Search

Background Significant improvements were made in the diagnosis and management of Paget-Schroetter syndrome (thrombosis of the axillary–subclavian vein) secondary to thoracic outlet syndrome during the past 50 years. The diagnosis has often been extremely difficult. Methods Multiple approaches both in diagnosis and therapy have been tried during the years. After recognizing that the underlying pathologic process resulted from an abnormal insertion of the costoclavicular ligament laterally on the first rib, along with hypertrophy of the scalenus anticus muscle, 506 of 626 extremities have been managed by thrombolytic therapy followed by prompt transaxillary resection of the first rib. These patients have been followed up from 1 to 32 years (average of 7.2 years ± 1.0 standard deviation). Results Four hundred eighty-six patients (96%) improved. Because the pathophysiology is not well understood, many venograms suggest intraluminal disease rather than external compression. Therefore, attempts at opening the narrowed vein with intraarterial techniques do not work. Use of percutaneous venous angioplasty with stents have all occluded in our experience, making further management difficult. Venous bypass grafts fail because of low venous pressure. Conclusions Recognition that an abnormal congenital lateral insertion of the costoclavicular ligament on the first rib causes venous occlusion in Paget-Schroetter syndrome has led to acute thrombolysis, followed by prompt first rib resection, as the ideal management.

The term "thoracic outlet" is the area between the neck and shoulder, over the top of the thorax, and under the clavicle. Knowledge of thoracic outlet anatomy and the four major areas of compression is cardinal for the surgeon to perform thoracic outlet syndrome decompression without injuring major structures, having a minimal number of complications, and avoiding malpractice litigation.

Most patients with thoracic outlet syndrome can be treated conservatively without surgery in a successful fashion. In general, patients with neurogenic thoracic outlet syndrome should be given physiotherapy when the diagnosis is made. Proper physiotherapy includes heat massages, active neck exercises, stretching of the scalenus muscles, strengthening of the upper trapezius muscle, and posture instruction. Because sagging of the shoulder girdle, which is common among middle-aged people, is a major cause in this syndrome, many patients with less severe cases are improved by strengthening the shoulder girdle and by improving posture. Most patients with thoracic outlet syndrome who have ulnar nerve conduction velocities (UNCVs) of more than 60 meters per second (mps) improve with conservative management. 2 If the conduction velocity is below that level, most patients, despite physiotherapy, may remain symptomatic, and surgical resectionofthefirstribandcorrectionofotherbonyabnormalities may be needed to provide relief of symptoms. If symptoms of neurovascular compression continue after physiotherapy, and the conduction velocity shows slight or no improvement or regression, surgical resection of the first rib and cervical rib, when present, should be considered. The transaxillary route is an expedient approach for complete removal of the first rib with decompression of the seventhandeighthcervicalandfirstthoracicnerverootsandthe lower trunks of the brachial plexus. First rib resection can be performed without the need for major muscle division, the needforretractionofthebrachialplexus,andthedifficultyof removing the posterior segment of the rib. In addition, first rib resection shortens the postoperative disability and provides better cosmetic results than the anterior and posterior approaches, particularly because 80% of patients are female.

Background Radial arteries are being used more often for coronary artery bypass grafting. A minimally invasive technique was devised for harvesting vessels and compared with the traditional harvesting technique. Methods In a prospective study of 200 consecutive patients undergoing coronary artery bypass grafting, 100 patients had traditional open radial artery harvesting and 100 underwent endoscopic radial artery harvesting. All patients had a preoperative modified Allen's test with Doppler imaging. The traditional technique involved a longitudinal incision over the radial aspect of the arm from the wrist to the antecubital fossa. The radial artery was dissected subfascially and removed. The endoscopic technique involved a 3-cm incision over the radial aspect of the arm. A vessel loop was placed around the artery and carbon dioxide was insufflated into the wound. The radial artery was dissected to the brachial artery and ligated with an Endo-loop ligature. The branches were divided with bipolar electrocautery and ligated with clips. Patients were evaluated for postoperative pain, bleeding, neuralgias, infection, and any adverse events. A p value of less than 0.05 was considered significant. Results All 200 radial arteries were successfully harvested and used as grafts. Patients who had undergone endoscopic radial artery harvesting had significantly fewer major complications than patients who underwent the open technique: hematomas (five versus no complications) or wound infections requiring antibiotics (seven versus one complication). The occurrence of major neuralgias that restricted function were also significantly lower postoperatively and 1, 3, and 6 months later (ten versus one, eight versus one, five versus zero, and one versus zero, respectively). Conclusions Endoscopic radial artery harvesting results in good cosmetic results, useable grafts, and minimal neuralgias. Endoscopic radial artery harvesting is better than traditional open radial artery harvesting.

