Search

I believe that the main policies that should be stressed in situations involving trainees in patient care are: 1) there must be good supervision of the trainees; and 2) there must be openness in responding to patient questions as to what parts of a procedure will be done by trainees and how experienced the trainees may be. I do not agree with the authors that every part of every procedure or overall treatment conducted by residents or interns needs to be described to every patient and that patients' permission must be sought for each arrangement.

This study was carried out to evaluate two techniques of widening the carotid bifurcation with autologous material after endarterectomy to determine whether the incidence of recurrent stenosis could be reduced. As a control, a similar series was performed without patching. Autologous saphenous vein was used as a patch in one group of patients, whereas in another, the bifurcation was widened by suturing the external carotid to the internal carotid artery, advancing the bifurcation by several centimeters, a technique we termed bifurcation advancement. All three groups were studied at least 1 year after operation by means of Doppler ultrasonography. We found no difference in either of the patched techniques compared with unpatched controls. Significant recurrent stenosis (greater than 50% diameter reduction) was found in 12.5% of reconstructions with a vein patch, 12.5% of those with bifurcation advancement, and 16.6% of those with simple closure. The overall incidence of significant recurrent stenosis was 13.8%, with symptoms occurring in 2.7%. (J VASC SURG 1987;6:350-4.)

A safe, effective method of inducing total body hyperthermia to 42°C (108°F) has been developed and applied to clinical subjects with advanced malignancy. Physiological and biochemical parameters have been studied to determine tolerance and detect toxicity. Treatments were well tolerated with appropriate life support measures, mainly fluid and electrolyte replacement. Occasional arrhythmias and superficial cutaneous burns were the major complications. No evidence of central nervous system dysfunction was detected. Serum enzyme elevations after treatment appeared to indicate hepatic cellular injury but no clinical problems resulted. Renal, pulmonary, and hematologic parameters showed no significant changes from baseline values. Two early deaths occurred in patients with massive liver replacement with tumor and such patients may not be appropriate subjects for hyperthermia. Cancer 40:3155-3159, 1977.

A more systematic approach to addressing the crucial issue of informed consent is needed in medical education. Surgeons cannot afford gaps in their medical education regarding the communication process with patients. We found that many surgical residents and faculty understand the mechanics of the informed consent process quite well and could perform well under the artificial circumstances of our video interview. Whether they would do as well if a real patient was considering nonoperative therapy, or was a ne'er-do-well, or an alcoholic is not known. Two main causes of interference with the process have been identified: conflicting messages which surgeons get from within the profession, from the courts, and from within themselves and lack of time for dialogue with patients, and poor timing of the consent process. Areas that were uncovered that need further investigation include the barrier created by some surgeons' internal, often unrecognized, biases about surgery being the only satisfactory mode of treatment for some illnesses and some surgeons' belief that longevity should be the goal of all therapy, without considering that for some patients, maintenance of certain quality lifestyles is more important than a longer life. We hope that surgeons can learn to look at the informed consent process as a wonderful opportunity to communicate their personal concern for the patient as a person, not just a sick gallbladder to remove, and that this process can become the channel through which the wounded relationship of the patient and the physician can be healed.

Alexis Carrel, a French surgeon, moved to America in 1904 and was awarded the Nobel Prize in 1912. In this eight-year interval, during which Carrel worked with Charles Guthrie at the University of Chicago as well as independently at the Rockefeller Institute in New York, he made some fundamental contributions to vascular surgery, such as establishing the use of autologous veins for arterial grafts. What is less well known is that he also made major contributions to thoracic and cardiac surgery by perfecting endotracheal anesthesia, demonstrating pulmonary and esophageal resections, and doing prophetic experiments on heart valves and coronary arteries: forty years passed before these operations were performed in a clinical setting.

