Superior sulcus (Pancoast) tumor: experience with 105 patients

BACKGROUND

The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed.

METHODS

There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12).

RESULTS

The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05).

CONCLUSIONS

The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.

Paraplegia after thoracotomy: report of five cases and review of the literature

Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

Penetrating cardiac injuries

One hundred nine penetrating cardiac injuries were reviewed: 49 gunshot wounds and 60 stab wounds. They were classified into four groups: group 1 (lifeless), 38; group 2 (agonal), 16; group 3 (shock), 33; and group 4 (stable), 22. Thirty-six patients in group 1 (94%) and 8 of 16 patients in group 2 (50%) underwent emergency room thoracotomy; 24 of 33 in group 3 (73%) and 20 of 22 (90%) underwent thoracotomy in the operating room. Twenty-one (38%) of 55 patients undergoing emergency room thoracotomy survived, whereas 47 (87%) of 54 patients undergoing operating room thoracotomy survived. Survival was 12 of 38 (31%) in group 1, 11 of 16 (69%) in group 2, 26 of 33 (79%) in group 3, and 18 of 22 (82%) in group 4 with an overall survival of 67 of 109 (61%). Gunshot wounds of the heart portend a worse prognosis than stab wounds. Survival of gunshot wounds was 20 of 49 (40%) compared with 47 survivors of 60 stab wounds (78%). Aggressive treatment, including emergency room thoracotomy, is justified for lifeless and deteriorating cardiac injury victims.

Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

Esophageal perforation: a therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Carcinoma of the esophagus: a comparison of the results of transhiatal versus transthoracic resection

The cases of 78 patients with primary esophageal carcinoma treated from 1977 to mid-1987 were retrospectively analyzed. Fifty-two of the patients underwent transthoracic esophagogastrectomy (TTE) and 26, transhiatal esophagectomy (THE). The two groups were statistically similar in preoperative characteristics except that more of the THE group had received chemotherapy; this group had relatively more tumors of the upper esophagus; and 20 (77%) of the THE group, compared with 50 (96%) of the TTE group, had tumors in stages III and IV. The incidence of major postoperative complications did not differ significantly between the two groups. There were five (19%) anastomotic leaks in the THE group, but only one led to a prolongation of hospital stay by more than 14 days, whereas all three (6%) of the leaks in the TTE group caused hospital stay to be prolonged several weeks. Overall morbidity was high: 75% (39/52) for the TTE patients and 85% (22/26) for the THE patients (p greater than 0.10). Hospital mortality was 6% (3/52) in the TTE group and 8% (2/26) in the THE patients (p greater than 0.10). There was no significant difference in actuarial survival either between the two groups as a whole or between those patients in each group who had stage III or IV tumors. We conclude that THE, among the types of patients for whom we used the procedure, provides long-term survival comparable with that provided by TTE without causing a significant increase in hospital mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental repair of ventricular septal defects using autologous right ventricular muscle flaps: preliminary report

Survival after repair of postinfarction ventricular septal defects remains poor, often due to extensive loss of contractile muscle in the septum or left ventricle. We evaluated whether a contractile flap of right ventricular muscle could be used to repair a similar ventricular septal defect to augment left ventricular performance in 7 fully instrumented mongrel dogs (weight, 23 to 28 kg). By using hypothermic bypass and cold fibrillatory arrest, a trapezoidal right ventricle flap was fashioned from the free wall of the mid to lower right ventricle, basing its widest portion anteriorly on the septum and left ventricle. A large, 2-cm-diameter core of septum was excised beneath this flap to simulate a postinfarct ventricular septal defect. The right ventricular flap was then invaginated through the defect and sewn to the left ventricular side of the septum with pledgeted sutures taken full thickness through the flap and septum in a "vest-over-pants" fashion. Contraction of the right ventricular flap was confirmed visually and by postbypass multiple gated acquisition scans. The right ventricular defect was closed with fascia lata. All dogs were weaned from bypass without inotropes. Precardiac and postcardiac outputs of 2.5 +/- 0.5 versus 2.3 +/- 0.4 L/min and left ventricular end-diastolic pressures of 4 +/- 2 versus 4 +/- 3 mm Hg were identical. No shunts were detected by oxygen saturation. Autopsies confirmed the integrity of the repair. We conclude that septal defects can be repaired by using contractile right ventricular muscle, thus preserving left ventricular function. This technique offers promise for repair of postinfarction ventricular septal defects by using autologous, already conditioned to contract, cardiac muscle, but its application in humans must await long-term testing.

