segmental graft to the aortic arch restores extremity circulation and eliminates the dysphagia.

Reappraisal of solitary bronchiolar (alveolar cell) carcinoma of the lung.

Twelve patients with solitary bronchiolar carcinoma had lobectomy and were followed for up to 16 years. The concept of a multicentric origin of bronchiolar carcinoma, maintained for more than eight decades, should be discarded. The neoplasm arises indolently and usually in an area of pulmonary fibrosis. After lobectomy patients can now expect to follow one of four courses: (1) to be alive and well without recurrence; (2) after several years to have pulmonary recurrence or a new carcinoma; (3) with minute spread at the time of lobectomy to have metastasis develop in a short period; or (4) to die of unrelated conditions. The overall 5-year survival with this tumor is about 75%. Late recurrence or the development of another primary tumor, however, prompts the need for prolonged follow-up. Immunologically, patients have circulating antibodies when well and demonstrable circulating antigens with recurrence. The survival rate of selected patients with solitary bronchiolar carcinoma (eliminating those patients with microscopic spread from the primary neoplasm at the time of resection and those dying of other causes) was 100% after 5 years and 75% after 10 years.

Current concepts in thoracic drainage systems.

Thoracic drainage systems are currently marketed in many varieties, resulting in significant cost and complicating patient management. Realistic needs have been identified from a survey of thoracic surgeons. These are: (1) clear plastic chest catheters with multiple drainage holes in sizes 28, 32, and 36F for adults and 16, 20, and 24F for infants and children; (2) serrated plastic connectors that can be sized at operation; (3) connecting tubes of clear plastic 6 feet long with a diameter of 1/2 inch; (4) a single graduated volume-collecting bottle of 1- to 2-liter capacity that can be emptied and marked, with a separate waterseal component and an associated manometer; and (5) a highflow vacuum source. A drainage system with these characteristics should be safe, effective, simple, and less costly.