Bullet wounds of the trachea.
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Adolescent↗
Biomedical subjects
C R Hatcher
Publications and source records attributed to C R Hatcher.
Cardioplegic infusion: the safe limits of pressure and temperature.
In patients with coronary artery disease, infusion of very cold cardioplegic solutions at elevated pressures may facilitate homogeneous cooling and cardioplegia. This study was designed to determine if very high infusion pressures or very low temperatures of the cardioplegic solution damages normal myocardium. In a hemodynamically controlled canine right heart bypass preparation, a crystalloid solution (Plasma-Lyte 148 with 30 mEq/L potassium chloride, 0 degree to 2 degrees C) was infused with separate control of the infusion pressures in the left anterior descending and circumflex arteries. A sonomicrometer measured regional myocardial function in each area. During a 100 minute arrest period, cardioplegic solution was reinfused every 20 minutes and reduced myocardial temperatures to an average of 9.4 degrees +/- 2.2 degrees C. In a comparison of infusion pressures of 50 versus 100 mm Hg and 100 versus 150 mm Hg, postarrest regional myocardial function was unchanged from prearrest. However, in a comparison of infusion pressures of 150 to 200 mm Hg, a significant fall in regional myocardial function was noted with the higher pressures (106% and 64% recovery, respectively, p less than 0.02, n = 6). Excluding the areas perfused at 200 mm Hg, comparison of regions cooled to less than 8 degrees C and to greater than 8 degrees C demonstrated no difference in recovery of regional myocardial function. In this study, elevation of cardioplegic infusion pressures to 150 mm Hg and lowering of myocardial temperatures to less than 8 degrees C caused no impairment of regional myocardial function.
Animals↗
Efficacy of coronary artery bypass grafting in elderly patients with coronary artery disease.
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Adult↗
Complications of intrathoracic Nissen fundoplication.
This report details our experience with 30 patients who had Nissen fundoplication. Six underwent transabdominal Nissen fundoplication, and 10 had transthoracic Collis-Nissen with the gastric wrap in a subdiaphragmatic position. Ten patients had a transthoracic Nissen with the wrap in a supradiaphragmatic position. Four patients had a transthoracic Thal-Nissen procedure. In 1 of 4 patients with a Thal-Nissen procedure, intrathoracic rupture of the stomach with gastro-bronchial fistula developed and necessitated left lower lobectomy. Four of 10 patient in whom the gastric wrap was left in the chest experienced severe complications: in 1 patient a lesser curvature ulcer developed and required hemigastrectomy; 1 patient had herniation of the fundoplication with gastric outlet obstruction and required operation for its correction; 2 patients had intrathoracic rupture of the gastric wrap and ultimately died. The 6 patients with transabdominal Nissen and the 10 with transthoracic Collis-Nissen with wrap placed in the abdomen did well This experience severely condemns the practice of leaving the fundoplication above the diaphragm.
Aged↗
Coronary bypass for relief of persistent pain following acute myocardial infarction.
Between January, 1976, and April, 1980, 116 patients had urgent myocardial revascularization for clinical instability within 30 days of acute myocardial infarction (MI). Group 1 (8 patients) had coronary bypass grafting within 24 hours of acute MI; Group 2 (20 patients) had coronary bypass grafting 2 to 7 days after acute MI; and Group 3 (88 patients) had coronary bypass grafting 8 to 30 days after infarction. Indications for operation were persistent or recurrent pain (81%), pain plus ventricular arrhythmias (12%), and pain plus compelling anatomy. The incidence of single-vessel, triple-vessel, and left main coronary artery disease was 28%, 31%, and 12%, respectively. There were no hospital deaths in the series. The incidence of inotropic requirements, postoperative intraaortic balloon pumping, ventricular arrhythmias, and perioperative infarction was higher in patients operated on within 7 days of acute MI than for patients having coronary bypass grafting after this time. There have been 5 late deaths during a mean follow-up of 14 months. Actuarial survival was 97% at 18 months. Seventy-one percent of patients are presently pain free. Graft patency was 84% in 17 patients recatheterized after coronary bypass grafting and in 14 patients, grafts placed into the area of infarction were patent. This study suggests that the frequency of perioperative complications will be increased in patients operated on within one week of MI, but after this period, coronary bypass grafting can be accomplished with the same morbidity as the of elective operation.
