W. Glenn Young

BRONCHIAL CARCINOID TUMORS: A RETROSPECTIVE ANALYSIS OF 126 PATIENTS

From 1970 until 1990, 8,958 cases of primary carcinoma of the lung were diagnosed at the Duke University Medical Center. During the same period, 126 patients (mean age, 53 +/- 13 years) were diagnosed with bronchial carcinoid. The overall survival was 78% for 5 years and 71% for 10 years. Surgical treatment in 106 patients included pneumonectomy (15), lobectomy (63 with 9 bronchoplastic procedures), stapled wedge resection (22), and bronchoscopic laser resection (6). The method of diagnosis was chest roentgenography (121), chest computed tomography (77), mediastinal tomography (31), bronchoscopy (81), bronchoscopic brushing and washing (50), bronchoscopic biopsy (40), transthoracic needle biopsy (27), thoracotomy (100), and autopsy (5). Univariate analysis of the medical history, presenting signs and symptoms, diagnostic test results, and pathologic data predicted improved survival (p less than 0.001) for: female sex (n = 58), asymptomatic presentation (n = 47), normal serum serotonin or urinary hydroxyindoleacetic acid levels (n = 76), peripheral location of the primary tumor (n = 50), pathologic stage I or II (n = 91), negative lymph nodes (n = 80), primary tumor 2 cm or less in diameter (n = 67), and typical histology (n = 80). No significance (p greater than 0.1) was observed for age, smoking history, race, family history of carcinoid, environmental exposure, or hemoptysis. The most important factors affecting survival defined by multivariate analysis were (p less than 0.01) pathologic stage, atypical histology, and asymptomatic presentation. Bronchial carcinoid tumors are unique, making up 1% to 2% of primary lung neoplasms and having an excellent prognosis after resection with a 95% 5-year and 93% 10-year survival for pathologic stage I disease.

Surgical Management of Congenital Coronary Artery Fistula

Abstract Twelve patients with congenital coronary artery fistula are reported. Angina, heart failure, cardiomegaly, and electrocardiographic abnormalities were frequent findings. All patients had the fistula demonstrated angiographically, and the flow through the fistula in 8 patients produced an average pulmonary-to-systemic flow ratio of 2.2 to 1. Eleven patients had surgical closure of the fistula, and all survived with no evidence of subsequent myocardial ischemia. Relief of symptoms, reduction in heart size, and improvement in the electrocardiogram were documented postoperatively. Catheterization of a patient two years following obliteration of the fistula demonstrated normal size and function of a previously massively dilated coronary artery. The relief of symptoms, correction of hemodynamic abnormalities, low operative mortality, and threat of serious complications all emphasize the importance of surgical correction of this condition.

Determinants of reoperation after 960 valve replacements with Carpentier-Edwards prostheses

During the period of 1977 to 1990, 960 Carpentier-Edwards standard prostheses (Baxter Healthcare Corp., Santa Ana, Calif.) were placed in 875 operations. Freedom from reoperation at 10 years was 57% +/- 4%, 76% +/- 3%, and 95% +/- 5% for mitral, aortic, and tricuspid valve replacement, respectively. Age was the only independent determinant of reoperation for both aortic and mitral valves. Likelihood of reoperation decreased with age, with freedom from reoperation after 10 years in patients aged less than 60 years versus 60 or more years being 65% +/- 5% versus 90% +/- 4% after aortic valve replacement and 48% +/- 5% versus 75% +/- 6% after mitral valve replacement. For mitral valve replacement, larger valve size made reoperation more likely, with freedom from reoperation at 10 years being 71% +/- 6% for sizes median less than 31 mm and 57% +/- 5% for sizes 31 mm or larger. For aortic valve replacement, prior median sternotomy reduced freedom from reoperation at 10 years from 80% +/- 3% to 25% +/- 5%. The low prevalence of reoperation affirms the suitability of the Carpentier-Edwards prosthesis for selected elderly patients and for tricuspid valve replacement. Because of their influence on the probability of reoperation, valve size and prior cardiac procedures also merit consideration in the choice of valvular prosthesis.

