Theodore Drapanas

Tracheo-innominate artery erosion: Successful surgical management of a devastating complication.

Successful management of a patient with tracheo-innominate artery erosion requires the rapid institution of specific resuscitative and operative measures. Ten patients seen at the Charity Hospital of Louisiana in New Orleans and 127 documented cases from the world literature were analyzed regarding predisposing factors, diagnostic features, resuscitative measures and operative treatment. Diagnoses associated with abnormal neck positioning were seen in 48% of patients with tracheo-innominate erosions. In 69% of 96 instances, the site of erosion was located at the cannula end and implicates excessive anterior pressure. Caution is recommended in those patients with abnormal neck positions, low placed tracheostomy stomas and individuals with asthenic habitus. Resuscitative measures were highly successful when the tracheal balloon was inflated or when the method of retrosternal finger pressure was used. All personnel providing care for patients with tracheostomies should be aware of the initial measure of balloon inflation. Operative measures which permanently interrupted the innominate artery in the area of possible future erosion were the most successful. Of the 22 cases in which the innominate artery was sacrificed, only one had evidence of cerebral ischemia. Timely institution of proper measures can result in salvage of an unexpected number of these otherwise dramatic fatalities.

Acute sigmoid volvulus. Concepts in surgical treatment.

Abstract 1. 1. A series of forty patients with seventy-one admissions for acute sigmoid volvulus was described. A total of 116 episodes were treated. 2. 2. Nonoperative decompression with a sigmoidoscope and a rectal tube was successful in eighty-two episodes of acute sigmoid volvulus in ninety-eight attempts with only one death which was apparently unrelated to the procedure. In no instance did failure of this treatment appear to complicate the subsequent operative treatment performed. Mortality from operative detorsion was 30 per cent; in primary resection, it was 50 per cent. 3. 3. An analysis of the recurrence rate reveals that 60 per cent of patients had two or more episodes of acute sigmoid volvulus which required treatment. This suggests that definitive resection of the redundant colon should be the ultimate goal of therapy. 4. 4. A rational treatment based on nonoperative decompression of the acute, nonstrangulated episode of sigmoid volvulus is discussed.

Minute pulmonary chemodectoma

The minute chemodectomas of the lung belong to the paraganglioma group of neoplasms, which include carotid and aortic body tumors. They are frequently multiple, small in size, and are nearly always detected fortuitously on histologic examination of sections of a lung taken from an older patient. They are believed to arise from the normal chemoreceptors of the lung. There is no indication that these small neoplasms are functional. It has been proposed that pulmonary chemodectomas may be induced by pulmonary thromboemboli. This possibility gains some support from an analysis of 10 new cases and a review of 46 cases previously reported.

Congenital Cystic Lesions of the Bronchi and Lungs

Abstract A consecutive series of 18 patients with bronchogenic or congenital lung cysts confirmed by operation or postmortem examination is reviewed. Thirteen patients had bronchogenic cyst, and 6 of them were symptomatic: 4 patients had acute or chronic infections and 2 had respiratory distress with hyperinflation of one lung. All 5 patients with congenital lung cyst had symptoms of chronic or repeated respiratory infections. Seventeen patients had operations for removal of their cyst; complications occurred in 6 patients, and there was 1 operative death. One patient died of acute respiratory insufficiency without having had an operation. The need for prompt recognition and immediate excision of bronchial cysts that are compressing a bronchus and causing respiratory distress is emphasized. The results of operation are reviewed. Removal of cysts, even when asymptomatic, is recommended.

Reactive edema and necrosis after restoration of blood flow in the limb

Abstract A model for study of the extremity having temporary circulatory interruption by a tourniquet and followed by restoration of blood flow has been used to evaluate the possible protective effects of local hypothermia and dexamethasone phosphate to prolonged circulatory arrest in the limb. Adult guinea pigs were consistently observed to develop edema after restoration of arterial flow after 3–4 of hindlimb ischemia. Cooling the limbs to 5–15°C during injury, administration of dexamethasone phosphate prior to or after injury, and a combination of hypothermia and dexamethasone phosphate prior to injury failed to prevent the edema. All animals not protected by hypothermia and observed for more than 24 hours developed necrosis and gangrene of the injured leg. Animals treated with local cooling during injury all survived with viable limbs. Results of this study fail to confirm a protective effect of either local hypothermia or dexamethasone phosphate in preventing the edema after the injury described. However, local hypothermia does consistently prevent necrosis after such injury. The possible clinical application of local hypothermia for limbs subjected to prolonged ischemia deserves further inquiry.