Peter B. Yaw

The Importance of One-Stage Median Sternotomy and Retroperitoneal Node Dissection in Disseminated Testicular Cancer

More than 350 patients with testicular germ cell cancer have been treated with cisplatin combination chemotherapy. Seventy-two with metastases to the thorax who had operation are discussed here. In a subgroup of 24 patients with additional retroperitoneal disease, a one-stage median sternotomy was performed in 18 patients, and a thoracotomy in 6, with retroperitoneal node dissection. Seventeen patients had similar pathological lesions in the thorax and retroperitoneum; in 7, the lesions differed. There was no operative mortality in the entire group. Overall, chemotherapy altered the metastases to mature teratoma in 28 patients, and 27 are long-term survivors. Among 22 patients with fibrotic, necrotic masses, 19 are long-term survivors; 6 of the 22 with persistent carcinoma had chemotherapy postoperatively and are long-term survivors. The overall cure rate for patients with disseminated testicular cancer is approximately 80%. Among those who had a one-stage thoracoretroperitoneal procedure, long-term survival is 83%; for the entire thoracic surgical group, it is 74%.

Autotransfusion of contaminated intraperitoneal blood: an experimental study.

Contamination of blood by bowel contents has been generally assumed as an absolute contraindication to autotransfusion. Since abdominal trauma is frequently accompanied by bowel injury and massive blood loss, a potential major use for autotransfusion has thus been precluded. To test this presumption, autologous blood grossly contaminated with feces was incubated in the peritoneal cavity and then autotransfused in dogs. The animals were hemorrhaged 20, 30, or 40% of their estimated blood volume, producing mild to severe hypovolemic shock. Reinfusion of contaminated blood had little effect on survival with 20 or 30% hemorrhage, but contamination markedly decreased survival with 40% hemorrhage:90% survived without contamination while only 30% survived with contamination. The use of antibiotics in a similar group of dogs subjected to 40% hemorrhage essentially eliminated the risk of autotransfusion: 90% of these dogs survived autotransfusion of contaminated blood.

Clotting competence of intracavitary blood in trauma victims

In order to assess more rationally the requirement for anticoagulation during intraoperative autotransfusion, the clotting competence of blood collected from the body cavities of 31 trauma victims entering our emergency department with indications for intraoperative transfusion was assessed. Blood was collected at thoracotomy or laparotomy prior to the institution of any anticoagulant measures and was assessed for clotting competence, the presence of fibrinogen, the presence of soluble fibrin monomere, and the appearance of fibrin degradation products. The prothrombin time, partial thromboplastin time, and thrombin time of this blood were markedly elevated; fibrinogen was absent; soluble fibrin monomer was absent; and fibrin degradation products were markedly elevated. Blood collected from body cavities is then incoagulable, and we suggest that in the autotransfusion of such a product the need for anticoagulation may be reduced.

Autotransfusion of blood contaminated by intestinal contents

In a series of 183 emergency operations in which intraoperative autotransfusion was used, 14 patients received blood contaminated by intestinal contents. Six of the 14 patients died early in the postoperative period, four of whom had received more than 16 liters of blood. Only two of the eight survivors had received comparable amounts of blood (13 and 17.5 liters). All eight received antibiotics upon admission; four had positive blood cultures within 24 hours of operation. Complications included acute tubular necrosis in three patients and bowel obstruction with intra-abdominal abscess in another. One of the patients with acute tubular necrosis died six weeks later; all others recovered. We believe this procedure may be life-saving in some cases.

The pectoralis major myofascial flap : Clinical applications in head and neck reconstruction

PURPOSE The pectoralis major myofascial (PMMF) flap, a simple variant of the pectoralis major myocutaneous (PMMC) flap, has been underemphasized as a reconstructive method in head and neck surgery. MATERIALS AND METHODS In the present study, we review our experience using 18 PMMF flaps for a variety of reconstructive purposes in 15 head and neck cancer patients treated at a tertiary care hospital. Twelve of the study patients were undergoing surgical salvage of a recurrent cancer, and 10 had received previous radiation. RESULTS The overall rate of flap complications in our series was 22%, and the incidence of major flap complications requiring surgical revision was 11%. CONCLUSION In our experience, the use of the PMMF flap for a variety of reconstructive tasks in the head and neck has been associated with a high overall success rate with avoidance of some of the limitations of the PMMC flap.

Eight years?? experience with civilian injuries of the colon

A chart review of 130 patients with colonic injuries treated between the years 1968 and 1976 were reviewed. Types of operative procedure, complication rate, mortality and hospital stay were tabulated. The patients treated by primary closure and exteriorized primary repair had a 2% mortality, while various staged procedures used in the remaining patients resulted in a 6% mortality. Complications were common in all types of repair and correlated with the severity of the injury. Primary closure of the injured colon can safely be accomplished in carefully selected patients. Staged procedures necessitate a secondary operation which we found to be relatively benign, and we continue to use staged operations in the majority of our patients with colonic injuries. This management protocol has resulted in a 4 to 6% over-all mortality.