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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.

Heikkinen, E. S., Simila, S., Laitinen, J. and Larmi, T. (Departments of Surgery, Paediatrics and Roentgenology, University of Oulu, Oulu, Finland). Infantile aneurysm of the ductus arteriosus. Acta Paediat Scand, 63:241, 1974.–A neoplastic-like density on X-ray is not a rare diagnostic problem in infancy. Nevertheless, knowledge about the infantile ductal aneurysm (IDA) producing a characteristic tumour-like mediastinal shadow on plain chest film is very limited. In 1972 the authors operated two newborns because of left-sided tumour-like mediastinal shadows produced by IDA. A very similar radiographic mass according to location, shape and opacity could he discerned retrospectively on the chest films of 10 other neonates in a material of 1 138 newborn babies, who had been radiographed mainly for respiratory troubles. Apparently the IDA is not so rare as considered in the literature. The patients presented herein were found during their first day tb have inadequate ventilation, a low Apgar score and respiratory acidosis. Therefore postnatal hypoxaemia was considered the most probable primary factor in the pathogenesis of IDA. A follow-up examination at the age of 6–24 months showed that the typical tumour-like mediastinal shadow had disappeared also in the non-operated patients. A spontaneous, uncomplicated involution seems to he the most usual outcome of IDA. HOWever, according to the literature IDA is a potentially dangerous abnormality. It calls for meticulous observation since surgical intervention is indispensable if fatal complications seem imminent.

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.

In this report we shall describe a case of aneurysm of the transverse aortic arch with no involvement of the proximal ascending aorta. The patient was operated upon successfully. Serious compression of the trachea causing pneumonia was the indication for emergency surgery. A new simplified technique for prosthetic replacement of the aortic arch is described: With the aid of cardiopulmonary bypass, a permanent bypass graft was inserted from the aorta to the brachiocephalic and left carotid arteries. The potential uses and advantages of the technique are briefly discussed.

A case is presented in which a Delrin occluder from a tilting-disc aortic valve prosthesis was found to be shrunken and degraded at autopsy. Shrinkage of the Delrin disc apparently was the indirect cause of death after a second operation performed for mitral valve insufficiency. During mitral valve replacements noncontrollable leakage caused by the Delrin occluder led to ischemic damage of the myocardium, resulting in a fatally low cardiac output. A similar shrinkage of the Delrin occluder was observed in four unused but autoclaved tilting-disc aortic valve prostheses; angulation was noted in one of these valves. The conclusion was drawn that Delrin should be discarded as occluder material.

In a random group of 20 dogs undergoing a 3-hour extracorporeal circulation bypass with a standard flow rate of 100 ml/min/kg, a significant relationship was observed between the changes in increased levels of SGOT, SGPT and BSP retention, in decreased levels of liver microsomal enzymes oxidizing chlorpromazine and pethidine and venous pH, pO2. and oxygen saturation and increased levels of venous pCO2. The conclusion was drawn that oxygen supply to the liver, hypercarbia and acidosis during cardiopulmonary bypass are partly responsible for these changes, and that haemolysis, haemo-dilution, anaesthesia and operative trauma also affect the serum enzymes.

Summary Human liver microsomes isolated from operation biopsy samples from patients with cholelithiasis or a malignant disease, were studied with respect to a drug-oxidizing monooxygenase system. The human liver contained about 30-40 mg of microsomal protein per gram of wet weight and about 50% of that was recovered in the microsomal fraction. The mean levels of cytochrome P-450, NADPH-cytochrome c reductase and cytochrome b5 in the livers of cholelithiatic patients were essentially similar to those in the livers of rat and guinea pig and only slightly lower than those in the rabbit liver. The cytochrome P-450-carbon monoxide difference spectrum exhibited a peak at 450 nm and, in microsomes from several smokers, no peak shift to 448 nm was evident. Studies with ethyl isocyanide as a ligand revealed a typical difference spectrum with a peak ratio at pH 7.4 of 455/430 nm of 0.46 and a pH intercept of at about 7.9. There was no correlation between cigarette smoking and a peak ratio. Drug-induced interactions of type I (SKF 525A, bromobenzene), type II (aniline, n-octylamine, KCN) and reverse type I (phenacetin, n-butanol) variety were detected in liver samples studied. Hexobarbital and aminopyrine gave either type I or reverse type I spectral changes. The spectral dissociation constant for aniline was of the same order of magnitude as in rat liver microsomes. These studies seem to indicate that although qualitative differences between hepatic monooxygenase systems in man and laboratory animals may exist, available evidence suggests that many essential differences are only quantitative in nature.

The literature on primary leiomyosarcoma of the vein is reviewed and a new case is presented. The disease is extremely uncommon, and only 40 cases have been published. Of these tumours, 25 were located in the caval vein and 16 in a peripheral vein. Pre-operative diagnosis is very difficult. The symptoms depend on the localisation of the venous obstruction produced by the tumour and on the completeness of the obstruction. Operative therapy should be given priority, and the results especially for peripheral vein tumours are satisfactory, despite the tendency to later metastases. The haemody-namic discomfort caused by radical excision of the tumour is slight, especially if collaterals have had time to develop.

