Leif Dernevik

Long-term follow-up of operative treatment for pulmonary metastases

From 1954 onwards, 132 patients underwent 165 resections for pulmonary metastases. No other forms of therapy were adopted. The operative mortality was 7.6% (10 patients). After a minimum follow-up of 5 years, the overall survival rate was 20%. The 10- and 15-year survival rates were 6% and 3%, respectively. The major cause of late death was recurrence or spread of the primary disease in 102 patients (83.6%) while 5 patients died of reasons not related to cancer. Fifteen patients (12.3%) are still alive, 13 of whom have no clinical cancer. The presence of symptoms, the disease-free interval of less than 1 year and the number of metastases showed a statistically significant detrimental influence on survival (P less than 0.001, P less than 0.05 and P less than 0.046, respectively). The best 5-year survivals of 42%, 24%, 23% and 23% were noted for metastases from malignancies in the body of the uterus, kidney, bone and colon, respectively. Longterm survival or clinical cure can be achieved with surgery alone by an aggressive approach in selected malignancies.

Surgical Removal of Pulmonary Metastases from Renal Cell Carcinoma

Thirty-three patients operated on for pulmonary metastases from renal cancer were followed up for a minimum of 5 years or to death. The 5-year survival was 21%. There was a tendency to better survival in patients operated by lobectomy rather than limited resection. Extended operations carried a grave prognosis. Manifest metastatic disease within one year after the primary operation showed shortened survival. Repeated operations were possible, with good results. It is concluded that operations for pulmonary metastases can be performed with good results. However, the effect is a palliative one as the ultimate cause of death in all instances was the spread of the cancer disease.

Effect of reduced aprotinin dosage on blood loss and use of blood products in patients undergoing cardiopulmonary bypass.

High-dose aprotinin reduces bleeding after cardiac surgery, but has also evoked concern with regard to potential side effects and hospital costs. To evaluate the effects of reduced-dose aprotinin on blood loss and need for blood transfusion, 40 patients undergoing myocardial revascularization were studied (double-blind, placebo-controlled). Postoperative bleeding was reduced by 40% and erythrocyte infusion by 85% in the group given 3 x 10(6) KIU aprotinin (1 x 10(6) as a loading dose before cardiopulmonary bypass, 1 x 10(6) in the priming volume and 2.5 x 10(5)/hour intraoperatively) Aprotinin concentrations during the operation were monitored and maintained above the required level. There were no adverse effects of the drug. Hospital expenditure on blood products was reduced by 51% when aprotinin was used. Our study suggests that aprotinin in reduced dosage diminishes bleeding and requirements for blood products, and that it should be given before, during and after cardiopulmonary bypass.

Reduction of post-thoracotomy pain by cryotherapy of intercostal nerves

In a prospective study, 144 patients undergoing thoracotomy were randomized to two groups: In 71 cases cryoanalgesia was applied intraoperatively to the intercostal nerves above and below the incision to relieve postoperative pain, and 73 (control group) received bupivacaine-adrenaline intercostal blockade at the end of the operation. The amount of administered narcotic and mild analgesics, the visual analogue pain scores, the need for further intercostal blockade and the number of postoperative bronchoscopies to clear retained secretion were significantly less in the cryoanalgesia group than in the controls. There were no late nerve complications after cryoanalgesia, which is recommended for routine use in thoracotomy.

Intraoperative Assessement of Coronary Flow and Coronary Vascular Resistance During Coronary Bypass Surgery

The measurement of coronary graft flow rates is a well-established method of assessing graft function intraoperatively. In order further to understand the dynamics of graft function, the resistance to the flow was considered a desirable measurement intraoperatively. The coronary vascular resistance (CVR) was estimated by applying the Poiseuille-Hagen equation. The CVR was estimated at zero cardiac work (during cardioplegic arrest) using fixed perfusion flow rates and estimating the pressures produced. After going off cardiopulmonary bypass (CPB), the bypass graft flow (F) was estimated by a standard ultrasound Doppler technique. The perfusion pressure over the perfused coronary graft was then determined and the CVR in the working heart ascertained. The CVR was studied in 178 vein grafts in 59 patients undergoing coronary bypass surgery. The mean CVR in the cardioplegic heart (c-CVR) varied from 0.81 to 2.3 mmHg/ml/min for various coronary artery diameters and was significantly higher in small diameter arteries compared with larger arteries (p < 0.0002). Consequently significant high flows were found in the large vessels compared with the smaller ones (p < 0.0001). The mean c-CVR during cardioplegia of 1.57 +/- 0.06 increased significantly to 1.75 +/- 0.07 mmHg/ml/min after the procedure (p-CVR) and was attributed to the dynamic resistance of the working heart. The post-CPB graft flow was significantly and negatively correlated to the c-CVR of the arrested heart. The measurement of coronary vascular resistance reveals coronary beds at potential high risk for inadequate perfusion. Such areas are usually fed by small vessels with low flows. The working heart, in turn, increases the coronary resistance following cardioplegia during the surgical procedure.