Surgical management of lung cancer with solitary cerebral metastasis

Between 1964 and 1986, 19 patients underwent resection of both a primary lung cancer and the associated brain metastasis. One patient underwent resection of 2 separate primary lung cancers and the associated metastases. The 12 men and 7 women ranged in age from 42 to 67 years (mean, 54.6 years). The cell type was adenocarcinoma in 12 tumors, squamous or adenosquamous cell in 5, large cell undifferentiated or anaplastic in 2, and malignant carcinoid in 1 tumor. The types of resection were as follows: lobectomy for 12 neoplasms, pneumonectomy for 5, bilobectomy for 2, and wedge resection for 1 neoplasm. Radiotherapy to the brain was given in connection with sixteen of the twenty craniotomies. The patient with 2 separate primary neoplasms survived 19 years before dying 5 months after the second craniotomy. The mean survival is 8.0 +/- 2.1 years (+/- the standard error), and the median survival is 1.67 years. Survival at 1 year was 65 +/- 10.7% and at 5 years, 45 +/- 11.1%. On univariate analysis, the following factors were found to correlate significantly with longer survival: a lung tumor in Stage I or II; negative mediastinal nodes; curative rather than palliative resection of the lung tumor; and age younger than 55 years. However, on multivariate analysis, only curative resection was a significant factor (p less than 0.01). We believe these results justify continued application of this combined surgical approach to patients having limited-stage lung cancer with a solitary brain metastasis.

Transhiatal esophagectomy for carcinoma of the esophagus: experience with 26 patients

Transhiatal esophagectomy was performed in 26 patients with esophageal carcinoma. The patients were selected for this procedure by means of transhiatal palpation of the tumor at laparotomy. Twenty had squamous cell carcinoma and 6, adenocarcinoma. The tumor locations were the upper third in 8, middle third in 12, and lower third in 6. On postoperative staging, 15 patients had Stage III and 6, Stage IV neoplasms. Among 25 elective resections there was 1 hospital death, which was due to severe coronary artery disease. One patient who had an urgent resection for a perforated carcinoma died of multisystem failure 32 days postoperatively. Complications included splenic injury requiring splenectomy in 5 patients; tracheal laceration in 2 patients (only 1 requiring a thoracotomy); azygos vein laceration requiring sternotomy for repair in 1 patient; chylothorax in 1; recurrent laryngeal nerve paralysis in 3 (temporary in 2); and transient anastomotic leaks in 3. Five patients had pneumonia with transient respiratory failure. Twelve of the operative survivors died of cancer 3.2 to 32 months postoperatively, and 12 are alive 3 to 28 months after operation. The actuarial survival is 53 +/- 11% (+/- standard error) at one year and 46 +/- 12% at two years. Transhiatal esophagectomy is a reasonable, safe operation that should be considered for tumors at all levels of the esophagus.

Achalasia associated with squamous cell carcinoma of the esophagus: a case report

A case of achalasia associated with squamous cell carcinoma of the esophagus is presented. Microscopic examination of the resected esophagus demonstrated abundant nerve fibers but absent ganglion cells throughout the tumor-involved segment. This finding is believed to be the cause of achalasia in this patient.

Thymectomy for myasthenia gravis: 14-year experience

Forty-eight consecutive patients with myasthenia gravis (MG) attended by generalized weakness were treated by complete thymectomy, performed transsternally in 46 patients and through a left thoracotomy in two with thymomas. There were no operative deaths. A 12-year-old child with fulminating MG died of acute pneumonia shortly after hospital discharge. Of the remaining 47 evaluable patients, thymectomy resulted in complete remission in six, marked improvement with a reduced need for medication in 20, and mild improvement on the same dosage of medication in 18. Neither the age of the patient, nor the histopathology of the excised thymus, nor the postoperative change in acetylcholine receptor antibody titer were found to have a significant influence on the response to thymectomy. If the ten patients who were 20 years of age or younger were excluded, the patients with a shorter duration of MG achieved a better response to operation. The authors conclude that thymectomy is effective treatment for MG, regardless of the age of the patient or the type of thymic pathology.

