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Seven patients with postpneumonectomy empyema who had had pulmonary carcinoma were treated with intrapleural antibiotic irrigation and closed-chest drainage. Two tubes were used to irrigate and drain the cavity. Although most patients had a bronchopleural or esophagopleural fistula, the treatment was successful in every case. Three of the 7 patients died of far-advanced carcinoma 1 to 2 years postoperatively, but none died of sequela of the empyema. In 3 patients with bronchopleural fistula, empyema recurred during the first postoperative year. However, it responded well to repeated irrigation and drainage. This simple, time-saving, and easily repeatable regimen proved to be both effective and also very comfortable for the patient. It has none of the disadvantages of open thoracic drainage or mutilating thoracoplasty.

Reactive hyperemic response of individual coronary arteries and of the whole heart to anoxia during coronary cannulation was investigated in 10 patients undergoing aortic valve replacement. Reactive hyperemic response in man is identical to that reported in experimental investigations. The duration of hyperemic response was dependent on the length of the preceding period of anoxia; the longer the period of anoxia, the more prolonged was the hyperemic response. No significant collateral circulation between the coronary arteries could be demonstrated during prolonged anoxia of an individual coronary artery. Blood flow debt was almost always overpaid, but the repayment percentage decreased with the lengthening of the anoxic period, being 460 percent after a short period of anoxia (2 minutes), 230 percent after an anoxic period of moderate length (3 to 5 minutes), and only 160 percent after a long period of anoxia (7 minutes). The total mean repayment of blood flow debt of the whole heart was 195 percent.

Intraoperative cardiac output and aortic and left ventricular pressures were measured simultaneously in 15 consecutive patients before and after aortic valve replacement (AVR) with the Bjork-Shiley tilting disc valve. The predominant lesion in these patients was aortic stenosis. The following hemodynamic indices were calculated: aortic valve area (AVA), determined by Gorlin s formula, effective orifice area, and effective area index. Their applicability as hemodynamic criteria of the immediate hemodynamic performance of the replaced valve is discussed. By every criterion, AVR greatly improved the hemodynamic performance. The effective area index seemed more suitable than the other indices for the intraoperative hemodynamic evaluation of the replaced aortic valve.

Thyrotropin-releasing hormone (TRH) has been shown to be present and have actions in the human gastrointestinal tract. We have studied urine TRH immunoreactivity (TRH-ir) levels in healthy subjects and patients with acute pancreatitis, gallstones, ulcerative colitis, or acute gastritis. The urine samples were prepurified by SP-Sephadex-C-25 cation exchange chromatography, subjected to reverse-phase high-pressure liquid chromatography, and assayed in our TRH radioimmunoassay. The mean urine TRH immunoreactivity values of healthy subjects were 4.42 +/- 1 ng/l (x +/- SEM); of patients with acute pancreatitis on the 1st day of hospitalization, 23 +/- 7 ng/l; on the 2nd day, 7 +/- 1 ng/l; and on the 3rd day 9 +/- 2 ng/l. Only the urine TRH levels of the pancreatitis patients on day 1 differed significantly (p less than 0.05) from the levels of the healthy subjects. Circulating TRH appears to be derived mostly from the pancreas, where the islets during acute pancreatitis are affected, and TRH is released into circulation and urine.

The effect of intragastric bile on lower oesophageal sphincter (LES) pressure was studied in 7 dogs. Five ml of fresh canine bile was instilled into the stomach, and its effect on LES pressure and intragastric pH was observed for one hour. In a control study 5 ml of physiological saline was used instead of bile. Bile instillation led to a statistically significant increase in LES pressure, which reached its maximum in 20 min. LES pressure returned to the resting level in 60 min. Saline instillation produced no significant change in LES pressure. The rise in intragastric pH was slight and equal in both groups. The results suggest that bile contamination of gastric juice, at least one of short duration, does not have any immediate harmful effect on LES competence in the dog.