Background The accumulation of activated leukocytes in the pulmonary circulation plays an important role in the pathogenesis of lung dysfunction associated with cardiopulmonary bypass (CPB). Patients undergoing valve surgery have prolonged CPB owing to the complexity of the surgery. The goal of this study is to determine if arterial leukocyte filters during CPB improve clinical outcomes after valve surgery. Methods A prospective analysis of all patients receiving only valve surgery with leukocyte arterial filters from June 1999 to June 2002 was compared with a case matched cohort during the same time period. Two hundred fifty patients were identified and compared with a cohort who did not have leukocyte filters used during CPB. The following study points were evaluated preoperatively and postoperatively: white blood cell count, platelet count, arterial blood gas, time to extubation, intensive care unit stay, and total length of hospital stay. Results There were 500 patients in the study. The following valve operations were performed: 92 mitral valve replacements, 168 aortic valve replacements, 152 mitral valve repairs, 80 combined valve repair/replacements, and 8 tricuspid valve repairs, all evenly divided between the two treatment limbs. Patients with leukocyte filters had the following findings compared with nonfilter patients: The time to extubation 10.3 versus 16.2 hours ( P = 0.009), postoperative respiratory quotient 407 versus 320 ( P = 0.02), total length of stay 5.4 versus 7.2 days ( P = 0.04). Conclusions The use of arterial leukocyte filters in patients undergoing valve surgery leads to earlier extubation, improved oxygenation, and a decreased length of stay. Leukocyte filters should be used during CPB for patients having valve surgery.

Adenocarcinoma, typically in the distal third of the esopha- gus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%) (1). The incidence of adenocarcinoma is clearly increas- ing; it will soon become the most prevalent type of cancer of the esophagus. No malignant tumor in the past 25 years has increased in incidence as much as adenocarcinoma of the esophagus. The primary risk of adenocarcinoma is related to the duration and se- verity of gastric-esophageal reflux and the progression of mucosal changes from Barrett's esophagus to dysplasia to adenocarcinoma. Early detection is the most important factor in determining sur- vival. Most patients present with stage IIB to stage IV disease, and most disease occurs at the gastroesophageal junction. Among patients with Barrett's esophagus, the risk of devel- oping adenocarcinoma is 0.2% to 2.1% each year; 77% of patients with adenocarcinoma have had Barrett's esophagus. Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma, since it could miss adenocarcinoma lo- cated somewhere else in that region. Forty percent of patients with Barrett's esophagus and dysplasia have invasive carcinoma in the resected specimen. The incidence of squamous cell carcinoma, which used to be the major cause of esophageal cancer, has significantly decreased. The decrease may be related to reductions in risk factors, which include smoking, excessive alcohol use, caustic lye injury or ther- mal injury, diet, obesity, achalasia, and tylosis. Typical symptoms of esophageal cancer include difficulty swallowing, with a feeling of fullness, pressure, burning, or cough- ing; a feeling of both liquids and solids becoming stuck behind the sternum; indigestion; emesis; and weight loss. Many patients attribute their symptoms to heartburn and do not seek the medi- cal care they need.

