Otto Gago

Descending necrotizing mediastinitis: Transcervical drainage is not enough

One of the most lethal forms of mediastinitis is descending necrotizing mediastinitis, in which infection arising from the oropharynx spreads to the mediastinum. Two recently treated patients are reported, and the English-language literature on this disease is reviewed from 1960 to the present. Despite the development of computed tomographic scanning to aid in the early diagnosis of mediastinitis, the mortality for descending necrotizing mediastinitis has not changed over the past 30 years, in large part because of continued dependence on transcervical mediastinal drainage. Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy--is advocated to salvage the patient with descending necrotizing mediastinitis.

The treatment of acute traumatic rupture of the aorta: A 10 year experience

Forty-three patients with aortic rupture secondardy to blunt trauma have been treated at the University of Michigan within the past 10 years with an overall salvage rate of 70%. The diagnosis should be suspected in anyone who has sustained a high speed decelerating injury, if the chest roentgenograrm shows media-stinal widening, whether or not there is hypertension of the upper extremities; systolic murmur, or external evidence of chest injury. Aortography should be employed to confirm the diagnosis and to determine the site or sites of rupture. Repair of the lesion should be undertaken as soon as possible and takes priority in most instances over associated injuries. Repair in almost all cases can be accomplished safely and quickly using a bypass shunt without the aid of extra-corporeal circulation.

Treatment of Bronchogenic Carcinoma with Mediastinal Metastases

Abstract Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 231 patients with bronchogenic carcinoma. Mediastinal metastases were found in 48 patients. Thirty-six of these 48 patients underwent mediastinal irradiation in the immediate postoperative period. Seven of the 36 patients receiving postoperative irradiation lived five years (an absolute five-year survival rate of 19.5%). Of 17 patients with squamous cell carcinoma and mediastinal metastases, 5 lived five years (a five-year survival rate of 29.5%); only 1 of the 17 patients with adenocarcinoma and mediastinal metastases lived five years (an absolute survival rate of 5.9%). No patient who did not receive mediastinal irradiation postoperatively survived five years. The presence of mediastinal lymph node involvement in patients with squamous cell carcinoma of the lung is not a contraindication to resection because long-term survival can be achieved in a significant percentage of these patients.

The Effect of Histological Cell Type on the Prognosis of Patients with Bronchogenic Carcinoma

Abstract Mediastinal lymph node dissection in conjunction with pulmonary resection was performed in 232 patients with bronchogenic carcinoma at the University of Michigan Medical Center from 1959 to 1965. The mediastinum was irradiated postoperatively in those patients with mediastinal metastases. The absolute five-year survival rate of the patients undergoing resection was 29.2%. Of 110 patients with squamous cell carcinoma, 37.2% lived five years free of disease. The overall five-year survival of those patients undergoing resection who had no hilar lymph node metastases was 45.7%, and it was 45% in those with hilar metastases only. The absolute five-year survival rate of the patients with mediastinal metastases who received radiation therapy was 29.5%. Of 76 patients with adenocarcinoma, 19.7% lived five years free of disease. The overall five-year survival of those patients undergoing resection who had no lymph node metastases was 33%, whereas none of the patients with hilar metastases survived and only 1 of 17 patients with mediastinal metastases survived five years free of disease. The findings suggest that the histological cell type is an important factor in determining the prognosis in bronchogenic carcinoma, especially if there is evidence of lymph node involvement. In addition, this study also suggests that it is the presence, and not necessarily the extent, of lymph node metastases in patients with squamous cell carcinoma that determines the survival rate following pulmonary resection, provided those patients with mediastinal metastases undergo postoperative mediastinal irradiation.

Brachial Plexus Injury Following Median Sternotomy Incision

Abstract The median sternotomy approach to intracardiac operations may be associated with damage to the brachial plexus similar to that reported with other types of operations. In 5 patients treated at the University of Michigan Hospital, varying degrees of upper extremity paralysis resulted from excessive spread of the retractors in an attempt to improve exposure of the heart.

The Value of Chest Wall Resection in the Treatment of Superior Sulcus Tumors of the Lung

Abstract The diagnosis of superior sulcus tumor was established in 35 patients at the University of Michigan Medical Center over the sixteen-year period from 1955 through 1970. Twelve patients underwent preoperative irradiation with cobalt 60 followed by radical en bloc excision of the chest wall. None of these patients survived five years. Twenty-three patients received radiation therapy with cobalt 60 only. Three of these patients survived five years free of disease. The absolute five-year survival in the entire group of patients was 8.6%. This study raises the question of the role of radical chest wall excision in the treatment of superior sulcus tumor.

Aggressive surgical treatment for caustic injury of the esophagus and stomach.

Abstract Two patients with severe liquid alkali burns of the esophagus and stomach are reported in whom an early esophagogastrectomy was performed. The value is stressed of an early exploratory operation as a diagnostic as well as therapeutic tool in patients with a history of ingestion of strong liquid alkali.

Clinical Use of Peirce—General Electric Membrane Oxygenator

Abstract The new Peirce-General Electric copolymer membrane oxygenator combined with a Sarns roller pump was used clinically for the first time on 24 children undergoing open-heart operations. The children ranged in age from 5 to 48 months (mean 27 months) and weighed between 3.6 and 16 kg. (mean 9 kg.). The priming volume averaged 120 ml. of blood for the 1-square-meter oxygenator and 240 ml. for the 2-square-meter oxygenator. The duration of perfusion varied from 36 to 180 minutes (mean 96 minutes), depending upon the complexity of the repair. During perfusion, flow rates averaged 127 ml. per kilogram of body weight with a pO 2 average of 350 mm. Hg (range 54 to 670). There was no significant change in acid-base balance during or immediately after the perfusion. Serum hemoglobin averaged 13.1 mg. per 100 ml. preoperatively, increased to 61.4 mg. per 100 ml. at the completion of the perfusion, and decreased to 18.4 mg. per 100 ml. by 24 hours postoperatively. Platelet count preoperatively averaged 228,000 and decreased to 119,000 at the conclusion of the perfusion; it increased to an average of 129,000 twenty-four hours after operation. There was no excessive bleeding postoperatively resulting from coagulation defects. The copolymer membrane has been shown in this group of patients to be an effective, reliable, and safe oxygenator for total cardiopulmonary bypass.

Mechanical Support of the Circulation by a Modified Pulsatile Roller Pump

Abstract A modified roller pump capable of delivering pulsatile blood flow synchronized with diastole provided satisfactory assisted circulation in 14 newborn calves. Hemodynamic studies showed a marked decrease in cardiac stroke work, while cardiac output and coronary flow were maintained at or near control levels. Postperfusion 131 Cs uptake studies showed increased circulation to ischemic myocardium in assisted calves when compared with controls.

Evacuation of Calcific Valvular Debris Using a Standard Ellik Evacuator

A simple but effective technique is described for removing calcific and other debris following aortic and mitral valve replacement. This technique uses an Ellik evacuator , which is readily available in most operating rooms. An 11-year experience is presented, documenting the efficacy of this method in several hospitals.