Management of penetrating cardiac injuries: the role of emergency room thoracotomy

Sixty-four consecutive patients with penetrating cardiac injuries were treated between January, 1977, and January, 1983, at the University of Maryland Hospital. Twenty-eight patients had major associated injuries of other organs. The patients were divided into groups according to their clinical status on arrival. An aggressive approach was utilized including early emergency room (ER) thoracotomy for "lifeless" or deteriorating patients. Three patients required immediate cardiopulmonary bypass for repair of their injuries. Twenty-one (57%) of the 37 patients undergoing ER thoracotomy survived; most of the deaths occurred in patients arriving "lifeless" from gunshot wounds. Twenty-four (89%) of the 27 patients who were in stable enough condition to undergo initial repair in the operating room (OR) survived. Overall survival was 45 patients (70%). Though superficial wound infections developed in 18 patients, there were no deep or systemic infections. None of the survivors sustained severe neurological sequelae. Five patients underwent late reoperations for closure of a ventricular septal defect (2), mitral valve replacement (1), and pericardiectomy (2) with no deaths. Though repair of penetrating cardiac injuries should preferably be carried out in the OR, immediate thoracotomy for "lifeless" or deteriorating patients can be performed in the ER with a low incidence of direct surgical complications and with high patient survival.

Colon interposition for benign esophageal disease: experience with 23 patients

Twenty-four colon interpositions were performed in a group of 23 patients comprising both adults and children between 1965 and early 1982. The indications for operation were caustic injury in 13 patients, peptic stricture in 6, congenital atresia or stenosis in 2, and gunshot or foreign body injury in 2. Long colon segments, consisting of isoperistaltic left colon in seven instances, antiperistaltic left colon in four, and right colon in five, were utilized for 16 procedures in 15 patients. Short segments of left colon were used in 8 patients, isoperistaltic in 6 and antiperistaltic in 2. There were no operative deaths. Ischemic complications necessitated removal of the transplant and replacement with another segment in 1 patient and revision or drainage procedures in 2 others. Strictures of the esophagocolic anastomosis occurred in 6 patients. Five of these strictures occurred among the 13 patients with caustic injury and appeared to be due to unrecognized caustic damage in the esophageal segment used for the anastomosis. Three patients died of unrelated causes eight months to 4 1/2 years after operation, and 3 others were lost to follow-up. Seventeen patients were available for current follow-up 1 to 16 years after operation, including 7 who were followed more than 7 years. When the swallowing ability of these 17 patients was assessed using rigorous criteria, 9 were found to have an excellent to good result; 5, a good to fair result; and 3, a poor result. No patient showed late deterioration of function. We conclude that interposed colon is the ideal esophageal substitute for the patient with benign disease.

Circular esophageal myotomy in the rhesus monkey: anatomical and physiological effects

Thirty-one rhesus monkeys were divided into six groups: a control group of 4 monkeys in which resection of 33% of the thoracic esophagus with end-to-end anastomosis was performed without myotomy, and test groups of 4 to 6 monkeys each in which circular myotomy in the proximal segment, distal segment, or both was combined with a 25% or 33% resection. In the control group, 2 of 4 monkeys survived. In the test groups, myotomy reduced longitudinal tension by 20 to 58%. Among the survivors were 4 of 6 animals that had 25% resection with proximal myotomy, 3 of 5 having 25% resection with distal myotomy, and 3 of 4 having 25% resection with combined proximal and distal myotomy. However, 4 of 5 monkeys that had 33% resection plus proximal myotomy and all 5 having 33% resection plus distal myotomy died of anastomotic leaks or strictures. Cineesophagography in surviving monkeys showed no motility disturbance at the myotomy sites. Manometry in 5 monkeys showed no change in resting lower esophageal sphincter pressure from that measured preoperatively. Postmortem examination in long-term survivors showed no stricture or dilatation at the myotomy sites. It is concluded that circular myotomy in the rhesus monkey reduces longitudinal tension, but compromise of the esophageal blood supply limits the usefulness of the procedure in bridging long gaps in the esophagus. Myotomy did not result in any motility disturbance or late anatomical sequelae, and therefore is still a valid procedure to facilitate the repair of short defects.

