Nonsurgical intervention in the resolution of acquired neonatal bronchial stenosis

A stricture of the right main bronchus developed in an 1100 gm premature (first delivered twin female) infant being mechanically ventilated for approximately 1 month. The stricture resolved with treatment consisting of three consecutive daily obturations with angiocatheters avoiding the use of a balloon inflation technique provoking a local dilation. The catheters were placed with a guide wire under fluoroscopic control. The clinical protocol advanced for the dilation of acquired bronchial stenosis was well tolerated by the patient. A 9-month clinical radiologic review confirmed normal pulmonary structures and functions. Catheter dilation is described as a new technique for treatment of bronchial stenosis in the very small infant.

Diaphragmatic pacing in the treatment of chronic respiratory insufficiency of quadriplegic patients

Following our experience with diaphragmatic pacing in 2 quadriplegic patients with bilateral diaphragmatic paralysis, we here present the indication for and the surgical technique of bilateral implantation of a diaphragmatic pacemaker. This mode of artificial ventilation appears to be superior to positive pressure ventilation for longterm ventilatory assistance of these patients.

Diagnostic and therapeutic value of thoracotomy in advanced pulmonary neoplasms

This study analyses retrospectively 100 consecutive thoracotomies performed for lung cancer before end 1986. Chest CT scan assessed mediastinal lymph node disease, chest wall invasion and mediastinal invasion, with an overall accuracy of 75, 93 and 91 per cent respectively; mediastinal lymph node disease was significantly more underestimated in the stage III group. Characteristics, type of surgical and adjuvant therapy and follow-up were analysed in the T3 (16 patients) and the N2 (18 patients) group. Complete resection was possible in only a minority of the cases: 3 in the T3 group and one in the N2 group. Of the T3 group, 3 patients have survived more than 3 years and 3 are actually still alive. Of the N2 group, only 2 patients are still alive. Most deaths were due to generalization of the disease.

A patient with two chronic posttraumatic aneurysms of the thoracic aorta

A case of successful replacement of two coexistent chronic post-traumatic aneurysms of the thoracic aorta is presented. Presumably, these aneurysms at the aortic isthmus and the descending thoracic aorta resulted from two different deceleration traumas.

Muscular fibrosis due to chronic intramuscular administration of narcotic analgesics

Chronic intramuscular injections, particularly of narcotic analgesics, are an uncommon cause of myopathy. We report two patients with pentazocine- and meperidine-related myopathy. Narcotic-induced muscular fibrosis and contractures must be considered in patients with a pattern of muscle involvement that does not conform to any recognized myopathy, but allows for self-administration of injections. Trauma due to needle puncture, repetitive infections and a local myotoxic effect of the drugs probably contribute to these lesions.

Posttraumatic rupture of the thoracic aorta

Ten patients with traumatic lesions of the thoracic aorta were seen in a hospital. Most were victims of traffic accidents and presented severe associated lesions along with their vascular trauma. We found that the vascular injuries were clinically manifest in only a minority of patients. The remaining ruptures were discovered through CT-scanning of the mediastinum or angiography. We believe that in every major trauma victim aortic lesions should be actively sought for by complimentary examinations to guarantee maximum survival of the patients.

Comparison of auscultation, continuous wave Doppler imaging, intravenous digital subtraction angiography and conventional angiography in diagnosis of carotid artery disease

The reliability of auscultation, continuous wave (CW) Doppler imaging, and intravenous digital subtraction angiography (IV DSA) in the assessment of carotid artery disease has been evaluated in comparison with conventional angiography in 30 patients. With auscultation, specificity and sensitivity for internal carotid artery (ICA) stenosis of 50% or more were 81% and 67% respectively. CW Doppler imaging detected ICA stenosis of 50% or more with a sensitivity of 83% and a specificity of 92% and ICA occlusion with a sensitivity of 60%. The specificity of IV DSA was 95% and the sensitivity for ICA stenosis of 50% or more and ICA occlusion were 75% and 100% respectively. Combining CW Doppler and IV DSA findings raised sensitivity for ICA stenosis of 50% or more and ICA occlusion to 89% and 100% respectively and specificity to 95%. The combination of CW Doppler and IV DSA is a safe and accurate test battery in the detection and categorization of carotid disease.

Transaxillary thoracotomy for treatment of spontaneous pneumothorax

This study reports the retrospective analysis of operative treatment of 20 cases of spontaneous pneumothorax during the last 4 years. Surgical indications included recurrence, recollapse of the lung on clamping the chest tube, nonexpansion of the lung despite adequate drainage or persistent air leak, and giant bulla. A transaxillary thoracotomy was used in all cases to treat sites of air leak and subpleural blebs by resection (14 cases) or oversutering (4 cases) combined with pleural abrasion (19 cases) or apical pleurectomy (1 case). This approach has met with excellent results without major morbidity or mortality.

