Effect of blood transfusion on survival after esophagogastrectomy for carcinoma.

BACKGROUND: There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious. METHODS: The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period. RESULTS: The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged. CONCLUSIONS: Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.

Clinical evaluation of a rapid immunochromatographic test for the diagnosis of dengue virus infection.

A rapid immunochromatographic test was compared to the hemagglutination inhibition assay for separate determinations of dengue virus-specific immunoglobulin M (IgM) and IgG levels in paired serum specimens from 92 patients (34 with primary dengue virus infection, 35 with secondary dengue virus infection, and 23 without dengue virus infection). The rapid test showed 99% sensitivity in the diagnosis of dengue virus infection. The majority (30 of 34 [88%]) of patients with primary infection showed positive IgM but negative IgG, while 34 of 35 (97%) patients with secondary infection showed positive IgG with or without IgM. Specificity in nonflavivirus infections was 96% (1 of 23 positive). The rapid test should be a useful aid in rapid diagnosis of dengue virus infection.

Evaluation of a commercial capture enzyme-linked immunosorbent assay for detection of immunoglobulin M and G antibodies produced during dengue infection.

A commercially available capture enzyme-linked immunosorbent assay (ELISA) for the detection of specific immunoglobulin M (IgM) and IgG antibodies produced during dengue infection (PanBio Dengue Duo) was evaluated with paired serum specimens from 176 patients. Diagnosis was based on a hemagglutination inhibition (HAI) assay, with patients having either primary dengue (n = 90), secondary dengue (n = 58), or no dengue (n = 28) infection. The combined use of IgM and IgG (sensitivity, 99%; specificity, 96%) was superior to the use of IgM alone (sensitivity, 88%; specificity, 96%) or IgG alone (sensitivity, 85%; specificity, 96%). Furthermore, with the first serum sample of the pair of serum samples, the ELISA was able to diagnose significantly more cases of dengue than the HAI assay (55% versus 14%). The results of the IgG capture ELISA gave a significant correlation with those of the HAI assay (r = 0.91; P < 0.0001), and the IgG capture ELISA could be used to distinguish between primary and secondary infection. The best distinction was observed when an IgG cutoff ratio of 3.0 was used, with 88% of primary infections and 98% of secondary infections being correctly classified. This ELISA should prove to be useful in the clinical diagnosis of dengue infection.

Prediction of requirement for, and outcome of, prolonged mechanical ventilation following cardiac surgery.

The prediction of requirement for, and short- and long-term outcome of, prolonged mechanical ventilation after cardiac surgery is ill-defined. The aims of this study were to isolate any predictive indices which might identify those groups of patients who may require prolonged ventilation postoperatively and to determine which factors significantly affect outcome in the prolonged-ventilation group. Following case note review of 139 consecutive cardiac surgical patients ventilated for > or = 7 days following surgery, 43 factors were recorded on each patient, including smoking, pulmonary function, chest infection, and chronic obstructive airways disease. Of 139 patients, 89 were discharged from hospital (64% survival); of these, 52 were alive at long-term follow-up (58% long-term survival). Statistical analysis identified urban residence, chronic obstructive airways disease, prolonged operation, and bypass time as significant predictors of requirement for prolonged ventilation postoperatively. On multivariate analysis five factors were predictive of increased intensive care mortality, including urban residence, inotrope days, sepsis, perioperative cerebrovascular accident and coagulopathy requiring fresh frozen plasma transfusion postoperatively. Following discharge from hospital, four factors were found to be significant predictors of increased mortality: these are impaired preoperative ejection fraction, increasing age, impaired preoperative pulmonary function, and abscence of preoperative aspirin medication. These factors should be considered in intensive care planning, long-term follow-up and importantly on clinical decision making in the individual patient.

Oesophagogastrectomy for carcinoma in patients under 50 years of age.

Oesophagogastrectomy for carcinoma of the oesophagus or gastric cardia has been reported as being associated with a poorer outcome in young adults than in older patients in an Oriental population. A retrospective analysis of 597 patients who underwent oesophagogastrectomy for carcinoma was undertaken to ascertain if resection in younger Scottish patients was associated with the same poorer outcome. Forty-seven patients aged less than 50 years were compared with 323 patients aged 50-69 years and 227 patients aged 70 years and older. Young patients had a higher incidence of distal third oesophageal tumours than older patients, who tended to have carcinomas of the gastric cardia. There were no differences with regard to tumour pathology, stage, extent of resection, hospital mortality or survival. In Scotland, carcinoma of the oesophagus or gastric cardia in young adults behaves similarly to that in older patients, and survival following resection is independent of age.

