Extrapulmonary small-cell carcinoma is uncommon. We report a rare case of small-cell carcinoma located in the mediastinum. The patient is still alive 6 years after combined local resection and chemotherapy. This seems to be the first reported case with such long survival.
The surgical management of two patients undergoing living transplantation for Budd-Chiari syndrome is reported. Mesenteriocaval shunt had previously been performed in both cases, followed by transcaval liver resection and hepatoatrial anastomosis after 3 and 5 years, respectively. Liver transplantation was necessitated by deteriorating liver function with portal hypertension and recurrent bleeding. The successful operation was performed via sternolaparotomy. Atrioatrial anastomosis was constructed during cardiopulmonary bypass, considerably simplifying the technical procedure and dramatically reducing blood loss.
Cellular activation with release of cytokines such as interleukin-6 (IL-6) occurs during cardiopulmonary bypass. IL-6 regulates a number of physiologic processes, and a possible role of IL-6 was recently postulated in the pathogenesis of changes in serum thyroid hormone concentrations in patients with nonthyroidal illness. The perioperative concentrations of triiodothyronine (T3) and IL-6 were determined in ten children undergoing open-heart surgery. Significant fall in T3 concentration was found postoperatively, while IL-6 increased significantly, peaking 2 hours postoperatively. The total accumulated IL-6 level 2 hours postoperatively was correlated to postoperative T3 concentration. A significant inverse correlation was found between T3 levels 24 and 48 hours postoperatively and total accumulated IL-6, and also between the percentage decrease in T3 concentrations and total accumulated IL-6. IL-6 release thus correlated inversely to T3 levels after cardiopulmonary bypass.
Mortality and morbidity during a period of two years after coronary artery bypass grafting in relation to age
To test the hypothesis of association between heart failure and altered haemostatic balance in patients with a mechanical valve prosthesis, comparisons were made between 20 patients with mitral valve replacement and stable chronic heart failure (group A), 20 with the same prosthesis but satisfactory haemodynamics (group B) and 20 age-matched controls (group C). The left ventricular ejection fraction was significantly highest (p < 0.001) in group A. The pulmonary artery systolic pressure was also highest in group A (p < 0.001), without significant difference between groups B and C. Two group A patients had a transient ischaemic attack. The D-dimer plasma concentrations and the antigenic and biologic von Willebrand factor activities were significantly greatest in group A. Significant correlation was found between the plasma concentrations of these activities and pulmonary artery systolic pressure and between D-dimer and ejection fraction. Platelet-activating factor was detected only in six group A patients. The observed relationship between haemostatic factors and heart failure in patients with mechanical heart-valve prosthesis advocates careful evaluation of von Willebrand factor and D-dimer in order to prevent embolic events in such cases.
A 32-year-old man received a left-sided thoracic stab wound, which was primarily treated with percutaneous tube thoracostomy. Ipsilateral empyema appeared 8 weeks later and subsequent investigations revealed herniation of the stomach through the diaphragm. The diaphragmatic rupture and a perforation in the gastric wall were repaired at thoracotomy. The literature on such wounds is reviewed.
Preoperative angiograms were reviewed in 86 (52%) of 165 patients who underwent intracardiac repair of tetralogy of Fallot in 1966-1976. The median age at repair was 7 years (range 9 months-55 years). Hypoplasia, stenosis or atresia of the pulmonary and aortopulmonary collateral arteries were present in 58 patients (67%). Hypoplasia of the main pulmonary artery was associated with hypoplasia of the pulmonary artery branches. In patients who received a transannular patch the pulmonary arteries were smaller than in those without patch. Three of five pulmonary artery branch stenoses were located at the site of a previous palliative shunt. The postrepair right ventricular/left ventricular systolic pressure ratio (P-RV/LV) measured in the operating room was compared with a predicted ratio based on pulmonary artery dimensions. High P-RV/LV was associated with poor prognosis. In survivors the post-repair P-RV/LV had fallen significantly 13-26 years later. Work capacity and pulmonary function at follow-up were not influenced by presence of pulmonary artery abnormalities. We conclude that such abnormalities, although common in patients with tetralogy of Fallot, did not per se influence physical performance in long-term survivors.