Angina Pectoris↗
Colon interposition for advanced nonmalignant esophageal stricture: experience with 40 patients.
This report details our experience in 40 patients with benign strictures of the esophagus who underwent colon (or gastric) interposition with our without esophageal resection between 1972 and 1980. There were 23 men and 17 women ranging from 5 to 76 years old. Twenty-seven patients had fibrotic strictures secondary to reflux esophagitis including 12 after failure of antireflux procedures; 4 had caustic strictures; 3 had a Barrett's esophagus; 2 had systemic candidiasis; 2 had scleroderma; and in 2 the etiology was undetermined. the right colon was used in 27 patients, the left colon in 4, the transverse colon in 1, and the jejunum in 1. In 7 patients the stomach was employed because of vascular insufficiency of the colon. Three surgical approaches were utilized. Manometric studies were done post-operatively in 10 patients. Complications occurred in 7 patients: cervical leaks, 4; reflux colitis, 2; and a late cervical stricture, 1. There were 4 deaths, only 1 of which was related directly to technique. This report summarizes the beneficial effect of right colon interposition for long esophageal strictures. Its vasculature is adequate, and it functions properly to propel food into the stomach irrespective of the peristaltic orientation.
Adolescent↗
Influence of left ventricular aneurysm on survival following the coronary bypass operation.
Patients having coronary bypass and aneurysm resection (N = 40) or aneurysm plication (N = 32) were compared with patients having coronary bypass without aneurysm (N = 2782). Unlike other series, the primary indication for surgery in the aneurysm patients was angina pectoris, with heart failure playing a secondary role. Multivessel disease was present in 83% of the patients with aneurysm. Total occlusion of the anterior descending coronary artery was more prevalent in the group of patients who had aneurysmectomy (75%) than in rhe group of patients who had plication (38%), and more grafts/patient could be performed in the plication group (2.6 vs 2.0). Location of the aneurysm was most often anteroapical (N = 55) and infrequently inferior (N = 6). Septal wall motion was akinetic or aneurysmal in 47% of the aneurysmectomy group, and 10% of the plication group. Postoperative requirements for inotropes or intra-aortic balloon assist was much higher in the aneurysm group (aneurysmectomy or plication) than in patients without aneurysm having bypass. Hospital mortality for aneurysm patients was 2.7% versus 1.4% in patients without aneurysms having coronary bypass. The actuarial survival rate at 42 months for all aneurysm patients was 90%. Improvement in anginal symptoms after plication and coronary bypass (96%) was more frequent than with aneurysmectomy and coronary bypass (76%) and this was attributed to larger viable muscle mass and greater revascularization. Although two-thirds of patients having surgery for aneurysms had improvement in heart failure symptoms after operation, 30% of those having aneurysmectomies and 35% of those having plications said they were unimproved after surgery. However, this could be explained by the finding that a significant number (35% of the aneurysmectomy and 45% of the plication group) were in heart failure Class I prior to operation. Hospital mortality has been progressively reduced and late survival increased by the surgical treatment of left ventricular aneurysm, primarily through early operation at a time when coronary bypass can be used as an adjunct to aneurysm resection or plication.
Aged↗
Reduced efficacy of coronary bypass surgery in women.
To estimate long-term efficacy of coronary bypass surgery, we examined our experience with 3155 patients observed over a 78-month period. Preoperative clinical profile, operative risk, and long-term symptomatic status and survival were compared in 2663 men and 492 women. To minimize influence of unequal baseline characteristics, surgical results were also compared in 412 pairs of men and women matched by computer for age, preoperative angina classification and number of diseased vessels. Operative mortality was not significantly different in matched patients. Women had smaller distal coronary arteries, more diabetes and hypertension, a higher rate of incomplete revascularization, and reduced graft patency compared with men. Cumulative survival for men and women was 92% at 42 months. At late follow-up, significantly more men were asymptomatic (70% vs 52%, p less than 0.001) and men achieved higher activity levels. We conclude that men have more symptomatic relief after coronary bypass surgery than women. A better-quality revascularization in men may be part of the reason for this outcome.
