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Biomedical subjects

D G Mulder

Publications and source records attributed to D G Mulder.

At least 37 records · Page 2Linked to original sources
PubMed1984

Esophageal perforations. The need for an individualized approach.

Since 1971 we have treated 33 patients with esophageal perforation caused by instrumentation in 21 patients, trauma in six, and spontaneous perforation in six. Chest pain, fever, mediastinal air, and an abnormal esophagogram were frequent but not invariable findings. Surgical therapy, consisting of primary repair and drainage in 12 patients, drainage alone in five, esophageal diversion in two, and esophagogastrectomy in one, was initiated within 24 hours in 14 patients, all of whom survived. A delay of more than 24 hours in six patients resulted in 33% mortality. Nine patients with small instrumental perforations were treated successfully with antibiotics alone, while three other patients with late traumatic (n = 2) and spontaneous (n = 1) perforations were treated nonoperatively; all three died. Overall mortality for the series was 15.5%. Except for small contained instrumental injuries, esophageal perforations demand prompt exploration, with primary repair and drainage as the procedure of choice.

Adolescent↗
PubMed1984

Pericardiectomy: a changing scene.

The indications for pericardiectomy as well as the causal factors have changed in recent years. Sixty-eight patients operated on at the UCLA Medical Center between 1955 and 1982 have been described. There were 37 male patients and 31 female patients. The indication for operation was acute pericarditis in 37 patients, of whom 31 had recurrent effusion, and chronic constrictive pericarditis in 31 patients, of whom 8 were calcific. The most common cause of pericardial disease was tumor (20 patients), followed by idiopathic (13 patients), uremic (7 patients), viral (7 patients), tuberculous (6 patients), rheumatologic (6 patients), and miscellaneous (9 patients) causes. In most patients, pericardiectomy was performed through a left anterolateral thoracotomy without cardiopulmonary bypass. We recommend wide excision of the anterior pericardium (phrenic nerve to phrenic nerve) for effusive pericarditis. For chronic constrictive disease, we advocate a more extensive resection that includes the anterior as well as the posterior pericardium, thus freeing the left and right ventricles. Excellent long-term results were obtained with pericardiectomy in 90 percent of the patients who survived the operation.

Adolescent↗
PubMed1983

Surgical management of subaortic stenosis.

The two most common causes for left ventricular outflow tract obstruction are discrete fibromuscular membrane (DMS) and idiopathic hypertrophic subaortic stenosis (IHSS). From 1955 to 1980, 195 patients were seen with subaortic obstruction, 50 of whom required operation. Thirty patients had excision of a subaortic membrane; 20 had resection of the hypertrophic muscular obstruction. The average preoperative gradient across the left ventricular outflow tract was 79 mm Hg. Postoperatively 40 patients were catheterized; two had gradients over 40 mm Hg, and both were in the DMS group. There were four operative and six late deaths (mean follow-up, 8.5 years), five occurring in the IHSS group (25%) and one in the DMS group (3.5%). Recurrent symptoms required reoperation in three patients with IHSS and one with DMS. Both groups benefitted from operation, but those with DMS had a better overall survival rate and fewer postoperative symptoms than those with IHSS.

Adolescent↗
PubMed1983

Thymectomy for myasthenia gravis.

Thymectomy was performed on 249 patients with myasthenia gravis between 1957 and 1981. During a follow-up period that ranged from 2 months to 24 years (mean 7.5 years), the remission rate for the entire group was 51 percent, and an additional 36 percent had improvement (87 percent benefited). In those 51 patients with thymoma, the remission rate was 37 percent, with 68 percent of the patients benefiting from operations. The remaining 198 patients fared better after the operation: 54 percent had remission and a total of 91 percent benefited. The female patients within this group had a 94 percent probability of benefit from operation. We conclude that most patients with myasthenia gravis will benefit from thymectomy, and that the improvement persists over an extended period of time in a high percentage of patients.

Adolescent↗
PubMed1983

Warm induction of cardioplegia with glutamate-enriched blood in coronary patients with cardiogenic shock who are dependent on inotropic drugs and intra-aortic balloon support.

