Naturally acquired babesiosis in a reindeer (Rangifer tarandus tarandus) herd in Great Britain

A provisional diagnosis of babesiosis was made in a reindeer herd in Scotland when seven animals died during 1997 and 1998. Additional clinical cases occurred, but the animals recovered after treatment. Thirty-one reindeer from the herd were tested for the prevalence of exposure to Babesia by the indirect fluorescent antibody test using a bovine isolate of Babesia divergens that had been passaged through gerbils. Infection rates were determined by Giemsa-stained blood smears. In addition, molecular identification of the infecting Babesiasp. was undertaken using SSU rRNA gene sequence analysis. It is likely that the organism causing babesiosis in this reindeer herd is B. divergens.

A prospective trial of inhaled nitric oxide in clinical lung transplantation

BACKGROUND

Reperfusion injury (RI) is a major cause of mortality and morbidity among lung transplant recipients. We sought to determine if prophylactic administration of inhaled nitric oxide (NO) to lung transplant recipients at reperfusion would prevent RI. We also hypothesized that if prophylactic NO proves ineffective in preventing RI then it may improve pulmonary hemodynamics and gas exchange in the subset of patients who develop RI.

METHODS

After informed consent, 28 consecutive, adult lung transplant recipients received NO at 20 ppm at reperfusion. NO was withdrawn for 15 min at 6 and 12 hr after reperfusion, and gas exchange and hemodynamics were measured.

RESULTS

Five of the 28 lung transplant recipients (18%) developed RI. Withdrawal of NO for 15 min in this subset of patients resulted in a significant rise in mean pulmonary artery pressure and a reduction in oxygenation index. All five patients with RI were kept on inhaled NO until full functional recovery of the allograft and were then weaned from mechanical ventilation. None required extracorporeal membrane oxygenation support; the early mortality in this group was 20% (1/5). The remaining 23 patients without RI had uneventful early postoperative course and were weaned from NO and mechanical ventilation within 36 hr of transplantation.

CONCLUSIONS

Prophylactic-inhaled NO does not prevent RI in human lung transplantation. However, inhaled NO, started at reperfusion, improves gas exchange and reduces pulmonary artery pressure in those patients who develop RI.

Lung volume reduction surgery: a cost and outcomes comparison of sternotomy versus thoracoscopy

It remains unknown whether it is better to perform lung volume reduction surgery (LVRS) through video-assisted thoracoscopy (VATS) or sternotomy. This study compares both approaches in terms of surgical and patient outcomes as well as the associated costs. All patients undergoing LVRS from 1995 to 1997 at one institution by a single surgeon (PFW) were investigated. Preoperative, postoperative, and cost data were obtained from medical and financial records. A total of 42 patients with severe emphysema underwent LVRS (19 via sternotomy and 23 via thoracoscopy). Both groups were comparable preoperatively. Comparison of intraoperative times revealed VATS takes longer to perform (sternotomy, 118 +/- 29 minutes; thoracoscopy, 168 +/- 20 minutes). Postoperatively, the sternotomy patients had more days on the ventilator, more days in the intensive care unit, more days with an air leak, and longer hospital stays. In both groups, the majority of patients reported improvement in oxygen dependence as well as quality of life. Neither surgical approach conferred any long-term medical advantage; however, the average total hospital costs and charges were reduced in the VATS group (average cost: VATS, $27,178; sternotomy, $37,299). This study concludes that 1) LVRS seems to be beneficial for selected patients with end-stage emphysema; 2) postoperative morbidity and length of hospital stay are decreased in the VATS group; 3) long-term improvement in postoperative pulmonary function is not influenced by surgical approach; and 4) the overall charges and costs of the VATS approach is less than that of sternotomy.

Mycophenolate mofetil versus azathioprine immunosuppressive regimens after lung transplantation: preliminary experience

BACKGROUND

Mycophenolate mofetil reduces episodes of biopsy-proven acute cellular rejection or treatment failure in the first year after kidney transplantation; however, limited data exist regarding the efficacy after lung transplantation.