Carcinoma of the esophagus: twelve years' experience with a philosophy for palliation

Twelve years of experience have now been gained with a new therapeutic approach to carcinoma of the esophagus. In this approach, the primary goal of treatment is palliation, with cure an important but secondary objective. Carcinomas in the upper third of the esophagus are treated by radiation therapy unless there is severe obstruction or tracheal invasion, in which case colon interposition is performed. Limited resection with esophagogastrostomy is performed through a right thoracotomy and midline laparotomy for neoplasms in the middle third of the esophagus and through a left thoracotomy for carcinomas in the lower third. Since 1969, 161 patients have been evaluated, of whom 107 (66%) have been managed according to the new protocol. Twenty patients with carcinomas of the upper third of the esophagus were treated primarily by radiotherapy and 7 by colon interposition. Resection was performed in 78 of the 80 patients with carcinomas of the middle and lower thirds. There were 9 operative deaths (10%). Palliation, of superior quality to that obtained by previous methods, was provided to 95 of the 107 patients. Survival also is at least on a par with that obtained before.

Pericardial window for malignant pericardial effusion

Seventeen patients with malignant pericardial effusion were treated by the creation of a pericardial window. This was done through a subxiphoid approach in 13 patients and through limited anterior thoracotomy or sternotomy incisions in 4. There were no deaths and no major complications attributable to the operation. In all patients, relief of the cardiac compression caused by the effusion was immediate and complete. No patient showed a clinically significant recurrence of the effusion, although 1 patient who had received irradiation required pericardiectomy for constriction 5 months later. Survival was determined principally by the extent of the primary malignancy. Six patients died of the primary tumors within 30 days, but 6 survived 3 to 12 months and 2 are alive at 8 and 21 months. It is concluded that creation of a pericardial window, preferably by the subxiphoid approach, is the treatment of choice for malignant pericardial effusion. The procedure provides an accurate diagnosis, carries virtually no mortality or morbidity, and affords immediate and long-lasting relief of cardiac compression.

Palliation of esophageal carcinoma with intraluminal tubes: experience with 30 patients

Between 1968 and 1978, 26 patients with carcinomas of the thoracic esophagus and 4 with adenocarcinomas involving the esophagogastric junction were treated by the insertion of indwelling intraluminal (endoesophageal) tubes. Four different types of tube were inserted by the pull-through technique. Thirteen of the 30 patients died in the hospital within 30 days. However, among the 20 patients who did not have neoplasms of the upper third of the thoracic esophagus or who had not had a prior resection, only 5 died. The principal cause of death was aspiration pneumonia. Survival averaged 2.5 months. Four patients survived 5 to 7 months. Deglutition was adequate in most patients but was not as satisfactory as after esophagogastrectomy. Our best results were obtained in patients with carcinoma of the middle or lower third of the esophagus, with or without an esophagorespiratory fistula, who had not had a previous resection.

Circular myotomy as an aid to resection and end-to-end anastomosis of the esophagus

Segments ranging from 40 to 70% of the thoracic esophagus were resected in 80 mongrel dogs. End-to-end anastomosis was effected after circular myotomy either proximal or distal, or both proximal and distal, to the anastomosis. Among dogs undergoing resection of 60% of the esophagus, distal myotomy enabled 6 of 8 animals to survive, and combined proximal and distal myotomy permitted 8 of 10 to survive. Cineesophagography was performed in a majority of the 50 surviving animals and showed no appreciable delay of peristalsis at the myotomy sites. When these sites were examined at postmortem examination up to 13 months after operation, 1 dog showed a small diverticulum but none showed dilatation or stricture. It is concluded that circular myotomy holds real promise as a means of extending the clinical application of esophageal resection with end-to-end anastomosis.

Management of lung contusion

One hundred and thirty-two consecutive patients with lung contusion were admitted during the three-year period of 1972 through 1974. All were treated with early intubation and mechanical ventilation with positive and-expiratory pressure with the postulate that such management would minimize the progression of interstitial edema, and intra-alveolar hemorrhage. If progressive increase in the alveolar/arterial oxygen tension gradient was not observed over the ensuing 24 hours, and in the absence of other non-thoracic indications of continuance of mechanical ventilation, patients were extubated and removed from the ventilator. All other patients were further ventilated and followed by daily chest roentgenograms and blood gas studies. Mean ventilation time was 6.2 days. Progressive hypoxemia and deterioration of pulmonary function were not seen. The incidence of pneumonia and tension pneumothorax was low. Overall mortality was 10.6 per cent. The most common cause of death was brain death. No deaths were the result of hypoxemia.