Coronary Artery Bypass↗
Surgical management of complications of acute myocardial infarction.
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Coronary Artery Bypass↗
Pulmonary function test criteria for operability and pulmonary resection.
Pulmonary function criteria for pulmonary resection, other than pneumonectomy, have not been previously described. A series of 500 consecutive pulmonary resections to which specific pulmonary function criteria were applied in determining the amount and the extent of feasible resection of the lung are presented. By application of these criteria, an accurate assessment of the type and extent of pulmonary resection a patient can tolerate without expected mortality can be made. With utilization of these criteria, the operative mortality for segmental resection was 0.2 per cent; for lobectomy, zero per cent, and for pneumonectomy, 4.4 per cent.
Adolescent↗
Transverse midventricular disruption after mitral valve replacement.
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Aged↗
Esophageal gunshot injuries.
During a 15-year period from August 1964 to August 1979, 48 patients with gunshot wound of the esophagus (24 of the cervical, 17 of the thoracic, and seven of the abdominal) were treated at Grady Memorial Hospital. In the majority of the patients, the initial history, physical findings, and chest roentgenograms were nondiagnostic for esophageal injury. Esophageal perforation was mainly suspected because the bullet tract was in close proximity to the esophagus or the bullet had traversed the mediastinum. The diagnosis of esophageal perforation was made by esophagography (29 patients), at the time of emergency surgical exploration for suspected other organ injuries (17 patients), or by esophagoscopy (one patient). All but one patient were treated surgically. The surgical procedure most commonly used was primary repair of the esophageal wound with wide drainage of the mediastinum. Thirty-eight (79.2%) of the 48 patients survived, 21 (87.5%) of the 24 patients with cervical, 11 (64.7%) of the 17 patients with thoracic, and six (85.7%) of the seven patients with abdominal esophageal wounds. Ten patients died, three with cervical wound, six with thoracic wound, and one with abdominal esophageal wound. Three patients died intraoperatively from major bleeding and the remaining seven died from the esophageal and/or other associated injuries, four to eight days after surgery. None of the seven patients who underwent primary repair with wide drainage and plication of the suture line with pleural flap or other tissue, died or developed leak at the suture line. This study suggests that the physical and roentgenographic findings in patients with esophageal injury are often nondiagnostic and frequently are masked by coincidental injury to other organs. Hence, a high index of suspicion is required for the diagnosis of esophageal injury from gunshot wounds and esophagography should be performed as soon as the patient's condition is stable in all patients who present with a missile wound in close proximity to the esophagus or traversing the mediastinum. All patients with perforation of the esophagus from bullet wounds should be operated upon as soon as possible after the diagnosis is made. Wide drainage of the mediastinum and primary repair of the esophageal wound and plication of the suture line with parietal pleura or gastric fundus provide the best possible results.
Abdominal Injuries↗
Clinical, anatomic and functional descriptors influencing morbidity, survival and adequacy of revascularization following coronary bypass.
