Donald R. Kahn

Treatment of Bronchogenic Carcinoma with Mediastinal Metastases

Abstract Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 231 patients with bronchogenic carcinoma. Mediastinal metastases were found in 48 patients. Thirty-six of these 48 patients underwent mediastinal irradiation in the immediate postoperative period. Seven of the 36 patients receiving postoperative irradiation lived five years (an absolute five-year survival rate of 19.5%). Of 17 patients with squamous cell carcinoma and mediastinal metastases, 5 lived five years (a five-year survival rate of 29.5%); only 1 of the 17 patients with adenocarcinoma and mediastinal metastases lived five years (an absolute survival rate of 5.9%). No patient who did not receive mediastinal irradiation postoperatively survived five years. The presence of mediastinal lymph node involvement in patients with squamous cell carcinoma of the lung is not a contraindication to resection because long-term survival can be achieved in a significant percentage of these patients.

Recurrence of a left atrial myxoma

Abstract A fatal recurrence of a left atrial myxoma was observed despite resection of the original tumor complete with its stalk and a portion of atrial septum. The evidence suggests that this recurrent tumor developed from “pre-tumor” cells in the region of the fossa ovalis. The rate of growth of the second tumor was faster than would have been predicted. Clinical manifestations were similar to those with the initial tumor. Wide excision of the atrial septum with the stalk of such tumors should offer the best chance for operative cure, but prolonged postoperative observation is important if signs of recurrence are to be detected at a time when operative removal can be carried out with minimal risk to the patient.

The Effect of Histological Cell Type on the Prognosis of Patients with Bronchogenic Carcinoma

Abstract Mediastinal lymph node dissection in conjunction with pulmonary resection was performed in 232 patients with bronchogenic carcinoma at the University of Michigan Medical Center from 1959 to 1965. The mediastinum was irradiated postoperatively in those patients with mediastinal metastases. The absolute five-year survival rate of the patients undergoing resection was 29.2%. Of 110 patients with squamous cell carcinoma, 37.2% lived five years free of disease. The overall five-year survival of those patients undergoing resection who had no hilar lymph node metastases was 45.7%, and it was 45% in those with hilar metastases only. The absolute five-year survival rate of the patients with mediastinal metastases who received radiation therapy was 29.5%. Of 76 patients with adenocarcinoma, 19.7% lived five years free of disease. The overall five-year survival of those patients undergoing resection who had no lymph node metastases was 33%, whereas none of the patients with hilar metastases survived and only 1 of 17 patients with mediastinal metastases survived five years free of disease. The findings suggest that the histological cell type is an important factor in determining the prognosis in bronchogenic carcinoma, especially if there is evidence of lymph node involvement. In addition, this study also suggests that it is the presence, and not necessarily the extent, of lymph node metastases in patients with squamous cell carcinoma that determines the survival rate following pulmonary resection, provided those patients with mediastinal metastases undergo postoperative mediastinal irradiation.

The Effects of Nonpulsatile Blood Flow on Canine Lungs

nder normal conditions in vivo blood flows in a pulsatile manner. That this is not an essential feature of the circulation U is shown by the regular successful practice of extracorporeal circulation using roller pumps, which give an essentially nonpulsatile flow, and by the palliation of cyanotic disorders by means of superior vena cava-right pulmonary artery anastomosis (Glenn operation). Nevertheless, it has been recently reported that pulsatile perfusion is in fact preferable to nonpulsatile perfusion for the performance of extracorporeal bypass [3, 14, 151, especially during lengthy procedures and when low flow rates are used [15]. Furthermore, experimental work has demonstrated that pulsatile flow has an important role in the maintenance of normal vasomotor tone [5] and gives improved function of the isolated kidney [lo] and liver [19] when compared with nonpulsatile flow. Lee and DuBois [12] elegantly demonstrated that the pulmonary capillary bed has a pulsatile blood flow under normal conditions, but whether this is an essential or incidental feature is not clear. This study examines the changes in oxygen uptake, pulmonary vascular resistance, and microscopic appearance of canine lungs subjected to nonpulsatile perfusion in both acute and chronic preparations.

Brachial Plexus Injury Following Median Sternotomy Incision

Abstract The median sternotomy approach to intracardiac operations may be associated with damage to the brachial plexus similar to that reported with other types of operations. In 5 patients treated at the University of Michigan Hospital, varying degrees of upper extremity paralysis resulted from excessive spread of the retractors in an attempt to improve exposure of the heart.

