Thoraxchirurgie, vaskulare Chirurgie最新文献

A new surgical method is presented, the transmediastinal pleurotomy. With this technique it is possible to explore the opposite lung from a standard thoracotomy and to perform diagnostic or therapeutic resections in suitable cases. So far we have performed 20 transmediastinal pleurotomies without any complications.

22 Fallot patients who had surgery after 21 years of age were thoroughly checked on an average of 11 years postoperatively. The mean functional classification according to the New York Heart Association was 1.5. Hemodynamic studies revealed excellent results. The mean systolic gradient across the pulmonary valve (delta p) was 14 mm Hg at rest and 31 mm Hg during exercise. The data assessed during exercise show that one cannot truly speak of a "total correction". Right ventricular systolic and enddiastolic pressures were elevated as well as the enddiastolic and endsystolic volumes. Right ventricular ejection fraction was significantly diminished (45%). Our results show that there was no significant difference between the patients with or without an outflow tract patch. Pulmonary insufficiency apparently bears no negative influence on long-term prognosis up to 11 years postoperatively in patients operated for tetralogy of Fallot.

Thirteen patients with ventricular tachyarrhythmias after myocardial infarction underwent surgery at the heart wall or at the coronary vessels. Ten of these patients had an aneurysm of the anterior wall or akinesia of the anterior wall which in some cases was associated with stenosis of the right coronary artery or of the circumflex artery. One patient showed an isolated stenosis of the right coronary artery. One patient died from recurrent ventricular fibrillation during hospitalization, another patient died from reinfarction 4 months later. All the other patients could be discharged and were improved significantly.

In a series of 432 aortocoronary bypass procedures endarterectomies were performed in 58 patients (13.4%) on 60 coronary arteries. Except of two vein patch grafts all endarterectomized arteries were bypassed with a saphenous vein graft. The majority of the patients had an endarterectomy of the right coronary artery. Clinical control investigations were performed in 43 out of 47 survivors including 30 with coronary angiograms 5.2 months (mean) after surgery. 26 out of 31 endarterectomized arteries (83.9%) were open angiographically whereas the patency rate to non-endarterectomized arteries of the same patients was 86.4%. The hospital mortality was high; 11 out of 58 patients (19%) deceased. All patients who died postoperatively had a three vessel disease with diffuse coronary sclerosis. Only three had no myodardial infarction prior to surgery, seven had one to four infarctions before surgery. The relatively high mortality intends for the future a more strict revision of the indications for coronary surgical procedures. But not in all cases the preoperative coronary angiograms and ventriculograms allow a clear estimation of the local arterial conditions.

Mobilization of the larynx resulting in a 2 to 2.5 cm gain of length can be used in tracheal resection as an alternative to more extensive procedures within the thorax with their specific complications. In the method of Dedo and Fishman the cranial insertions of the thyrohyoid muscle are resected, the thyrohyoid membrane is divided and the two horns of the thyrohyoid cartilage are cut. Difficulties in swallowing may persist for long periods of time but usually can be overcome. In the suprahyoideal method of Montgomery the cranial muscle-insertions at the hyoid are divided and the hyoid bone is transsected leaving the small and large horns. Disturbances of swallowing are not to be expected with this method. Likewise postoperative tube-feeding is not required. The suprahyoid method probably is to be preferred.

Increasing clinical experience has led to a world wide expansion of glutaraldehyde fixed aortic heterografts for valve replacement in patients. The distinct advantage of this valve is a very low rate of thrombembolic complications during the postoperative course. In our hospital 324 such prostheses of the types Hancock and Carpentier have been implanted in 290 patients. In 154 cases follow-up 6 months to 3 years after the operation have been obtained. Thrombembolic complications occured in 1,4%. Other postoperative complications were hepatitis (13,4%), and valvular endocarditis (1,5%). Postoperative control of patients after isolated mitral or aortic valve replacement revealed improved clinical conditions in 90,9%. Dysfunctions of the valve have not been observed. For aortic valve replacement prostheses of a diameter of 27 and 29 mm have been used. In mitral and tricuspid position generally size 31 mm and 33 mm valves were implanted. The decision to use glutaraldehyde fixed biological valves requires the observation of long time results demonstrating reliable mechanical stability of such valves for some decades.

Corrected transposition of the great arteries is often associated with other cardiac anomalies. We report our experience with the correction of the associated cardiac defects in 13 cases: ventricular septal defect with pulmonary hypertension (5 cases), ventricular septal defect with obstruction of pulmonary outflow tract (5 cases), obstruction of pulmonary outflow tract (2 cases), ostium primum defect (1 case). The possible surgical approaches for repair of the cardiac anomalies are described and the results of the operative correction are communicated. Precise diagnosis, the knowledge of the unusual disposition of the conducting tissues and new surgical approaches are prerequisite for successful correction.

The degree of intraoperative myocardial injury was determined in two groups undergoing different methods of myocardial protection by observing the LDH and its isoenzymes up to the 11th postoperative day. Both groups consisted of patients who underwent mitral- and aortic-valve replacement. In the first group myocardial protection consisted of Kirsch cardioplegia (2) combined with conventional coronary perfusion in cases of aortic-valve replacement. In the second group the same initial cardioplegic procedure was followed by the noncorpuscular, hypothermic and aerobic coronary perfusion by Bleese and Döring (1). No difference was noted among the mitral valve patients. During the 11 days postoperative period, the aortic valve patients in the first group demonstrated a significantly higher LDH activity than the mitral-valve cases whereas LDH activity of aortic-valve patients in the second group resembled that of the mitral valve cases. Since the length of extracorporal circulation and ischemia did not vary significantly, the LDH behavior in the aortic-valve cases of the first group may be explained by the inferiority of the myocardial protection method used. In comparison with the other methods conventional coronary perfusion resulted in more myocardial injury.

Postulating that sufficient radicality in operative treatment of all forms of broncho-pulmonary carcinoma is only guaranteed by lobectomy or pneumonectomy 80% of the patients will be inoperable due to anatomical or functional reasons. From the surgical and technical point of view this number can hardly be changed. However, functional limits could be overcome by the use of segmental or subsegmental methods of resection in adequate cases of tumor localization. 88 patients, who had segmental or subsegmental resection more than five years ago were reinvestigated. Out of these patients, one had died postoperatively, 43% had died of their primary tumor disease and 17% of other diseases. 40% had survived the follow-up period. 60% of our patients with tumor stage T1N0 were still alive after 3.5 years. Considering the lack of alternative treatment limited lung resection can be of real advantage when applied critically.

In considering the results achieved through resection of small-cell bronchogenic carcinoma, the following factors are taken into account: age, localization, staging of the tumor, lymph node involvement, type of resection and adjuvant chemotherapy and radiotherapy. Furthermore, the fate of patients not operated provides a sound basis for comparison with the surgically treated group. In contrast to other authors, these results indicate that small cell carcinomas with limited dissemination have a relatively good prognosis following resection. The cooperative study undertaken in the German Democratic Republic, which included a very large patient collective, resulted in a similar conclusion.