The clinical presentation of thoracic outlet syndrome depends on which anatomic structure is compressed in the area of the thoracic outlet (eg, the axillary-subclavian artery, vein [Paget-Schroetter syndrome, or effort thrombosis], brachial plexus, or the sympathetic nerves). The clinical syndrome may be isolated to one or a mixture of these compressed anatomic structures. Although there are multiple compressive forces, the first rib is the common denominator, and extirpation of this structure is the “gold” standard for therapy. The various syndromes are discussed in their clinical order of frequency. For severe nerve compression, whether upper or lower brachial plexus, the best surgical procedure is the transaxillary first rib resection, anterior scalenectomy, and neurovascular decompression. Axillary-subclavian vein occlusion (ie, Paget-Schroetter syndrome) is best treated with early diagnosis, intravenous thrombolysis of the clot, transaxillary first rib resection anterior scalenectomy, and resection of the costoclavicular ligament. Arterial compression, occlusion, or aneurysm may occur with or without peripheral emboli and require a supraclavicular approach with arterial ligation, endarterectomy, or bypass grafts from the supraclavicular subclavian to the infraclavicular brachial artery. Compression of the sympathetic nerves produces vasospasm, Raynaud’s phenomenon, or Raynaud’s disease, requiring dorsal sympathectomy as well as first rib extirpation occasionally. This may be performed through the transaxillary, supraclavicular posterior, or thoracoscopic approach. Recurrent thoracic outlet syndrome may involve any or all of the above anatomic syndromes. The surgical approach is best from the posterior, high thoracoplasty, muscle-splitting incision, performing neurolysis of the C7, C8, and T1 nerve roots and the brachial plexus as well as release of any vascular constriction.

Background . The evaluation of 312 extremities in 294 patients with Paget-Schroetter syndrome (effort thrombosis of the axillary-subclavian vein) over 30 years provides the basis for optimal management determination. Methods and Results . Group I (35 extremities) was initially treated with anticoagulants only. Twenty-one developed recurrent symptoms after returning to work, requiring transaxillary resection of the first rib. Thrombectomy was necessary in eight. Group II (36 extremities) was treated with thrombolytic agents initially, with 20 requiring subsequent rib resection after returning to work. Thrombectomy was necessary only in four. Of the most recent 241 extremities (group III), excellent results accrued using thrombolysis plus prompt first rib resection for those evaluated during the first month after occlusion (199). The results were only fair for those if seen later than 1 month (42). Conclusions . An early diagnosis (less than 1 month), expeditious thrombolytic therapy, and prompt first rib resection are critical for the best results.

Acute axillosubclavian vein thrombosis is a disorder of the anterior thoracic outlet, and is always associated with an abnormally lateral insertion of the costoclavicular ligament. This is a low pressure system associated with extrinsic compressive forces, and conventional intraluminal therapy designed to treat atherosclerotic arterial lesions is not appropriate in this situation. In our experience of over 600 extremities with this condition, prompt thrombolysis followed by thoracic outlet decompression leads to excellent results in over 95 % of patients, especially if treatment is instituted soon after thrombosis occurs.

Operative transluminal coronary artery balloon angioplasty has been used for over 3000 lesions in 1000 patients since 1980. Initially it was only used for distal stenoses not accessible to coronary bypass grafting in 200 patients. Recatheterization of patients who had intraoperative transluminal balloon angioplasty of the proximal left anterior descending, right, and circumflex coronary arteries 3 years previously revealed excellent patency of both the bypass grafts and the dilated native coronary arteries. This observation supports the thesis that with properly constructed bypass anastomoses competitive flow does not significantly mandate graft thrombosis. Subsequently, intraoperative balloon angioplasty has been performed for both proximal and distal stenoses in 800 patients to improve native coronary artery perfusion and maximize revascularization. Follow-up from 1 to 7 years revealed perioperative myocardial infarction in 21 patients (2.1%) and death in 19 patients (1.9%). Recatheterization from 1 to 7 years after the operation in 51 patients (41 with symptoms) revealed that patency was almost as prevalent in arteries subjected to angioplasty (82%; 137/167) as in bypass grafts (84%; 102/122). Intraoperative balloon angioplasty appears to improve coronary artery perfusion without detrimental competitive flow when used with bypass grafts.

Superior pulmonary sulcus carcinoma, or Pancoast's tumor, was first identified in 1932 by H. K. Pancoast, who described a small tumor at the apex of the lung producing a characteristic pain pattern and rapid, universal mortality. Despite early indications that this type of carcinoma was amenable to neither radiation nor surgery, the current treatment approach calls for irradiation therapy (3,000 rad over 2 to 3 weeks) followed by surgical resection of the chest wall, lower brachial plexus, and en bloc resection of the lung. In selected patients with negative mediastinal nodes, this approach has been associated with a 34% 5-year and a 29% 10-year survival.

