Pill induced esophageal ulceration and stricture following cardiac surgery.
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Ascorbic Acid↗
Biomedical subjects
G M Graeber
Publications and source records attributed to G M Graeber.
Changes in serum creatine kinase and lactate dehydrogenase caused by acute perioperative myocardial infarction and by transatrial cardiac surgical procedures.
A prospective clinical study was conducted to ascertain if a patient's postoperative elevation in serum creatine kinase MB isoenzyme coupled with determination of the lactate dehydrogenase1/lactate dehydrogenase2 ratio could differentiate whether atrial or ventricular myocardium was the source of these changes. Animal studies have shown that atrial myocardium is as rich a source of creatine kinase MB as is ventricular myocardium. Atrial myocardium has a lactate dehydrogenase1/lactate dehydrogenase2 ratio less than 1.00, whereas in ventricular myocardium the ratio is greater than 1.00. Sixty-four patients were assigned to six groups on the basis of serial electrocardiograms and vectorcardiograms by a cardiologist who was unaware of their clinical courses. The control group (Group 1) consisted of 16 patients admitted to the coronary care unit who had no electrocardiographic changes. Three surgical groups without electrocardiographic or vectorcardiographic evidence of perioperative myocardial infarction were studied: 10 patients undergoing routine coronary artery bypass procedures (Group 2), six adults undergoing repair of secundum atrial septal defect (Group 3), and 13 patients having mitral valve replacement (Group 4). Two groups of surgical patients who had acute perioperative transmural myocardial infarctions confirmed by serial electrocardiograms and vectorcardiograms were studied: 15 patients (Group 5) who had elective coronary artery bypass procedures and four (Group 6) who had mitral valve replacement. This study suggests that serum creatine kinase MB levels in excess of 50 IU/L on the postoperative day 1 and day 2 samples coupled with serum lactate dehydrogenase1/lactate dehydrogenase2 ratios greater than 1.00 on the postoperative day 2 and day 3 samples support the diagnosis of acute myocardial infarction. Patient groups undergoing procedures necessitating atriotomies had average elevations in serum creatine kinase MB and in the lactate dehydrogenase1/lactate dehydrogenase2 ratio, but these were significantly less than those seen when acute perioperative myocardial infarction had occurred.
Adult↗
The use of computed tomography in the evaluation of mediastinal masses.
A retrospective analysis was conducted to ascertain whether computed tomography had increased diagnostic accuracy while decreasing the number of tests needed in the preoperative assessment of patients with mediastinal masses. A total of 42 patients were entered into the study: Fifteen patients were evaluated before the advent of computed tomography (No CT) and 27 patients had computed tomography during their evaluation (CT). The No CT group comprised 10 male and five female patients (2:1 ratio); the age range was 8 months to 61 years. The CT group included 15 male and 12 female patients (1.25:1.0 ratio), the age range being 21 to 70 years. In each group, both invasive and noninvasive studies were done. Although the CT group had 40 noninvasive tests, 27 were computed tomographic scans. The additional 13 noninvasive tests and the five invasive tests added no significant diagnostic information. In the No CT group, preoperative evaluation as to the cystic or solid nature of the mass was correct only four of 13 times (31%). In the CT group, 22 of 25 patients had accurate assessment as to the cystic or solid nature of the lesions (88%). In addition, extension of the mass into other structures, consistent with malignancy, was correctly diagnosed preoperatively in nine of the patients in the CT group. Two had extension of the mass at operation not preoperatively diagnosed (82% accuracy). None of the No CT group was given an assessment of possible mass extension preoperatively. The results suggest that mediastinal masses can be evaluated by computed tomography with a high degree of accuracy for predicting the nature, size, location, and involvement of other organs by the mass. The use of other tests before resection generally yields little additional information.
Adolescent↗
Creatine kinase (CK): its use in the evaluation of perioperative myocardial infarction.
Establishing the diagnosis of acute perioperative myocardial infarction by the mere presence of a serum CK-MB band alone is not valid. Laboratory investigations have shown that tissues other than ventricular myocardium hold appreciable quantities of CK-MB. Moreover, each of the laboratory methods commonly used for measuring serum total CK and its isoenzymes have inherent strengths and weaknesses. Hence, accurate evaluation of perioperative CK-MB bands requires determination of the amplitude and the temporal course of the elevation. Confirmation of the CK-MB findings by analysis of another enzyme system is advisable. Serum lactate dehydrogenase isoenzymes can fulfill this role. Institution of a dual enzyme evaluation is achieved easily in most hospitals and can yield a very high degree of sensitivity and specificity. The final step in diagnostic accuracy is completed by continuing evaluation of the enzyme diagnostic system in each individual institution.
