Acute cholecystitis in the immediate postoperative period following esophagogastrectomy.

Postoperative acute cholecystitis (PAC) occurs after 0.06 per cent of all operations. However, PAC may occur in up to 3.1 per cent of patients after gastrectomy. This increased incidence of PAC is due to bile stasis and gall bladder ischemia promoted by vagotomy and gastrohepatic ligament dissection during gastrectomy. Despite similar factors during esophagogastrectomy PAC is rarely reported in large American series of patients undergoing esophagogastrectomy. We report two cases of PAC occurring after esophagogastrectomy.

Detection of occult thymoma during exercise thallium 201, technetium 99m tetrofosmin imaging for coronary artery disease.

Thallium (Tl) 201 and technetium (Tc) 99m tetrofosmin single-photon emission CT are routinely used in the evaluation of coronary artery disease. Mediastinal tumors demonstrate Tl 201 and Tc 99m tetrofosmin uptake. We report a 56-year-old man who developed chest pain after a previously successful angioplasty and stent of the left anterior descending coronary artery. He underwent a Tl 201, Tc 99m tetrofosmin exercise study. Abnormal mediastinal activity was visualized in both the Tl 201 and Tc 99m tetrofosmin images. Subsequently, the patient underwent resection of a stage II thymoma. Unanticipated focal extracardiac accumulation during myocardial scintiscanning should lead to further investigation to exclude mediastinal tumor.

Management of aortobronchial fistula with graft replacement and omentopexy.

Massive hemoptysis due to a recurrent aortobronchial fistula after repair of a thoracic aortic aneurysm developed in a 64-year-old woman. The infected aortic tissue was resected and replaced with an in situ Dacron graft covered by omentum. The patient is alive and well 15 months later.

Oxygen free radical scavengers decrease reperfusion injury in lung transplantation.

An in vivo canine model was used to assess the ability of an oxygen free radical scavenger to decrease reperfusion injury in lung transplantation. In 12 dogs, the left lungs were transplanted after they had been preserved for 24 hours at 4 degrees C after pulmonary artery flushing with modified Eurocollins solution. In 6 dogs, dimethylthiourea, a potent oxygen free radical scavenger, was added to the flush solution and was also given to the recipients just before reperfusion. In all animals, the contralateral pulmonary artery and bronchus were ligated and lung function was assessed for 12 hours or until death. Three dogs died prematurely in the control group, whereas only 1 dog died prematurely in the dimethylthiourea group. This resulted in a statistically significant difference in the average length of survival (p less than 0.05). Pulmonary artery and right atrial pressures were significantly lower in the dimethylthiourea group during the first 6 hours (p less than 0.05). Treatment with dimethylthiourea resulted in a significantly higher arterial oxygen tension at 4 hours, and intrapulmonary shunt tended to be lower. Thus, it would appear that dimethylthiourea has a protective effect on lungs preserved for 24 hours before transplantation in dogs.

Improved lung preservation using a dimethylthiourea flush.

The purpose of this study was to evaluate the ability of dimethylthiourea (DMTU), a low molecular weight hydroxyl free radical scavenger, to improve preservation of the lung for transplantation. Following preservation, 15 isolated canine left lower lobes were reperfused for 90 min with autologous blood. Five group I lobes served as controls and were not subjected to ischemia prior to reperfusion. Five group II lobes were flushed and submerged in a cold Euro-Collins solution and stored for 4 hr at 4 degrees C prior to reperfusion. Group III lobes were flushed with a 20 mM DMTU-enhanced Euro-Collins solution, stored for 4 hr, and then reperfused. The isogravimetric method was utilized to determine the capillary permeability coefficient (Kfc) for the reperfused lobes. The Kfc values were 0.10 +/- 0.01, 0.17 +/- 0.01, and 0.10 +/- 0.008 ml/min/mm Hg/100 g lung for groups I, II, and III, respectively (P less than 0.01 II vs I, III). Extravascular lung water values in the reperfused lobe were 4.44 +/- 0.45, 6.57 +/- 0.38, and 5.23 +/- 0.22 ml/g blood free dry lung weight for groups I, II, and III (P less than .05, II vs. I, III). Lung lipid peroxidation, measured as thiobarbituric acid-reactive material, was higher in group II, 146 +/- 6 nmole/g, than in either group I, 90 +/- 5 nmole/g, or group III, 91 +/- 4 nmole/g (P less than 0.01). The results indicate that the addition of DMTU improves hypothermic lung preservation by reducing lipid peroxidation and edema formation upon reperfusion.