For years, patients with "effort" thrombosis were treated by anticoagulants and conservative exercise; and if recurrent symptoms developed when they returned to work, they were considered for first-rib resection. Recently, use of thrombolytic agents with early surgical decompression of the neurovascular compression has markedly reduced morbidity, such as postphlebitic syndrome and the necessity for thrombectomy. A review of 67 patients seen over 25 years showed that 34 were initially treated with heparin sodium and then Coumadin (crystalline warfarin sodium). Recurrent symptoms developed in 21 after they returned to work and necessitated transaxillary first-rib resection to relieve symptoms. Eight also underwent thrombectomy. Recently, 33 patients were initially treated with thrombolytic agents and heparin, followed promptly by early first-rib resection. The evaluation and efficacy of this therapy have been established by frequent and repetitive venograms and careful follow-up of patients. Most of the patients showed improvement with thrombolytic agents. Remaining stenoses that suggested intravascular thrombosis were usually secondary to external compression of the vein by the clavicle, costoclavicular ligament, rib, or scalenus anterior muscle. Venous thrombectomy was necessary in only 4 patients in whom the clot was not controlled by thrombolytic therapy and operative release of compression. There were no deaths in the series.

Recognition that many patients with benign sclerosing mediastinitis have smoldering disease responsible for failure of surgical procedures or for development of collateral circulation in patients with superior vena caval obstruction has markedly improved management of these difficult patients. Histoplasmosis complement fixation titers have been used to detect unsuspected subacute disease and to follow the therapeutic adjunctive management with ketoconazole, an oral antifungal agent. Twenty-two patients with benign sclerosing mediastinitis demonstrated a variety of symptoms relating to the area of compression: superior vena cava, 13; esophagus, 3; pulmonary artery and pericardium, 3; and trachea, 3. Histoplasmosis was documented in 12 patients. Operation is used initially for diagnosis, to rule out carcinoma, and to treat the complications: superior vena caval reconstruction, 6; tracheal decompression, 2; right middle lobectomy, 1; esophageal decompression, 2; division of tracheoesophageal fistula, 1; and release of pericardial effusion and cardiac tamponade, 1. Postcardiotomy syndrome occurred in 1 patient and wound infection in another. No deaths resulted. In 6 cases of histoplasmosis, symptoms recurred in 100% of patients and were successfully managed with ketoconazole treatment, and then clinical progress was monitored with serial histoplasmosis complement fixation studies. One patient had four superior vena caval reconstructions at an outside hospital, each 1 year apart, with symptoms recurring each time. With ketoconazole therapy alone, she has been asymptomatic for more than 2 years. Vigorous search for a fungal cause may even obviate the necessity for surgical intervention. If an operation is necessary, preoperative and postoperative use of ketoconazole has assured success.

The high mortality rate associated with revascularization for stenosis of the left main coronary artery and impairment of the left ventricle (classes III and IV) has been significantly reduced by a twofold approach: combating hypotension during induction of anesthesia and preventing ischemia resulting from anoxic arrest, often needed to facilitate the insertion of the left coronary anastomoses. These two goals have been successfully achieved by (1) a readiness to institute circulatory assist by means of femoral-to-femoral cardiopulmonary bypass and (2) augmentation of coronary flow through immediate insertion of a vein graft between the aorta and right coronary artery, if the anatomy permits.

Postcardiotomy syndrome following coronary vein bypass procedures may cause graft occlusion as a result of the associated myxedematous hyperemic inflammation that later forms dense obliterative fibrosis. Variability of symptoms and onset make early recognition of postcardiotomy syndrome difficult. However, the presence of the classic triad of fever, chest pain, and pleuropericardial reactions along with leukocytosis and elevated sedimentation rate should suggest the diagnosis. Early recognition and prompt institution of steroid therapy offer relief of symptoms and regression of inflammation and probably reduce the incidence of graft occlusion. From early experience with 14 patients who developed postcardiotomy syndrome and received only symptomatic treatment, 12 developed graft occlusion, whereas in 31 subsequent patients with this syndrome who were treated with steroids, only 5 demonstrated graft occlusion.

Carcinomas in the superior pulmonary sulcus produce "Pancoast's syndrome," involving pain in the shoulder and the ulnar distribution of the arm and hand, as well as Horner's syndrome. Careful evaluation and appropriate staging select the patients for preoperative irradiation (3000 rads) over a two- or three-week period. After a two- to four-week interlude, surgical resection of the chest wall, lower brachial plexus, and lung en bloc produces a five-year survival rate of over 30 per cent. Contraindications to this therapeutic approach include an excessive extension of the tumor into the neck or vertebrae, substantial mediastinal node metastases, and peripheral tumor dissemination.