Celestin tube intubation was performed in 108 patients with unresectable carcinoma of the esophagus and cardia, in 83 per cent as the initial operation and in 17 per cent after exploration. The hospital mortality rate was 16 per cent, including a 7.4 per cent mortality rate from technical causes. The most frequent causes of death were perforations of the esophagus and cardia and aspiration pneumonia. Nonfatal complications occurred in 13 per cent of surviving patients, obstruction and dislodgment of the tube being the most common. All patients were able to swallow at discharge, and 91 per cent of them could take food by mouth until the time of death. In 9 per cent, additional palliation, usually esophagoscopy or gastrostomy, was required. Ninety-one patients survived one to 21 months (average 5.8 months). The 6 month survival rate was 44 per cent and the one-year survival 9 per cent.

The effect of hepatic resection, hepatic artery ligation (HAL), and artery ligation combined with regional infusion of 5-fluorouracil (HAL + 5-FU) on liver function was investigated by liver tests including antipyrine in 20 patients with liver cancer. One month after resection the conventional liver tests except serum albumin were normalized, but the rate of antipyrine elimination was still significantly reduced. This suggests that the oral antipyrine test may be a sensitive reflector of the reserve capacity of the liver. Palliative procedures (HAL +/- 5-FU) had a transient effect on conventional liver tests and a negligible effect on functional liver capacity as determined by the antipyrine test or serum albumin concentration. On the basis of our results it remains unknown whether antipyrine determination provides any additional advantage over serum albumin as a measure of functional liver capacity in localized liver diseases, such as liver tumours.

A simplified left atrial-distal aorta bypass for operative treatment of extensive dissecting, Type III, aneurysms of the distal thoracic aorta is reported. In this technique the lower part of the body is perfused through a large cannula placed into the true lumen of the severed distal aorta. The indications and advantages of the method are discussed.

Five geriatric patients with spontaneous rupture of the liver caused by hepatic malignancies were operated upon without mortality. Liver resection seems to be the treatment of choice, but in selected cases with unresectable tumours ligation of the hepatic artery alone is preferable to an attempt to control haemorrhage by packing and suture.

Various factors involved in the structure and functional control of the gastroesophageal antireflux mechanism were investigated experimentally in dogs and in a clinical series, with special attention to manometric examination of the lower esophageal sphincter (LES). The prevention of the compressive action of extrinsic paraesophageal structures did not lead to changes either in LES pressure or in LES response to increases in abdominal pressure. The mechanism intrinsic to the gastroesophageal junction, the LES, seems to be primarily responsible for the maintenance of gastroesophageal competence. Also, the LES response to increased ultra-abdominal pressure appears to be a property of the LES itself. Vagotomy performed at different levels did not produce a change in LES pressure, whereas LES response was significantly attenuated after each type of vagotomy. The vagus nerves apparently have no important role in the maintenance of LES pressure, whereas LES response seems to be mediated by a vagal reflex. Intragastric bile instillation caused a significant rise in LES pressure, but chronic intragastric bile contamination did not lead to changes in gastroesophageal competence. This suggests that intragastric bile contamination does not have a deleterious effect on LES competence and does not seem to predispose to gastroesophageal reflux. Of the drugs generally used in premedication for or induction of anesthesia, atropine decreased LES pressure significantly. Metoclopramide, in turn, produced a significant rise in LES pressure and, when administered before atropine, was capable of preventing the depressant effect of atropine on LES pressure. Thus, routine use of metoclopramide in premedication for or induction of anesthesia to prevent the depressant effect of atropine on LES pressure and the possible consequent gastroesophageal reflux, pulmonary aspiration, and postoperative pulmonary complications should be considered. The mean LES pressure after surgery for reflux esophagitis was significantly greater in patients with an objectively good operative result than in those with an objectively poor result. However, some overlapping occurred in LES pressure values between these two groups. The correlation between LES manometry and other examination methods in the evaluation of the operative result of reflux esophagitis seems to be rather good.

