Thomas B. Ferguson

The treatment of malignant pleural effusions.

One hundred thirty‐three patients with 154 treated malignant pleural effusions were reviewed. Carcinoma of the breast, bronchogenic carcinoma, and lymphomas were the most frequent tumors causing malignant pleural effusion. Cytologies were positive in 67% of the 125 effusions examined. Local treatment consisted of thoracentesis, tube thoracostomy with or without nitrogen mustard instillation, irradiation, or pleurectomy. Patients were followed for recurrence of effusion and return of symptoms for an average of 6 1/2 months. Statistical analysis showed that 37% of 66 hemithoraces (60 patients) treated with tube thoracostomy and nitrogen mustard were free of effusion 3 months after treatment, and 29% 6 months after therapy. Fifty‐three percent of these patients were asymptomatic at 6 months, and 39% at 1 year after treatment. Thoracentesis with or without nitrogen mustard instillation was distinctly inferior to the tube and nitrogen mustard method. Pleurectomy in selected cases proved worthwhile.

Oat cell carcinoma of the lung: A review of 138 cases

All cases seen during the 11 years from 1956 through 1966 are reviewed. They comprised 10% of the bronchogenic cancer population. Males predominated 19:1. There was no positive correlation with cigarette smoking. In most of the patients symptoms were present less than 3 months before diagnosis. Only four patients (3.0%) had overt hypercoticism. Histologic confirmation was easily obtained; bronchoscopic biopsy was positive in 60% of the cases. Our operability rate (60%) and resectability rate (27%) are almost as high as for epidermoid carcinoma; others have reported much lower rates. There are two 5‐year survivors, the only asymptomatic patients in the series. In both, the tumor already had prominent vascular invasion, and one had regional lymph node involvement. The survival rate was 5.4% of the resected patients and 1.4% of the total group.

Intraaortic balloon counterpulsation: Patterns of usage and outcome in cardiac surgery patients

Between January 1, 1986, and May 6, 1991, 7,884 cardiac surgical procedures requiring cardiopulmonary bypass were performed at our institution, including 672 (9.8% of adult procedures) performed in 669 patients that were associated with preoperative (n = 240), intraoperative (n = 353), or postoperative (n = 79) use of an intraaortic balloon pump. The mean age of recipients was 65.3 years (range, 16 to 89 years). Intraaortic balloon pump usage increased during the study period from 6.4% of patients (83/1,298) in 1986 to 12.7% of patients (169/1,333) in 1990. The relative distribution between preoperative (mean, 35.7%), intraoperative (52.5%), and postoperative (11.8%) insertion remained nearly constant during the study period. The overall operative (30-day) mortality for patients with preoperative, intraoperative, or postoperative insertion of the intraaortic balloon pump was 19.6%, 32.3%, and 40.5%, respectively (X2 = 16.4; p less than 0.001). Although use of the intraaortic balloon pump in the intraoperative and postoperative settings is accompanied by a favorable outcome in most patients, the high associated mortality suggests the need for earlier use of the intraaortic balloon pump or other supportive measures such as the ventricular assist device.

Percutaneous Transthoracic Aspiration Needle Biopsy

An experience based on 1,211 patients has shown aspiration needle biopsy to be a valuable technique for diagnosing bronchogenic carcinoma and other localized intrathoracic lesions that are beyond the reach of the fiberoptic bronchoscope. In 896 patients with malignant intrathoracic neoplasm, the aspirate demonstrated malignant cells in 96%. A false cytological diagnosis of carcinoma occured in 2 patients, for a true positive rate of 99%. However, the true negative rate was only 87%. In 77% of 31 immunosuppressed patients, the causative agent of a focal infectious process was diagnosed. Pneumothorax was the only notable complication, occuring in 24% of patients, with 14% requiring chest tube drainage. The procedure is relatively simple and rapid, generally causes little patient discomfort, and can be performed in virtually any hospital.

Adenocarcinoma of the lung in men. A clinicopathologic study of 100 cases

One hendred adenocarcinomas of the lung were studied. Adenocarcinoma accounted for 9% of primary pulmonary malignancies in men examined for this study. Clinical features included peripheral location (65%), frequent lack of symptoms (28%), and difficulty in making a diagnosis prior to thoracotomy. Seventy‐one per cent of the adenocarcionmas were resected with only 9% 5‐year cures. Vascular invasion, pleural invasion, and degree of tumor differentiation were of no prognostic significance, but metastasis to lymph nodes and large tumor size were adverse factors. Almost half of the adenocarcinomas were associated with pre‐existent pulmonary scars, with transition from atypical metaplasia to carcinoma. Scar‐associated carcinomas seemed to have a more favorable prognosis. Reasons for the low cure rate are unclear. The incidence of lymph node and vasular nvasion is comparable to other bronchogenic and “recurrences” or “pulmojnary metastasis” may represent second primaries arising in such foci.