Esophagectomy for carcinoma in the octogenarian.

BACKGROUND: Esophageal carcinoma is predominantly a disease of the elderly, a group often only considered for palliative therapies. METHODS: A case note review identified 31 octogenarians undergoing resection for carcinoma of the esophagus or gastric cardia over a 12-year period ending December 1994. RESULTS: Nineteen patients made either an uncomplicated postoperative recovery (n = 12) or suffered minor complications (n = 7). Of the 12 patients who suffered moderate or severe complications, 5 died (in-hospital mortality, 16%). The deaths included 2 of 3 patients who underwent emergency operation for esophageal perforation and 3 of 28 patients who underwent elective esophagectomy (elective mortality rate, 10.7%). Nineteen of the 26 survivors (73%) experienced no further dysphagia. The 5-year survival rate was 17%. CONCLUSIONS: Elective esophageal resection can be performed safety in selected octogenarians who have no or few coexisting medical problems and present with a localized carcinoma that is technically easy to resect. Patients undergoing emergency operations or in whom moderate or severe postoperative complications develop often have poor physiologic reserve and are therefore at risk of early postoperative death.

Hufnagel revisited: a descending thoracic aortic valve to treat prosthetic valve insufficiency.

In 1953 Hufnagel and Harvey reported their successful treatment of aortic valve insufficiency by the implantation of a ball-valve prosthesis into the descending thoracic aorta. Since then, great advances in technology, surgery, and anesthesia have made aortic valve replacement a more common procedure with relatively low mortality. This remains true for the vast majority of prosthetic valve replacements. However, cases requiring reoperation can be difficult, leading to a much higher degree of morbidity and mortality. In selected patients who require repeated approaches to the aortic root we propose that Hufnagel's original idea may still be of value to reduce the severity of aortic insufficiency. We report our experience in 4 cases of aortic prosthetic incompetence, all of which were improved by two New York Heart Association functional classes after a modification of Hufnagel's procedure.

Influence of obesity on the early and long term results of surgery for coronary artery disease.

In order to determine the effect of obesity on the results of coronary artery bypass graft (CABG) surgery, we compared 250 obese patients undergoing CABG procedures between 1984 and 1987 with 250 age- and sex-matched controls of normal body mass index (BMI) undergoing CABG in the same period. The obese group had a greater incidence of diabetes mellitus (p less than 0.02), hypertension (p less than 0.05), hyperlipidaemia (p less than 0.05), and left main stem coronary artery disease (p less than 0.001). No differences were identified in the surgery performed, but obesity was associated with prolonged total bypass time (p less than 0.05). Operative mortality was 0.8% in both groups. Multivariate analysis demonstrated obesity to be an independent risk factor for perioperative morbidity (p less than 0.05). Univariate: respiratory (p less than 0.01); leg wound (p less than 0.001); myocardial infarction (p less than 0.02); arrhythmias (p less than 0.02); sternal dehiscence (p less than 0.02). At a mean follow-up time of 36.9 months obese patients exhibited a greater incidence of significant recurrent angina (p less than 0.01), which was associated with further weight gain (mean 12.2 kg; linear correlation: p less than 0.001, r = 0.891). Although in CABG surgery operative mortality is not increased in obese patients, aggressive pre- and postoperative weight control is indicated to reduce both perioperative morbidity and the incidence of recurrent angina.

Small cell carcinoma of the oesophagus: report of three cases and review of published cases.

Small cell carcinoma of the oesophagus is a rare tumour with a poor prognosis. This report presents evidence favouring chemotherapy as the primary treatment.

Strut fracture and disc embolisation of a Björk-Shiley aortic prosthesis: emergency operation with survival. Case report.

Strut fracture with disc embolisation from a Björk-Shiley prosthesis in the aortic position is extremely rare, and almost invariably fatal. We report a case in which the patient survived emergency surgery for this complication. The pathogenesis of strut fracture, its prevention, diagnosis and management are discussed.