Clinical data on 3,479 consecutive patients having coronary bypass surgery were retrospectively analyzed. Perioperative complications, incomplete revascularization, and reduced long-term survival could frequently be correlated with manifestations of myocardial damage. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% vs. 3.8% and 4.2%). Inotropic requirements in the perioperative period were significantly increased for patients with preoperative left ventricular dysfunction; a history of heart failure or multiple infarctions did not significantly increase the incidence of inotropic requirements. Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3,040). Hospital mortality was significantly increased by history of myocardial infarction, hypertension, heart failure, extent of anatomic disease, presence of preoperative ST-T wave changes, and severe abnormalities of left ventricular function. Hospital mortality in patients with ejection fraction </=0.35 was 3.4% vs. 1.3% for those >0.35. Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure all significantly affected long-term survival. Occurrence of perioperative myocardial infarction did not adversely influence long-term survival. Patients with normal left ventricular function had excellent 42 month survival regardless of vessel disease (95%, 96%, and 94% for single, double, and triple vessel disease, respectively). Survival was significantly less for such patients with abnormal left ventricular function. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. The important effect which complete revascularization had on long-term survival appeared to increase with increasing severity of coronary disease. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced once manifestations of left ventricular damage have occurred.
Adult↗
The spectrum of left main coronary artery disease: variables affecting patient selection, management, and death.
A total of 178 patients having a diagnosis of left main coronary artery stenosis were divided into three groups as follows: surgical, Group I (n = 135 patients); operable medically treated, Group II (n = 21 patients); and inoperable, Group III (n = 22 patients). Groups 1 and 2 were comparable with regard to clinical profile, extent of anatomic coronary disease, and left ventricular function. Inoperable patients had a much higher incidence of prior myocardial infarction (especially anterior), more severe distal coronary disease, and markedly depressed left ventricular function. The hospital mortality rate for surgical patients was 4% (6/135). The late mortality rate, (median follow-up = 23.4 months) was 7% (9/135). For operable patients, the late mortality rate was 43% (9/21) at 28 months. In the inoperable group, the late death rate at 20 months was 59% (13/22). Actuarial survival at 24 months for the three groups was: 88%, 66%, and 42%, respectively. Of the nine patients who died in the operable group, two had less than 75% obstruction of the left main coronary artery and two had normal left ventricular wall motion. Although patients with higher grades of left main coronary artery stenosis and reduced left ventricular function are at greater risk, patients with less obstruction and good left ventricular function are also at risk and should have myocardial revascularization with some sense of urgency. The population of left main coronary artery stenosis is a heterogeneous one, and comparison of surgical versus medical therapy should exclude inoperable patients. The operative mortality rate has been greatly reduced in recent years (2% in the last 100 cases); this is attributed to careful monitoring in the critical prebypass period, aggressive pharmacologic treatment of increased preload, tachycardia, and hypertension, and improved aurgical technique, with emphasis on careful myocardial preservation. Adherence to these principles makes frequent use of the intra-aortic balloon either before or after revascularization unnecessary.
Cardiac Catheterization↗
Carcinoma of the lung: five-year experience in a university hospital.
A review of 161 patients who underwent a curative surgical resection for carcinoma of the lung in a University Hospital during a five-year period is presented. Particular reference is made to importance of preoperative staging of lesions; the group of patients with Pancoast's tumor; the group of patients 70 years or older, and the group of patients with impaired pulmonary function.
Adult↗
Carcinoma of the superior pulmonary sulcus.
From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.
Adenocarcinoma↗
Esophageal carcinoma: an aggressive approach.
During a 3-year period, 45 patients with esophageal carcinoma (18 of the lower and 27 of the middle third) underwent esophagectomy and esophagogastrostomy. All patients were considered to be in Stage I and Stage II preoperatively, but at the time of operation, 66% were found to have Stage III disease. All patients underwent mobilization of the stomach through a laparotomy, and resection of the esophagus and reconstruction of the continuity of the gastrointestinal tract through a separate right lateral thoracotomy incision. Following operation, 22 patients (10, Stage I and II and 12, Stage III) received no radiotherapy and 23 patients (5, Stage I and II and 18, Stage III) received radiotherapy. Two patients died in the immediate postoperative period, for a surgical mortality of 4.8%. Because of the acceptable survival and enhancement of quality of life, esophagectomy and esophagogastrostomy should be offered not only to Stage I and II patients with esophageal carcinoma but also to selected patients with Stage III disease and those with lower and middle third esophageal lesions.
Adult↗
What role should the intra-aortic balloon have in cardiac surgery.
Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.
Adult↗