Repair of pericardial rupture by abdominal transphrenic approach solely

The abdominal transphrenic approach enabled us to repair a left lateral pericardial rupture on a polytrauma patient who also had a rupture of the spleen and a retroperitoneal hemorrhage. A pericardial exploration was necessary because of a sudden upper venous congestion syndrome during operation, suggestive of a cardiac tamponade.

Posterior mediastinal sarcoidosis

We report two cases of enlargement of the posterior mediastinal lymph nodes due to sarcoidosis. Bilateral hilar enlargement, pulmonary parenchymal involvement, or extrathoracic manifestations of sarcoidosis were absent. A diagnostic thoracotomy had to be performed in both instances.

Femorofemoral bypass grafting in high-risk patients

A total of 37 extra-anatomic femorofemoral bypasses were inserted for severe unilateral iliac artery stenosis or a thrombosed graft limb of an aorto-bifemoral bifurcation graft. All patients were severely debilitated and at high risk for direct aorto-iliac reconstruction. 30% suffered severe claudication; 70% had ischemic restpain or trophic lesions. 43% died during a mean follow-up period of 17 months. This study demonstrates that the extra-anatomic femoro-femoral bypass procedure is an effective alternative therapeutic modality for high-risk patients with an acceptable operative mortality (5.4%) and morbidity to improve the quality of life.

Fibromuscular dysplasia of the internal carotid artery

An observation on symptomatic fibromuscular dysplasia of the internal carotid artery, surgically treated by graduated internal dilatation is presented. Fibromuscular dysplasia is a segmental, nonatheromatous disease of small to medium-sized arteries, affecting mainly renal arteries. Involvement of the internal carotid artery is often an incidental angiographic finding in asymptomatic patients, but can be associated with specific neurologic symptoms requiring surgical treatment. The histopathologic character, the pathogenesis, the clinical manifestation, the diagnosis and the therapeutic possibilities of this affection are discussed.

Recurrent pulmonary embolism: importance, diagnosis, management and prevention

Pulmonary emboli, even small, cause irreparable lung damage. Recurrent pulmonary emboli further increase the amount of non functional lung tissue and may result in incapacitating respiratory disease or death. It is therefore mandatory that the disease be correctly diagnosed and adequately treated. As prevention is better than cure, every patient presenting with clinical signs of deep venous thrombosis (DVT) should be correctly explored. The site and size of thrombosis must be visualized preferably with contrast venography with imaging of the veins of the limbs, iliac veins and vena cava. Risk factors such as obesity, immobilization etc. must be taken into account. Underlying disease such as heart disease and venous insufficiency must be treated. Malignancy must be looked for as in a recent series of patients with primary DVT which were studied, 15% presented with an up till then unknown malignant disease. In patients presenting with recurrent DVT this percentage rose to 20%. When a patient presents with DVT of the femoro-iliac vena cava axis, aggressive treatment must be adopted. Fibrinolysis or if this is contra-indicated, thrombectomy will be used. A vena cava filter may be necessary and longterm anticoagulation is mandatory. The same rationale is applicable in cases of pulmonary embolus whether it is a primary event or a recurrence.

Small artery syndrome in women

During the past four years, 106 women underwent aortography and peripheral runoff studies for peripheral vascular disease. Eleven patients presented with "small vessels" and were selected for this study. They were significantly younger than the rest of the group (a mean age of 52 versus 66 years). A clear history of claudication was elicited in all patients. Rest pain was present in four patients. Most patients were small in stature but not obese. Weak or absent femoral and distal pulses and abdominal or femoral bruits were common. Angiography demonstrated a narrow infrarenal aorta, narrow iliac and common femoral arteries and a straight course of iliac arteries. Atherosclerotic lesions involved mainly the aortoiliac segment, but were confined to the superficial femoral artery in two patients. Reconstruction was achieved by endarterectomy or transluminal angioplasty in segmental aortoiliac disease and aortobifemoral or aortobi-iliac graft in diffuse disease. Femorpopliteal or iliopopliteal graft or lumbar sympathectomy was performed in patients with significant femoral disease. In one patient, an acutely occluded femoral segment was replaced by a venous interposition graft. Two patients were treated conservatively. There were no operative deaths. Nine patients were markedly improved at follow-up examination. Graft thrombosis occurred in one patient with combined aortobi-iliac and iliopopliteal graft. The high incidence of single bifurcating lumbar arteries at the fourth and fifth lumbar vertebrae supports the hypothesis that aortic hypoplasia may result from embryonic overfusion of the dorsal aortas. Lipid abnormalities existed in 54 per cent of the patients. All women were heavy smokers and 73 per cent had a positive family history of cardiovascular disease.