Repair of acute traumatic rupture of the aorta without extracorporeal circulation.

n this era of rapid transportation, the increasing incidence of traumatic rupture of the thoracic aorta has almost paralleled the inI creasing number and speed of highway vehicles. Strassmann [231 found only a 1% incidence of aortic rupture in 7,000 autopsies in 1947. Recent reports from both the United States [8] and Europe [241 show that the incidence of traumatic rupture of the aorta is now between 10 and 15% in automobile fatalities. Traumatic rupture of the thoracic aorta carries a grave but not necessarily hopeless prognosis if it is managed adequately. Death by exsanguination is instantaneous in 80 to 90% of the patients who sustain aortic rupture [lo, 171. In the remaining 10 to 20% the aortic blood is contained by the adventitia, pleura, and surrounding tissue. A false aneurysm is formed, and the patient survives at least temporarily. Since most of these patients will die from lethal secondary hemorrhage within three weeks if they are not treated [lo, 171, it is imperative that the diagnosis be established quickly and that repair be carried out.

Replantation and transplantation of the canine lung

Summary Autotransplantation of the left lung was successfully performed in nine dogs. Study of these animals showed no severe reaction to operation, an almost normal chest x-ray, and a grossly normal appearance of the lung at necropsy. The bronchograms, angiograms and histologic appearance of the autografted lungs were normal. The pulmonary function of the transplanted lung, as determined by contralateral pneumonectomy in one animal, was satisfactory. Homograft of the left lung was done in eight pairs of animals. Study of these animals showed a progressively severe reaction to operation after the second day, characterized by listlessness, cough, and thin, foamy, serous sputum. Progressive homogeneous density in the left lung field beginning on the third or fourth day progressed to total opacification of the left chest by the seventh postoperative day. At necropsy these lungs were slightly swollen, wet, heavy and dark red. Histologic study of the pulmonary tissue at two days was normal except for slight perivascular inflammatory cell infiltration. By the fourth day, pulmonary edema was marked and the inflammatory cell reaction was greatly increased. Severe necrosis was present after the seventh day.

Coagulation Defects and Bleeding in Open-Heart Surgery

emorrhagic diathesis associated with extracorporeal circulation has been described by a number of investigators, many of H whom have emphasized the presence of specific coagulation defects [ 1, 6, 10, 1 1, 16-1 81. Unfortunately, information on the clinical significance of these abnormalities with respect to incidence and their effect on hemostasis has been lacking. With the increasing use of extracorporeal circulation in cardiac surgery, there is a demand for a means of evaluating the adequacy of hemostasis. As a consequence, the interpretation of the results of routine coagulation procedures has agsumed greater importance. The following study was undertaken to provide such information and includes a description of 50 patients, 15 with excessive blood loss and 35 with “normal” postoperative blood loss. It was presumed correctly that a distinct separation of the two groups of patients could be made on the basis of the coagulation studies.

Aggressive surgical treatment for caustic injury of the esophagus and stomach.

Abstract Two patients with severe liquid alkali burns of the esophagus and stomach are reported in whom an early esophagogastrectomy was performed. The value is stressed of an early exploratory operation as a diagnostic as well as therapeutic tool in patients with a history of ingestion of strong liquid alkali.

Improving function of hearts preserved for 24 hours by controlling reperfusion.

With the use of an extracorporeal working dog heart preparation, we studied whether the function of hearts undergoing 24 hr of 4 C ischemic arrest is improved by initially reperfusing the hearts with a modified blood perfusate. Hearts were arrested and cooled to 4 C using either a modified extracellular solution (DKS) or a modified Collins solution. After 24 hr at 4 C the preserved hearts were perfused with either normal blood at 35 C or with a cardioplegic blood perfusate at 20 C. Five or more hearts were included in each of the four subgroups. The subgroups subjected to the modified blood perfusate were switched to normal blood perfusion after an initial 45 min of perfusion at an arterial blood pressure of 45 to 50 mm Hg. Hearts preserved with the modified Collins solution when perfused only with normal blood attained an average left ventricular (LV) function of 75% of control, while the hearts preserved by the same method but reperfused initially with blood cardioplegia attained 93% of control LV function (P < 0.01). Hearts preserved for 24 hr with the DKS solution maintained synchronous beats but did not work when perfused with normal blood, but functioned at 40% of control levels when initially reperfused with blood cardioplegia. Hearts preserved with modified Collins and initially reperfused with blood cardioplegia had tissue levels of Na and K not significantly different from control hearts; the ratio of [K]/[Na] being 1.5 Hearts preserved by the same method but reperfused only with normal blood had significantly higher tissue levels of Na than control hearts, the ratio of [K]/[Na] being only 1.1. All hearts preserved with DKS for 24 hr lost K and gained Na. By using a modified Collins preservation solution and by controlling the reperfusion environment, dog hearts were preserved for 24 hr with nearly normal LV function.