Recurrent Left Atrial Myxoma Report of a Case

Recurrence of a left atrial myxoma 6 years after the initial resection is reported. This, to our knowledge, is the second such case, and it emphasizes the need for a complete resection of the underlying atrial septum or atrial wall in cases of myxoma.

The use of the TDMAC-heparin shunt in replacement of the descending thoracic aorta.

The use of a flexible polyvinyl tube bonded with tridodecylmethylammonium-heparin (Gott) as a temporary shunt during the resection of lesions of the descending thoracic aorta has proven a safe and simple means of providing adequate circulation to the abdominal viscera and spinal cord. This technique avoids the metabolic consequences of ischemia to the lower body, diminishes left ventricular afterload during aortic clamping, and obviates the requirement for systemic anticoagulation associated with pump bypass. Between September 1970 and October 1974, 24 patients have been operated using the TDMAC shunt. There were two deaths (9%) among the 22 patients undergoing elective resections. Two patients with acutely dissecting and ruptured aneurysms expired. Followup data has been obtained on all patients from one to 46 months postoperative. The ease with which the shunt is inserted and its adaptability to varied clinical and anatomic situations is stressed. We feel that TDMAC-Heparin shunt provides the best method of circulatory support for elective operative procedures on the descending thoracic aorta.

Thoracic Aneurysmectomy Utilizing the TDMAC-Heparin Shunt

Abstract Clear heparin-bonded polyvinyl shunts were used during resection of descending thoracic aortic aneurysms for one year from July, 1970, through June, 1971. Eight patients were operated upon with 7 survivors; the single death was that of a patient with a rupture into the left pleural cavity. In our experience the use of this shunt is superior to techniques of temporary support that require systemic anticoagulation and pump bypass. The TDMAC-heparin shunt is simple and safe to use and adaptable to many anatomical situations; it provides ample distal blood flow and eliminates the need for systemic heparinization. Based on this initial rewarding experience, we believe this shunt offers advantages over all other techniques now being used for intraoperative circulatory support during descending thoracic aneurysmectomy.

Transbronchial catheterization of pulmonary abscesses

A major indication for bronchoscopy in patients with pulmonary abscess is the need to establish adequate drainage. Often, associated bronchial swelling precludes direct entry into the cavity with standard suctioning devices. Satisfactory drainage may require numerous bronchoscopic procedures, prolonging hospitalization and subjecting the patient to the complications of pyogenic pulmonary abscess. We have recently adopted the technique of passing angiography catheters through the rigid bronchoscope into the abscess cavity, thereby facilitating the bacteriological diagnosis and drainage of the cavity.

Laboratory and initial clinical studies of nifedipine, a calcium antagonist for improved myocardial preservation.

This report summarizes five years of laboratory investigations and the initial six-month clinical experience with a calcium antagonist, nifedipine, added to a cold hyperkalcmic cardio-plcgic solution for enhancement of myocardial protection. Regional ischemia was created in 112 dogs and global ischemia in 98 dogs, under normothermic and two hypothermic states. Control solutions, two clinical cardioplegic solutions, and nifedipine solutions were compared. Infusion of nifedipine during regional ischemia and repcrfusion intervals resulted in a two-to-thrccfold reduction in injury volume and maintenance of normal left ventricular function in contrast to infusion of nitroprusside. Nifedipine solutions (0.2 μ/ml) provided superior preservation of left ventricular function in comparison to the two cardioplegic solutions after one hour of global ischemia at 37 C and two hours at 18 C. In a clinical trial of nifedipine in cold potassium cardioplegia, 38 high risk patients with poor ventricular function have been treated; 22 of which were intensively studied serially with radionuclide ventriculography and pyrophosphate scans, myocardial isoenzyme determinations, 24 hour EKG recordings and intra-and postoperative hemodynamic studies. Of the 35 patients admitted to the intensive care unit (ICU), 33 have survived. Stroke work and cardiac indices return promptly to near normal levels after operation. The time-isoenzyme activity curves are low and radionuclide determined ejection fractions show no change for the study group. Death from acute postischemic cardiac failure did not occur in treated patients and the usage of intra-aortic balloon pump (IABP) has decreased threefold in comparison with 40 similar high risk patients treated concurrently with cardioplegic solution alone. It is concluded that nifedipine is a potent adjunct to cold hyper-kalemic cardioplegic solution in high risk patients.