Bypass grafts from the internal mammary artery (IMA) to the coronary artery, performed with small suture and optical magnification, have been found to have an extremely high late patency rate when compared with saphenous vein grafts. This is thought to be due to the use of autogenous artery instead of vein, the closer approximation in size between graft and artery, the fact that one anastomosis instead of two is necessary, and because microsuture with magnification produces a smoother anastomosis. This has led us to explore the use of the splenic artery for coronary bypass to the distal right coronary artery on the diaphragmatic surface of the heart. Three patients have had a right coronary bypass using splenic artery brought through the membranous portion of the diaphragm. Two of these patients also had an IMA-to-left anterior descending coronary artery bypass. Thus, autogenous artery bypass to the two most frequently obstructed coronary branches has been shown to be practical.

Five years of experience using unsupported and mounted fascia lata and pericardial heart valves in human beings is summarized. This experience as well as the experiences reported by others has led me to the conclusion that autogenous pericardium and fascia lata—because of the raw, exposed collagen surfaces—are not satisfactory tissues from which to construct heart valves.

To compare the ability of intermittent calf compression with that of sequential leg compression to prevent venous stasis, the clearance time of radiopaque dye, as determined by sequential phleborheograms performed on anesthetized patients, were compared. Calf compression was superior to no compression in clearing the dye from the calf alone, but did not aid clearance from the rest of the leg. Sequential leg compression was superior to intermittent calf compression in clearing dye from the calf and popliteal areas. Since intermittent leg compression has been as effective as small-dose heparin therapy in preventing postoperative deep venous thrombosis [7], the use of sequential leg compression may prove to be more effective and have less complication than heparin administration.

Much of the confusion surrounding the repair of asymptomatic abdominal aortic aneurysms relates to inaccuracies in their measurement, both preoperatively and intraoperatively. Multiple measurements of aneurysms at operation have convinced us that the largest and least variable diameter is the anteroposterior diameter measured from aortic wall anteriorly to vertebral bodies posteriorly. This APto-spine distance is accurately predicted by ultrasonography to within 0.3 cm. Computerized tomography does no better. Plain radiography is accurate but seldom applicable. When properly estimated, aneurysm size can be accurately determined preoperatively by either ultrasonography, computerized tomography, or plain radiography, in that order of preference. Since the decision to operate on asymptomatic aneurysms is based largely on their size, accurate preoperative estimation is essential.

We believe that when the indications for operation for spontaneous pneumothorax are met, the procedure of choice is bilateral resection of apical blebs and pleural abrasion through a median sternotomy. This approach allows easy access to both lungs and pleural spaces for a condition that is bilateral 100 per cent of the time. The operative morbidity is minimal and it essentially eliminates both ipsilateral and contralateral recurrence of pneumothorax with an operation that is of lesser rather than greater magnitude.

Of 67 patients with penetrating neck wounds admitted to the hospital between 1969 and 1979, 22 (32.8%) were taken to the operating room and 14 (63.6%) were found to have major structural damage. Three patients died (4.4%), all as a direct result of their associated head injuries and none as a result of their neck wounds, regardless of management. Five patients (7.4%) had complications. The average hospital stay for patients undergoing surgery was 4.9 days; for those observed with multiple injuries, 4.6 days; and for those observed with isolated neck wounds, 2.4 days. Indications for selective exploration are presented.

Ten premature infants with severe idiopathic respiratory distress syndrome and a large patent ductus arteriosus who underwent ligation are discussed. There were no surgical deaths, but two late deaths occurred. Three similar infants who were not operated on are also presented; all of them died. An additional forty-four such patients with ductus ligation reported on recently were reviewed. Evidence is presented that strongly supports ligation of the ductus as soon as it becomes apparent in infants with severe respirator-dependent idiopathic respiratory distress syndrome. The diagnosis of patent ductus arteriosus is reliably established clinically, and the relatively high complication rate associated with cardiac catheterization in premature infants contraindicates its use.

Thoracoabdominal aortic aneurysms present the greatest challenge to the vascular surgeon. The inclusion technique, which is based on reattachment of visceral vessel origins to openings made in the replacment aortic graft, was developed by Crawford and his associates. It can be accomplished much more rapidly and with less loss of blood than previous methods and has been shown to reduce the level of operative morbidity and mortality.