Occult diaphragmatic injury from stab wounds to the lower chest and abdomen.

Ninety-five patients with stab wounds to the lower chest and abdomen underwent routine abdominal exploration. Eighteen of these patients had diaphragmatic injury and in five patients it was the only injury found. Isolated diaphragmatic injury in asymptomatic patients cannot be reliably delineated by either serial physical examination or peritoneal lavage. Delayed recognition of incarcerated diaphragmatic hernia after stab wounds to the lower left chest and upper abdomen has an associated mortality rate of 36%. The anatomic area of concern can be defined as stab wounds that penetrate the left side of the chest below the fourth intercostal space anteriorly, the sixth intercostal space laterally, and the tip of the scapula posteriorly. Exploratory laparotomy is necessary in these patients until a reliable nonoperative method is established that can exclude injuries to the diaphragm.

Reperfusion injury in the lung preserved for 24 hours.

The left lower lobes of 28 canine lungs were isolated, preserved, and then reperfused for 150 minutes. Five groups of lobes were studied: group 1, control (n = 5); group 2, one hour of warm ischemia (n = 5); group 3, one hour of warm ischemia + oxygen free radical scavengers (n = 5); group 4, 24 hours of cold ischemia (n = 8); and group 5, 24 hours of cold ischemia + oxygen free radical scavengers (n = 5). Oxygen free radical scavengers consisted of superoxide dismutase and catalase (100 micrograms/mL) given at the moment of reflow. Extravascular lung water (grams per gram of blood-free dry lobe weight) after reperfusion was 2.75 +/- 0.19, 5.46 +/- 0.60, 4.08 +/- 0.37, 9.43 +/- 0.98, and 6.91 +/- 0.95 for groups 1 through 5, respectively (p less than 0.05, groups 2 through 5 versus group 1; p less than 0.05, group 2 versus group 3 and group 4 versus group 5). Lung tissue lipid peroxidation, measured as thiobarbituric acid reactive material, was 117 +/- 14, 314 +/- 19, and 163 +/- 25 nmol/g dry lobe weight for groups 1, 4, and 5, respectively (p less than 0.05, group 4 versus group 1 and group 4 versus group 5). The data suggest that oxygen free radical scavengers attenuate reperfusion injury after long-term hypothermic lung preservation.

Evaluation and management of massive lower gastrointestinal hemorrhage.

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.

Scalpel versus electrocautery in modified radical mastectomy.

Forty nine consecutive mastectomy patients were randomized to one of two groups. Twenty four patients had skin flaps created with the cold scalpel and twenty five with the electrocautery. The two groups were similar with respect to age, stage of disease, size of tumor, and weight. Cautery patients had significantly less operative blood loss when compared with scalpel patients, 352 versus 507 milliliters, respectively, P less than 0.05. No cautery patient required transfusion compared with three transfused scalpel patients, P less than .005. Total postoperative hemovac drainage and hospital stay were not significantly different between the two groups. Although the number of fever days and wound complications were slightly higher in the cautery group, the difference was not statistically significant. The electrocautery may be superior to the scalpel for mastectomy.

Intra-abdominal complications of cardiopulmonary bypass operations.

The records of 6,452 consecutive patients who underwent cardiopulmonary bypass procedures were examined for intra-abdominal complications. There were 60 complications in 51 patients for an incidence of 0.94 per cent. The mortality rate was 59 per cent. Complications included bleeding in the gastrointestinal tract in 20, intestinal ischemia in 16, acute cholecystitis in 11, pancreatitis in five, small intestinal obstruction in three, perforated ulcer in two, hepatic necrosis in two and splenic laceration in one instance. Clinical risk factors included advanced age, emergency operation, valvular surgical treatment, hypotension, intra-aortic balloon pump, pressors and reoperation. Patients with a prolonged pump time had an increased risk of intraabdominal complications (p less than 0.001).

Sex related survival differences in instances of melanoma.

While data concerning melanoma survival differences between the sexes as they relate to anatomic site, stage and age is scattered throughout the literature, few single studies on one large population of patients with melanoma have specifically addressed all the confounding variables proposed to account for such sex related survival differences. Data were collected for 1,489 patients with melanoma observed at Duke University Comprehensive Cancer Center. Females had a more favorable prognosis than males. This survival difference could not be fully explained by differences in the anatomic site of the primary, Clark level of invasion, histologic type or ulceration of the primary lesion or age at diagnosis between males and females. There is growing epidemiologic and biochemical evidence that melanoma may be affected by sex hormones.