Monica L. McDonald

Barrett's esophagus: Does an antireflux procedure reduce the need for endoscopic surveillance?

Barretts esophagus, a premalignant condition associated with chronic gastroesophageal reflux, carries an approximate 40-fold increase in the incidence of adenocarcinoma. Between 1975 and 1994, 113 patients with Barretts esophagus underwent antireflux procedures at the Mayo Clinic. The antireflux procedure was performed more than 3 months after the diagnosis of Barretts disease in 39 patients (34.5%) and during the initial preoperative evaluation in 74 (65.5%). Uncut Collis-Nissen fundoplication was performed in 69 patients (61.1%), Nissen fundoplication was performed in 16 (14.2%), cut Collis-Nissen fundoplication was performed in 12 (10.6%), Belsey repair was performed in nine (8.0%), Collis-Belsey repair was performed in six (5.3%), and Nissen fundoplication with an anterior gastropexy was performed in one (0.9%). There was one operative death (0.9% mortality). Morbidity occurred in 41 patients (36.3%), including cardiac arrhythmia in eight (7.0%), pneumonia in six (5.3%), empyema in five (4.4%), hemorrhage in four (3.6%), myocardial infarction in two (1.8%), and wound dehiscence, wound infection, perforated duodenal ulcer, and postoperative leak in one each (0.9%). Median follow-up for the 112 survivors of operation was 6.5 years (range 4 months to 18.2 years). Excellent or good alleviation of symptoms was obtained in 92 patients (82.2%). Ninety-nine patients (88.4%) are currently alive and 13 (11.6%) have died. Three patients (2.7%) subsequently had adenocarcinoma of the esophagus after the antireflux procedure at 13, 25, and 39 months; two of these died of cancer. The incidence of esophageal carcinoma in this select group of patients was one in 273.8 patient-years of follow-up. We conclude that although antireflux procedures in patients with Barretts esophagus result in long-term control of reflux symptoms, the possibility of esophageal cancer still exists. Endoscopic surveillance should therefore be recommended.

Purely internal thoracic artery grafts: outcomes

BACKGROUND Most of our patients with coronary artery disease have undergone bypass exclusively with purely internal thoracic artery grafts (PITA). Our goal has been to lengthen the time a patient benefits from coronary bypass operations. The present report describes an 8.5-year study of outcomes including mortality and the need for reintervention in patients who have undergone bypass with PITA. METHODS We studied 897 patients who underwent PITA with a total of 3,784 internal thoracic artery (ITA) grafts (4.2 grafts per patient). Connecting ITA to ITA along with sequential anastomosis made the procedure possible. RESULTS Early mortality for the group was 2.3%. Freedom from death was 86% and freedom from reintervention was 94% at 5 years after the operation. CONCLUSIONS The acceptable early and late mortality and the 94% freedom from reintervention as long as 8.5 years after operation in this group of patients inspire us to continue choosing PITA for patients with three-vessel coronary artery disease.

Pulmonary resection for metastatic breast cancer

Between 1982 and 1992, 60 consecutive female patients underwent pulmonary resection for metastatic breast carcinoma. Median age was 58 years (range, 21 to 81 years). The median tumor-free interval after primary breast cancer operation was 2.2 years (range, 7 days to 20.6 years). Thirty-one patients (51.6%) had solitary pulmonary metastases. Forty patients (66.7%) had complete pulmonary resection, which consisted of wedge excision in 33, lobectomy in 6, and pneumonectomy in 1. The remaining 20 patients had incomplete resection, which consisted of wedge excision in all. Altogether, 8 patients (13.3%) had development of postoperative complications, which included pneumothorax, prolonged air leak, pulmonary embolism, retained secretions requiring bronchoscopy, atrial fibrillation, and chest tube site infection. There was one operative death (1.7%). Follow-up was complete in all patients and ranged from 23 days to 10.7 years (median, 3.5 years). Recurrence developed in 32 of the 39 survivors (82.1%) who had complete resection. Median disease-free interval after lung resection was 1.6 years (range, 23 days to 9.3 years). Overall 5-year survival was 37.8% (95% confidence interval, 25.1% to 50.5%). The 40 patients who had complete resection had a 5-year survival of 35.6% (95% confidence interval, 20.4% to 50.8%) as compared with 42.1% (95% confidence interval, 19.0% to 65.3%) for the 20 patients with incomplete resection (p = not significant). Although pulmonary resection is safe, we could not demonstrate improved survival after complete pulmonary resection of metastatic breast carcinoma in this highly selected group of patients.

