Alan C. Peterson

Treatment of caustic injuries of the esophagus: a ten year experience.

The methods of managing 32 patients sustaining caustic injuries to the esophagus are assessed. Treatment of these patients must be individualized according to the type of caustic ingested, the degree of burn and other clinical signs. While an aggressive approach is favored for second and third-degree burns in the form of early esophago-gastrectomy with subsequent colon interposition, operation is not necessary in all patients, particularly those with first-degree burns. The use of antibiotics is recommended as soon as the diagnosis of esophageal injury is established. The efficacy of steroids in preventing stricture formation, especially with third-degree burns, is questioned.

Cardiac transplantation in patients with preexisting malignancies.

A history of preexisting malignancy has been considered a contraindication to cardiac transplantation. The reasons for this prejudice include concerns about potentially deficient intrinsic immunomodulation and fear of cancer recurrence (or development of second cancers) because of therapeutic immunosuppression. In the past four years at the Northern Indiana Heart Institute seven patients with preexisting malignancies underwent cardiac transplantation. Their two-year survival rate was 100%, which is comparable to a rate of 81% in non-malignancy patients. After an average 31 months of follow-up (range = 6–56 months), only one patient has had a recurrent tumor (basal cell carcinoma). Statistical comparison of immunosuppression dosages, incidences of rejection, and incidences of infections between patients with preexisting malignancy and those without preexisting malignancy was performed. We found that the only significant difference was an increased number of infections in preexisting malignancy patients. Additionally, we found no difference in the incidence of posttransplant coronary artery disease in the preexisting malignancy group when compared with those patients without preexisting malignancies. This study demonstrates that patients who have been successfully treated for malignancies have no greater incidence of rejection than those patients without preexisting malignancy. Furthermore, preexisting malignancy patients require no significant modulation of immunosuppression. Although preexisting malignancy patients have a higher incidence of infections than patients without preexisting malignancy, their two-year survival is not worse than the patients without preexisting malignancy.

Endarterectomy, vein patch, and mammary bypass of the anterior descending artery

Occasionally the left anterior descending (LAD) coronary artery contains such diffuse calcific atherosclerosis that an area suitable for distal anastomosis with the internal mammary artery (IMA) cannot be found. Additionally, the LAD of some patients contains multiple areas of stenosis, which would prevent free outflow from the IMA graft. In these cases the potentially increased operative risk of LAD endarterectomy is justified to avoid leaving poorly revascularized areas of anteroseptal heart. In an effort to provide the long-term patency benefits of IMA grafting for these patients without the technical difficulty of a lengthy IMA to LAD anastomosis, we have combined saphenous vein patch reconstruction with IMA bypass when LAD endarterectomy is required.

Factors contributing to recurrent carotid disease following carotid endarterectomy

BACKGROUND Retrospective analysis was performed to assess the effect of gender, age, hypertension, diabetes, and smoking upon residual disease, recurrent disease, and progression of disease following carotid endarterectomy (CE). The effect of patch versus primary closure was also studied. METHODS Postoperative duplex studies were performed following 323 CEs at months 1, 6, 12, and 24. Residual disease was defined as luminal stenosis >59% at 1 month. Progression of disease was defined as stenosis at any month that was greater than stenosis at month 1. Recurrent disease was nonresidual stenosis >79%. RESULTS Correlation was found between age at operation <65 years and cigarette smoking; both also correlated with progression of disease on serial studies, as well as recurrent stenosis <79%. Primary closure of the arteriotomy correlated with residual disease. CONCLUSION Primary closure of the arteriotomy following CE increases the likelihood of residual disease. Smokers and those aged <65 years are predisposed to progression of postoperative disease, and to development of recurrent stenosis.

Effects of pulsatile perfusion upon left ventricular function

Abstract This study compares the effects of pulsatile and nonpulsatile perfusion upon myocardial contractility. After 2 hr of ventricular fibrillation, control animals demonstrated a 37% decrease in left ventricular force, a 48% decrease in left ventricular compliance, and an increase in endomyocardial water content. On the other hand, after 2 hr of ventricular fibrillation, animals undergoing pulsatile perfusion had no significant change in ventricular diastolic compliance and only a 14% decrease in left ventricular force. The results of this study show that the addition of pulsatile perfusion minimized the deleterious effects of ventricular fibrillation upon myocardial contractility.

The Effect of Glucagon in Animals on Chronic Propranolol Therapy

Eleven adult mongrel dogs were divided into two groups. Group 1 animals served as controls and Group 2 received propranolol (6 mg/kg/day) orally in divided doses for 15 to 21 days. Prior to cardiopulmonary bypass, cardiac output, first derivative of left ventricular pressure (dp/dt), peak systolic pressure, heart rate, and central venous pressure were recorded. The animals were then placed on cardiopulmonary bypass and subjected to 30 minutes of global ischemia at the myocardial temperature of 32 degrees C. Following cessation of cardiopulmonary bypass the baseline studies were repeated. In Group 2 animals following the repeat studies, glucagon was administered at a rate of 0.13 microgram/kg/min. The cardiac index and dp/dt were decreased by 43.3% (p less than 0.001) and 40.5% (p less than 0.001) in comparison to Group 1 animals. In Group 2 dogs, after bypass and glucagon infusion, cardiac index increased by 38% (p less than 0.02), dp/dt rose by 78% (p less than 0.05), and peak systolic pressure increased by 24.8% (p less than 0.05). These studies show the benefit of glucagon in the treatment of low cardiac output in the presence of beta-adrenergic blockade.

Surgical Management of Neonates with Complex Preductal Aortic Coarctation

Neonates having repair of aortic coarctation commonly have associated ventricular septal defect and patent ductus arteriosus. Prostaglandin E1 is used to dilate the ductus and improve the patients preoperative condition. An operative technique that maintains ductal patency until the final stages of anastomosis is presented. We believe it has contributed to our present improved results.

Bronchogenic Carcinoma and Postoperative Empyema: Is Survival Really Enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.

Cardiac Transplantation: First-Year Experience in a Community Hospital

The issue of decentralizing heart transplant services, formerly restricted to a few large medical centers, is currently under review by federal and state governments. We present the results of the first year of cardiac transplantation at a 385-bed community hospital. Twelve patients were selected according to generally accepted criteria from a pool of 24 referrals, all from within 75 miles of our institution. All patients were in New York Heart Association Class IV preoperatively. The one-year survival rate was found to be 82%, which is equivalent to that reported by established centers. All surviving patients were fully rehabilitated. Rates of infection and rejection were lower than expected, and costs were about half the national average. This series, in all likelihood, tests the limits to which the decentralization of cardiac transplant services can be taken. We conclude that cardiac transplantation can be accomplished at a community hospital with results, even for the first patients undergoing transplantation, comparable to those obtained by established programs at major medical centers.