Howard K. Leonardi

Heparin resistance after preoperative heparin therapy or intraaortic balloon pumping

Heparin resistance, defined as failure of 500 IU per kilogram of body weight of heparin to prolong the activated clotting time (ACT) to 480 seconds or longer, was noted during 949 of 4,280 (22%) consecutive open heart surgical procedures performed on adults between 1986 and 1991. The total population was divided into the following four groups: group 1, preoperative intraaortic balloon support without concomitant heparin therapy (n = 138 patients); group 2, preoperative intravenous heparin therapy (n = 741 patients); group 3, intraaortic balloon support with concomitant intravenous heparin therapy (n = 137 patients); and group 4, controls, not receiving preoperatively the therapy given groups 1, 2, or 3 (n = 3,264 patients). The ACT response to an initial dose of 500 IU/kg of heparin and the incidence of heparin resistance were 596 +/- 203 seconds and 30% in group 1; 506 +/- 149 seconds and 50% in group 2; 520 +/- 159 seconds and 53% in group 3; and 705 +/- 234 seconds and 14% in group 4, respectively. These results indicate that preoperative intravenous therapy and intraaortic balloon support are associated with a decreased ACT response to intraoperative heparin. Baseline ACT levels and preoperative platelet counts were not predictive of heparin resistance. A reduced ACT response to the initial dose of heparin was associated with increased requirements for supplementary anticoagulant therapy during the ensuing period on cardiopulmonary bypass, indicating that the decreased sensitivity to heparin extends beyond the initial episode of heparinization.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral pulmonary resection for bronchiectasis: a 40-year experience.

Ninety-nine patients underwent bilateral pulmonary resection for severe multisegmental bilateral bronchiectasis at the Overholt Thoracic Clinic during the period 1937 to 1977. A total of 216 operations were performed, and 20 patients underwent three or more procedures. The operative mortality was 1.4% and the incidence of severe complications, 7%. Follow-up ranged from 1 to 30 years (average 10.2 years). Only 1 patient was lost to follow-up. Improvement in pulmonary symptoms was achieved in 83 patients; there was no improvement in 9 patients; and 4 patients were worse following resection. The results suggest that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection.

Benign lesions mimicking malignant tumors of the esophagus

Three cases of benign lesions which mimicked malignant tumors of the esophagus are described. In all three cases, two inflammatory pseudotumors and one case of diffuse leiomyomatosis, the clinical presentations, radiologic features, and gross pathologic findings led to the mistaken diagnosis of carcinoma at thoracotomy. The benign nature of the processes was recognizable only on microscopic examination. Although most benign tumors of the esophagus are localized solitary lesions that are easily distinguished from carcinoma, occasionally benign conditions may present as infiltrative, ulcerated mass lesions. Inflammatory pseudotumor and diffuse leiomyomatosis should be included in the differential diagnosis of esophageal malignancies.

Replacement of the thoracic aorta with intraluminal sutureless prosthesis

A survey of the collective experience reveals that between 1976 and 1990, a sutureless intraluminal prosthesis was used to replace the ascending thoracic aorta, arch, and descending thoracic aorta in 122, 14, and 81 patients, respectively. During these 217 operations, at least 364 of the 434 anastomoses were performed by sutureless fixation. The underlying disease processes consisted of acute and chronic dissections; atherosclerotic, Marfans, and mycotic aneurysms; and intraoperative disruptions of the ascending aorta. The data in the literature suggest that sutureless fixation shortens aortic cross-clamp time and reduces blood loss. Early graft-related complications were few and probably can be further reduced by improving surgical techniques. The incidence of paraplegia and renal failure after descending aortic grafting was identical at 2.5%. The operative mortality rate for ascending aortic, arch, and descending aortic replacement was 13.1%, 42.9%, and 14.8%, respectively. Long-term follow-up of 143 patients revealed satisfactory graft function with three possible device-related deaths and no other known complications attributable to the prosthesis. There are, however, anecdotal references to late complications from the intraluminal prosthesis. Most of these relate to faulty implantation techniques, but some could be due to flaws inherent in the concept of sutureless grafting. The collective experience suggests that grafting of the thoracic aorta is less hazardous with the sutureless than with the conventional sutured anastomosis technique. The implications of the anecdotal accounts about late complications remain to be determined.

Coronary artery bypass grafting in patients with transplanted livers

Coronary artery bypass grafting was performed on 3 patients for refractory angina pectoris 48, 5, and 40 months after orthotopic liver transplantation. At the time of the cardiac operation, all 3 patients had drug-induced moderate renal dysfunction, and 1 of the 3 exhibited mild chronic rejection of the graft. Maintenance immunosuppressive therapy was continued during the cardiac operation and the perioperative period. Stress-dose steroids and standard prophylactic antibiotics were also employed. All 3 patients tolerated the cardiac surgical procedure without hepatic decompensation, excessive bleeding, infection, impaired wound healing, and other complications related to the transplanted organ or to the immunosuppressive therapy. Early postoperative liver function test results showed mild transient deterioration. One patient experienced a brief psychotic episode and massive upper gastrointestinal bleeding. Both complications were attributed to the steroids used in immunosuppressive therapy. Follow-up ranging from 2 to 24 months after coronary artery bypass grafting revealed that the patients were active and had no cardiac symptoms or manifestations of hepatic decompensation. It appears from this limited experience that cardiac operations can be performed safely in patients who have previously undergone liver transplantation.

Complications of the Nissen fundoplication.

A more astute selection of patients and greater attention to technical details will preclude most complications. The first step is standardizing the technique, with avoidance of unnecessary ancillary maneuvers. Equally important is a thorough preoperative evaluation. With these considerations in mind, the authors believe that Nissen fundoplication is the preferred method of treatment for patients with uncomplicated gastroesophageal reflux refractory to medical therapy.

Surgical management of chest wall tumors.

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.

Thoracic surgery and the war against smoking: Richard H. Overholt, MD

Richard H. Overholt was born at the beginning of the twentieth century when thoracic surgery hardly existed. During the first 20 years of his life progress in the field was slow. The next 20 years, which coincided with Overholts surgical training and his early years as a thoracic surgeon, saw a rapid and almost explosive growth. Overholts contributions were legion. They included the worlds first successful right pneumonectomy, advancements in surgical treatment of tuberculosis, development of segmental resection, and introduction of the prone operative position. He was a bold and creative pioneer thoracic surgeon with consumate technical skills. Sixty years ago, when Overholt started his career as a thoracic surgeon, the hazards of smoking were not appreciated, the habit was fashionable, and consumption of tobacco was rapidly rising. In the early 1930s Overholt was among the very few physicians who recognized the perils of smoking and initiated a long but initially unrewarding antismoking crusade. By the early 1950s evidence about the ill effects of tobacco use began to accumulate. Organized medicine, voluntary health groups, and governmental agencies joined in a concerted effort to educate and to contain smoking. During the ensuing 30 years the antismoking movement achieved ever-increasing success. Today, it is widely recognized that smoking is a major health hazard and tobacco consumption is on the decline. Richard Overholt issued the first warning signals about the perils of tobacco and served as an indefatigable leader of the antismoking crusade throughout his professional career.