Biomedical subjects
Publications and source records attributed to R F Heitmiller.
After esophagectomy in which a surgical jejunostomy is performed, there is a small group of patients whose jejunostomy tube has been removed who require late postoperative nutritional support. For these patients, a percutaneous replacement jejunostomy technique is described that is simple and safe and that allows for enteral alimentation.
Massive arterial bronchogenic tumor embolus is rare, and most commonly occurs intraoperatively during pulmonary resection. Arterial obstruction from the tumor embolus carries substantial morbidity and mortality. For those patients who survive embolectomy, prognosis is most closely correlated with the TNM staging of the primary lung tumor ignoring the tumor embolus.
We describe our results with cervical esophagoesophageal anastomosis. This approach has been used with success in 4 patients. It has the advantage of avoiding esophagectomy in patients with benign disease and allows restoration of esophageal continuity in patients having limited options for esophageal replacement.
The left thoracoabdominal incision is approaching its first century of use. Although less popular than the Ivor Lewis and transhiatal techniques, it continues to be a useful approach for esophageal or gastric tumors near the gastroesophageal junction. For these tumors, the incision provides excellent exposure, and maximizes reconstructive options during esophagogastrectomy. The incision has a proven track record of safety and is well-tolerated.
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Fifteen consecutive patients undergoing transhiatal esophagectomy for esophageal carcinoma were studied cineradiographically to evaluate postoperative pharyngeal function. Cinepharyngo-esophagograms were obtained preoperatively and 1 week (range: 6 to 10 days) and 1 month (range: 18 to 52 days) postoperatively. One week after transhiatal esophagectomy, new radiographic swallowing abnormalities were identified in 10 patients (67%). The most common abnormalities observed were laryngeal penetration or aspiration (seven patients, 47%) and incomplete laryngeal elevation (five patients, 33%). Abnormal epiglottic tilt was seen in only two patients (13%). No postoperative pharyngeal retention and no cricopharyngeal obstruction to swallowed contrast was observed. One month after transhiatal esophagectomy, all radiographic swallowing abnormalities had resolved or improved. Laryngeal penetration or aspiration is common after transhiatal esophagectomy and is a consequence of diminished airway protection with incomplete laryngeal elevation rather than a result of esophageal obstruction with "spill-over" aspiration. These changes resolve or improve within the first postoperative month.
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Duodenobronchial fistulas are an extremely rare subgroup of abdominobronchial fistulas, which include bronchobiliary, gastrobronchial, enterobronchial, colobronchial, and splenobronchial fistulas. Only one case of a duodenobronchial fistula has been previously reported. Duodenobronchial fistulas occur as a complication of a duodenal injury. The characteristic symptoms are a cough that produces copious bilious secretions, shortness of breath, and fever. The diagnosis is made by contrast gastrointestinal studies. Treatment requires an abdominal approach with interruption of the fistula at its duodenal origin and control of the inciting inflammatory process. With prompt diagnosis and treatment, thoracic drainage or pulmonary resection should not be needed.
Congenital H-type tracheoesophageal fistulas (TEF) are rare. Long-standing respiratory symptoms are the most common presenting complaints. Patients with these fistulas have a congenital esophageal motor abnormality characterized by uncoordinated, low-amplitude peristalsis of the esophageal body; both low and normal lower esophageal sphincter pressures have been described. These findings persist despite fistula repair. A case history of an adult patient with congenital TEF is presented and the literature is reviewed. This patient is unusual in that esophageal symptoms (dysphagia) were more prominent than the usual respiratory symptoms.
A patient with a benign encapsulated intrathoracic vagal schwannoma is presented and the literature is reviewed. The right paratracheal tumor was identified incidentally on a chest film and excised using a right thoracotomy. Although rare, vagal schwannomas should be considered for any mediastinal mass along the vagus nerves especially when the paratracheal tumor produces minimal or no respiratory symptoms suggesting a slow-growing, encapsulated process.
Mucoepidermoid lung tumors are uncommon, representing 0.2% of all lung tumors and 1% to 5% of bronchial adenomas. Eighteen patients with mucoepidermoid tumors are reported. There were 10 male and 8 female patients with a mean age of 36.8 years (range, 9 to 62 years). On the basis of mitotic activity, cellular necrosis, and nuclear pleomorphism, we subclassified these tumors as low grade (15 patients) or high grade (3 patients). The achievement of complete resection and low-grade versus high-grade staging correlated with prognosis. All 12 patients who had a low-grade tumor that was completely excised are alive with no evidence of disease at a mean follow-up of 4.7 years (range, 1 to 27 years). All high-grade tumors proved fatal within 16 months. Two of the 3 high-grade tumors were unresectable because of extensive local disease. Patients with low-grade tumors and microscopically positive margins require close follow-up and can undergo a successful repeat resection. Nine of the 16 resections were sleeve resections, high-lighting the importance of conservative lung-sparing procedures in these central airway tumors. Both patients with an unresectable high-grade tumor had radiation therapy postoperatively and died 11 months later. The role of radiation therapy with high-grade tumors or incomplete resection has yet to be determined.
A partial muscle-sparing technique is presented that combines the advantage of muscle sparing with the wide exposure offered by a posterolateral incision. The technique is simple and quick, does not require elaborate equipment, and facilitates thoracotomy closure.
The left thoracoabdominal incision is approaching its first century of use. Its history is reviewed. The incision provides wide exposure of the spleen, stomach, left hemidiaphragm, aorta, and esophagus; exposure is not limited to the distal esophagus. Because of the superb exposure it offers, its wide clinical application, and its overall safety, the thoracoabdominal incision should continue to be a viable surgical option in current thoracic surgical practice.
We compared multidose crystalloid hyperkalemic cardioplegic solutions with and without added red cells in 24 canine hearts subjected to 5 hr of arrest at 10 degrees C. All cardioplegic solutions were fully oxygenated at 4 degrees C before delivery. Since blood cardioplegia contained Ca++ carried over with the red cells, Ca++ was added to the crystalloid solution in one group. The table below shows the hematocrit (HCT) and ionized Ca++ concentrations of the cardioplegic solutions, and coronary arteriovenous oxygen difference during infusion of cardioplegic solution (AVO2) (ml O2/100 ml). Recovery during reperfusion is shown as percent of prearrest left ventricular function (LVF) and prearrest myocardial ATP concentration.