Colon interposition for esophageal substitution.

Abstract Restoration of alimentary tract continuity after destruction or removal of the esophagus may be accomplished by several methods, one of these being interposition of a segment of colon. This operation may be required for congenital anomalies; chemical burns; resection of stricture, varices, or tumor; or bypass of inoperable carcinoma. The right, transverse, or left colon may be used; the pattern of the blood supply may be the determining factor. The retrosternal route is generally preferred, but the colon segment may be placed intrathoracically or subcutaneously. The major complications directly related to operation are gangrene of the colon segment and anastomotic leakage. The mortality following operation for benign disease is 7.5%; for malignant disease it is 24.5%.

Studies of Blood Flow in Aorta-to-Coronary Venous Bypass Grafts in Man

Pressure-flow measurements were obtained from the vein graft of 57 patients undergoing a single aorta-to-coronary bypass procedure. The flow contour was similar to phasic left coronary artery flow in dogs except for a transient increase during systole possibly related to elongation of the graft. Flow was highest during bypass and decreased to a stable value 30 min after bypass. In 42 patients, flow at this time was 35+/-2 cm(3)/min (mean+/-sem).NO CORRELATIONS WERE DEMONSTRATED BETWEEN FLOW AND THE FOLLOWING: left vs. right grafts, presence or absence of collaterals, total vs. partial block, or the presence or absence of ventricular dyskinesis. In 32 patients, no correlation between these anatomic findings and the presence of reactive hyperemia was demonstrated. In 17 patients, occlusion of the graft for 10 sec resulted in a mean 51.5% flow debt repayment. In nine patients, injection of 0.3 mug of isoproterenol into the graft increased flow from 45+/-6 to 69+/-9 cm(3)/min within 4-7 sec without changes in rate, pressure, time derivative of left ventricular pressure (LV dp/dt), or left ventricular end diastolic pressure (LVEDP). Maximum increases to 87+/-10 cm(3)/min occurred 12-20 sec after injection with concomitant changes in these parameters. Intravenous infusion of norepinephrine did not change vascular resistance, whereas phenylephrine did. In six patients, injection of 0.2 mug of norepinephrine into the graft decreased flow from 49+/-6 to 25+/-5 cm(3)/min within 5-8 sec. Intravenous infusion of 0.15 mg of nitroglycerin decreased coronary vascular resistance from 2.7+/-0.4 to 2.3+/-0.3 mm Hg/cm(3) per min. In five patients, 0.12 mg of nitroglycerin injected into the graft increased flow from 46+/-7 to 71+/-13 cm(3)/min and lasted 20-40 sec.

In-hospital and long-term outcome after porcine tricuspid valve replacement

Porcine bioprostheses are often used for tricuspid valve replacement, yet the long-term outcome after this procedure is not well documented. Therefore, the records of 129 patients undergoing tricuspid valve replacement with Carpentier-Edwards (n = 88) or Hancock (n = 41) prostheses between 1975 and 1993 were reviewed. The operation required a repeat median sternotomy in 66 of 129 (51%) patients, whereas 67 of 129 (52%) underwent double or triple valve replacement. Operative mortality was 14% (2/14) in patients undergoing first-time isolated tricuspid valve replacement and 27% (35/129) overall. Survival at 5, 10, and 14 years was 56% +/- 5%, 48% +/- 5%, and 31% +/- 9%, and freedom from tricuspid reoperation at 5, 10, and 14 years was 96% +/- 3%, 93% +/- 4%, and 49% +/- 17%. No valve thrombosis was observed. In this largest reported series of porcine bioprostheses in the tricuspid position, long-term freedom from valve-related events was excellent because of a low incidence of valve thrombosis and a valve durability of 13 to 15 years in a population with limited life expectancy.

Esophageal Intramural Diverticulosis

Abstract This paper presents 3 patients with esophageal intramural diverticulosis and discusses the roentgenographic, manometric, histological, and microbiological picture attendant to this disease. Evidence is given to support chronic infection of esophageal submucosal glands as the predominant cause.

