John R. Derrick

Surgical management of spontaneous pneumothorax by bleb ligation and pleural dry sponge abrasion

Summary Experimental and clinical experience with dry sponge pleural abrasion for pleural space obliteration has led to the conclusion that this method is effective, less traumatic than pleurectomy, and is more reliable with less chance of adverse host reaction than chemical irritants. Bleb ligation, decompression, and excision is believed to be a simplified method for the surgical management of emphysematous blebs. The combination of bleb ligation and excision and dry sponge pleural abrasion is advocated as a method of choice in the surgical management of noninfectious spontaneous recurrent or persistent pneumothorax.

Recent experience with tuberculous pericarditis.

Twelve patients with tuberculous pericarditis were found among 1,194 patients with tuberculosis treated at the University of Texas Medical Branch over a 10-year period, an incidence of 1%. Surgical treatment was undertaken in 4 patients, and the rest were treated medically. The surgically treated patients had no major complications, and none of them died. In the medically treated group, however, 1 patient died, 1 had an anaerobic empyema, and 1 experienced respiratory arrest. In addition, the average hospital stay was 33 days less in the surgically treated group. Early surgical intervention should be carried out in patients with tuberculous pericarditis who do not respond promptly to adequate antituberculosis chemotherapy.

Needle biopsy of the lung in diffuse parenchymal disease: An analysis of 151 cases

Summary Of 220 percutaneous cutting needle biopsies of pulmonary disease, 151 patients were biopsied for purposes of diagnosis of diffuse parenchymal disease. Diffuse disease was divided into generalized and lobar disease because of differences in technical management, complications, and productivity. A postbiopsy chest tube was inserted in all cases of generalized lung disease. Tissue diagnosis was established in 90 per cent of the patients with diffuse disease with a serious complication rate of 1.3 per cent and a mortality of 0.66 per cent. The present experience suggests that needle biopsy is the procedure of choice in patients with more advanced generalized lung disease and in patients with lobar diffuse disease. Open biopsy is recommended as the procedure of choice for good risk patients with generalized bilateral parenchymal disease.

Intrapleural Instillation of Quinacrine for Treatment of Recurrent Spontaneous Pneumothorax

We used intrapleural instillation of quinacrine hydrochloride in 20 patients (Group A) with recurrent spontaneous pneumothorax (one bilateral) and compared their clinical course with 19 patients who underwent thoracotomy and scarification or pleurectomy (Group B) and 63 patients treated by tube thoracostomy alone (Group C). In Group A, there was one complication of treatment, a pneumothorax immediately following tube removal, which necessitated repeat tube thoracostomy, and there was one late ipsilateral recurrence 2 years after treatment. These 20 patients with 21 recurrent spontaneous pneumothoraces treated with intrapleurally administered quinacrine have been followed for from 6 months to more than 4 years with only one late recurrence on the treated side. Eight patients in Group B had postoperative complications: 2 patients who had had pleurectomy required reoperation for postoperative bleeding; lobar pneumonia developed in 3; 1 had lack of total expansion of the lung; an intrathoracic hematoma developed in 1; and an ipsilateral pneumothorax necessitating tube thoracostomy developed in 1. In Group C, the rate of recurrence of pneumothorax was 23% during the first year following treatment. Intrapleural instillation of quinacrine is a simple, low-risk, reliable, and effective treatment for recurrent spontaneous pneumothorax, and is equally as effective as thoracotomy and scarification.

Carotid Kinking as a Cause of Cerebral Insufficiency

With proper diagnosis based on history, physical findings, and arteriographic and pressure studies, it has become apparent that carotid artery kinking is a more common cause of strokes than was formerly believed. Because kinking is easily corrected, every patient with stroke deserves examination sufficient for determination of whether the carotid arteries are kinked. Two cases are cited in which multiple syncopal attacks were relieved when flow past a kink in the common carotid artery was reestablished.

Use of Cold Cardioplegic Solution for Vein Graft Distention and Preservation: A Light and Scanning Electron Microscopic Study

To evaluate the effect of a cardioplegic solution on the endothelium of the saphenous vein, portions of this vein were harvested from each of 5 patients undergoing coronary artery bypass operation. Each sample was divided into five segments. One segment was distended with heparinized saline solution, one with heparinized blood, and one with heparinized cardioplegic solution (25 mEq of potassium per liter). All of the distending solutions were kept at 10 degrees C, and pressure was carefully limited to 200 mm Hg. The fourth segment of vein was distended with heparinized saline solution but no effort was made to limit distending pressure, and the fifth segment was not distended. All samples were then examined with light and scanning electron microscopy. There were no great morphological differences in the endothelium of veins distended to 200 mm Hg with saline solution, blood, or cardioplegic solution. The morphology of these samples compared favorably with the control vein endothelium although scattered areas of endothelial disruption were present in every sample. Veins distended without pressure control showed massive endothelial disruption. The particular solution used to distend the sephenous veins is not as important as limiting the distending pressure.

The Surgical Significance of Aberrant Renal Arteries in Relation to Systemic Hypertension

Three cases of hypertension associated with vascular insufficiency of aberrant renal arteries are presented. Two patients were subjected to revascularization procedures. The types of pathologic processes associated with aberrant renal arteries in production of segmental renal ischemia are discussed. Considerations of diagnosis and therapy of such lesions are reviewed.

Gastrointestinal Erosion after Prosthetic Arterial Reconstructive Surgery

Abstract Sixty-one cases of arterioenteric fistula and one case of bowel erosion by arterial grafts have previously been reported. Three additional cases of gastrointestinal erosion, one in a patient in whom a fatal aortoenteric fistula subsequently developed, are presented. It is speculated that bowel erosion precedes most cases of arterioenteric fistula secondary to prosthetic grafts. Methods of prevention and correction are discussed. The increasing complexity of abdominal reconstructive arterial surgery and the preference for plastic prostheses may well lead to an increased incidence of bowel erosion. A more aggressive approach in suspected cases could lead to diagnosis at the erosion stage and a subsequently lowered mortality.

Vascular trauma: A review of 250 cases☆

Abstract Two hundred fifty vascular injuries of all types seen at the University of Texas Medical Branch, Galveston, Texas during the period from January 1960 through January 1970 have been reviewed. Methods of evaluation and management of the primary injury are discussed along with the complications. The mortality was 2.4 per cent (6 deaths) in this series and two-thirds (four deaths) were in the group in which treatment was delayed. Emphasis is placed on immediate exploration of all penetrating wounds in the region of major vessels. Early recognition and prompt repair of the vascular injury is paramount for reduced morbidity and mortality. Twenty-six cases of delayed vascular injury are reviewed. Also, twenty-five cases of iatrogenic vascular injury are reviewed and their management is discussed. The management of special and difficult problems is briefly illustrated.

Congenital absence of the left pericardium with surgical correction

Abstract A case of congenital absence of the left pericardium is reported in which a silastic graft was used to stabilize the hypermobile left ventricle. This is believed to be the 128th such case reported in the English literature. The incidence, pathogenesis, diagnosis, clinical significance and corrective procedures have been briefly discussed. In view of at least 8 cases reported in the past year, this anomaly should not be considered the rarity that it once was.