Harold C. Urschel

Coronary Artery Bypass Occlusion Secondary to Postcardiotomy Syndrome

Abstract Postcardiotomy syndrome following coronary vein bypass procedures may cause graft occlusion as a result of the associated myxedematous hyperemic inflammation that later forms dense obliterative fibrosis. Variability of symptoms and onset make early recognition of postcardiotomy syndrome difficult. However, the presence of the classic triad of fever, chest pain, and pleuropericardial reactions along with leukocytosis and elevated sedimentation rate should suggest the diagnosis. Early recognition and prompt institution of steroid therapy offer relief of symptoms and regression of inflammation and probably reduce the incidence of graft occlusion. From early experience with 14 patients who developed postcardiotomy syndrome and received only symptomatic treatment, 12 developed graft occlusion, whereas in 31 subsequent patients with this syndrome who were treated with steroids, only 5 demonstrated graft occlusion.

Reoperation for Recurrent Thoracic Outlet Syndrome

Recurrent thoracic outlet syndrome that requires reoperation accounts for 1% of first rib resections. Symptoms in a series of 30 patients were mainly neurological and consisted of pain and paresthesia involving the neck, shoulder, arm, and hand and were severe and unrelenting. Recurrence of symptoms ensued from one month to seven years following initial rib resection, with the majority appearing within the first three months. Nerve conduction velocities were diminished to an average of 51 m per second, well below the normal of 72 m per second. Reoperation was required after a period of extensive physiotherapy and muscle relaxants. The high posterior thoracoplasty approach is recommended for all reoperations, as it gives better exposure to achieve safe neurolysis of the plexus and complete excision of the regenerated periosteum and posterior rib remnant, which were present in almost all patients. Results of reoperation were gratifying, and postoperative nerve conduction velocities were improved to an everage of 66 m per second.

Surgical management of esophageal carcinoma

Adenocarcinoma, typically in the distal third of the esopha- gus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%) (1). The incidence of adenocarcinoma is clearly increas- ing; it will soon become the most prevalent type of cancer of the esophagus. No malignant tumor in the past 25 years has increased in incidence as much as adenocarcinoma of the esophagus. The primary risk of adenocarcinoma is related to the duration and se- verity of gastric-esophageal reflux and the progression of mucosal changes from Barretts esophagus to dysplasia to adenocarcinoma. Early detection is the most important factor in determining sur- vival. Most patients present with stage IIB to stage IV disease, and most disease occurs at the gastroesophageal junction. Among patients with Barretts esophagus, the risk of devel- oping adenocarcinoma is 0.2% to 2.1% each year; 77% of patients with adenocarcinoma have had Barretts esophagus. Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma, since it could miss adenocarcinoma lo- cated somewhere else in that region. Forty percent of patients with Barretts esophagus and dysplasia have invasive carcinoma in the resected specimen. The incidence of squamous cell carcinoma, which used to be the major cause of esophageal cancer, has significantly decreased. The decrease may be related to reductions in risk factors, which include smoking, excessive alcohol use, caustic lye injury or ther- mal injury, diet, obesity, achalasia, and tylosis. Typical symptoms of esophageal cancer include difficulty swallowing, with a feeling of fullness, pressure, burning, or cough- ing; a feeling of both liquids and solids becoming stuck behind the sternum; indigestion; emesis; and weight loss. Many patients attribute their symptoms to heartburn and do not seek the medi- cal care they need.

“Collis-Belsey” Fundoplication for Uncomplicated Hiatal Hernia and Gastroesophageal Reflux

The combined Collis gastroplasty-Belsey Mark IV fundoplication was used in 86 patients with uncomplicated hiatal hernia followed for up to 8 years. Marked relief of symptoms was obtained, with no initial morbidity and mortality. Recurrence of hernia occurred in 1 patient. Minimal gastroesophageal reflux was observed in a few patients. Manometric and pH studies performed after operation showed a competent valve without notable esophageal reflux. The Collis gastroplasty creates a lesser curvature gastric tube that lengthens the so-called functional esophagus and eliminates tension at the suture line of the Belsey Mark IV fundoplication.