Pulmonary resection was performed electively through a median sternotomy in 174 patients. The first 61 of these patients were compared with an equal number having pulmonary resection through a lateral thoracotomy. Both groups were similar in regard to sex, age, pathological condition, and type of resection. The patients undergoing median sternotomy had a shorter operative time and less postoperative pain, and were discharged from the hospital sooner than the patients having resection through a lateral thoracotomy. The cardinal technical essentials to expeditious pulmonary resection through a median sternotomy involve unilateral pulmonary ventilation with a double-lumen endotracheal tube, arterial pressure and gas monitoring, and proper lung packing and retraction. Two patients died, 1 of infection and 1 of bleeding; neither death was related to the incision. Certain pulmonary procedures are better performed through a lateral thoracotomy, and these include resection of a superior sulcus carcinoma, pulmonary resection with posterior chest wall extension, and left lower lobe resection in patients who demonstrate obesity, cardiomegaly, or an elevated diaphragm.

With the advent of direct coronary artery revascularization, the high mortality rate from cardiac disease associated with carotid endarterectomy can be favorably altered by simultaneous or staged revascularization for combined lesions. The choice for combined or sequential procedures is determined by the severity of the disease both clinically and anatomically in each system. Review of 32 patients with both severe coronary and carotid occlusive disease established that selective surgical intervention has been successful, with no deaths and only minimal morbidity. Simultaneous revascularization was carried out in 8 patients with preinfarctional angina, significant left main lesion or triple vessel disease producing a functional lesion of the left main coronary artery, and tight carotid lesion. Staged operations were performed in the remaining 24 patients. Priority of staging was determined by the extent of disease in each system.

(1) Sixty-one patients with superior vena caval obstruction are reviewed, of which six are secondary to benign disease. (2) Diagnosis is usually made by bronchoscopic examination or clinical evaluation. Supraclavicular or mediastinal node biopsy, and anterior thoracotomy are only employed in selected cases, because of the increased risk of hemorrhage. (3) Current preferred therapy for malignant lesions employes the initial use of chlorothiazide (Diuril) and intravenous nitrogen mustard followed by irradiation therapy. (4) In malignant lesions, the direct surgical attack to palliate the symptoms of superior vena caval obstruction is not as effective as conservative therapy and produces a higher morbidity, mortality and failure rate. The prognosis depends on the underlying disease. (5) Surgical resection has failed to extend survival in malignant cases and is not as effective as radiation alone. (6) An unusual case of a large cell undifferentiated carcinoma of the lung presenting superior vena caval obstruction with metastases to the cervical lymph nodes had survived six years following nitrogen mustard and irradiation therapy. (7) A patient with mediastinal Hodgkin's disease is alive with a patent Teflon graft between the superior vena cava and right atrium which was constructed five years ago for superior vena caval obstruction.

Although so-called valve reconstruction procedures at the gastroesophageal junction provide marked relief for most patients with gastroesophageal reflux and hiatal hernia, there is a recurrence rate of 10 to 15%. Many of the recurrences are in patients with obesity, severe pulmonary disease, or stricture, or in patients who have developed a recurrence from other previous types of surgical therapy. Since the primary cause of failure in hiatal hernia repair is tension on the distal esophagus, which is created as a result of securing an adequate length of intraabdominal esophagus, the Collis gastroplasty, which lengthens the esophagus by construction of a tube of the lesser curvature of the stomach, combined with a Belsey reconstruction of the gastroesophageal angle and dilation in cases of stricture, has been successfully employed over the past three years in patients with factors that predispose to recurrence. This technique provides adequate length without tension, and in more than 39 such patients there has been no evidence of reflux or recurrence of hernia by clinical symptoms or cine esophagogram. No mortality or significant morbidity has been observed.