METHODS

In a 2-center, nonrandomized concurrent cohort study (level III evidence), we analyzed the incidence of biopsy-proven acute cellular rejection (International Society for Heart and Lung Transplantation grade > or=A2) and decrement in pulmonary function during the first 12 months after successful lung transplantation. All patients received induction immunosuppression with antithymocyte globulin (< or=5 days' duration), cyclosporine and prednisone, in addition to either mycophenolate mofetil (2.0 g/d) [n=11] or azathioprine (1 to 2 mg/kg per day) [n=11].

RESULTS

During the first 12 months after lung transplantation, the mycophenolate mofetil group experienced significantly fewer episodes of acute cellular rejection than the azathioprine group (0.26+/-0.34 vs 0.72+/-0.43 episodes/100 patient-days [mean+/-SD], p < 0.01; 95% CI for the difference=0.126 to 0.813). The change in forced expiratory volume -1 second [deltaFEV1] (liters) between the 3rd and 12th months after lung transplantation was analyzed for the two treatment groups. For this interval, deltaFEV1 for the mycophenolate mofetil group was +0.158+/-0.497 L vs -0.281+/-0.406 L for the azathioprine group (p < 0.05; 95% CI for difference=+0.0356 to 0.843). During the first year, there was 1 death in each group attributed to bronchiolitis obliterans syndrome with concurrent pneumonia. There were no differences in incidence of cytomegalovirus or bacterial infections between the treatment groups; however, a higher prevalence of aspergillus sp airway colonization in bronchoalveolar lavage fluid was observed for the mycophenolate mofetil group (p < .05). The prevalence of bronchiolitis obliterans syndrome at 12 months was 36% for the azathioprine group vs 18% for the mycophenolate mofetil group (p=NS).

CONCLUSIONS

Our preliminary experience with mycophenolate mofetil after lung transplantation suggests a decreased incidence of biopsy-proven acute cellular rejection. Furthermore, less decline in FEV1 after 12 months may suggest a reduced incidence or delayed onset for development of bronchiolitis obliterans syndrome. Prospective randomized trials with low beta error (level I evidence) should be performed to assess the efficacy of mycophenolate mofetil vis-à-vis acute allograft rejection and bronchiolitis obliterans syndrome.

Use of leukocyte depletion to decrease injury after lung preservation and rewarming ischemia: an experimental model

BACKGROUND

Hypothermia is critical for proper lung preservation. Ideally, the lungs should be maintained at the optimal preservation temperature during the entire ischemic interval. Lung rewarming during implantation is commonly observed. This study was undertaken to investigate the severity of rewarming ischemia on preservation injury and the possibility of minimizing this by use of leukocyte depletion during initial reperfusion.

METHODS

Four experimental groups were tested as follows: neonatal piglet heart-lung blocks were either (1) placed on an isolated, blood-perfused, working heart-lung circuit without intervening ischemia (control, n = 6), (2) reperfused on the circuit with whole blood (WB, n = 6) after 13 hours of preservation, (3) reperfused with WB after 12 hours of preservation and 1 hour of rewarming (RWB, n = 5), or (4) reperfused with leukocyte-depleted blood for an initial 10 minutes followed by WB, after 12 hours of preservation and 1 hour of rewarming (n = 6). All groups were studied for 4 hours.

RESULTS

The partial pressure of arterial oxygen and lung compliance were significantly lower in the RWB group than in controls (113.8+/-33.1 vs 417.3+/-6.2 mm Hg, p < 0.01; and 0.8+/-0.2 vs 2.9+/-0.4 ml/cm H2O, p < 0.05, respectively). Pulmonary vascular resistance and lung wet/dry weight ratios were significantly higher in the RWB group than in controls (15884.1+/-11354.8 vs 6108.3+/-1309.9 dyne x sec x cm[-5], p < 0.05; and 7.13+/-0.24 vs 5.82+/-0.35, p < 0.05, respectively). The WB and leukocyte-depleted groups did not differ significantly from controls for any measured parameter.

CONCLUSIONS

This model confirms that rewarming ischemia during lung implantation exacerbates reperfusion injury. Leukocyte-depleted reperfusion as tested for a short period of time (10 minutes) ameliorates this injury and therefore should be considered for clinical lung transplantation.

L-arginine administration during reperfusion improves pulmonary function

BACKGROUND

Nitric oxide is crucial to the maintenance of vascular homeostasis. Because nitric oxide levels decline upon lung reperfusion, infusion of L-arginine, a nitric oxide precursor, during reperfusion might prove effective at ameliorating reperfusion injury.

