Esophagogastrostomy with the EEA stapler.

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeon's error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.

Thymectomy for myasthenia gravis in the young adult. Long-term results.

An 8 year experience with a prospective treatment program for patients with myasthenia gravis is reviewed with particular focus on the results in patients less than 35 years of age. Twenty myasthenic young adults with an average age of 24 years and a duration of symptoms of 22 months, excluding two with the juvenile form, had thymectomy followed by short-term anticholinesterase and long-term prednisone therapy. All of the 18 patients with a short duration of symptoms are in markedly improved condition and 61% of them are in remission after a mean postoperative period of 32 months. The longest follow-up period is 7.3 years. Two patients have mild improvement. There was no correlation between thymic disease and clinical result. Complete en bloc extirpation of all thymic and adjacent tissue through a median sternotomy is advocated. The patients were treated postoperatively with prednisone, 100 mg/day, a regimen which gradually is changed to every other day medication and finally a gradual reduction of dosage. There have been no operative or late deaths and no serious complications of therapy. The effects have been long lasting, with not a single instance of significant recurrence of symptoms of myasthenia gravis 6 months after thymectomy.

Multiple valve replacement: changing status.

Review of our experience with multiple valve replacement over a 6-year-period revealed a recent marked reduction in operative risk. Operative mortality for 62 patients operated on before 1974 was 34%; for 44 patients operated on since 1974, mortality was only 11%. In both groups, mortality was clearly related to the preoperative cardiac functional status. Several recent technical advances including myocardial protection by topical hypothermia, shortened perfusion time, and the intraaortic balloon pump may all have contributed to the reduced operative risk.

Posterior ventricular aneurysm, severe mitral regurgitation, and rupture of the left ventricle after acute myocardial infarction: six-year survival after surgical correction.

Posterior ventricular aneurysm and severe mitral regurgitation due to acute myocardial infarction are rarely recognized during life. This report describes the successful surgical treatment of a patient with this combination of lesions who at operation was found to have rupture of the left ventricle as well. Aneurysmectomy, mitral valve replacement, and coronary artery bypass were performed with a gratifying late result. Aggressive investigation of patients with hemodynamic deterioration after posterior myocardial infarction may identify surgically correctable mechanical complications.

Reconstructive valve surgery.

Despite continued refinement of heart valve prostheses, valve replacement carries risks of thromboembolic, mechanical, and infectious complications, and long-term success is further limited by the eventual wear of prosthetic parts. In many patients with congenital or acquired valve diseases, valve function may be improved, if not restored, by reconstructive techniques, prosthetic replacement being thereby avoided or delayed. This review examines the current status of reconstructive procedures for management of diseased valves, with emphasis on long-term results and post-operative hemodynamic studies. In many instances the choice between reconstruction and replacement of a diseased valve remains controversial. The documented success of selectively applied reconstructive techniques, however, weighs against expedient decisions for prosthetic replacement and supports a continuing search for new techniques.

Pharmacological preservation of the ischemic heart.

This study was based on the concept that intracellular accumulation of calcium plays a role in mediating ischemic myocardial injury and that inhibition of entry of calcium into cells may have a salutary effect on the ischemic heart. Nifedipine, a potent vasodilator and inhibitor of transmembrane calcium flux, was infused into the aortic root of 6 dogs (5 microgram/kg/hr) during 2 hours of myocardial ischemia while on cardiopulmonary bypass. Seven control animals received normal saline at the same flow rate and temperature (20 degrees C). The results showed that none of the 7 control animals were able to maintain adequate aortic pressure or cardiac output after 30 to 60 minutes of normothermic reperfusion. All had marked left ventricular failure and were unresponsive to large doses of inotropic agents. In contrast, the 6 dogs treated with nifedipine were weaned from bypass either without difficulty or requiring small doses of calcium chloride and norepinephrine. Light microscopy demonstrated more marked ischemic damage in the control group than in the group of drug-treated dogs. We conclude that the concept of inhibition of transmembrane calcium flux offers a new and potent method for myocardial preservation during ischemia.

Long-term function of aortic homografts as the right ventricular outflow tract.

Physical examination, chest roentgenography, phonocardiography, and right heart catheterization were used to evaluate the function of composite aortic homografts inserted as right ventricular outflow tracts in 13 patients 1.8 to 7 years previously. All homografts in these patients who were followed for 2 or more years demonstrated calcification of the aortic wall, but valve leaflets were spared. Moderate pulmonary insufficiency was present in eight patients with single cusp partial homografts, but was well tolerated in all. Homograft valve insufficiency was mild in five patients with complete homografts. No patient had an outflow tract gradient greater than 32 mm Hg. The average gradient was 18.5 +/- 2.7 (SEM) mm Hg. Abnormality of pulmonary blood flow was found in three patients and could be related to previous Waterston or Potts anastomoses. No late morbidity due to homograft degeneration has occurred and the long-term function of these conduits appears to be good.