Investigation of dilute solutions of hydrogen peroxide as an improved method of oxygenating tissues over hyperbaric oxygenation has been conducted. Hydrogen peroxide given intra-arterially in the regional system or directly to the exterior of an organ is decomposed into oxygen and water and produces oxygen tensions ranging from 3 to 8 atmospheres pressure regionally. This does not require lung transport, can be given continuously over long periods of time, can be administered by a single physician without expensive equipment and large teams and avoids decompression and compression hazards, as well as pulmonary and CNS toxicity of hyperbaric oxygenation. Hydrogen peroxide has been demonstrated to be an adjunctive source of oxygen for the anoxic or ischemic heart and can improve resuscitation in refractile arrhythmias or cardiac arrest. Intra-arterial infusion has been noted to reverse the atheroderotic process, potentiate the effect of irradiation on malignant tumors, increase the localization of radioisotopes in malignant tumors, protect against Clostridium welchii infections, promote wound healing and serve as an excellent source of regional oxygenation without significant systemic toxicity. Further investigation in all areas is necessary to establish the quantitative value and limitations of H2O2.

Observations on the ultrastructural morphology of benign mediastinal neurolemmoma, neurofibroma, and ganglioneuroma are presented. Distinguishing features of each tumor are described as observed in this study and reported in the literature. In neurolemmoma, the Antoni type A cells exhibit a cellular differentiation totally different from that of the Antoni B cells. The Antoni type A cells are characterized by numerous thin cytoplasmic processes emanating from a cell body with a narrow rim of cytoplasm. The Antoni type B cells lack these processes and have abundant cytoplasm which possesses a complex system of organelles. The extracellular compartment of Antoni type A tissue is composed of Iacunae outlined by lamina similar in appearance to the basement membrane surrounding the principal tumor cells. Neurofibroma is distinguished by elongated cells with a few thick cytoplasmic processes interspersed with occasional myelinated and unmyelinated axons in an extensive collagenous stroma. The principal tumor cells are distinguished from fibroblasts by the basement membrane coating their plasmalemma. Ganglioneuroma is characterized by the presence of large ganglion cells and their satellites and a vast number of myelinated and unmyelinated axons. A well-defined basement membrane coats the tumor cells. The small, membrane-bound osmiophilic granules encountered in the cytoplasm of ganglion cells have been observed in other tumors arising in sympathetic ganglia and paraganglionic cells.

Hemangiopericytoma is a potentially malignant tumor of vascular origin. It usually is a solitary lesion and may arise in the chest or in extrathoracic areas. It is usually encapsulated. Microscopic features vary with the degree of differentiation of the individual tumor. The more differentiated variety exhibits abundant capillaries with open lumina surrounded by ovoid tumor cells; in the less differentiated tumors, the capillaries lack lumina and the tumor cells are spindle shaped. The prognostic significance of the microscopic pattern is controversial. However, prominent mitotic activity, necrosis, hemorrhage, and increased cellularity are ominous signs and are usually noticed in tumors that later exhibit malignant behavior. The larger the lesion, the more likely that it will be symptomatic. Treatment of choice is ample surgical resection.

A case of giant fibrovascular polyp of the esophagus with a review of the literature is presented. The lesion is benign and pedunculated and may attain giant proportions. Symptoms are related to esophageal obstruction. Death by asphyxia can occur. Small lesions can be removed endoscopically with a snare. Larger lesions should be excised using a formal surgical approach.

Pulmonary giant cell carcinoma is one of the most highly malignant neoplasms of the lung. Eighteen patients with this tumor are presented. Histologically the neoplasm is composed of a preponderance of multinucleated giant cells, round cells, and spindle cells. Some of the most differentiated tumors show adenocarcinomatous foci and ultrastructural features of secretory epithelium favoring its classification as a variant of pulmonary adenocarcinoma. The giant cells of this neoplasm can be differentiated from those encountered in undifferentiated large cell carcinoma and epidermoid carcinoma by the abundant cytoplasm, the presence of more nuclei and nucleoli, and the significant degree of phagocytosis. The clinical picture and roentgenographic findings present no pathognomonic features.

Recurrent thoracic outlet syndrome that requires reoperation accounts for 1% of first rib resections. Symptoms in a series of 30 patients were mainly neurological and consisted of pain and paresthesia involving the neck, shoulder, arm, and hand and were severe and unrelenting. Recurrence of symptoms ensued from one month to seven years following initial rib resection, with the majority appearing within the first three months. Nerve conduction velocities were diminished to an average of 51 m per second, well below the normal of 72 m per second. Reoperation was required after a period of extensive physiotherapy and muscle relaxants. The high posterior thoracoplasty approach is recommended for all reoperations, as it gives better exposure to achieve safe neurolysis of the plexus and complete excision of the regenerated periosteum and posterior rib remnant, which were present in almost all patients. Results of reoperation were gratifying, and postoperative nerve conduction velocities were improved to an average of 66 m per second.