[Systematic research on an etiology in apparently primary deep venous thrombosis. Apropos of 59 cases]

Primary deep vein thrombosis was confirmed by phlebography in 59 cases between Jan. 1981 and Jan. 1984 in the department of Cardiovascular Surgery of the Academic Hospital of the V.U.B. Brussels. Investigations conducted in all patients included blood and urine analyses, chest radiography, electrocardiogram, gynecologic or urologic examinations and abdominal and pelvic ultrasound imaging. Findings demonstrated one or more risk factors in 92% of cases, the principal ones being obesity, a history of thromboemboli and, in women, the use of oral contraceptives. Nine patients had cancer and 4 of these received combined surgery-chemotherapy. All cases of so-called primary deep vein thrombosis should be investigated routinely for risk factors, because of the need and possibilities for treatment in some of them, particularly since procedures are non-invasive, of low cost, and easily performed during initial heparin therapy.

Surgical management of spontaneous pneumothorax

Spontaneous pneumothorax is a common surgical problem. Although the general principles of drainage of the pleural space and of prevention of recurrence seem well known, the literature shows differences in success rates concerning the treatment of a first pneumothorax and of the eventual recurrences. This is probably due to some technical factors and different views on the therapeutical strategy. In this retrospective review of 62 patients with spontaneous pneumothorax, 8 were treated by bed rest for their not enlarging and less than 20% pneumothorax, and 54 were treated by closed chest tube thoracostomy with an early success rate of 93.5% at the first admission. The simultaneous use of scarifying agents and closed chest drainage appears useful for the treatment of immediate or first recurrence. Sixteen patients were readmitted later for ipsilateral recurrence. According to the magnitude of their pneumothorax, they were treated by bed rest or tube thoracostomy with scarifying agents. Four of these patients needed thoracotomy with oversuturing of subpleural blebs and pleurodesis. The total thoracotomy rate of the initial patient population was 12.9% after an average follow up period of 24.8 months.

Disposition of and clinical response to salicylates in patients with rheumatoid disease

The disposition of salicylic acid (SA) and its metabolites and the clinical response to long-term aspirin treatment at varying doses were assessed in patients with rheumatoid disease. Steady-state kinetics of SA (total and unbound), salicyluric acid (SUA), gentisic acid (GA), and clinical status were estimated weekly in 10 patients with rheumatoid arthritis. Eight received a soluble aspirin form and two received an enteric-coated form. The starting dose of aspirin in each patient was 1.8 gm (soluble) or 1.95 gm (enteric-coated) daily. Weekly increments in dose were made until a satisfactory clinical outcome was achieved. The final aspirin dose range was 3.6 to 8.1 gm daily, which resulted in mean steady-state plasma SA concentrations (CpSA) from 56 to 375 mg/l. Since the mean total CpSA increased approximately proportionately over the dose range, there was little change in total SA clearance. By contrast, increasing aspirin dosage resulted in decreased clearance and disproportionate increases in unbound SA (CpuSA). The maximum velocity of conversion of SA to SUA (Vm) increased significantly, from 57.3 +/- 11.7 mg/hr at an aspirin dose of 1.8 gm/day to 71.4 +/- 19.4 mg/hr at the next highest dose (2.7 to 3.6 gm/day), with no further change with increasing dosage. Km ranged from 0.4 to 1.2 mg/l for CpuSA and from 5.5 to 17.2 for total CpSA. Renal clearance of SUA (ClSUA) ranged from 124 to 893 ml/min and correlated with creatinine clearance. ClGA ranged from 23 to 164 ml/min, and ClSA ranged from 0.1 to 17.1 ml/min; neither correlated with creatinine clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endarterectomy of the superficial femoral artery using an oscillating loop]

A short series of half closed endarterectomies of superficial femoral artery with oscillating ringstripper is presented. The technique used is described, and major problems are discussed. Results are published and confrontated with the clinical events. Three criteria are withheld for indication of this procedure: the superficial femoral artery has to be completely occluded and not calcifiated; the popliteal artery has to be angiographically normal; two out of three arteries below knee have to be permeable. The authors advocate oral anticoagulation for a relatively long postoperative period.