The effectiveness of prophylactic desmopressin acetate in reducing hemorrhage after cardiopulmonary bypass operations is controversial. We conducted a prospective, randomized, placebo-controlled, double-blind trial to determine its effectiveness and safety in such patients. Eighty-three evaluable patients undergoing valvular heart operations were randomized to receive desmopressin (0.3 microgram/kg) (41) or placebo (42) after cardiac bypass. Demographic characteristics were similar in both groups. There was no significant difference in total 24-hour blood loss between groups (desmopressin 1064.8 +/- 647.1 ml versus placebo 844.4 +/- 507.6 ml; p greater than 0.05), or in the requirement for red blood cell, platelet, or fresh frozen plasma transfusion, or for reexploration for control of hemorrhage. Neither was there a difference in the occurrence of thrombotic complications between groups. Analysis of factor VIII activity, von Willebrand factor, or von Willebrand factor multimers failed to show significant correlations with blood loss or differences between groups except for factor VIII activity, which was significantly higher in the desmopressin group 1 hour after operation than in the placebo group. A detailed comparative analysis of similar trials to determine the reasons for different outcomes suggests that desmopressin should not be used routinely as a prophylactic agent to reduce postsurgical hemorrhage, but that it may be beneficial when used in patients who already manifest excessive bleeding postoperatively.

Between 1949 and 1976, 899 patients underwent treatment for achalasia of the esophagus at the Mayo Clinic, 431 by forceful hydrostatic or pneumatic dilation and 468 by a standardized transthoracic esophagomyotomy. Esophageal leak and mediastinal sepsis was an uncommon but major complication of both types of therapy, occurring four times more often with dilation (4%) than with myotomy (1%), although no deaths resulted from this in either group. The 30-day mortality was 0.2% after myotomy and 0.5% after forceful dilation. Although there was minimal morbidity and mortality with either modality, the late results were significantly superior after myotomy. Excellent to good results were obtained by 85% of the group treated with myotomy but only by 65% of those treated with hydrostatic dilation. Late poor results were encountered three times more frequently after dilation (19%) than after myotomy (6%). Analysis of poor results after myotomy indicates that late serious complications of gastroesophageal reflux developed in only 3% of patients operated on.

An intraluminal adenoid cystic carcinoma (cylindroma) in the patient reported herein involved just the membranous portion of the distal region of the trachea and extended caudally to include the carina and the membranous portions of both main-stem bronchi--a total linear involvement of 6 cm. The tumor occluded 90% of the airway in its greatest extension. Conservative resection of this extensive tumor was successfully performed by membranous tracheal reconstruction with a pedicled autogenous pericardial patch graft.

Colonoscopy was employed to attempt detorsion of volvulus of the right colon in four patients considered to be high-risk surgical patients. In one patient detorsion was accomplished, so that emergency laparotomy became unneccesary. The site of torsion was reached in every patient. When detorsion does not occur reasonably soon after the colonoscope enters the right colon, persistent efforts are more likely to be harmful than helpful. Abdominal symptoms in a patient who has been ill or injured for some time should suggest the possibility of volvulus of the right colon. Early diagnosis and earlier employment of colonoscopy would almost surely result in an increased rate of success in accomplishing detorsion. When detorsion is accomplished, subsequent resection of the right colon should be seriously considered as, without it, volvulus is said to recur frequently.

Mesothelioma, even of the pleura alone, is a ubiquitous pathological designation. The diffuse variety is associated with an ominous prognosis. The localized mesothelioma generally has been assumed to be benign. A review of tumors from 60 patients with localized pleural mesothelioma seems to justify separation into benign (52 patients) and malignant (eight patients) variants. Histologic criteria are used primarily to make this division. No single clinical feature allowed preoperative predictability concerning benignity or malignancy, although extrathoracic osteoarthropathy was seen only with benign lesions (20 percent), usually those greater than 7 cm. Follow-up periods of as long as 24 years revealed recurrent tumor in only two of the 58 patients with benign lesions and revealed a survival curve identical to that of the general population. All of the patients with the malignant variety had recurrence or metastasis, and all but one were dead within 2 years of the initial operation. One patient died of tumor complications after 9 years. More aggressive local resection is indicated for the malignant variant.