In an internal thoracic artery intended as a graft in coronary angioplasty, multiple intramural haematomas impeded blood flow and consequently precluded use of the artery as a free graft. The cause was found to be cystic medical necrosis of the internal thoracic artery. A good result was obtained with three single aorto-coronary venous bypass grafts.
Tricuspid regurgitation arising from chest trauma 46 years earlier was successfully corrected by valve reconstruction in a 67-year-old man. As the merits of valve repair are well established, it can be advocated for traumatic tricuspid regurgitation, regardless of the time from the causal injury.
Acute infective endocarditis was surgically treated in 42 patients (36 male, 6 female), aged 6-66 (mean 43.9) years. The causal microorganism was identified in 26 cases (61.9%) and the portal of entry in 12. The main indication for surgery was cardiac failure. In 23 cases (54.7%) only the aortic valve was affected. The mean NYHA function class was 3.35 preoperatively and 1.85 postoperatively. All typical surgical findings were preoperatively recognized at echocardiography. Twenty-six ball-type and 16 tilting disk valves were inserted. The early mortality was 4.7% (2 cases), due to low cardiac output and bleeding. High early postoperative morbidity (23%), possibly resulted from too long interval from onset of disease to surgery, viz. 1-18 (mean 6.3) months. It is concluded that timely operation for acute infective endocarditis is effective.
A 76-year-old woman presented with an intrathoracic malignant peripheral nerve-sheath tumour accompanied by mediastinal lipomas. The tumours were resected, but the schwannoma recurred 4 months later. The patient died of pneumonia after a second operation. To our knowledge, this is the first published case of malignant intrathoracic tumour of nerve-sheath origin associated with lipomas.
Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.
Release of calprotectin and interleukin-8 (IL-8), changes in leukocyte counts and subsets and influence of extracorporeal ultrafiltration were evaluated during and after cardiopulmonary bypass (CPB) in 18 children undergoing open-heart surgery for congenital heart anomalies. Ultrafiltration was used in nine cases and nine were controls. Calprotectin concentration rose after start of CPB, peaking 48 hours postoperatively, with no significant intergroup difference. Positive correlation was found between duration of CPB and calprotectin (peak level and accumulated total). Circulating IL-8 was detected in all patients perioperatively, peaking at wound closure in the ultrafiltration group and at termination of bypass in the controls. CPB duration correlated significantly to peak level and accumulated total of IL-8. Seven of nine ultrafiltrate samples contained IL-8 at levels similar to the plasma concentration. Changes in white cell counts were mainly attributable to neutrophils. The two subgroups did not differ significantly in neutrophil counts. Neutropenia found after 10 minutes of CPB was replaced by neutrophilia, with maximal values postoperatively. Calprotectin and IL-8 thus were released into the circulation during CPB in children. Ultrafiltration did not affect the plasma concentrations of these substances, and only IL-8 was detected in the ultrafiltrate.
In a patient presenting with a roentgenographic retrocardiac density, left pleural effusion and distal oesophageal displacement, echocardiography confirmed presence of a pseudocyst in the posterior mediastinum. Pancreatic origin was suspected. Left thoracolaparotomy revealed the large (900 ml), exclusively mediastinal pseudocyst, surrounding the aorta and adherent to the diaphragm, with high amylase content. Decompression was achieved with a retrocolic and gastric Roux-en-Y loop by transdiaphragmatic cystojejunostomy.