Effect of high-dose aprotinin on blood cell filterability in association with cardiopulmonary bypass

BackgroundPrevious studies showed that high-dose aprotinin reduces postoperative bleeding in heart surgery and that blood cell rheologic parameters correlate to postoperative bleeding and other complications. MethodsTo evaluate the blood cell rheologic effect of high-dose aprotinin in patients undergoing coronary artery bypass graft surgery, we studied 68 patients (34 receiving high-dose aprotinin during the operation) by use of a microfiltration method to assess blood cell trauma during cardiopulmonary bypass. ResultsIn the control group, red cell filtration rate (RFR, μL/s) values were significantly reduced from a preoperative level of 55.8 to a level of 37.2 on day 1 (P< 0.002) and to a level of 44.5 on day 6 (P< 0.05) after surgery. The respective values for white cell filtration rate (WFR, μL/s) were 17.0, 8.2 (P< 0.002), and 10.0 (P< 0.005). In the aprotinin group, RFR (μL/s) values were reduced, but not as significantly (58.8 preoperative. 48.1 on day 1, P>0.05, and 50.4 on day 6, P>0.05). The respective values for WFR (μL/s) were 17.5, 15.7 (P>0.05), and 15.8 (P>0.05). ConclusionsBlood cell rheologic function, which is known to be an important factor for adequate microcirculation and which when reduced is associated with postoperative morbidity, was shown to be protected by aprotinin in this study.

CONCOMITANT LUNG CANCER AND SURGICAL HEART DISEASE

Concomitance of pulmonary carcinoma and heart disease poses problems of management. We encountered this disease combination in 6 of 2,139 patients operated on with extracorporeal circulation during a 5-year period. Our policy has been to correct the heart disease first. The tumour was subsequently operated on in five of the six patients, but the sixth was subjected only to excisional biopsy of malignant tumour nodules during the heart operation. There was no operative mortality. Three patients died in the follow-up period. A treatment strategy is suggested, based on our experience and on a review of the literature.

CHANGES IN PLASMA ZINC AND URINARY EXCRETION OF ZINC AFTER OPERATION WITH EXTRACORPOREAL CIRCULATION

Sixteen adults undergoing cardiac surgery were studied with respect to postoperative levels of zinc in plasma and urinary excretion of zinc. The preoperative plasma concentrations of zinc were normal. On the first postoperative day the mean for the series had fallen from 15 to 7.2 mumol/l. A gradual rise followed, and on the fifth day all patients had plasma zinc above the lower limit of normal range. The urinary excretion of zinc was significantly increased on the first, second and fifth days after surgery. The mean total of zinc in the urine during five days was 67 mumol. The short-term fall in plasma zinc level had no discernible effect on wound healing. It was therefore apparently harmless and did not indicate a need for zinc supplementation.

Half-dose aprotinin does not affect haemorheological properties in patients undergoing bypass surgery.

ObjectiveTo investigate haemorheological changes in patients undergoing coronary artery bypass grafting and to determine whether the protective effect on haemorheology of high-dose aprotinin also exists under a half-dose regimen. MethodsForty patients were studied in a double-blind, placebo-controlled study design. Patients in the aprotinin group received half of the standard high dose of aprotinin during surgery. Erythrocyte and white-cell clogging rates as well as whole blood and plasma viscosity were measured. Viscosity results were expressed as a ratio to the viscosity of saline. ResultsErythrocyte and white-cell clogging rates were increased significantly, whereas whole blood and plasma viscosity were decreased significantly during cardiopulmonary bypass. The reduction in viscosity had a strong correlation to haemodilution. There was no significant difference in any of the measured variables between the aprotinin and the placebo groups. ConclusionThis study showed that blood cell damage occurred during cardiopulmonary bypass surgery, as measured by a raised clogging rate. This tendency was the same in both groups and therefore no increased potential for microthrombi could be attributed to aprotinin haemorheologically. However, half-dose aprotinin did not show any preserving effect in haemorheology when the blood-cell clogging rate and blood viscosity were studied.