METHODS

Neonatal piglet heart-lung blocks were preserved with Euro-Collins solution for 12 hours, rewarmed at room temperature for 1 hour, and reperfused for 10 minutes with either whole blood (n = 5), whole blood containing L-arginine (10 mmol/L; n = 6), or leukocyte-depleted blood (n = 6) on an isolated, blood-perfused, working heart-lung circuit. After the initial 10 minutes, all blocks received whole blood for 4 hours. Control blocks were continuously perfused on the circuit without intervening ischemia (n = 6).

RESULTS

The partial pressure of oxygen in the whole blood group (113.8 +/- 33.1 mm Hg) was significantly less than in controls (417.3 +/- 6.2 mm Hg; p < 0.01). Lung compliance was significantly less in the whole blood group (0.8 +/- 0.2 mL/cm H2O) than in controls (2.9 +/- 0.4 mL/cm H2O; p < 0.01). The L-arginine and leukocyte-depleted blood groups showed no significant difference from controls.

CONCLUSIONS

L-Arginine infusion during reperfusion improves pulmonary function, making it a simple alternative to leukocyte depletion.

Immunocytologic analysis of cells obtained from bronchoalveolar lavage in a model of rat lung allograft rejection

Left lung transplantation (n = 30) between BN rat (RT1n) and LEW rat (RT1(1)) was performed to examine serial changes in the inflammatory cell profile and T-cell subsets occurring in bronchoalveolar lavage (BAL) obtained after transplantation. Transplanted animals were sacrificed on Days 1 to 7 post-transplantation. Previous studies show that lung allografts between these rat strains were strongly rejected within 7 days. The serial change in the cell profile of BAL showed a marked initial predominance of polymorphonuclear leukocytes, a decrease in macrophages, and a temporary increase in number of eosinophils on Day 2 post-transplantation. A gradual increase in lymphocytes coincident with progression of rejection was also noted. Immunocytologic studies using monoclonal antibodies specific for rat T-cell subsets and interleukin-2 receptor (IL-2R) showed significant increase in pan-T-cells on Days 3, 4, and 5 and T-suppressor/cytotoxic (CD8 positive) fraction on Days 4 and 5, whereas the T-helper (CD4 positive) fraction peaked on Day 2. The frequency of T-cells expressing IL-2R (55 kDa), indicating activated T-cells, significantly increased as early as Day 2 and maintained its high value thereafter. mRNA levels for IL-2R were detectable in the allografts on Day 2 and peaked on Day 5 post-transplantation. The value of CD4/CD8 T-cell ratios rose initially and then dropped below 1.0 on Days 4 and 5. These values differed markedly from those of syngeneic transplants (Lew-->Lew) examined on Day 5 post-transplantation. First, no significant changes in BAL cytology were seen when syngeneic transplants were compared with normal (Lew) lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional distribution of lung perfusion and ventilation at rest and during steady-state exercise after unilateral lung transplantation

Cardiopulmonary exercise testing has previously demonstrated a reduced maximum oxygen uptake and anaerobic threshold, as well as abnormal wasted ventilation fraction and gas exchange after unilateral lung transplantation. To further explain the mechanisms of these abnormalities, we assessed the regional distribution of pulmonary blood flow and ventilation at rest and during steady-state exercise in nine recipients of unilateral lung transplants. Krypton-81 (81mKr) aerosol and technetium-99m (99mTc) were utilized to assess lung ventilation (V) and perfusion (Q), respectively. The digitalized images were trisected to analyze apical, mid-, and basilar lung perfusion and ventilation in both the transplanted and native lung, both at rest and steady-state upright exercise. Results were compared with previously reported data obtained in normal subjects in our laboratory using the identical technique. At rest, 75 +/- 13 percent of perfusion was directed to the transplanted lung; however, the corresponding fractional ventilation was only 67 +/- 14 percent. During exercise, there was no significant change in fractional perfusion or ventilation. Resting apical perfusion in the transplanted lung was higher than normal in four patients and comparable to normal in five patients. In contrast to the augmentation of apical perfusion observed in normal subjects during upright exercise, none of our patients increased the regional perfusion to the apices during exercise in either transplanted or native lungs. These unexpected responses suggest either more maximal allograft apical recruitment at rest due to the increased allograft perfusion or an abnormality in the apical pulmonary vasculature after transplantation. Furthermore, the relative mismatch in ventilation and perfusion in transplanted and native lungs suggests regions of high V/Q in the native, and low V/Q in the transplanted lung. This mismatch is most pronounced in recipients of single lung transplants for pulmonary vascular disease.

