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Biomedical subjects

P R Walbaum

Publications and source records attributed to P R Walbaum.

At least 19 recordsLinked to original sources
PubMed1992

Low dose preoperative radiotherapy for carcinoma of the oesophagus: results of a randomized clinical trial.

One-hundred-and-seventy-six patients with potentially operable squamous cell carcinoma or adenocarcinoma of the middle or lower thirds of the oesophagus were randomly assigned to preoperative radiotherapy or surgery alone. Patients assigned to the radiotherapy arm received 20 Gy in 10 treatments over 2 weeks, using parallel opposed 4 MV beams. The preoperative radiotherapy was not associated with any significant acute morbidity or any increase in operative complications. The median survival of the overall group of 176 patients was 8 months, and the 5-year survival was 13%. There was no significant difference in the survival of the 90 patients who received preoperative radiotherapy and the 86 who were managed by surgery alone. Proportional hazards analysis identified lymph node involvement, high tumour grade and male sex as significant adverse prognostic features, but the treatment option assigned had no prognostic significance. It was concluded that low dose preoperative radiotherapy offered no advantage over surgery alone.

Adenocarcinoma↗
PubMed1992

Management of chylothorax complicating extensive esophageal resection.

Between January 1983 and May 1987, 255 esophagectomies were performed for carcinoma of the middle (40 patients) or lower (215 patients) esophagus. All patients were operated upon through a left thoracolaparotomy and underwent a radical en bloc resection of the tumor along with all palpable mediastinal nodes. Ten patients had chylothorax develop postoperatively. There were seven men and three women with a mean age of 65.7 years (range of 37.0 to 81.0 years). Parameters that were statistically evaluated for possible correlation to increased incidence of chylous fistula were age, sex, site and size of tumor, histologic type, mediastinal lymphatic involvement and elective prophylactic ligation of the major thoracic duct (MTD) at the conclusion of the procedure. It was found that elective ligation of the MTD was associated with a lower occurrence of chylothorax (2.1 per cent) as compared with those with no routine ligation (9 per cent), p less than 0.05. The leak was successfully treated by repeated thoracotomy and mass ligation of the MTD in eight patients, while one patient underwent closed tube thoracostomy. In one instance, only a pleuroperitoneal shunt was performed. The over-all hospital mortality rate from chylothorax was 10 per cent and there was a late death because of pneumonia. We recommend prophylactic ligation of the MTD in all instances of extensive esophageal resection for the prevention of chylothorax, as well as early thoracotomy for the management of established leaks.

Aged↗
PubMed1989

Comparison of ventricular septal surgery and mitral valve replacement for hypertrophic obstructive cardiomyopathy.

We have reviewed the results of two different forms of surgical management of hypertrophic obstructive cardiomyopathy refractory to medical therapy. Twenty-one patients were treated with 22 procedures between 1963 and 1987. Eleven underwent a ventricular septal procedure by myotomy with or without myectomy, and 11 underwent mitral valve replacement (MVR), 1 of whom had previously undergone a ventricular septal procedure. The groups were comparable with respect to severity and duration of symptoms, age range, electrocardiographic features, and hemodynamic changes. Mitral valve replacement produced a greater and more consistent reduction in the left ventricular outflow tract pressure gradient than a ventricular septal procedure (MVR, 68.3 mm Hg preoperatively and 2.5 mm Hg postoperatively; ventricular septal procedure, 60.1 mm Hg preoperatively and 13.4 mm Hg postoperatively). This was associated with better postoperative ventricular configuration in diastole and more apparent loss of midcavity narrowing in systole. Ejection fraction did not fall after a ventricular septal procedure but decreased significantly from a mean of 79% to a mean of 61% after MVR. Similarly, left ventricular end-diastolic pressure remained unchanged after a ventricular septal procedure but fell from a mean of 26.6 mm Hg to 17 mm Hg after MVR. Although both groups experienced a generally satisfactory symptomatic result, this appeared more reliable with MVR. We suggest that MVR offers a more predictable improvement than a ventricular septal procedure and may be the procedure of choice for units with limited experience with ventricular septal procedures.

Adolescent↗
PubMed1989

Long term survival after pulmonary resection for small cell carcinoma of the lung.

A retrospective review was undertaken of the long term survival of 97 patients with histologically proved small cell carcinoma of the lung resected during the 10 years January 1977-December 1986. Twenty seven patients (28%) had stage I disease, 29 (30%) stage II, and 41 (42%) stage III. Patients with stage I and II tumours were managed by resection alone. Patients with stage III disease received adjuvant chemotherapy (cyclophosphamide, doxorubicin, and vincristine). Pneumonectomy was undertaken in 75 patients, lobectomy in 21, and wedge resection in one patient. Three patients died within 30 days of operation. The cumulative five year survival of all patients, irrespective of tumour stage, was 17%. The cumulative five year survival was 35% for patients with stage I disease, 23% for stage II, and zero for stage III. The median survival for patients with stage III tumours was 17 months. There was no significant difference in cumulative survival between patients with stage I and II disease. Cumulative survival, however, was significantly better for patients with stage I and II disease than for those with stage III disease. The data suggest that for patients with stage I and stage II disease surgery offers the prospect of long term survival.