Cardiac Surgical Procedures↗
Rib fracture healing in experimental flail chest.
Sixteen dogs were placed under general anesthesia and flail segments of the left chest were created by transecting ribs 7,8,9, and 10 anteriorly and posteriorly. Fractures were 10 cm apart so that a 10-cm flail segment encompassing four ribs was created. In Group I, the control (N = 5), the chest wall muscles were closed without any stabilization of the fractures. Group II (N = 5) had stabilization of both anterior and posterior fracture sites by polypropylene sutures. Group III (N = 6) had stabilization of the fractures in ribs 7 and 8 with 2.5-cm bone grafts taken from the left fourth rib. Ribs 9 and 10 were stabilized by polypropylene sutures. The study established a canine model for flail chest. It also showed that strut stabilization of rib fractures with bone grafts promotes better healing than suture stabilization. It suggests that using bone grafts taken from another rib to stabilize flail segments may be unsatisfactory since the rib used as a donor showed no signs of regeneration at 30 days.
Animals↗
Desmoid tumor of the paraspinous muscle involving the chest wall.
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Adult↗
Creatine kinase and lactate dehydrogenase in the muscles encountered during median sternotomy and in the myocardium of the cardiac chambers.
The validity of using creatine kinase MB and lactate dehydrogenase serum isoenzymes to confirm the diagnosis of perioperative myocardial infarction in patients who have had cardiac operations has been questioned, since both have been detected in skeletal muscles. Little is known concerning the concentration of either isoenzyme in the muscles routinely encountered during median sternotomy. Since we have previously shown that the dog is an adequate model in which to study creatine kinase and lactate dehydrogenase isoenzymes, eight healthy dogs were placed under general anesthesia and 1 gm blocks were resected from selected muscles (intercostals, rectus abdominis, diaphragm, and sternothyroid) and from the walls of all four cardiac chambers. Each 1 gm block was homogenized individually in Ringer's lactate, centrifuged, and the supernatants were analyzed for total creatine kinase and lactate dehydrogenase activity by spectrophotometry. Isoenzymes were determined by agarose gel electrophoresis. The study shows that the chest wall muscles and atrial myocardium have appreciable quantities of creatine kinase MB. Hence, serum creatine kinase MB bands in the perioperative period can be generated by manipulation of chest wall muscles and the atrial wall as well as by infarction of the ventricular myocardium.
Animals↗
Radiation associated malignancies of the esophagus.
This report documents the experience of the authors with two patients who had received thoracic radiation for disseminated teratocarcinomas of the testis, survived their malignancies, and subsequently developed squamous cell carcinomas of the esophagus. To the authors' knowledge, only 11 other cases of esophageal malignancies arising in patients who had received previous mediastinal irradiation have been reported in the world literature. With increasingly successful mediastinal radiation for malignant disease resulting in prolonged patient survival, an increasing number of such patients with subsequent esophageal malignancies can be anticipated. Close follow-up of patients receiving radiation therapy to periesophageal tissues is recommended, and prompt evaluation of any symptoms of esophageal dysfunction is indicated.
Adult↗
Results of myocardial revascularization in black males.
The impact of black-white differences in the prevalence of risk factors for coronary heart disease on the outcome of coronary bypass surgery has not been well defined. Preoperative status, coronary anatomy, and surgical results were reviewed in 54 black males operated on between December 1970 and August 1983. With the use of criteria established by the New York Heart Association, five patients were classified in class II, 34 were in class III, and 15 were in class IV. Five patients had unstable angina. The most common risk factor, cigarette smoking, occurred in 43 patients (80%). Thirty patients (56%) had hypertension, 10 (19%) were diabetic, 14 (26%) were obese, and 23 (43%) had a family history of coronary disease. Elevated cholesterol and triglyceride levels were present in 8 and 12 patients, respectively. An average of 2.9 grafts per patient was placed. Overall operative mortality was 5.6%. Prior to the use of cardioplegia in 1978, there were two deaths among 14 patients (mortality, 14%). Since 1978 there has been one death among 40 patients (mortality, 2.5%). Although immediate operative mortality appears not to be affected by black-white status, long-term prognosis may be influenced significantly by the high prevalence of hypertension and diabetes and the lower prevalence of hyperlipidemia among black patients.