5-Hydroxytryptamine (5-HT) was infused intra-cavally in 7 patients at a rate of 800 µg/min during thoracotomy. Samples were aspirated prior to resection of the lung through cannulas introduced into the main common pulmonary artery and vein, both before the infusion and 10 min and 15 min after its start. Brachial and pulmonary artery pressures, pulse rate and electrocardiogram were recorded at the same time. Degradation of 5-HT was found to occur throughout the circulation; thrombocytes were apparently able to inactivate almost all the infused 5-HT by means of their absorption mechanism. The proportion inactivated by the lungs was, at the most, one-third. The majority of the infused 5-HT which passed through the pulmonary barrier, was probably in an inactive form in the thrombocytes, since its influence on systemic blood pressure was slight.

SUMMARY Sixty patients were given thiopentone sodium in a single intravenous “sleep-dose” of 2–8 mg per kg body weight during induction of routine oxygen-nitrous oxide-halothane anaesthesia. The prothrombin index was determined prior to premedication, immediately after operation and 24 hours postoperatively. An average, but clinically insignificant, fall in the prothrombin index was discovered, being especially marked 24 hours postoperatively. The alterations in the prothrombin percentage, however, seemed to follow a pattern in which lower doses of thiopentone mostly caused a rise, whereas larger doses were followed by a reduction in the prothrombin index. ZUSAMMENFASSUNG 60 Patienten erhielten Thiopenton-Natrium als intravenose Einschlafdosis von 2 bis 8 mg pro kg Korpergewicht wahrend der Einleitung einer ublichen Sauerstoff-Lachgas-Halothan Narkose. Der Prothrombinindex wurde vor der Praemedikation, unmittelbar nach der Operation und 24 Stunden postoperativ bestimmt. Es wurde ein durchschnittlicher, aber klinisch insignifikanter Abfall des Prothrombinindex entdeckt, der 24 Stunden nach der Operation besonders deutlich war. Die Veranderungen des Prothrombin-Prozentsatzes schienen jedoch einem Muster zu folgen, bei welchem niedrige Dosen von Thiopenton meist einen Anstieg, hohere Dosen jedoch ein Absinken des Prothrombinindex zur Folge hatten.

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.

Glycopyrrolate was labelled in one methyl group with tritium and its fate was studied in six patients with T-tube drainage by determining serum levels as well as the biliary and urinary excretion of radioactivity after intravenous injection. More than 90 % of the radioactivity had disappeared from serum in 5 min and after 30 min almost no radioactivity could be found. The highest radioactivity in bile was found in samples taken 30 or 60 min after the injection. However, measurable radioactivity was found in most cases after 48 h. The first urine samples (0–3 h) showed the greatest radioactivity, and in 48 h 85% of the total radioactivity was excreted into the urine. Paper chromatography showed that both in bile and in urine over 80% of the radioactivity corresponded to unchanged glycopyrrolate. That appreciable amounts of glycopyrrolate were excreted into the bile suggests that the spasmolysis achieved with glycopyrrolate could be based partly on a local action on the bile ducts.

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.

Single aortic valve replacement with the Bjork-Shiley tilting disc valve prosthesis has been performed in 50 patients since April 1971. None of the total of six deaths (12.0%) was attributable to malfunction of the prosthesis or to embolic complications. Follow-up examination showed insignificant or moderate prosthetic regurgitation in two patients and moderate paravalvular leakage in one patient. A slight intravascular haemolysis was found in two cases, one of them without marked regurgitation, and a slight reversible cerebral thrombo-embolism in two. Clinical improvement was observed in 43 of the 44 survivors during the 6 to 12 months of follow-up. Objective evidence of improvement was verified by cardiac catheterization following the replacement of aortic valve with the Bjork-Shiley tilting disc prosthesis.

Coexistent pulmonary tuberculosis and cancer of the lung were studied with comparison of two identical groups of 1769 persons each. The pulmonary tuberculosis series consisted of patients treated at Paivarinne Sanatorium between 1949 and 1953 and the control series of employees from two industrial plants in the city of Oulu. The names in each group were checked against those in the Finnish Cancer Register. Cancer of the lung was the most common neoplasia in both groups. Four cases of cancer of the lung, all males, were found in the pulmonary tuberculosis group, but in the control group there were six cases, again all males. However, the pulmonary tuberculosis morbidity in the control group between 1954 and 1967 was high, and two of the six cases from the control series had subsequently contracted pulmonary tuberculosis also.

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.

Ligation of the hepatic artery without complete dissection of the liver was performed on eight patients with nonresectable hepatic tumors. Three patients had a marked preoperative clinical and chemical obstructive, intrahepatic jaundice, which disappeared postoperatively. Relief of pain and decrease of enlarged liver were initially noticed in seven patients. Hepatic sepsis was a serious complication with fatal outcome in one nonjaundiced man. The hypoxic necrosis of tumors resulting in a remission of symptoms in the survivors and the disappearance of cholestasis in three jaundiced patients was, however, temporary. After two to six months, the jaundice and other symptoms recurred. The conclusion is drawn that a prolonged life expectancy is perhaps not obtained, but a worthwhile, symptomatic improvement and palliative effect can be achieved by hepatic artery ligation.