Alveolar Cell Carcinoma of the Lung: A Retrospective Analysis of 205 Patients

From 1970 to 1986, survival of 205 patients with alveolar cell carcinoma was retrospectively studied. Analysis examined the predictive value of presenting symptoms and diagnostic screening results for pathological Stage III or IV disease (advanced) and survival. The lesion presented as a peripheral mass in 121 patients (59%) and as an infiltrate in 84 (41%). Follow-up data were available on 199 patients (97%). Variables analyzed included indices of background or risk factors, presenting symptoms, diagnostic test results, and clinical management. Seventy-nine patients (39%) had a histological diagnosis of advanced disease by TMN staging criteria. Of the 152 deaths (74%), 117 (77%) were related to the pulmonary carcinoma. Univariate analysis associated short-term and long-term anorexia, weight loss, generalized weakness, and profound dyspnea with advanced disease and ultimately with death due to cancer. Multivariate logistic regression analyses suggested that weight loss and dyspnea disclosed independent information about the likelihood of advanced disease for this population (p less than 0.0003). Cox proportional hazard regression analyses of survival revealed a significant association between weight loss and death due to alveolar cell carcinoma after pathological stage was taken into account (p = 0.001). In this series, the 80 patients with Stage I disease had the best prognosis (5-year survival of 55%). There was no significant difference in disease-free survival between patients having wedge resection (N = 17) and those having lobectomy (N = 63) for Stage I disease.

Complete and incomplete revascularization at aortocoronary bypass surgery: Experience with 392 consecutive patients

Abstract This report presents our experience with “complete” and “incomplete” revascularization in 392 consecutive patients undergoing aortocoronary artery bypass surgery. Patients were considered to have had “complete” revascularization only if all major coronary arteries with 70 per cent occlusion received at least one bypass graft. Patients were considered “incompletely” revascularized if any vessel with a 70 per cent or more occlusion did not receive at least one bypass graft. The “completely” revascularized cohort contained 186 patients and the “incompletely” revascularized cohort contained 206 patients. The survival of the “completely” and “incompletely” revascularized cohorts was compared postoperatively and at 6, 12, and 24 months using the Chi-square test. Relief of anginal pain rates were compared at 6, 12, and 24 months using the Chi-square test. Analyses were repeated after stratifying for number of vessels diseased. The subgroup with one vessel diseased was, by definition, “completely” revascularized. No significant difference in survival or relief of anginal pain was demonstrated in the total group or in subgroups with 2 and with 3 vessels diseased. The data indicate that “complete” revascularization is not closely coupled to two-year survival or relief of anginal pain.

The Modern Use of Thoracoplasty

Thoracoplasty is a time-honored but, at present, rarely indicated procedure for reducing thoracic cavity volume. This study reviews a series of 30 patients treated with thoracoplasty over a 14-year period (1970 through 1983). Indications were to close a persistent pleural space in 28 patients and to tailor the thoracic cavity to accept diminished lung volume concomitant with a pulmonary resection in 2 patients. Persistent pleural space, often associated with a bronchopleural fistula (24 patients), occurred after operation in 19 patients: following pulmonary resection in 17 patients, resection of mesothelioma in 1 patient, and following decortication without resection in 1. In the remaining 9 patients with a persistent pleural space, problems developed from primary lung destruction due to tuberculosis (4 patients), postpneumonic empyema (1 patient), or as late infection of a residual pleural space many years after therapeutic pneumothorax and collapse therapy for tuberculosis (4 patients). The overall success rate of thoracoplasty in eliminating intrathoracic space problems was 73%. There were 3 deaths (10%) and 5 failures to heal, representing a 33% failure in the first half of the series (to 1976) and a 17% failure rate thereafter (1 death and 1 nonhealing patient). The primary underlying disease was tuberculosis in 23 patients, 8 of whom had concomitant aspergilloma and 1, atypical tuberculosis. The failures were analyzed and reviewed to clarify the principles for the successful use of thoracoplasty. It is concluded that thoracoplasty is a rarely required salvage-type procedure applicable to moderately debilitated patients in whom it is considered desirable to eliminate open drainage.(ABSTRACT TRUNCATED AT 250 WORDS)