Adult↗
Serum creatine kinase and alkaline phosphatase in experimental small bowel infarction.
Serum creatine phosphokinase (CK) and alkaline phosphatase (ALP) rise after mesenteric infarction; it is not known which one rises earlier or which one has the greater elevation. This experiment compared and contrasted the elevations in both these enzyme systems after acute small bowel infarction. Isoenzymes of both systems were analyzed to determine if any qualitative changes occurred. After baseline blood samples had been drawn, 10 dogs had midline laparotomies under general anesthesia. Each was assigned to one of two groups according to a randomized block design. Controls (CON) were closed after exploration (N = 5). The infarction (INF) group had ligation and division of the arteries to the jejunum and ileum (N = 5). Blood samples were obtained from both groups at 3, 6, 9, 12, 24, and 27 hr after surgery. Sera were analyzed for total CK and ALP activity by automated spectrophotometry. Isoenzymes were determined by agarose gel electrophoresis. Serum CK rose faster and to a higher level than ALP after small bowel infarction (470 +/- 181 vs 196 + 28 IU/liter). CK-BB was a better marker of small bowel necrosis than was intestinal ALP. The elevation of both CK and ALP by 12 hr after infarction may be a diagnostic aid if similar changes occur in humans.
Alkaline Phosphatase↗
An analysis of creatine phosphokinase in the mucosa and the muscularis of the gastrointestinal tract.
Previous work has shown that mesenteric infarction causes elevation of total serum creatine phosphokinase (CPK) and each of its three isoenzymes. The exact origin of the CPK has not been determined. Little is known about the actual tissue distribution of CPK in bowel. Experiments were performed to confirm the expectation that CPK was present in the bowel wall and to determine its concentration and the distribution of CPK isoenzymes in the muscularis and mucosa, respectively. Multiple segments were resected from the esophagus, stomach, duodenum, jejunum, ileum, and the proximal and distal colon of normal dogs. The mucosa (MUC) was separated from the seromuscular (MSL) tissue in each of the segments and 1-g samples were analyzed individually for total CPK activity by spectrophotometric analysis and for isoenzyme distribution by agarose gel electrophoresis. The results show that all three isoenzymes of CPK are present throughout the GI tract and that the majority of CPK found is in the MSL. Hence, elevations in serum CPK associated with injuries to the GI tract suggest seromuscular injury. While no isoenzyme is located specifically in the bowel, certain associations were seen. CPK-MM, presumably from striated muscles, was most prevalent in the esophagus. In other portions of the bowel all three isoenzymes were present almost equally. In the mucosa the levels of CPK-MM and CPK-BB always exceeded the level of CPK-MB. Knowledge of the distribution of CPK and its isoenzymes in bowel provides a framework for studying and interpreting serum levels of CPK during bowel injury.
Animals↗
Disruption of left brachiocephalic vein.
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Brachiocephalic Veins↗
An alternate method of ventricular venting--the pulmonary artery sump.
The need for venting the heart during cardiopulmonary bypass has been the topic of continued debate. Potential disadvantages and drawbacks have been noted with traditional modes for venting. A technique for venting the heart is presented using a pulmonary artery catheter. The relative advantages and merits of this approach are discussed.
Cardiac Catheterization↗
Differentiation of vascular prostheses in dogs with serial tests of in vivo platelet reactivity.
Three different vascular prostheses (standard weight knitted Dacron, double velour knitted Dacron, and expanded polytetrafluoroethylene) were implanted in the aortas of dogs, and serial determinations of platelet survival and platelet serotonin were monitored at 12-week intervals for 1 year. Prostheses were then removed and luminal coverage with endothelialized neointima and production of prostacyclin were measured. Changes in platelet survival were correlated with changes in platelet serotonin, and both measurements reflected in vivo platelet reactivity with the vascular prostheses. These changes were unique for each type of prosthesis and were dependent upon physical characteristics and the rate and degree of coverage of the prosthetic surface with endothelialized neointima that produced prostacyclin. Prostheses that reduced platelet survival and platelet serotonin the least as shown by serial evaluation were found at harvest to be the most completely paved with nonthrombogenic neointima. In dogs, these techniques allow differentiation of vascular prostheses and provide a useful animal model for their evaluation.
6-Ketoprostaglandin F1 alpha↗
Cystic lesion of the thymus. An occasionally malignant cervical and/or anterior mediastinal mass.