Bronchopleural fistula. Thirteen-year experience with 77 cases

Bronchopleural fistula, although reduced in incidence in recent years, remains a grave complication of pulmonary disease and of pulmonary resection. In a series of 77 patients treated for bronchopleural fistula over a 13 year period, 49 of whom had postresection fistulas, only 44 (57.1 percent) were cured of the fistula and 15 (19.5 percent) died. Prevention assumes great importance. Key factors in prevention are avoidance of pulmonary resection in tuberculous patients with positive sputum; overzealous dissection of the bronchus; a long bronchial stump; tumor in the bronchial stump; contamination of the pleural cavity; and too little tissue left behind to fill the pleural space. Treatment should be surgical. In none of the six patients treated conservatively was the fistula obliterated. Seventy-one patients were treated surgically, and 133 operations were needed to effect fistula obliteration in the 44 patients (62 percent) in whom this was achieved. Adequate surgical drainage has always been the sine qua non of effective treatment, and yet this alone brought about closure of the fistula in only nine patients. Early resuture of the bronchial stump succeeded in only two of five patients. Thoracoplasty combined with drainage effected closure in seven of 11 patients. The highest rate of fistula closure with the lowest mortality occurred among the 20 patients who underwent myoplasty, usually combined with a limited thoracoplasty. In this group, the fistula was obliterated in 16 patients, with one death.

The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients

Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was combined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.

Carcinoma of the esophagus: experience with a philosophy for palliation

The preliminary results of a new therapeutic approach to carcinoma of the esophagus were reported in 1972. The primary objective of treatment should be palliation, with cure an important but secondary goal. Lesions in the upper third of the esophagus are treated by irradiation unless there is severe obstruction or tracheal involvement, in which case colon bypass is carried out. Limited resection and esophagogastrostomy is performed through a right thoractomy and midline laparotomy for middle-third lesions and through a left thoracotomy for lower-third carcinomas. Since 1969, 85 patients have been evaluated, of whom 65 (76%) have been treated according to the new protocol. Thirteen patients with upper-third carcinomas were treated primarily by radiation therapy and 6 by colon bypass. Resection was performed in 45 of the 46 patients with middle- and lower-third lesions. There were 5 operative deaths (9.8%). The quality and duration of palliation have been far superior to that achieved by previous methods of treatment and, perhaps surprisingly, survival rates have improved.

Ruptured thoracic aorta due to blunt trauma

Thirty-six ruptured thoracic aortas have been diagnosed in a total of 3,500 patients seen at the Maryland Institute for Emergency Medicine in the past 5 years. To our knowledge, no ruptured thoracic aortas have gone undetected. A new method of performing portable chest radiography has been developed which we feel clarifies the diagnosis of mediastinal hematomas and which allows us to determine which patients will undergo aortography. The reported survival rate of 75% is felt to be due to the rapidity with which these patients are brought to the hospital and use of a carefully planned protocol which permits early diagnosis and treatment. These results are due to the combined efforts of the Maryland State Police Helicopter System, the traumatologists, anesthesiologists, nurses, paramedics, radiologists, and thoracic surgeons working together as a completely integrated team.

Pericarditis with effusion complicating esophageal perforation

Among 24 patients with esophageal perforation treated during the past 6 years, 3 patients developed pericarditis with effusion as a life-threatening complication. In the first patient pericarditis was found at autopsy, the diagnosis having been suspected but not proved during life. In the other 2 patients pericardial decompression was performed and both survived. Common denominators in the 3 patients were delayed diagnosis and treatment of the perforation, with resultant empyema. Further, the diagnosis of pericarditis with effusion was difficult and delayed, because mediastinitis and associated pleuritis and pneumonia obscured the cardiac silhouette on chest roentgenogram. It is recommended that a high index of suspicion of pericarditis be maintained in patients with esophageal perforation, especially in those in whom the perforation is diagnosed late.

Pulmonary aspergillosis: an analysis of 41 patients

During the period 1969 to 1974, 41 patients having cultures positive for aspergillus were seen on the thoracic surgical services of the University of Maryland and Mt. Wilson State Hospitals. Intracavitary mycetoma was present in 36 patients. In 32 the underlying disease was chronic cavitary tuberculosis, 5 had decreased immunity due to other diseases, and in 3 no underlying disease was noted. One final patient developed a mycetoma following repair of tetralogy of Fallot. Hemoptysis, the predominant symptom, occurred in 23 patients, all of whom were from the group with intracavitary mycetoma. Hemoptysis was life-threatening in 8 patients, severe but not life-threatening in 12, and minimal in 3. Fifteen patients underwent pulmonary resection with 2 deaths. Both patients who died had undergone emergency resection for life-threatening hemoptysis; the fungus ball had developed following a previous resection for tuberculosis, and both had poor pulmonary reserve. Of 10 patients with hemoptysis who were not treated surgically, chiefly because they were poor operative risks, 4 died. This study suggests that pulmonary aspergillosis, particularly of the intracavitary type, is a potentially life-threatening disease. Because of the suddenness with which massive hemoptysis may occur, pulmonary resection is recommended for all patients with intracavitary mycetoma who do not constitute prohibitive operative risks.

