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T R Coughlin

Publications and source records attributed to T R Coughlin.

10 recordsLinked to original sources
PubMed1992

Coronary artery bypass without cardiopulmonary bypass.

The purpose of this article is twofold: to describe our technique for performing coronary artery bypass grafting without cardiopulmonary bypass (off pump) and to demonstrate that this operation is safe, in terms of mortality and certain indices of morbidity. Very little has been published in regard to off-bypass operations. From 1985 through 1990, 220 patients underwent operation off bypass; 220 on-pump controls were retrospectively matched for number of grafts, left ventricular function, and date of operation. Groups were compared in terms of mortality and ten indicators of morbidity. The same analysis was performed for ten subgroups. We found no statistically significant difference between groups in mortality (off pump, 1.4% [3/220]; on pump, 2.4% [5/220]), which held across all subgroups. Patients undergoing operation off pump required blood far less often (not transfused: off pump, 72.7% [160/220]; on pump, 54.6% [116/220]; p = 0.005 by Fisher's exact test), and the low output state occurred statistically less frequently off pump (off pump, 5.5% [12/220]; on-pump, 12.7% [28/220]; p = 0.01 by Fisher's exact test). Further research should be directed to which subgroups can be operated on to advantage off pump and which, if any, groups of patients should be confined to on-bypass operations.

Adult↗
PubMed1990

Esophageal perforation: a therapeutic challenge.

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Adult↗
PubMed1989

Carcinoma of the esophagus: a comparison of the results of transhiatal versus transthoracic resection.

The cases of 78 patients with primary esophageal carcinoma treated from 1977 to mid-1987 were retrospectively analyzed. Fifty-two of the patients underwent transthoracic esophagogastrectomy (TTE) and 26, transhiatal esophagectomy (THE). The two groups were statistically similar in preoperative characteristics except that more of the THE group had received chemotherapy; this group had relatively more tumors of the upper esophagus; and 20 (77%) of the THE group, compared with 50 (96%) of the TTE group, had tumors in stages III and IV. The incidence of major postoperative complications did not differ significantly between the two groups. There were five (19%) anastomotic leaks in the THE group, but only one led to a prolongation of hospital stay by more than 14 days, whereas all three (6%) of the leaks in the TTE group caused hospital stay to be prolonged several weeks. Overall morbidity was high: 75% (39/52) for the TTE patients and 85% (22/26) for the THE patients (p greater than 0.10). Hospital mortality was 6% (3/52) in the TTE group and 8% (2/26) in the THE patients (p greater than 0.10). There was no significant difference in actuarial survival either between the two groups as a whole or between those patients in each group who had stage III or IV tumors. We conclude that THE, among the types of patients for whom we used the procedure, provides long-term survival comparable with that provided by TTE without causing a significant increase in hospital mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1989

Postoperative conduction disturbances: a comparison of blood and crystalloid cardioplegia.

Conduction system disturbances after cardioplegia are well described. Our four-man group changed in mid-1987 from standard crystalloid cardioplegia (35 mEq/L of KCl) to blood cardioplegia (4 parts blood to 1 part cardioplegia) (18 mEq/L of KCl) based on experimental and clinical evidence that blood cardioplegia provides better myocardial protection. Shortly thereafter, we anecdotally noted increased conduction abnormalities. This prompted us to compare serially all patients undergoing coronary artery bypass grafting during 1987 for perioperative and late conduction system disturbances after either crystalloid or blood cardioplegia. Surgeons and techniques including topical cooling did not differ. Forty-one (23%) of 179 patients with crystalloid cardioplegia had conduction disturbances versus 141 (49%) of 289 patients with blood cardioplegia (p less than 0.001). Perioperative complete heart block requiring atrioventricular sequential pacing occurred in 20 patients with crystalloid cardioplegia versus 67 patients with blood cardioplegia (p less than 0.002), and atrioventricular block requiring permanent pacing was present in 4 and 12 patients (p less than 0.001), respectively. Left bundle-branch block was found in 8 patients given crystalloid cardioplegia and 28 patients with blood cardioplegia (p less than 0.05); right bundle-branch block, 12 and 68 patients (p less than 0.001); left anterior hemiblock, 8 and 37 patients (p less than 0.001); and interventricular conduction delay, 15 and 53 patients (p less than 0.005), respectively. Bifascicular block occurred in 4 patients receiving crystalloid cardioplegia versus 23 receiving blood cardioplegia (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

Renal allograft biopsy and conversion of cyclosporine to azathioprine.

A prospective nonrandomized study was conducted to evaluate the results of two conversion protocols on two similar groups of renal graft recipients totaling 54 patients who were converted from CsA to AZA at 6-12 months posttransplant. With protocol I, 24 patients (3 haploidentical, 21 cadaveric recipients) were converted with a graft biopsy followed by a 14-day overlap of CsA and AZA before the CsA dose was tapered and discontinued in 6 days. Of the 24 patients, 8 were found to have occult rejection in biopsy and received methylprednisolone 500 mg boluses for three days before overlap started. Thirty patients (2 haploidentical, 28 cadaveric recipients) were converted with protocol II, which had CsA and AZA overlap and tapering schedules identical to those of protocol I without a preconversion biopsy. Follow-up extended as far as 3 years posttransplant. There was a substantial incidence of chronic rejection and graft loss after conversion in protocol II patients. We also found that there was a possible link between postconversion acute rejection and late graft loss from chronic rejection. The incidence of acute rejection after conversion was significantly lower among protocol I patients as compared with that of protocol II (4% vs. 37%, P less than 0.001). However, if 8 patients with occult rejection in the preconversion biopsy were added to the total number of postconversion rejection in protocol I, the incidence of postconversion rejection in this group (38%) would be similar to that of protocol II. Using the time of conversion as the onset of the risk, protocol I patients had better graft survival than protocol II (100% vs. 80%, P less than 0.005) at 3 years posttransplant. If conversion becomes necessary, we recommend a preconversion graft biopsy to identify and treat patients with occult rejection before the beginning of CsA and AZA overlap, especially for those patients whose creatinine is higher than 2 mg/dl without obvious cause before conversion.

Antilymphocyte Serum↗
PubMed1988

Bilateral granular cell tumors of the posterior mediastinum.

Granular cell tumors are uncommon and generally benign lesions that are commonly accepted to be of Schwann cell origin. These tumors occur most frequently in the skin and oral cavity and are generally asymptomatic. However, when signs and symptoms occur, they are relative to the organ or site involved. The histological features are distinct. Surgical resection is curative in almost all cases, with only rare local recurrences. We report a case of symptomatic bilateral granular cell tumors arising in the posterior mediastinum.

Adult↗
PubMed1977

Hernia reduction en masse.

A case of hernia reduction en masse is reviewed. Discussion of the pathogenesis, diagnosis, and operative approach suggests that the use of taxis in the reduction of incarcerated hernia should be tempered by awareness of potential complications including mass reduction. Diagnosis is by history with the persistence of intestinal obstruction after reduction is a key feature. A preperitoneal approach is recommended for facility of reduction, resection, and anatomic hernia repair.

Aged↗