Hemodynamic responses to exercise after lung transplantation

A reduced exercise tolerance, maximum oxygen uptake (VO2max), and anaerobic threshold have been reported after lung transplantation (LT). We prospectively assessed the hemodynamic responses to incremental cycle ergometry before and after LT in eight recipients. All recipients underwent a 6-week formal exercise training program. The VO2max increased after versus before LT (13.4 +/- 0.8 vs 9.2 +/- 0.8 ml/min/kg) (p < 0.01). No transition thresholds by analysis of arterial standard bicarbonate were discerned before LT, while the thresholds after LT were abnormally low (VO2 = 9.4 +/- 0.6 ml/min/kg or 35 +/- 3 percent of predicted maximum VO2). An early rise in arterial lactate was similarly observed after LT. Maximum stroke volume index increased in six of seven patients after versus before LT (51 +/- 4 vs 37 +/- 2 ml/beat/m2) (p < 0.05). Three patients demonstrated an increased mean pulmonary arterial pressure at rest, while pressures during exercise were elevated in six. Pulmonary vascular resistance was mildly elevated after LT but decreased appropriately during incremental exercise and was associated with normal cardiac output responses. We conclude that pulmonary vascular abnormalities occurred during hemodynamic exercise testing in the majority of LT recipients; however, exercise limitation was primarily attributed to cardiovascular limitation or to deconditioning in five of the recipients. In the remaining three, the exercise study was considered to be submaximal by virtue of low peak heart rates. A persistent state of deconditioning may have important implications with respect to exercise training regimens after LT.

Serum interleukin-2 levels in lung transplant recipients: correlation with findings on transbronchial biopsy

Serum interleukin-2 (IL-2) levels were examined in the serum of 17 lung transplant recipients who underwent transbronchial biopsies to diagnose reasons for allograft dysfunction. Over 60 transbronchial biopsies were performed in these 17 patients in a 22-month observation period. Mean serum IL-2 levels were significantly elevated in patients experiencing allograft rejection (p less than 0.01), cytomegalovirus pneumonia (p less than 0.0006), and bacterial/fungal pneumonia (p less than 0.01), when compared with those with normal or nondiagnostic findings on transbronchial biopsies. Serum IL-2 levels were not extraordinarily elevated as seen in other types of allograft rejection and did not differentiate between infection and rejection. In addition, overlapping values were seen in the patient groups tested. Despite these limitations, elevated serum IL-2 levels in lung allograft recipients may provide supplemental information helpful in deciding when to perform transbronchial biopsies.

Induction chemotherapy with mitomycin, vindesine, and cisplatin for stage III unresectable non-small-cell lung cancer: results of the Toronto Phase II Trial

PURPOSE

The 5-year survival rates with surgical resection for preoperatively identified stage IIIA N2 non-small-cell lung cancer (NSCLC) are less than 10%. A pilot study of mitomycin, vindesine, and cisplatin (MVP) induction chemotherapy was undertaken in an attempt to improve the curative potential of surgery in this group of patients.

PATIENTS AND METHODS

Thirty-nine patients with mediastinoscopy stage IIIA N2 NSCLC received two cycles of MVP. Responding patients underwent thoracotomy for resection and two further courses of MVP.

RESULTS

The overall response rate was 64% (25 of 39) with three complete and 22 partial responses. Twenty-two patients were resected, which included a radical mediastinal node dissection. Eighteen resections were complete and four were incomplete. Pathologically, three patients (7.7%) had no tumor remaining. Toxicity included two postoperative deaths secondary to a bronchopleural (BP) fistula, mitomycin pulmonary toxicity in two patients, and septic deaths in four patients. Twenty-eight patients have died; 20 have recurrent or progressive disease. Eight of the 18 patients completely resected have recurred, with a median time to recurrence of 20.6 months. Sites of recurrence include two locoregional, five distant (two in brain), and one in both. Median survival of all 39 patients is 18.6 months, with a 3-year survival of 26%. The median survival for those patients completely resected was 29.7 months with a 3-year survival of 40%.

