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Biomedical subjects

J M Piehler

Publications and source records attributed to J M Piehler.

64 records · Page 4Linked to original sources
PubMed1982

Bronchogenic carcinoma with chest wall invasion: factors affecting survival following en bloc resection.

Sixty-six patients (54 men and 12 women) with primary bronchogenic carcinoma and documented chest wall invasion underwent en bloc chest wall and pulmonary resection at the Mayo Clinic between January 1, 1960, and January 1, 1980. Ages ranged from 36 to 85 years, with a mean of 62.2. Forty-eight lobectomies, 16 pneumonectomies, and 2 wedge excisions were performed. After operation, 31 patients were classified as T3 N0 M0, 7 as T3 N1 M0, and 12 as T3 N2 M0. In 16 patients, the N classification could not be determined (T3 Nx M0). Operative mortality was 15.2%. Actuarial five-year survival (Kaplan-Meier method) of the 56 patients surviving operation was 32.9%. Five-year survival for patients with T3 N0 M0 neoplasms was 53.7%; five-year survival for patients with N1 and N2 neoplasms was only 7.4% (p = 0.001). The effect of various factors on survival, both singularly and in combination, was assessed by Cox's proportional hazards model. Only age had a significant association with survival. Among patients with T3 N0 M0 neoplasms, five-year survival was 84.6% for those 60 years of age or less and 27.7% for patients who were older than 60 years (p = 0.009). We conclude that en bloc resection for primary bronchogenic carcinoma with chest wall invasion, while associated with a significant mortality, can be performed with a strong likelihood of long-term survival if regional lymph nodes are not metastatically involved and there is no evidence of distant metastasis.

Adult↗
PubMed1982

Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia.

Composite graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. In most cases, cephalad displacement of the coronary ostia permits direct reimplantation of the ostia into the composite graft. Occasionally, anatomical factors exist that preclude the safe advancement of the ostia to the graft for direct anastomosis. A method for dealing with this problem utilizing a short interposed polytetrafluoroethylene graft between coronary ostia and composite graft is presented.

Aorta↗
PubMed1982

Unexplained diaphragmatic paralysis: a harbinger of malignant disease?

The records of 103 male and 39 female patients with unexplained diaphragmatic paralysis were reviewed. A probable cause of the paralysis was not revealed by the initial history, physical examination, or review of plain chest roentgenograms. Paralysis occurred on the left in 82 patients (58%), on the right in 58 (41%), and bilaterally in two (1%). Initially, 64 patients (45%) had symptoms; dyspnea, cough, and chest wall pain were the most common. Long-term follow-up showed the best prognosis to be for patients with chest wall pain and cough (improvement in 82% and 78%, respectively); dyspnea improved in only 34% of patients with this complaint. Intrathoracic malignant lesions with phrenic nerve involvement were subsequently diagnosed in five patients (3.5%) and progressive neurogenic atrophy in one (0.7%). Roentgenographic follow-up showed return of normal diaphragmatic position in only 12 instances (9.2%). Patients with unexplained diaphragmatic paralysis are unlikely to have an underlying occult malignant or neurologic process, but recovery of diaphragmatic function is also unlikely and subsidence of related symptoms is variable.

Adolescent↗
PubMed1982

Primary pulmonary leiomyosarcomas. A light and electron microscopic study.

Fewer than 100 cases of primary leiomyosarcoma of the lung have been reported, few of which have been studied by electron microscopy. We performed clinicopathologic studies, including fine structural analysis, of two such cases. Their ultrastructural features differed in part from those of other smooth-muscle tumors, which may help exclude other malignant pulmonary lesions from the differential diagnosis.

Adult↗
PubMed1982

Results of surgical treatment of ascending aortic dissections occurring late after cardiac operation.

Seven patients (one woman) have been seen with ascending aortic dissections at a mean of 8.8 years (6 months to 20 years) after cardiac operation. Previous cardiac operations included saphenous vein coronary artery bypass grafts (CAB) (two), aortic valve replacement (AVR) (one), aortic valvulotomy (one), AVR plus CAB (two), and patch closure of a ventricular septal defect and repair of a perforated aortic cusp (one). During the initial operation, three of seven patients had dilatation of the ascending aorta. Five of seven patients were hypertensive at the time of diagnosis of dissection. Six patients were managed by operation. A composite prosthetic aortic valve and ascending aortic graft with implantation of coronary ostia and saphenous vein grafts was utilized in three patients. In three the repair was by graft replacement of the ascending aorta alone. Five of six patients survived repair and were asymptomatic at discharge. Subsequent problems resulting from distal, descending thoracic, or abdominal aortic extension of the dissection were frequent and necessitated fenestration (one patient) or a graft replacement of the infrarenal aorta (one patient). We conclude that patients may be predisposed to aortic dissection occurring late after cardiac operation, possibly related to prior aortic valvular disease or systemic arterial hypertension. Operative repair is feasible and relatively safe. Follow-up for potential complications of distal aortic problems seems indicated. Techniques of operative repair in these patients are emphasized.