Post-transfusion purpura following open heart surgery: management by high dose intravenous immunoglobulin infusion.

We present three cases of post-transfusion purpura (PTP) developing in the immediate post operative period after open heart surgery. All had developed platelet specific antibodies and severe anaphylactoid reactions occurred to platelet transfusion in two cases. Treatment with high dose intravenous immunoglobulin (IV IgG) led to complete recovery in two patients one of whom demonstrated a marked biphasic response pattern to therapy. The other died from congestive cardiac failure. PTP is a potentially fatal complication which may well become more frequent with increasing blood product usage.

Surgical management of left ventricular aneurysm and diffuse coronary artery disease: immediate and long term results in patients receiving three or more grafts.

Because little information is available concerning the outcome of surgery for left ventricular aneurysm when multiple concurrent coronary grafts are required, we have reviewed 35 consecutive patients undergoing aneurysm surgery and multiple (greater than or equal to 3) grafts between December 1973 and April 1984. There were 6 operative deaths (17%). All occurred amongst those (16) undergoing LV plication procedures with no deaths amongst those (19) undergoing aneurysm resection (p less than 0.01). Operative mortality was not influenced by preoperative functional status, left ventricular end diastolic pressure, completeness of revascularisation, endarterectomy (13 patients) or whether cold crystalloid cardioplegia or intermittent aortic cross clamp with ventricular fibrillation was used. Overall 5-year actuarial survival was 70% with survival beyond surgery being 84% to 5 years and independent of the type of aneurysm procedure. Of the survivors, 16 were improved by 1-3 functional classes, 3 were unchanged and one was worse. Surgery in this group of patients offers the prospect of good symptomatic improvement and survival figures which at least equal the results of less complex ventricular aneurysm surgery and exceed those reported for medical management.

Wound colonisation following cardiac surgery. Reduction by adjuvant use of preincisional, presternal antibiotic infiltration: a double blind prospective randomised study.

In a double blind, prospective, randomised study of 100 patients undergoing elective cardiac surgery, a significant (p less than 0.01) reduction in wound colonisation, defined as positive culture of any wound discharge irrespective of wound appearance, occurred in those receiving preincisional presternal antibiotic infiltration (2%) as compared to a control group who received a similar volume of normal saline by the same route (24%). Both groups received, in addition, the same conventional intravenous regimen of broad spectrum antibiotic. A comparable concurrent group of patients, not entered into the study, demonstrated a wound colonisation rate similar to the trial control group (22%), thus excluding an adverse bias from the control saline infiltration. Analysis of control cases demonstrated a significant (p less than 0.001) discriminant effect in the degree of preoperative haemodilution with haematocrit falling on bypass by a mean of 25% in those who developed wound colonisation as compared to 13% in those who did not.

Avoidance of patent anterior grafts at revisional coronary artery surgery: use of a lateral thoracotomy approach.

The use of a right or left lateral thoracotomy is described as an alternative approach to revisional coronary artery surgery for patients with patent anterior grafts. Five patients underwent successful revisional coronary artery grafting with a total of three internal mammary artery grafts and three saphenous vein grafts. This is a safe technique in patients for whom repeat median sternotomy is potentially hazardous, notably those with patent anterior grafts or close apposition of the heart to the sternal table.

Wound prophylaxis in thoracic surgery: a new approach.

A prospective double blind, randomised study was performed in 100 patients undergoing major elective thoracic surgery to assess a new method of prophylaxis of wound infection using one preincisional intraparietal infiltration of cefuroxime sodium along the line of proposed incision as the sole protection against wound infection. A significant (p less than 0.01) reduction in the incidence of wound infection occurred in the antibiotic treated group (2%) compared with the control group (20%), who received by the same route the same volume of saline only. The groups were comparable with respect to age, sex, pathological condition, and operative variables. The use of additional antibiotics was significantly greater in the control group (p less than 0.01), largely owing to a much greater incidence of postoperative pulmonary infection in the control group (60%) than in the antibiotic treated group (40%). No morbidity was associated with this technique. The organisms found in oesophageal and bronchial operative luminal specimens did not correlate with postoperative wound or pulmonary infection or with organisms causing these infections. Reductions in wound and pulmonary infection rates equivalent to those produced by conventional multiple dose parenteral regimens were achieved by this technique.