ALTHOUGH vascular prostheses enjoy widespread clinical acceptance, 1-8 the application of autologous tissue as arterial substitutes is an appealing concept. The purpose of this study was to reevaluate the use of autologous anterior rectus fascia as an arterial graft with longer periods of observation in order to clarify conflicting results of similar studies previously reported. 9,10 Materials and Methods Healthy mongrel dogs were anesthetized using sodium pentobarbital for veterinary use (Diabutal) administered intravenously in doses of 30 mg/kg of body weight. Through a midline abdominal incision, the skin and subcutaneous tissue were reflected laterally and the anterior rectus fascia was exposed. An appropriate section of this fascia was excised and cleaned of all muscle fibers and connective tissue. The fascial segment was then folded over a catheter stent so that the parietal surface corresponded to the intimal aspect of the tubular graft constructed as shown in Fig 1. Using a

Residual coronary air embolism after heart-lung bypass is an occasional cause of poor myocardial contractility and low cardiac output. To quantitate the amount of myocardial depression from given amounts of air and to explore the most efficient way to remove coronary air, 19 dog experiments were carried out. During extracorporeal circulation, balloons were inserted into the right and left ventricular cavities to measure isovolumetric myocardial contractility. Small amounts of air injected into the aortic root caused transient myocardial depression with rapid recovery. Repeated injections of small amounts of air produced an additive effect—more depression and slower recovery with each injection. A pure peripheral vasoconstrictor was not as effective as an inotropic drug such as ephedrine or isoproterenol in improving contractility. By far the most effective method of removing air from the coronary arteries and improving contractility and color of the myocardium was to increase the perfusion flow rate for one minute to one and one-half to two times normal. Large amounts of foam appeared from the coronary sinus when flow rates were increased, and hearts intractable to electrical defibrillation became pink and responded to a single shock.

A new technique for coronary revascularization, involving anastomosis of the splenic artery to the posterior descending right coronary artery, is described and illustrated angiographically. This technique has been used in 12 patients and has been shown to provide more durable anastomoses than comparable venous routes.

The distensibility of the splanchnic portion of the portal system has been evaluated by studying pressure and volume changes with or without any interruption of blood flow. The results of these determinations indicate two types of distensibility of the system: (1) a rapid elastic distension representing relatively small volumes, and (2) a secondary phase of slow distension, designated "delayed compliance," which represents a significantly greater volume change. It is concluded that delayed compliance is of major importance in the pooling of blood in peripheral blood vessels under conditions of maintained elevation of venous pressure.

Alexis Carrel, MD, at the beginning of this century, performed numerous original experiments, first with Charles Guthrie at the University of Chicago (Ill) between 1904 and 1906 and at the Rockefeller Institute in New York, NY, between 1906 and 1914. For the first time, an animal laboratory was established where dogs could be operated on with aseptic surgical technique, thus reducing infection. Vascular anastamosis was technically improved, veins were shown to function as arterial substitutes, limbs were reimplanted, and kidneys and hearts were transplanted and shown to function for a short time (rejection was not understood at the time). At the Rockefeller Institute, arterial segments from animals of the same or different species, preserved in several ways, were shown to function as arterial conduits in dogs. Carrel was among the first to use endotracheal oxygenation to allow intrathoracic operations on the lungs, esophagus, and heart. In 1910 he performed a

History is an esoteric exercise unless we use it to guide our future. I should therefore like to record the recent history of arterial grafts from a personal vantage point, paying particular attention to the mistakes I have made and the lessons I have learned. Finally, I would like to use this experience to point out the directions I think we should go, especially in the development of small-caliber grafts for coronary bypass and distal leg arteries. INITIAL GRAFT ATTEMPTS Forty years elapsed between the demonstration by Carrel and Guthrie 1.2 that homologous and heterologous veins and arteries could serve as arterial grafts in experimental animals and their first use in man. Modern arterial surgery began its logarithmic growth in 1948, just 30 years ago, when Gross et al 3 demonstrated that arterial allografts could be preserved and used satisfactorily in humans. In his development of surgery for coarctation in