Adult↗
PubMed1982

Cardiovascular effects of protamine sulfate in man.

Systemic hypotension is commonly observed in association with the administration of protamine after cardiopulmonary bypass. Previous studies have not conclusively demonstrated whether protamine induces its effect by altering myocardial performance or by changing systemic vascular resistance (SVR) or both. To elucidate the hemodynamic effects of protamine sulfate administration (150 mg/m2 body surface area), we studied 22 patients following cardiopulmonary bypass. In Group I (N = 8) protamine was infused over 30 seconds and while in Group II (N = 8), over 60 seconds. Group III (N = 6) received calcium chloride (20 mg/kg) prior to protamine administration. The hemodynamic response was assessed by continuous recording of myocardial contractile element velocity (maximal value-Vpm), aortic blood flow, systemic and pulmonary arterial and right atrial pressures, and electrocardiogram. A significant (p less than 0.05) decrease in the systolic, diastolic and mean blood pressure was observed in all groups. A significant increase in cardiac index and a significant decrease in SVR was observed in all groups. A small depression in Vpm was detected in those patients who experienced a mean blood pressure fall greater than 10 mm Hh. Heart rate and left ventricular end-diastolic pressure (LVEDP) did not change significantly. The response to protamine sulfate among the three groups was similar. These results demonstrate that protamine-induced hypotension is primarily the result of peripheral vasodilatation only partically compensated by an increase in cardiac index. In some patients, these changes were associated with a small decline in myocardial contractile state. Hemodynamic changes were transient (less that 3 to 4 minutes), unrelated to the rate of administration, and not prevented by preinjection of calcium chloride.

Blood Pressure↗
PubMed1981

Decannulation from the tenuous aorta.

Arterial decannulation from a diseased aorta at high pressure can be hazardous. A technique increasing the safety of this maneuver is described.

Aortic Diseases↗
PubMed1978

Primary carcinoma of the gallbladder.

Data from 6,222 patients with primary carcinoma of the gallbladder reported upon in the past 15 years have been analyzed. The disease occurs predominately in elderly females who often present with extremes of clinical symptoms, suggesting, on one hand, benign calculous disease or, on the other, advanced incurable malignant disease. Laboratory and x-ray data tend to confirm the clinical diagnosis of incurable disease, but do not aid in determining those patients with early, potentially curable lesions. The biologic nature of the tumor makes most carcinomas unsuspected findings at the time of operation and limits those patients presenting with resectable disease to about 25 per cent. The over-all five year survival of patients with carcinoma of the gallbladder is only 4.1 per cent. Furthermore, virtually the only survivors are those with lesions resected early that were not apparent to the operating surgeon and of the papillary cell type without significant invasion of the wall of the gallbladder. If the tumor is recognized and believed to be resected, survival is only 2.9 per cent, with failures caused by locally recurrent tumor. Despite the obvious failure of management of carcinoma of the gallbladder, therapeutic advantage has not been taken of the tumor's propensity to remain locally invasive by extending the scope of the traditional cholecystectomy to include en bloc hepatic wedge resection and regional lymphadenectomy in treating patients with recognized malignant tumors. Reoperation for delayed hepatic resection and lymph node dissection should be considered in selected patients with carcinoma unsuspected at operation but noted in the resected specimen. Selected application of this approach might offer the chance of cure to a small, but definite, group of patients who are currently being undertreated.

Adult↗
PubMed1977

Primary carcinoma of the gallbladder.

The clinical records of 48 patients with primary carcinoma of the gallbladder seen at the Dartmouth-Hitchcock Medical Center over the past 25 years were reviewed. Of the 37 patients with unresected tumors, there were no survivors. Of the 11 patients with resected tumors, one survived five years, two died before five years without evidence of recurrence, and the remainder died with locally recurrent tumor. This experience reemphasizes the inadequacy of the present surgical approach to the disease. The tendency of carcinoma of the gallbladder to spread initially by local invasion of the liver bed and by metastases to regional lymph nodes has often been neglected by those treating the disease. Wedge resection of the liver and regional lymphadenectomy in addition to cholecystectomy are theoretically advantageous and should be striven for in the case of resectable tumors, even if reoperation is required.

Adenocarcinoma↗