This report reviews the initial clinical application of our experimental studies inducing cardioplegia with a warm (37 degrees C) glutamate-enriched blood solution in ischemically damaged hearts. Over 15 months, 23 consecutive coronary patients requiring preoperative intra-aortic balloon and inotropic drug support for cardiogenic shock underwent operation for left ventricular power failure. Twelve patients were given a warm glutamate-enriched blood cardioplegic solution during the first 5 minutes of aortic clamping before multidose cold (4 degrees C) glutamate blood cardioplegia was begun; 11 patients received standard multidose cold blood cardioplegia without glutamate. All patients had comparably depressed left ventricular performance preoperatively despite maximal inotropic and balloon support and showed evidence of extending myocardial infarction. They did not differ in the number of grafts placed (3.7 +/- 0.2), associated valve and aneurysm procedures (seven patients) or cross-clamp time (89 +/- 6 minutes). All patients received warm blood cardioplegic reperfusion before aortic unclamping. The perioperative mortality was 9% (2/23); both patients who died received cold blood cardioplegia without glutamate. In addition to lower mortality, patients receiving warm glutamate blood cardioplegia exhibited better hemodynamics, allowing earlier discontinuation of inotropic drug infusion (1.3 +/- 0.5 versus 2.7 +/- 0.8 days, p less than 0.05) and intraaortic balloon support (1.2 +/- 0.2 versus 3.6 +/- 0.5 days, p less than 0.05). Late mortality was 30%, resulting in a 65% overall survival rate (2 to 15 months) for the entire series of patients. The operative principles evolving from this early experience include (1) warm blood cardioplegic induction, (2) glutamate enrichment, (3) meticulous attention to cardioplegic distribution and grafting sequence, (4) warm cardioplegic reperfusion before unclamping, and (5) graft perfusion during construction of proximal anastomoses. Hopefully, further application of these techniques will improve results in these extremely high risk coronary patients requiring operation.

Aged↗
PubMed1983

Mediastinal parathyroid adenomas. A cause of persistent hyperparathyroidism.

Unrecognized mediastinal parathyroid adenomas that are inaccessible via a standard cervical exploration are an important cause of persistent primary hyperparathyroidism. Of 26 patients evaluated at UCLA Medical Center for persistent primary hyperparathyroidism, six required sternotomy (5) or thoracotomy (1) for cure of their disease. Analysis of these six patients suggests that aberrant embryologic development is the most logical explanation for the ectopic location of these mediastinal adenomas. In most instances, preoperative localization of the adenoma is possible. Permanent hypoparathyroidism occurs in a significant percentage of patients undergoing reoperative parathyroid surgery. Efforts to minimize postoperative morbidity should include a careful and systematic approach to the preoperative and intraoperative management of patients with mediastinal adenomas, as well as consideration of autotransplantation or cryopreservation of parathyroid tissue.

Adenoma↗
PubMed1982

The value of open lung biopsy in the immunosuppressed patient.

To evaluate the impact of the open lung biopsy on diagnosis and therapy in the immunosuppressed patient, 68 such patients managed at UCLA from 1975 to 1980 were reviewed. Most had hematologic malignancies, and all were severely immunosuppressed. The rates of surgical mortality (1 operative death) and morbidity were minimal. There were 10 diagnostic differences apparent when biopsy results were compared with autopsy findings in 28 autopsied patients. Therapy was initiated or modified in 19 patients on the basis of open lung biopsy. Forty-four patients lived 1 year or less, 14 for more than 1 year, and 10 were lost to follow-up. Of 42 patients with an untreatable disease on the basis of lung biopsy, 67% died and 33% lived to leave the hospital. Of 25 patients with a treatable disease, 56% died and 44% left the hospital. Of 28 autopsied patients, only 12 were receiving appropriate medication at time of death despite biopsy. The patient whose disease is generally characterized by brief survival like acute leukemia, and whose situation is most desperate, unfortunately benefits least from open lung biopsy. We conclude that this procedure has only a modest impact in the management of these critically ill patients and should be used conservatively.

Adolescent↗
PubMed1981

Persistent and recurrent hyperparathyroidism.

Twenty-six patients with persistent or recurrent primary hyperparathyroidism after an initial cervical exploration are presented. Failure of the first operation was related in part to an ectopic location of the abnormal parathyroid tissue (in 58 percent), and to a discrepancy in the histologic diagnosis between the frozen-section analysis at the time of operation and the final pathologic interpretation (in 55 percent). Before secondary operation, selective venous sampling for parathormone levels and arteriography were accurate in localizing the lesion in 88 and 71 percent of cases, respectively. A plan for intraoperative management of these difficult problems is suggested.

Adenoma↗
PubMed1980

Superiority of blood cardioplegia over asanguinous cardioplegia--an experimental and clinical study.