Sixteen patients, aged 10 to 70 years, had carcinoid tumors of the lower respiratory tract treated by various resective tracheobronchoplastic procedures. These represent 8.8 percent of 181 patients with carcinoid lesions treated during a recent 20 year period. All 16 patients had respiratory symptoms, and one patient also had the carcinoid syndrome. Roentgenographic changes ranged from a mass or atelectasis (or both) through unilateral lung hyperinflation to clear lungs with subtle filling defects in major airways. All tumors were visualized endoscopically, and 13 patients had biopsies. Histopathologically, all tumors were "typical" carcinoids . Before operation, the patients had minimal or no respiratory insufficiency, although flow-volume and ventilation-perfusion abnormalities were noted when major airways were affected. Surgical management at thoracotomy was as follows: (1) simple wedge tracheobronchotomy without lung resection (five patients); (2) bronchial sleeve resection without lung resection (three patients); and (3) bronchial sleeve with upper lobe resection (eight patients). These 16 operations were performed with eight technical anatomic variations. No early or late deaths occurred. One patient had early transient atelectasis, and three patients required late endoscopic removal of suture granulation tissue. All patients were alive without recurrence of tumor or carcinoid syndrome or other respiratory complications 6 months to 19 years postoperatively. Pulmonary resection should be avoided unless there is histologic evidence of tumor extension into lung parenchyma or irreversible pulmonary suppuration distal to the obstructive tumor.

Fifty-three patients were treated for pedunculated adenomatous polyps that contained foci of invasive cancer confined to the stroma. This entity is a stage of malignant involvement intermediate between in situ carcinoma and frank infiltrative cancer that invades the muscularis mucosae. Metastases to regional lymphatics were not observed. Local removal of such lesions without regional lymphadenectomy is adequate treatment.

In eight dogs, a separated, vagally innervated pouch was made from the gastric fundus. Electrodes were implanted on the pouch, and an antral gastric fistula was created through which gastric juice was drained externally during all tests. After recovery, the fasted, conscious dogs received intravenous infusions of 154 mM NaCl to which randomly selected doses of pentagastrin were intermittently added while intraluminal pressure and electric activity of the distended pouch were recorded. Transthoracic vagotomy was then performed, and the dogs were restudied. Before vagotomy, pentagastrin decreased the amplitude of the phasic changes in intraluminal pressure and of the bursts of spiking potentials of the pouch. The D50 for inhibition of mean intrapouch pressure was 4.2 ng/kg per min. After vagotomy, pentagastrin still decreased intrapouch pressure and inhibited fundal spikes, but larger doses were required to produce equivalent decreases in pressure. The D50 was 41.4 ng/kg per min after vagotomy. Our conclusion is that pentagastrin-induced relaxation of the canine gastric fundus is impaired, but not abolished, by vagotomy.

Resection of typical bronchial carcinoid was carried out in 203 patients. The average age was 48 years, and the sex distribution was approximately equal. Bronchoscopy was the most definitive diagnostic procedure, even though 15% of the tumors were located in the segmental bronchus or beyond. Conservative resection including local removal of the lesion was the treatment of choice, but distal suppuration and location of the tumor necessitated pneumonectomy in 54 (27%) of the patients. The incidence of metastasis was 5% (11 patients), and the overall hospital mortality was 3%. Of patients who qualified for follow-up, 94% survived 5 years, and of those who were asymptomatic preoperatively, 98% survived 5 years. The 10- and 25-year survival rates for the group as a whole were 87 and 66%, respectively.

The deep femoral artery is often peculiarly resistant to atherosclerosis when the common and superficial femoral arteries are severly affected. At the Mayo Clinic between 1964 and 1972, 43 patients had aorta-deep femoral artery bypass as the definitive revascularization procedure for arteriel insufficiency of the lower extremities. Of the patients with grade 1 ischemia, 82% became asymptomatic as did 44% of those with grade 2 ischemia and 43% of those with ulceration and incipient gangrene. After 2 years, 25 of 40 (62%) previously symptomatic lower extremities had remained asymptomatic (in 31 patients available for follow-up evaluation). The rates were 68% and 55% after 3 and 4 years, respectively.