The value of thoracoplasty before extensive unilateral resection for pulmonary tuberculosis

Among 24 patients who required extensive unilateral resection for tuberculosis, 17 underwent adequate thoracoplasty before resection and seven others received either no thoracoplasty before resection or an inadequate one. These two groups were comparable as to severity of disease and operative risk. The incidence of serious complications was 83 per cent in the latter group compared to 12 per cent in the former. While the number of patients in each group is too small for a statistically valid comparison, the results suggest that an adequate thoracoplasty before resection is of definite value in preventing pleural complications after extensive unilateral resection for tuberculosis.

The association of carcinoma of the esophagus with achalasia

Among 156 patients with achalasia who were treated during a 13 year period, two developed squamous cell carcinoma of the esophagus. The first, a 33-year-old man, developed a carcinoma of the upper third of the esophagus 2 years after the onset of symptoms of achalasia. He was treated by a Heller myotomy and radiation therapy and survived 16.7 months. The second, a 60-year-old man, had had symptoms of achalasia for 15 years. He is alive with suspected recurrence 6 months after undergoing esophagogastrectomy for a carcinoma of the middle and lower thirds. A summary of the literature regarding carcinoma complicating achalasia is presented. This indicates that carcinoma arises in at least 1 to 7 per cent of patients with achalasia. Delay in diagnosis is common. The treatment need not differ from that of carcinoma without a chalasia, but the prognosis is dismal. Since there is evidence that retention esophagitis is a premalignant condition, it should be possible to prevent the development of carcinoma in achalasia by early cardiomyotomy in cases in which hydrostatic dilatation is not completely effective. A plea is made for closer surveillance of patients with achalasia so that, if carcinoma supervenes, it may be detected at an early stage.

Surgical treatment of pulmonary infections caused by atypical mycobacteria

Pulmonary disease caused by atypical mycobacteria frequently constitutes an indication for operative treatment, since these bacteria are usually resistant to most forms of chemotherapy. Since 1968 11 patients having pulmonary infection caused by atypical mycobacteria underwent pulmonary resection. All patients, except one who had bilateral disease, left the hospital with negative sputum status. Pulmonary resection is an effective means of therapy for atypical mycobacterial pulmonary infection. Such treatment can be carried out with low morbidity and mortality, and is indicated in cases of poor response to drug treatment or persistent residual lesions.

Use of the umbilical vein to study the splanchnic and portal beds in shock and trauma: II. Metabolic studies

Perumbilical portal vein catheters and arterial and central venous catheters were inserted in 16 patients recovering from trauma or other shock-producing events, and in 5 patients who later developed shock. This permitted serial measurement of blood gases, pH, and the levels of ammonia, lactate and certain other metabolites in all three circulatory systems simultaneously. Nine of the trauma patients were never in shock, had no liver disease or injury and consequently formed a baseline group for comparison with the shock patients. In the shock patients there was a significant degree of hypoxemia in the portal venous blood and an increase in the arterialportal oxygen saturation difference. Their portal venous blood showed a lower pH and a higher pCO(2) than did the portal blood of the patients who had never been in shock. In 3 of the 4 shock patients who died, the total blood lactate showed a greater increase in portal venous than in the arterial or central venous blood. In shock there was also an increase in portal venous blood ammonia which was later accompanied by increments in arterial and central venous blood ammonia. This suggests impairment of hepatic urea synthesis, allowing escape of ammonia through the liver. These phenomena, when added to the finding previously reported of an elevated portal venous pressure in some shock patients, lend support to the hypothesis that in certain cases of shock there is increased impedance to flow of portal blood through the liver with resultant stasis in the portal-splanchnic bed and ischemichypoxic hepatocellular injury.

Use of the umbilical vein for manometric and radiographic studies of the splanchnic and portal beds in shock and trauma

Images