Adult↗
PubMed1987

Esophagogastrectomy for benign esophageal stricture. Fate of the esophagogastric anastomosis.

Eighty-nine patients who had resection of benign esophageal stricture with esophagogastrostomy were reviewed through medical records and by mailed questionnaire. The 30-day mortality rate was 8.9%. Seventy-six patients were available for follow-up for an average of 66.4 months (Group 1). Forty-three of these patients were followed up for longer than 5 years (Group 2). The incidence of postoperative heartburn in Groups 1 and 2 was 7.9% and 7.0%, respectively. The incidence of postoperative dysphagia in Groups 1 and 2 was 39.4% and 30.2%, respectively, with most episodes occurring within 2 years of operation. The vast majority of these patients required multiple esophageal dilatations over a long time. The high rate of restricture precludes support for the routine use of an esophagogastric anastomosis after resection of benign esophageal stricture.

Adult↗
PubMed1986

A prospective evaluation of the Björk-Shiley, Hancock, and Carpentier-Edwards heart valve prostheses.

From 1975 to 1979, 540 patients undergoing valve replacement were entered into a randomized trial and received either a Björk-Shiley (273 patients) or a porcine heterograft prosthesis (initially a Hancock valve [107 patients] and later a Carpentier-Edwards prosthesis [160 patients]). Two hundred and sixty-two patients required mitral valve replacement, 210 required aortic valve replacement, 60 required mitral and aortic valve replacement, and eight also required associated tricuspid valve replacement (six mitral valve replacement; two mitral plus aortic valve replacement). Analysis of 34 preoperative and operative variables showed the treatment groups to be well randomized. In-hospital mortality was not significantly different among patients receiving the three prostheses for aortic valve replacement (7.6% overall) and mitral plus aortic valve replacement (10% overall), but there was a higher in-hospital mortality for patients undergoing mitral valve replacement with the Carpentier-Edwards prosthesis (15.5% compared with 8.8% overall; p = .03). This difference could not be explained on the basis of any preoperative or operative variable. Median follow-up was 5.6 (range 2.8 to 8.3) years. Actuarial survival after mitral valve replacement was 56.7 +/- 7.0% at 7 years, that after aortic valve replacement was 69.6 +/- 9.6% at 7 years, and that after mitral plus aortic valve replacement was 62.5 +/- 20.0% at 7 years. There was no significant difference in actuarial survival of patients receiving the three prostheses within the mitral, aortic, and mitral plus aortic valve replacement groups, nor was there a difference when these groups were amalgamated. Thirty-seven patients required reoperation for valve failure (15 with Björk-Shiley, 12 with Hancock, and 10 with Carpentier-Edwards valves; p = NS) and 11 died at reoperation (four with Björk-Shiley, four with Hancock, and three with Carpentier-Edwards valves; overall operative mortality 29.7%). Up to 7 years after surgery, there was no significant difference in the incidence of thromboembolism in patients with different prostheses undergoing mitral or aortic valve replacement. There were too few patients undergoing mitral plus aortic valve replacement for meaningful comparison. There was no significant beneficial effect of anticoagulants in patients undergoing mitral or aortic valve replacement with porcine prostheses, but patients were not randomly allocated to anticoagulant treatment. All patients with Björk-Shiley prostheses received anticoagulants.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMed1985

Diagnosis and management of spontaneous transmural rupture of the oesophagus (Boerhaave's syndrome).

The presentation, diagnosis and management of 14 cases of spontaneous transmural oesophageal rupture have been reviewed. Analysis suggested that the classical triad of vomiting, chest pain and subcutaneous emphysema was rare (1/14) and therefore misleading. Abdominal pain and tenderness obscured the clinical picture; the temporal relationship of pain to vomiting varied and subcutaneous emphysema was uncommon (4/14). Consequently, only two cases were correctly diagnosed on presentation and diagnosis in the others was markedly delayed (average 4 days). Contrast swallow examination, when eventually performed, was diagnostic. Twelve patients underwent repair: four under 24 h, who all survived and eight over 24 h, amongst whom there were one (12.5 per cent) operative and two (25 per cent) late deaths. Conservative management was successful in the remaining two cases. Oesophageal fistula, empyema and incorrect initial surgery were common and serious complications. Management options are reviewed and their relative merits considered.

Adult↗
PubMed1984

Wound prophylaxis in thoracic surgery: a new approach.