This study compares experimental and clinical results using both an asanguinous and sanguinous vehicle for delivering the cardioplegic solution. Animals receiving blood cardioplegia had better left ventricular function after unclamping, significantly less post-ischemic myocardial edema, and a better ability to augment flow and oxygen consumption. Patients receiving blood cardioplegia had also better myocardial performance with high cardiac outputs and lower left atrial pressure, and showed less evidence of myocardial damage. We conclude that oxygenation of the cardioplegic solution provides superior myocardial protection to that seen when the same solution is used in an asanguinous vehicle.

Animals↗
PubMed1979

Surgical management of extensive tracheal lesions.

Resection and end-to-end anastomosis has been effective in correcting localized tracheal obstruction. This procedure can be utilized in the definitive management of extensive tracheal lesions requiring the resection of at least eight tracheal rings. Important clinical considerations are the precise preoperative assessment of the lesion, careful planning of anesthetic management, choice of the appropriate incision, avoidance of circumferential dissection, and the construction of an anastomosis free of disruptive tension.

Adult↗
PubMed1979

The use of computed tomography to evaluate suspected mediastinal tumors.

Thirty patients with suspected mediastinal tumors were evaluated by computed tomography (CT) at UCLA Medical Center. Twenty patients with myasthenia gravis were examined for possible thymomas, benign and malignant; and 10 patients were studied for other mediastinal masses (including teratoma, seminoma, mediastinal lipomatosis, carcinoma, lymphoma, and paravertebral abscess). The CT scan was found useful in several respects: (1) yielding information not available by conventional radiographic techniques; (2) defining the anatomical location and extent of mediastinal tumors; (3) detecting pulmonary metastasis and involvement of mediastinal nodes in cases of malignancy; and (4) establishing the diagnosis of benign mediastinal fatty masses. On the basis of our early experience, we believe CT is a valuable adjunct in the preoperative assessment of patients with suspected mediastinal tumors.

Humans↗
PubMed1979

Diagnosis and management of postoperative pulmonary hypertensive crisis.

In this paper we discuss two infants and one child who experienced a previously unreported complication after complete correction of a large, unrestrictive ventricular septal defect. Two patients had documented pulmonary hypertensive crises and severe right-heart failure secondary to hypoxia and pulmonary vasoconstriction. These crises were associated with significantly increased right ventricular (RV) peak systolic and end-diastolic pressures and right-to-left shunting via a foramen ovale which, in turn, exaggerated the hypoxis. The crises were treated successfully with tolazoline in the second and third patients. RV pressure returned to normal values and have remained normal up to 12 months postoperatively in the second patient. Although the RV pressures decreased with tolazoline in the third patient, they never reached normal values. Postoperative monitoring of pulmonary artery and RV pressures in infants with large ventricular septal defects is essential when unexplained complications are encountered. Tolazoline proved to be very effective in the treatment of two patients with pulmonary vasoconstriction secondary to hypoxia.

Heart Septal Defects, Ventricular↗
PubMed1979

Reversal of ischemic damage with secondary blood cardioplegia.

After severe ischemic injury, it is usually necessary to prolong bypass to enhance recovery. This study tests the hypothesis that the best reversal of ischemic damage is achieved by briefly rearresting the postischemic heart with a continuous infusion of an oxygenated cardioplegic solution (secondary blood cardioplegia) during the period when bypass must be prolonged. Twenty dogs underwent 45 minutes of normothermic ischemic arrest. Fifteen minutes after unclamping, no heart could support the systemic circulation. In all dogs, oxygen demands were lowered by extending bypass for 30 minutes. In 10 of these dogs, demands were further lowered by rearresting the heart for 5 minutes with a continuous infusion of a 37 degrees C blood cardioplegic solution (K+28 mEq/L; pH 7.6; Ca++ 1 mEq/L) at a pressure of 50 mm Hg. Hearts treated with secondary blood cardioplegia showed greater recovery in the rate of contraction (-dP/dt 75% versus 62%, p less than 0.05) and relaxation (-dP/dt 76% versus 58%, p less than 0.05), better recovery of compliance (85% versus 51%, p less than 0.05), a higher stroke work index (0.72 versus 0.50 gm-m/Kg, p less than 0.05), and more ability to augment oxygen uptake (85% versus 45%, p less than 0.05) to meet the demands of the working heart than hearts treated by prolonging bypass alone. We conclude that rearresting the heart with a brief, continuous infusion of a blood cardioplegic solution results in more complete reversal of ischemic damage than possible by prolongation of a bypass alone. We believe that the increased recovery with secondary cardioplegia results from diversion of delivered oxygen toward reparative processes rather than its being expended needlessly on electromechanical work during the time when bypass must be prolonged.

Animals↗