Biomedical subjects
Publications and source records attributed to W B Cannon.
A Univent bronchial blocker tube was used in a ten-year-old patient undergoing videothoracoscopy. Paediatric Univent tubes offer an alternative to balloon-tipped catheters for providing single-lung ventilation (SLV) in children too small for adult size double-lumen tubes.
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A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs ("blind" placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.
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Video-assisted thoracic surgical approaches appear to be viable alternatives to thoracotomy when surgical management of spontaneous pneumothorax is required. Apical bullae of the lung can be resected, and pleural abrasion can be accomplished with minimal postoperative morbidity and usually a shorter postoperative stay in hospital. Fifteen patients with primary (n = 9) and secondary (n = 6) spontaneous pneumothoraces have recently been treated by our group with the video-assisted thoracic surgical approach. Secondary pneumothoraces in the 6 patients were a result of cystic fibrosis (n = 2) and chronic obstructive pulmonary disease (n = 2), iatrogenic (n = 1), and post heart-lung transplantation (n = 1). All were treated by endoscopic stapled resection of bullous disease and pleural abrasion. There were no deaths. In 2 patients with secondary spontaneous pneumothorax, recurrent pneumothoraces developed eventually requiring thoracotomy for direct surgical management.
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The EEA stapler was used in 205 patients over a 7 year period with 19 complications (9 percent) and 1 death (0.5 percent). Meticulous attention to technique and familiarization with the EEA stapler are necessary to achieve such results. The use of mechanical and oral antibiotic bowel preparation, perioperative systemic antibiotics, povidone-iodine irrigation of the rectal ampulla, and meticulous surgical technique have combined to lower the complication rate of this procedure to a minimum. The EEA stapler has greatly improved the safety and ease of anterior sigmoid resections and now provides a frequent alternative to abdominoperineal resection in many patients with midrectal and even low rectal lesions.
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Over a 4 year period, we refined a protocol for treatment of airway obstruction due to recurrent lung carcinoma. Patients undergo bronchoscopy with the Nd:YAG laser available on standby. If bronchial obstruction is found to be due to extrinsic compression, an endobronchial catheter is inserted for iridium 192 brachytherapy, treating a cylindrical volume 7.5 to 15 mm in radius. If an endobronchial lesion is found, the presence of complete versus partial bronchial obstruction determines the course of treatment. Total airway obstruction is treated with the laser until a channel is created and then an endobronchial catheter is placed for adjuvant endobronchial radiotherapy to treat a cylindrical volume 5 mm in radius. Partial airway obstruction is treated with an endobronchial catheter and radiotherapy alone. Segmental obstruction is also treated with a distally placed endobronchial catheter instead of the laser. Using this protocol, we hope to minimize risk to the patient by restricting the use of the laser with its inherent higher potential rate of complications to cases of total obstruction. In addition, we expect to prolong the duration of palliation with endobronchial radiotherapy. The laser is an excellent tool to reopen occluded bronchi, but it is relatively ineffective in producing long-term tumor control. Instead, we have found that placement of a temporary transtracheal endobronchial catheter for radiotherapy is a simple, low-risk procedure that can be safely performed even in critically ill patients. The endobronchial catheter can provide good to excellent long-term palliation for patients with both partially and totally obstructed endobronchial lesions or malignant extrinsic compression of major airways.
Repair of adult inguinal hernia has been done on an outpatient basis at our surgical facility for the past six years. In 616 consecutive repairs, complications have been remarkably few: one patient was electively admitted to hospital, two hernias have recurred and one patient needed to be catheterized. Patient acceptance has been enthusiastic.
The traditional treatment of pneumothorax has been with a chest tube and hospitalization. A series of 35 patients with 41 pneumothoraces treated on an outpatient basis is presented here. A no. 12 chest tube connected to a Heimlich valve led to successful treatment in 88 percent of the cases. Failure of treatment requiring hospitalization occurred in 12 percent of cases and was due only to persistent air leaks. No complications occurred.
Standard angiographic techniques formerly used exclusively as diagnostic modalities have been modified to serve as definitive or adjunctive therapeutic measured. The techniques include transcatheter embolization; infusion of vasoactive drugs, chemotherapeutic agents and radioactive particles; tamponade of bleeding arteries and balloon catheters; extraction of vascular foreign bodies and retained biliary tract stones and transluminal arterial dilation. These techniques have been proved effective and safe when used judiciously.
The angiographic and clinical features of two cases of mediastinal angiofollicular lymph node hyperplasia (Castleman's disease) are presented. The masses were angiographically and microscopically extremely hypervascular. Both patients had profuse bleeding at initial surgery. In one patient, angiographic embolization after an initial attempt at resection made complete excision possible. These lesions behave in a benign fashion, and complete surgical excision is curative.
Staging laparotomy, consisting of splenectomy and biopsies of liver, lymph nodes, and bone marrow, is a very useful adjunct in the workup of a patient with Hodgkin's disease. In this series of 400 patients, 1.0 per cent required reoperations for complication, 3.7 per cent had major complications, and 14.0 per cent had minor complications from the operation. Further evidence of Hodgkin's disease was discovered in 42.0 per cent of the cases and a change from the clinical to the pathologic stage occurred in 27.5 per cent of these cases. The surgeon's task in the treatment of Hodgkin's disease and other malignant diseases is to document and mark the areas of involvement so that accurate and appropriate therapy can be given, while morbidity and mortality are minimized.
A 43-year-old female alcoholic had massive hematobilia secondary to arterial trauma of a liver biopsy. The arterial bleeding site was successfully embolized through an angiographic catheter with Gelfoam sponge. No liver ischemia occurred and the patient has remained well.
Staging laparotomy, consisting of splenectomy and biopsies of liver, lymph nodes, and bone marrow, is a very useful adjunct in the workup of a patient with Hodgkin's disease. In this series of 400 patients, 1 percent required reoperations for complication, 3.7 percent had major complications, and 14 percent had minor complications from the operation. Further evidence of Hodgkin's disease was discovered in 42 percent of the cases and a change from the clinical to the pathologic stage occurred in 27.5 percent of these cases. The surgeon's task in the treatment of Hodgkin's disease and other malignant diseases is to document and mark the areas of involvement so that accurate and appropriate therapy can be given, while minimizing morbidity and mortality.