Animal studies have shown increased endothelin in bronchoalveolar lavage (BAL) fluid during unmodified rejection. We performed radioimmunoassay of endothelin in 59 BAL fluid samples from ten patients at different times after lung transplantation. All patients received immunosuppressive therapy (cyclosporin, azathioprine and methylprednisolone). Reference BAL samples were obtained from six controls. Of the 59 test samples, five were collected during rejection episodes, confirmed by clinical outcome, BAL cytology and radiology (rejection group), and 19 were taken during bacterial, viral or fungal infection (infection group). The endothelin content of BAL (pg/ml) was significantly greater in the rejection group than in the infection group (61.1 +/- 3.8 vs 40.6 +/- 2.0) or in the 35 samples taken in uncomplicated course after lung transplantation (40.9 +/- 5.4), p < 0.01. The endothelin level in BAL. fluid from the controls was only 3.0 +/- 1.4 pg/ml, significantly less (p < 0.005) than in all the lung-transplanted groups. Endothelin in BAL fluid thus was increased after lung transplantation, and still further during rejection.
UNLABELLED The objectives were to measure the pressure--cross-sectional area relations and intrinsic stiffness of the porcine aorta in vivo. METHODS Measurements were made in 12 pigs, weight 30, 50 or 75 kg, proximal and distal to the bifurcation of the renal arteries, using an electrical impedance system which was located inside a balloon mounted on a catheter. Vessel cross-sectional area (CSA) was assessed by measuring impedance of the fluid inside the balloon during distension. RESULTS In vitro testing demonstrated the accuracy and reproducibility of impedance planimetry. In vivo steady-state CSA values showed non-linear relationship with rising distension pressures. Mean CSA values rose with increasing weight of the pigs. the suprarenal aorta was larger than the infrarenal only in 75 kg pigs (p < 0.05). At three measurements the within-subject variation was 0.89% and the between-subject variation 99.11%. Nitroglycerine infusion produced only minor, insignificant CSA increase, indicating negligible tone in the abdominal aorta. All segments showed circumferential wall strain-tension relations with exponential behaviour uninfluenced by weight class or site in the aorta. CONCLUSION Information of vascular mechanics in vivo is obtainable by catheterization of the abdominal aorta.
A 12-year-old child with tricuspid atresia and acquired hypoplasia of the left pulmonary artery was successfully treated with unilateral Fontan operation. Angiography at age 2 months had shown a normal left pulmonary artery, and a modified Potts shunt was performed. An emergency central shunt was required a year later. Reinvestigation 5 years after the initial operation revealed severe hypoplasia of the left pulmonary artery.
Warm, continuous blood cardioplegia should theoretically maintain cardiac arrest for hours without ischaemic or hypothermic injury. In the absence of in vivo studies of myocardial metabolism and ultrastructural and/or functional preservation during and after more than 2 hours of cardiac arrest and after weaning from bypass, we devised a porcine model with a closed extracorporeal circuit for the heart alone. Normothermic blood cardioplegia was administered antegrade and recirculated for 2 or 4 hours, each in seven pigs. After aortic declamping all were successfully weaned from bypass and reperfused for 1 hour. Thereafter we found no significant intergroup difference in haemodynamic characteristics (average fall in mean arterial pressure 31.7 +/- 3.2% and 26.9 +/- 2.6%) or blood analyses. After 5 and 60 minutes of cardiac arrest there was minimal lactate production (5.7 +/- 10.7 and 0.5 +/- 10.5 nmol/l, respectively), whereas in the remainder of the arrest period there was lactate uptake, indicating aerobic heart metabolism. Our setup avoids systemic hyperkalaemia, gives good cardiac protection with no deterioration between 2 and 4 hours and is well suited for studies on the quiescent, blood-perfused oxygenated heart.
In 100 left human lungs the main bronchus, the pulmonary artery and the pulmonary veins were injected with 65% methyl methacrylate (Duracryl) and then digested in sulphuric acid. The resulting specimens were studied concerning the divisions of the lingular bronchus and the types of arterial and venous vascularization of the lingula. As a rule the lingular bronchus divided into two segmental bronchi. A single lingular artery was found in 80% of the cases and a single lingular vein in 58%. Atypical bronchial divisions were almost always associated with unusual types of vascularization. Patterns of bronchial division showed complete concordance with those of arterial vascularization of the lingula in 64% of the lungs and consistency with venous drainage patterns in 54%.