A prospective double blind, randomised study was performed in 100 patients undergoing major elective thoracic surgery to assess a new method of prophylaxis of wound infection using one preincisional intraparietal infiltration of cefuroxime sodium along the line of proposed incision as the sole protection against wound infection. A significant (p less than 0.01) reduction in the incidence of wound infection occurred in the antibiotic treated group (2%) compared with the control group (20%), who received by the same route the same volume of saline only. The groups were comparable with respect to age, sex, pathological condition, and operative variables. The use of additional antibiotics was significantly greater in the control group (p less than 0.01), largely owing to a much greater incidence of postoperative pulmonary infection in the control group (60%) than in the antibiotic treated group (40%). No morbidity was associated with this technique. The organisms found in oesophageal and bronchial operative luminal specimens did not correlate with postoperative wound or pulmonary infection or with organisms causing these infections. Reductions in wound and pulmonary infection rates equivalent to those produced by conventional multiple dose parenteral regimens were achieved by this technique.

Aged↗
PubMed1983

Surgical management of native valve endocarditis.

From 1972 to 1981 40 patients have required urgent valve replacement for left-sided bacterial endocarditis. The aortic valve was replaced in 31 patients, the mitral valve in four, and both in five patients. Twenty-six patients (65.5%) were in functional class IV heart failure according to the New York Heart Association criteria, and 13 patients (32.5%) were in class III heart failure at the time of operation. One patient in class II was operated on urgently for multiple cerebral embolism but died of fatal cerebral haemorrhage. In 22 patients (55%) there were no pre-existing valvular lesions and these patients were found to be more liable to develop severe haemodynamic failure. Premature closure of the mitral valve, documented by M-mode echocardiography, was a useful diagnostic aid and successfully determined the best timing of surgery in 14 out of 20 patients with severe aortic regurgitation. Cardiac arrest before operation appeared to be a significant risk factor (p = 0.0015) unless followed by immediate cardiopulmonary bypass. There were eight operative deaths (20%). Of 26 patients who were in functional class IV heart failure, 19 were operated on within four days of their haemodynamic deterioration and all survived. The operation was delayed in the remaining seven patients and none of them survived (p = 0.000003). There were no operative deaths among the patients in class III heart failure. There was only one episode of reinfection in the 16 patients followed up for at least three years. The duration of postoperative antibiotic treatment (four to six weeks in our patients), rather than any preoperative antibiotic regimen, seems to be important for preventing reinfection. At present there are 28 survivors, of whom 24 are in functional class I and four in class II.

Adolescent↗
PubMed1983

Surgical management of prosthetic valve endocarditis.

Operative mortality in patients with prosthetic valve endocarditis (PVE), who already have severe hemodynamic failure, is extremely high (35% to 84%). Over a period of 10 years, between 1972 and 1981, fourteen consecutive urgent operations were performed for PVE in 12 patients. On thirteen occasions the patients were in severe hemodynamic failure (NYHA Functional Class IV), and five of them had early PVE (within 60 days of previous operation). In all patients at least two of the other recognized risk factors, such as presence of non-streptococcal organisms, detachment of the prosthesis, and myocardial invasion, were present. All of the patients but one were operated upon within 48 hours of their hemodynamic deterioration, and there was one postoperative death (operative mortality 7%). Our results indicate that an acceptable surgical mortality in patients with intractable heart failure due to early and late PVE can be achieved by prompt surgical intervention despite the presence of multiple risk factors.

Endocarditis, Bacterial↗
PubMed1980

An unusual case of large right atrial myxoma.

A case of right atrial myxoma is described. The patient had vague and variable symptoms and it was not until five years after first presentation that she had developed clinical and electrocardiographic evidence of right atrial hypertrophy, and angiocardiographic evidence of a fist-sized myxoma which was subsequently removed surgically.

Adult↗
PubMed1980

Spontaneous dissection of the oesophagus.

Spontaneous rupture of the oesophagus is a well-known entity. Partial or intramural rupture of the oesophagus has been described but is not so well known, and the purpose of this paper is to draw attention to this condition. The clinical presentation, radiological appearances, and treatment of two such cases are described.

Aged↗
PubMed1979

Surgical management of bronchial carcinoma invading the chest wall.

In a 20-year period (1958-77) 43 patients underwent combined pulmonary and chest wall resection for bronchial carcinoma with local invasion of the thoracic wall. The clinical data, symptoms, surgical procedures, pathology, and results are reviewed. Pain was the usual presenting symptom. The operative mortality was 16%, respiratory complications causing most of the postoperative morbidity and mortality. These complications were less common after pneumonectomy. Long-term survival was achieved in only three cases with a corrected three-year survival rate of 10%. The survivors had certain pathological and operative features in common that may have prognostic significance. Recurrent carcinoma was responsible for most late deaths. Despite the poor overall prognosis, surgical management provided reasonable palliation and occasionally resulted in prolonged disease-free survival.

Adult↗