CONCLUSIONS

We conclude (1) that MVP is an effective but toxic chemotherapeutic regimen for limited NSCLC; (2) the median survival seems to be prolonged; and (3) the role of induction chemotherapy followed by surgery in stage IIIA N2 NSCLC requires a phase III randomized trial to compare it with other treatment modalities.

Vascular rejection and graft eosinophilia in rat lung allografts

Allogeneic lung transplantation was performed using a rat model in order to assess the pathologic changes that developed during the process of rejection. The left lungs of 38 BN rats (RT-1n) were orthotopically transplanted into LEW rats (RT-1). The allografts developed the well-known changes of perivascular, peribronchial, and interstitial lymphocytic infiltrates resulting in necrosis of the pulmonary parenchyma at 7-8 days after transplantation. In addition, we document two findings that have not been reported previously in lung transplantation: vasculitis and eosinophilic infiltrates. Vasculitis with swelling and vacuolization of the endothelial cells was observed in transplants as early as 3 days following transplantation. Vasculitis with fibrinoid necrosis of the vessel wall was prominent at 7-8 days after grafting. The allografts also exhibited eosinophilia at 2 to 4 days following transplantation. The density of eosinophils in the inflammatory infiltrate reached a peak of 20% on Day 3 post-transplantation. These findings suggest an important role of humoral immunity and a possible involvement of eosinophils in lung allograft rejection.

Technique of successful clinical double-lung transplantation

Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.

Esophagectomy for complex benign esophageal disease

We evaluated the use of total thoracic esophagectomy and replacement with stomach in a group of 21 patients between 1976 and 1986 who had undergone multiple unsuccessful esophageal operations. All patients had between one and four unsuccessful operations for benign esophageal disorders. Sixteen patients had primary motor disorders: achalasia in nine and esophageal spasm in seven. Of these patients, 11 also had recurrent gastroesophageal reflux and peptic esophagitis. Complicated reflux disease characterized by severe esophagitis, stricture, and impaired peristalsis without primary motor disorder occurred in five patients. In one patient a functionally impaired long-segment colon interposition was removed and replaced with stomach. Total thoracic esophagectomy and cervical esophagogastric reconstruction was done in all patients. The transhiatal approach was chosen for resection in 16 patients and thoracotomy was used in the other five. There was one perioperative death (5%), from massive aspiration 4 days after transhiatal esophagectomy. Other complications included transient anastomotic leak (three patients), tracheoesophageal fistula (one), recurrent nerve palsy (one), and transient hoarseness (two). Follow-up is complete between 1 and 10 years and reveals the following functional results: 12 patients good to excellent, seven fair, one poor. In this patient group in which multiple prior procedures have failed to improve severe incapacitating symptoms, we believe further attempts at hiatal reconstruction are unlikely to succeed. For this circumstance, we recommend total thoracic esophagectomy with the use of stomach as the replacement organ of choice.

Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe

Despite a common misconception, bronchogenic carcinoma of the left upper lobe frequently metastasizes to lymph nodes not only in the anterior mediastinum (para-aortic and subaortic) but also in the superior mediastinum. Anterior (parasternal) mediastinotomy can be used to assess only the former compartment. This procedure alone, if not done in conjunction with standard cervical mediastinoscopy, will fail to disclose technically unresectable N2 or N3 disease of the left upper lobe involving the superior mediastinum. We have developed a technique to explore and sample nodes from both regions by extending a standard cervical mediastinoscopy, eliminating the need for a second incision when the anterior mediastinal compartment requires assessment. We have prospectively analyzed the first 100 procedures that we performed. This technique has been found to be accurate and exceptionally safe with one superficial wound infection as the only complication. We can recommend this single staging procedure for preoperative assessment of bronchogenic carcinomas of the left upper lobe.