The combined Collis gastroplasty—Belsey Mark IV fundoplication was used in 86 patients with uncomplicated hiatal hernia followed for up to 8 years. Marked relief of symptoms was obtained, with no initial morbidity and mortality. Recurrence of hernia occurred in 1 patient. Minimal gastroesophageal reflux was observed in a few patients. Manometric and pH studies performed after operation showed a competent valve without notable esophageal reflux. The Collis gastroplasty creates a lesser curvature gastric tube that lengthens the so-called functional esophagus and eliminates tension at the suture line of the Belsey Mark IV fundoplication.

Esophageal trauma may be caused by penetrating or blunt external forces, instrumentation or foreign bodies, spontaneous or post-emetic rupture and chemical burns.

A SERIOUS DEGREE of hemobilia (hemorrhage into the biliary tract) is uncommon. It usually results from extrahepatic sources such as rupture of a hepatic artery aneurysm into the bile duct or erosion of a biliary calculus into an adjacent vessel. 1,2 Even less common is hemobilia of hepatic origin which may be caused by trauma to the liver, 3,4 malignant tumors, 5 and many other rather esoteric conditions. This present report concerns a case of hemobilia secondary to a liver abscess which required a major resection of the right lobe of the liver for ultimate control. Report of a Case A 75-year-old female was admitted to the Surgical Services of the Massachusetts General Hospital on April 29, 1962, because of persistent and severe hemobilia. Sixteen months prior to admission, cholecystectomy and choledochotomy had been performed in another hospital. Multiple stones were removed from the common bile duct. Postoperative cholangiography showed

Rapid hypothermia applied locally to the heart effects an excellent cardioplegia while simultaneously protecting the organ from anoxia. The remainder of the body is maintained at mild hypothermic levels with extracorporeal circulation, thereby avoiding the disadvantages of deep generalized hypothermia to levels necessary for cardiac arrest. No addition or extraction of chemical agents is necessary. Cardiac temperatures below 16C. provided successful and safe cardiac arrest in 52 dogs. Two different methods were investigated. One employed intermittent coronary perfusion with 2C. fluid and external local application of 2C. saline to the heart. The other, a modification for aortic valve surgery, utilized lavage with external cold saline with only initial perfusion of the coronary arteries. Both provided operative arrest in less than one minute, easy maintenance for periods from 30 to 120 minutes, and rapid re-establishment of regular sinus rhythm and normal blood pressure in every animal. The technique allowed uninterrupted surgery for the entire period of cardiac arrest. Eighty-five percent of the animals survived longer than two days postoperatively. Histological examination of the hearts and lungs revealed no significant tissue damage. For perfusion at lower temperatures Ringer's solution proved superior to blood, 50 percent blood-saline mixture, or dextran, because of its lower viscosity, physiological electrolyte content, and commercial availability. (Author)

Systemic mycoses are caused by certain species of Deuteromycetes and Schizomycetes. The primary infection occurs in the lung and is acquired by inhaling spores or hyphae. The severity of the infection varies from a subclinical type to a disseminated and often fatal disease. The clinical diagnosis of the infection must be substantiated by morphological demonstration of the fungus in tissues or culture. The mode of therapy is determined by the nature and stage of the infection.

To the Editor:— Pulmonary resection for isolated metastatic tumor has now been established as potentially curative. 1-4 The chances for cure appear to depend principally on the type of primary tumor and the interval between resection of the primary tumor and resection of the metastatic lesion. We have recently resected a second pulmonary metastasis of an osteogenic sarcoma 35 years after extremity amputation for the primary tumor and 17 years after thoractomy and resection of the first metastasis. The remarkable behavior of this usually highly malignant tumor has prompted the present report. Report of a Case:— A 68-year-old white woman entered the hospital with a three-week history of chest pain on the right side and hemoptysis. X-ray films of the chest revealed an 8-cm mass in the upper lobe of the right lung which appeared to contain calcium (Fig 1). In 1933, at age 33 the patient underwent amputation of

A combination of proximal vein bypass graft and distal (CO2) gas endarterectomy for revascularizing a diffusely and totally obstructed left anterior descending coronary artery was successfully performed in five patients. This technical improvement provides immediate blood flow in an artery not previously considered amenable to surgical reconstruction.