A remotely controlled, programmable insulin delivery system was implanted in a diabetic man and the feasibility of the technique was examined. Specific problems included (1) development of an appropriate surgical approach, (2) identification of methods to assess the integrity of the insulin delivery system following implantation, and (3) assessment of plasma glucose and free-insulin profiles obtained with the implanted system. The insulin pump was implanted submuscularly through a midline abdominal incision. The insulin reservoir was placed subcutaneously to allow percutaneous refilling. The insulin delivery catheter terminated in the peritoneal space. No postoperative wound infection occurred and rapid healing of the surgical site ensued. In vivo assessment of the system included (1) dye contrast roentgenography, (2) vasopressin stimulation, and (3) reservoir volume monitoring. Short-acting insulin was then placed in the implanted reservoir and delivered by the system for one month. Mean plasma glucose concentration declined to normal levels, as did glycosylated hemoglobin. Plasma insulin profiles were normalized with appropriate insulin peaks with each meal. We conclude that implantation of a remotely programmable insulin pump is feasible in type I diabetic man. Additional studies are necessary to define which patients will benefit from this type of insulin delivery system. (JAMA1982;247:1848-1853)

In a patient who had undergone right nephrectomy for renal carcinoma 20 years earlier, anuria developed following left renal artery embolism. Nine days later, renal artery embolectomy was successfully performed. This represents the longest reported anuric interval between the onset of symptoms and successful treatment. Intraoperative, intra-arterial instillation of human fibrinolysin seemed to facilitate the removal of thrombotic material from the distal renal artery branches. Renal artery occlusion is reversible, at least occasionally, after prolonged nonfunction.

Direct anastomosis of the end of the internal mammary artery to the side of the distal left anterior descending coronary artery with microsurgical technique produces an immediate increase in myocardial perfusion rather than a delayed increase as after mammary artery implantation. The distal left coronary artery is usually soft and widely patent even in patients with diffuse disease of this vessel. Seven consecutive patients have undergone this procedure; five had a simultaneous aorto-right coronary artery bypass with the saphenous vein. All but one survived and were markedly improved.

Although there have been extensive tests made of the retention or loss of tensile strength of various synthetic fabrics used as arterial grafts, no controlled experiments have been reported of the strength of the anastomotic bond between synthetic graft and host vessel. Such an investigation was deemed important because of the occasional late development of partial disruption at the suture line between graft and host vessel with formation of a false aneurysm. It has been postulated that such disruptions occur from the failure of a strong bond to develop between graft and host, which gives way completely when silk suture weakens and finally breaks. This study was planned to determine the strength of the anastomotic bond in experimental animals and in man many months after grafting, and to determine if the strength of this bond was dependent on the residual tensile strength of suture material. Methods A. Animal Experiments. —Teflon

Hypothermia as a valuable adjunct to intracardiac surgery has had two limiting factors which have interfered with its widespread acceptance. The relative frequency of ventricular fibrillation which may be irreversible and the short interval of safe blood-flow stasis have been the chief disadvantages observed in attempts to perform intracardiac surgery under hypothermia. The ventricular chambers are not accessible in the cold state, since ventriculotomy causes a very high incidence of fibrillation. The cause of fibrillation is being vigorously studied in many clinics. Swan and his co-workers 8 have investigated the metabolic and electrolyte changes occurring at lowered temperature. Lange, Weiner, and Gold 5 found electrocardiographic changes in hypothermia suggestive of cardiac hypoxia. Penrod, 6 on the other hand, believed that oxygen utilization of the heart was normal at 20C, since he found no change in coronary arteriovenous oxygen differences from those in the normothermic animal. Coronary flow was not measured