Paul T. DeCamp

Homologous veins as an arterial substitute: Long-term results

From 1968 through 1982, 129 homologous vein grafts were used in 91 patients in the following positions: 75 in the femoropopliteal, tibial, or peroneal artery; 38 in the aortocoronary artery; 13 in the aortopulmonary artery; and one each in the atrioventricular fistula, carotid-subclavian artery, and brachial-radial artery. In the lower extremity patency ranged from 0 to 121 months (mean 22.4 +/- 4.4 months). All grafts were performed for limb salvage, and 75% of the patients had undergone previous operations. Cumulative patency by the life-table method showed that while 50% of grafts occluded by 1 year, 60% of the remaining grafts continued to be functional for more than 5 years. Fifty percent of the aortocoronary bypass grafts studied were occluded at 1 year. Eight of the 13 systemic pulmonary artery shunts were patent at time of death, revision, or total correction. Multiple revisions and thrombectomies are required to maintain patency of homograft veins. The outcome is variable and unpredictable. The inconsistency is due to the antigenicity of the graft. If one is committed to the necessary efforts required to ensure long-term patency, the homologous saphenous vein is a suitable substitute when autogenous tissue is unavailable.

THE EARLY RECOGNITION OF BRONCHOGENIC CARCINOMA

Although early diagnosis is desirable in practically all illnesses, it is of utmost importance in malignant neoplastic disease. Cancer is primarily a disease of older persons. As a result of better medical care and increased longevity, the older age group in our population has increased, and thus the total number of cancer cases has steadily multiplied in spite of efforts to control and correct precancerous lesions. Of all the cancers of the body, bronchogenic carcinoma is increasing more rapidly than any other. In 1912, Adler (1) was able to collect only 374 cases of cancer of the lung and stated, “On one point, however, there is complete consensus of opinion and that is that primary malignant neoplasms of the lung are among the rarest form of disease.” In the brief span of forty years, primary cancer of the bronchus has become one of the most frequent malignant lesions in general, and is the most frequent malignant lesion in men. In the ten-year period from 1938 to 1948, the deaths from bronchogenic carcinoma in the United States increased 144 per cent (from 6,732 in 1938 to 16,450 in 1948). During this same period, deaths from all types of cancer increased 31 per cent (from 149,214 in 1938 to 195,594 in 1948). From 1920 to 1948, the death rate from bronchogenic carcinoma in theunited States increased over ten times (1.1 per hundred thousand population in 1920 to 11.3 per hundred thousand in 1948). The proportion of deaths from cancer of the lung to all cancer deaths has also increased throughout the years. In 1920, lung cancer represented 1.1 per cent of all cancer deaths; in 1930, 2.2 per cent; and in 1948, 8.3 per cent. We have the temerity to predict that if the increase in the incidence of bronchogenic carcinoma continues proportionately as it has up to the present time, in 1970 it will represent 18 per cent of all cancers, or almost 1 in 5. It is obvious, therefore, that the early recognition of bronchogenic carcinoma is imperative, provided, of course, that something can be accomplished if such recognition is made early. That bronchogenic carcinoma is a disease primarily of older persons is illustrated by our experience in 1,122 cases, of which 38 per cent were in the sixth decade and 40 per cent in the seventh decade; only approximately one-fourth were less than 50 years of age. Overholt (2) and others (3,4) have shown that the resectability of lung cancer can approach 100 per cent if the diagnosis is made and treatment instituted early, even before the patient has symptoms. In this consideration, one should define what is meant by early recognition. The desideratum, of course, is recognition of the condition early in the course of the disease, which does not necessarily mean shortly after the onset of symptoms. There is undoubtedly a great deal of variation in the rate of growth of bronchogenic carcinoma, since it has been our experience that not infrequently patients who have had symptoms for a considerable period of time have operable lesions

Prevention and Management of Acute Cholecystitis

Acute cholecystitis is a common, serious disease of the biliary tract. Since recognizable chronic symptoms usually precede these attacks, dangerous acute cholecystitis can be largely prevented by performance of cholecystectomy as soon as the stones are discovered, particularly if symptomatic.

The Postphlebitic Syndrome

Etiology By definition, the initiating etiologic factor is extensive thrombophlebitis which may occur spontaneously or following a precipitating episode such as operation, parturition, systemic infection or trauma. Classically the acute attack is accompanied by severe pain, swelling and fever. Actually the initial symptoms are frequently mild and the onset may be marked only by the insidious appearance of edema. In diagnosis caution must be exercised because studies in our clinics indicate that occasionally chronic edema and all the complicating features usually associated with the postphlebitic syndrome may occur spontaneously or following injury in the absence of any anatomic or physiologic evidence of venous thrombosis. In view of this, it is difficult to assess accurately the relative importance of venous thrombosis and recanalization, as against secondary factors such as infection or trauma in the development of the subsequent postphlebitic syndrome.