In a prospective, randomized, nonblind clinical trial, single-dose intrarectal metronidazole prophylaxis reduced significantly (p

Arteriosclerotic aneurysm of the thoracoabdominal aorta, involving one or more visceral branches, was successfully operated on in eight patients. Two of the aneurysms had ruptured. The left diaphragm-splitting thoracoabdominal incision through the 8th intercostal space, using a retroperitoneal route, gave unrestricted exposure. A temporary aortofemoral shunt effectively protected abdominal organs and spinal cord from perioperative ischemic damage. The step-by-step reattachment technique into ready-made side limbs in the woven Dacron graft ensured that visceral and renal ischemic times remained within acceptable limits. Perfusion cooling of the abdominal organs was done in one patient in whom shunt could not be used. A standby autotransfusion device was life-saving in another case. All the patients recovered without major complications. Moderate elevation was found as regards serum creatinine levels in seven patients and liver enzymes in four patients, but the values normalized within a month. No paraplegic complications occurred, although all bleeding intercostal and lumbar arteries were ligated intra-aneurysmatically in seven of the eight patients. Seven patients are well 20 to 60 months postoperatively, with patent and well functioning grafts. One patient died of lung cancer after 7 months. Four of the 18 revascularized arteries in three patients were shown by control angiography to be occluded, but without serious sequelae. Our experience suggests that most thoracoabdominal aortic aneurysms are suitable for surgical correction, with acceptable risk. Elective surgery is therefore recommended.

The effects of some drugs generally used in premedication for and induction of anaesthesia on the lower oesophageal sphincter (LOS) pressure were investigated in 30 dogs, using the modern oesophageal manometric technique. In thiopental-induced anaesthesia, a distinct pressure gradient was noted between the LOS and gastric pressure. Atropine eliminated this pressure gradient almost completely. Metoclopramide increased the LOS pressure significantly, and subsequent atropine administration was unable to bring it down. Metoclopramide administered after atropine was unable to elevate the LOS pressure reduced by atropine. Succinylcholine had no observable lasting effect on the LOS pressure. The present findings seem to indicate that of the drugs generally used in premedication for and induction of anaesthesia, atropine significantly reduces the LOS competence, thereby creating favourable conditions for gastro-oesophageal reflux (GOR) and consequent postoperative pulmonary complications. Use of metoclopramide in premedication for or induction of anaesthesia to eliminate the depressant effect of atropine on the LOS pressure appears to be indicated.

Fatal microemboli occurred in 3 of 100 consecutive patients having aortic valve replacement; 2 occurred during perfusion before the microfilter era, and 1 occurred intraoperatively despite the use of in-line filters. In all 3 patients cerebral symptoms were present immediately postoperatively, and each died of severe brain damage. On postmortem examination cerebral calcium microemboli were verified in only 2 patients, although the brain of each patient contained minute infarctions. However, calcium particles were found in the kidneys of all 3 patients. Thus the kidneys proved to be the best place for detection of calcium emboli on postmortem examination. Although the microfilters currently available effectively prevent microemboli during extracorporeal circulation, the surgeon should be aware that embolization can also occur immediately after discontinuation of perfusion. The means of protecting the patient from this are discussed.

Coronary vascular resistance was investigated in 10 patients undergoing aortic valve replacement using continuous constant-pressure coronary perfusion at 32°C. After coronary flow was initiated, resistance was low but increased steadily until it reached a certain resting level. The plateau was attained faster after a short period of anoxia than after a longer period. The initial postischemic resistance was dependent on the duration of preceding anoxia, being of the same magnitude after short and moderate periods of anoxia but significantly higher after a long period. This resistance difference between the groups lasted for the whole perfusion. The total coronary resistance and flow reached a plateau in 30 minutes, while resistance increased threefold but flow decreased to half of the initial postanoxia flow. Our results indicate the importance of initiating coronary perfusion soon after aortic cross-clamping to avoid increase in the initial vascular resistance and subsequent inadequate myocardial flow.

There was good parallelism between serum ferritin levels and the amount of bone marrow stainable iron in 123 patients with gastritis, gastric ulcer and duodenal ulcer. A serum ferritin concentration of about 20-25 micrograms/l is the approximate level below which stainable iron cannot be demonstrated in the bone marrow.