Incidence of mediastinal node involvement in clinical T1 bronchogenic carcinomas

The incidence of mediastinal node involvement of T1 non-small-cell bronchogenic carcinomas was determined in 262 patients for the period June 1981 to January 1986. All patients underwent mediastinoscopy as part of their evaluation. Thirty-five patients (13%) had clinical primary T1 lesions. There were 17 adenocarcinomas, 10 squamous cell carcinomas, 6 large-cell anaplastic carcinomas and 2 bronchoalveolar carcinomas. Five patients had node involvement at mediastinoscopy: two had large-cell anaplastic carcinomas and one was a squamous cell carcinoma. Thoracotomy in the remaining 30 patients revealed 2 with pleural metastases, 1 with left upper lobe adenocarcinoma with metastases to the subaortic nodal area (not assessed by cervical mediastinoscopy). The other patients underwent resection, for a resectability rate of 90%. Therefore the overall incidence of mediastinal node involvement in this series was 17% (6 of 35) and was found to be highest among patients with large-cell anaplastic carcinomas (2 of 6), followed by adenocarcinomas (3 of 19) and squamous cell carcinomas (1 of 10). The larger number of large-cell anaplastic carcinomas in this series probably accounts for the higher incidence of N2 disease found compared with that of previous studies in the literature. Accordingly, preoperative mediastinal staging is recommended for all T1 large-cell anaplastic carcinomas and adenocarcinomas and for suspicious lesions of undetermined histology.

Incarcerated parahiatal hernia with gastric necrosis

A parahiatal diaphragmatic hernia developed five years after transthoracic Heller myotomy. Failure to recognize this complication resulted in strangulation and necrosis of the gastric fundus. To our knowledge, this is the first reported case of a postoperative parahiatal hernia that did not follow the use of a diaphragmatic counterincision. Prompt recognition of this complication will prevent unnecessary morbidity and mortality.

Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula

Postpneumonectomy empyema, with or without bronchopleural fistula, remains an infrequent but serious complication of pulmonary resection. We reviewed our experience with the Clagett procedure in 31 patients with postpneumonectomy empyema. Seven had empyema alone and 24 had empyema with bronchopleural fistula. Ten patients died of metastatic disease without attempted closure of the thoracostomy window. In eight patients the total Clagett procedure was completed; window closure was permanent in two patients, but the remaining six had recurrence of empyema (four of whom had persistent occult fistulas). In eight further patients, persistent infection prevented attempted closure of the window. Five patients refused further surgical procedures. In only two of 31 patients were we able to achieve permanent closure of the thoracostomy window. Based on this experience, we conclude that open window thoracostomy provides adequate drainage and an excellent interim or permanent treatment of the infected pneumonectomy space. However, the presence of persistent bronchopleural fistula prevents successful completion of the total Clagett procedure. In our series, there were no deaths related to empyema or the surgical procedures performed for it.

Modern thirty-day operative mortality for surgical resections in lung cancer

Modern postoperative mortality rates for resectional operations for lung cancer are not readily available. In recent publications estimating the risk factors for surgical resection, mortality rates of 10% to 15% for pneumonectomy and 5% to 7% for lobectomy are frequently quoted. In order to determine modern operative mortality rates (up to 30 days postoperatively), the Lung Cancer Study Group (LCSG) analyzed the surgical mortality rates of the various participating centers during the years 1979 to 1981. A total of 2,200 resections for lung cancer were available for analysis. Of the 2,220 resections performed, 1,058 were lobectomies, 569 were pneumonectomies, and 143 were lesser resections (segmental or wedge). Eighty-one postoperative deaths occurred from among the 2,220 resections (3.7%). The mortality rate for pneumonectomy was 6.2% and for lobectomy, 2.9%. Lesser resections carried a 1.4% mortality rate, not statistically different from lobectomy. In patients under the age of 60 years, the mortality rate was 1.3%, 60 to 69 years, 4.1%, and over 70 years, 7.1%, all significantly different (p less than 0.01). The postoperative mortality rate for patients 70 years or older was 7.1% (pneumonectomy 5.9% and lobectomy 7.3%). It is obvious that greater care was taken in selection among the older pneumonectomy patients. The striking similarity of postoperative mortality rates for resectional operations for lung cancer among the various centers of the LCSG and among the various institutions within these centers suggest that these data are a reasonably accurate analysis of modern surgical mortality rates in the treatment of lung cancer.