Between 1965 and 1982, we treated 46 patients with cystic lesions of the thymus. Thirty patients had anterior mediastinal cysts, nine had cysts which were large enough to be both cervical and mediastinal, and seven had cervical cysts. The majority (40/46) presented with asymptomatic masses. Six patients presented with distinct complaints: dysphagia (four patients), hoarseness owing to vocal cord paralysis (one patient), and cervical pain (one patient). All six had benign thymic cysts. The diagnosis of a cystic mass was established prior to operation by ultrasonography and computed axial tomography in our last three patients. These two techniques delineated the capsule and the central fluid in those three cases. All 46 patients had the mass resected without mortality or significant morbidity, except for resection of the phrenic nerve in one patient with malignant cystic thymoma. Cervical cysts were excised through cervical incisions. Cysts located in the anterior mediastinum and cervical-mediastinal cysts required median sternotomy or right thoracotomy for successful resection. Pathological examination showed that 39 patients had benign thymic cysts, three had benign cystic thymoma, two had malignant thymoma, one had a seminoma arising in the thymus, and one had a lymphoblastoma. We believe that a cystic thymic mass which can be detected by ultrasonography and computed tomography, although usually benign, does not eliminate the possibility of malignancy, and resection, therefore, is indicated.
Adolescent↗
Management of patients with malignant thymoma.
This report documents the results of therapy in 23 patients treated for malignant thymoma between 1944 and 1979. Of the group, 22 patients had neoplasms which invaded mediastinal structures; six had distant metastases. Four patients had myasthenia gravis and one had erythroid hypoplasia associated with collagen vascular disease. No deaths were associated with primary therapy, which included an operative procedure in all cases. Follow-up ranged from 4 months to 18 years (mean 5.63 +/- 1.03 years, SEM). Fifteen patients died, with postoperative survival times ranging from 4 months to 18 years (mean 3.8 +/- 1.27 years). Five patients were alive without recurrence from 3 to 11 years postoperatively (mean 6.8 +/- 1.36 years), and three patients were alive with recurrence or distant metastases from 4 to 17 years postoperatively (mean 10.75 +/- 2.66 years). Differences in survival on the basis of tumor cell type were not statistically significant. Therapeutic groups were analyzed for 5 year survivors, tumor deaths within 5 years of therapy, deaths due to other causes, deaths due to tumor after 5 years, those presently alive, and longest known survivor. The data suggest that complete surgical excision offers the best chance of long-term survival when compared to partial resection plus irradiation (p less than 0.05). No statistical significance could be demonstrated between the groups who had complete resection with versus without postoperative irradiation. There also was no statistically significant difference between the group of patients receiving irradiation following partial excision of most of their tumor and the group receiving irradiation following only biopsy of the lesion. This observation suggests there is no value in so-called "debulking procedures" and suggests that irradiation may be of value in local control of thymoma. Perpetual surveillance is necessary since late recurrence is common.
Adolescent↗
Elevated levels of peripheral serum creatine phosphokinase with strangulated small bowel obstruction.
Experimental arterial bowel infarction can cause elevations in levels of peripheral serum creatine phosphokinase (CPK), lactic dehydrogenase (LDH), and their isoenzymes. To test whether these changes would occur in strangulated small bowel infarctions, 18 dogs were placed under general anesthesia and randomized to one of three categories: laparotomy alone, simple mechanical small bowel obstruction, or strangulated small bowel infarction induced by incarcerating bowel in a surgically created ventral hernia. Serum samples were drawn for 48 hours postoperatively. Total CPK and LDH activity were determined by automated spectrophotometry; isoenzyme levels were determined by agarose gel electrophoresis. Levels of peripheral serum CPK and each of its isoenzymes became significantly elevated in the dogs with strangulated infarction. Such elevations did not occur with LDH. The findings suggest that changes in peripheral serum CPK could prove helpful in evaluating bowel viability in cases of intestinal obstruction.
Animals↗
Rupture of the left main-stem bronchus with a polyvinylchloride double-lumen tube.
Double-lumen tubes have proved to be a useful adjunct in thoracic surgery. Their use has become quite commonplace, particularly since the introduction of the softer polyvinylchloride (PVC) tubes, which are technically easier to use and may carry less risk for serious complications. Any such tube, however, can cause life-threatening complications. We present a case with such a complication related to the use of a PVC double-lumen tube and make recommendations regarding the use of these tubes to minimize the risk of serious intraoperative complications.
Aged↗