Benign biliary strictures: Repair and outcome with a contemporary approach

BACKGROUND The Hepp-Couinaud technique is an innovative approach for repair of proximal biliary strictures. We have used this method selectively for bile duct reconstruction since 1982. Our aim was to analyze our experience with the surgical repair of benign biliary strictures in the decade since the Hepp-Couinaud technique has become an integral component of our surgical management strategy. METHODS Seventy-two patients undergoing surgical repair of benign biliary stricture between 1983 and 1992 were reviewed retrospectively. A grading system on clinical symptoms, results of liver function studies, and need for reintervention was used to assess outcome. RESULTS For the 27 patients with noniatrogenic strictures, followed up a mean of 3.9 years, excellent or good results (grade A or B) were obtained in 88.9%. For the 45 patients with iatrogenic strictures, followed up a mean of 4.6 years, 86.7% were categorized as grade A or B. The cumulative probability of anastomotic failure was significantly less for the 21 patients in whom the Hepp-Couinaud method was used when compared with the 24 patients in whom it was not (p = 0.032). Outcome was not influenced by age, time delay from injury to reconstruction, preoperative stenting, the number of previous repairs, or the duration of postoperative stenting. CONCLUSIONS Surgical reconstruction affords excellent or good results for the vast majority of patients with benign biliary strictures. For proximal iatrogenic strictures superior anastomotic durability is achieved with the Hepp-Couinaud technique.

Hemodynamic Performance of Small Aortic Valve Bioprostheses: Is There a Difference?

BACKGROUND There is the potential for left ventricular outflow obstruction when small aortic valve bioprostheses are employed in normal-sized or large adults. It has been hoped that bovine pericardial valves would improve hemodynamic performance in the smaller tissue valve sizes. METHODS To determine in vivo hemodynamic performance of heterograft aortic valve prostheses, we analyzed echocardiographic data from patients receiving 21- or 23-mm Carpentier-Edwards pericardial, Medtronic Intact, and Carpentier-Edwards porcine bioprostheses. In addition, data from 19-mm Carpentier-Edwards pericardial valves were included for comparison of hemodynamic performance between valve sizes. Doppler echocardiography was performed in 151 patients within 2 weeks of operation. Left ventricular outflow gradient was derived from continuous Doppler measurements of flow velocity, and effective orifice area was calculated by the continuity equation. RESULTS There were statistically significant differences in hemodynamic performance of different sized prostheses for each valve type (effective orifice area, p < 0.01; valvular gradient, p < 0.03). There were, however, no significant differences in effective orifice area or mean gradient for different valve types within each size category. CONCLUSIONS The in vivo hemodynamic performance of these three different aortic valve heterograft bioprostheses is similar. Patient-prosthesis mismatch with heterograft prostheses, as demonstrated by the indexed effective orifice area can be avoided by appropriate sizing and use of annular enlarging techniques when necessary.

Mitral valve injury after blunt chest trauma

Isolated mitral valve injury after blunt chest trauma is a very rare event. This disruption, causing sudden and severe mitral regurgitation, will rapidly lead to congestive heart failure and death unless operatively corrected. A high index of suspicion coupled with appropriate diagnostic tests will provide the diagnosis and allow operative correction. We report a patient who survived this injury and review all previous reports of blunt traumatic disruption of the mitral valve.

Carcinoid heart disease and carcinoid syndrome: successful surgical treatment

Tumor debulking can greatly improve quality of life for patients with malignant carcinoid syndrome, but hepatic cytoreduction is confounded by carcinoid heart disease, which can cause postsinusoidal portal hypertension, thereby increasing the risk of death from hemorrhage during hepatic resection. We describe a patient with metastatic carcinoid syndrome and carcinoid heart disease who had repair of his carcinoid heart disease and, after improvement of right-sided heart function, had successful hepatic debulking of carcinoid metastases.