Reduction in local recurrence and improved survival in surgically treated patients with small cell lung cancer

To assess the role of operation in the treatment and prevention of local recurrence in limited small cell lung cancer, we analyzed retrospectively 35 patients undergoing surgical resection for small cell lung cancer between 1976 and 1982. Twenty-eight patients underwent resection for presumed non-small cell histology. Seven later patients had planned combined modality therapy consisting of chemotherapy and prophylactic cranial irradiation followed by surgical resection and irradiation to the primary site. Twenty-four patients received adjuvant postoperative chemotherapy and/or radiotherapy. All patients have been treated and followed up for a minimum of 1 year. There were 19 patients in Stage I and 16 in Stages II and III. In 15 patients, relapse has occurred. The commonest site of first relapse was brain (7/15). Five of these patients had received prophylactic cranial irradiation. In only two patients was there a relapse locally in the hemithorax and/or mediastinum--one with NO disease and one with N1 disease. No local recurrence was noted in six patients with N2 disease. Only two relapses have occurred beyond 1 year--both in brain. In those patients surviving more than 2 years, no relapses have occurred. The median survival time for patients with Stage I disease is 158 weeks and for those with Stages II and III, 92.4 weeks. The median survival time for the whole group is 92.4 weeks with a projected 5 year survival rate of 24%. It appears that surgical resection may help to prevent local recurrence in small cell lung cancer, even in N1 and N2 disease. In our series, projected 5 year survival rates are similar to those seen in the surgical treatment of patients with non-small cell lung cancer. The eventual role of operation in the prevention of local recurrence and improvement in overall survival of limited small cell lung cancer awaits prospective randomized trials.

A modified Sugiura procedure

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose-fundal wrap. Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, ad coagulopathy, died in the postoperative period. Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.

The role of the esophageal body in the antireflux mechanism

The competency of the cardia depends on the interaction of the distal esophageal sphincter (DES) pressure and the length of the DES exposed to the positive-pressure environment of the abdomen. These two components were measured in 20 normal control volunteers and 126 patients with objectively proved gastroesophageal reflux. The results, when plotted on a grid with the horizontal bar representing the length of the abdominal esophagus and the vertical bar representing the DES pressure, indicated that factors in addition to the mechanical components of the cardia were important in the antireflux mechanism. The 24-hour esophageal pH records from the patients and the antireflux mechanism. The 24-hour esophageal pH records from the patients and normal subjects were analyzed as to the number of reflux episodes that occurred per hour while the patients were in the supine position and the ability to clear the refluxed acid by the propulsive "P"pump" of the body of the esophagus. It was concluded that the antireflux mechanism of the esophagus consists of a valvular cardia and a propulsive "pump" action of the body of the esophagus. The failure of either may lead to abnormal acid exposure but can be compensated by one or the other in normal subjects. Failure of both invariably leads to abnormal acid exposure. The cardia can fail either mechanically (i.e., having inadequate valvular components) or functionally (i.e., having normal valvular component but abnormal number of reflux episodes per hour). The latter suggests gastric pathology. Precise diagnosis of the reason for abnormal acid exposure is needed to develop a rational basis for therapy.

The Sugiura procedure for bleeding esophageal varices: a modification

The Sugiura procedure is an operation for control of bleeding esophageal varices. Splenectomy, extensive paraesophagogastric devascularization, and transection and anastomosis of the esophagus are performed through two incisions. The modifications described by the authors, such as the single thoracoabdominal incision and use of a stapler, simplify and shorten the operation. Preliminary results in nine patients are encouraging.

Spectrophotometry as a tool for assaying endotoxins

A spectrophotometric method is reported for assaying endotoxins over a wide concentration range, including low parts per billion levels. Five solution of endotoxins. Escherichia coli 0127:B8, Escherichia coli 055:B5, Salmonella abortus-equi, Salmonella enteritidis, and Shigella flexneri, were examined. Each exhibited an absorption maximum at 259 nm, but the absorptivities differed in each case. Thus, rigorous quantification requires that the identity of the endotoxin be known. The uv absorbance and the statistical data for the standard curves for three groups of standard solutions are presented. The absorbance for each group was linear with concentration within acceptable limits.