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Patient Care in Cardiac Surgery, Fourth Edition
31
Henderson, Ryder, Marryatt: Esophageal Myotomy and Total Fundoplication Hernia Repair
vious hiatal hernia repairs and the esophagus was damaged at that previous operation. My final point concerns the preservation of the HPZ. I have not at any time preserved the HPZ. I am concerned that HPZ preservation produces a major problem in these patients. The only other study reporting this approach that I am aware of is that of McGiffin and co-workers [lo] in 1982. They operated on 8 patients and reported on 7, and 2 of the 7 required reoperation because of esophageal HPZ obstruction. I have seen 6 such patients despite the fact that I do not use that approach and have always extended the myotomy to include the HPZ. A summary of the case of 1 patient will illustrate the clinical problem. The preoperative radiological study of this particular patient showed a small hiatal hernia and diffuse spasm. He had
an extended myotomy to the apex of the chest with the HPZ preserved. The patient was asymptomatic for 6 months. However, by the time 1 saw him in consultation, he was unable to eat solids and was unable to maintain hydration. The lower esophagus could be seen dilated with an intact HPZ. This has been a difficult patient to manage. I treated him by a Heller myotomy only, extending the myotomy through the HPZ. The short-term 6-month follow-up is satisfactory. I believe that despite Dr. Ellis’s excellent experience with this approach, we still have to look at it in the long-term review, and I think it very important that we should be careful until this is an established procedure. Certainly there is adequate evidence to suggest that obstruction and dilatation of the esophagus are a major risk.
REVIEW OF RECENT BOOKS
Patient Care in Cardiac Surgery. Fourth Edition Douglas M . Behrendt, M . D . , and W. Gerald Austen, M . D . Boston, Little, Brown, 1985 280 pp, illustrated, $22.50
Reviewed by ] d i e A . Swain, M . D . This fourth-edition paperback, by two respected teachers and practitioners of cardiac surgery, continues the high quality of its predecessors. The first two chapters concisely cover preoperative and intraoperative care of the patient, including such useful items as sample orders and checklists. Particularly helpful are short sections on the management of patients on specific medications or with problems such as coagulopathy and renal failure. The final seven chapters deal with early and late postoperative care of adults and children, with cardiovascular and pulmonary systems featured in individual chapters. Management of the typical patient without complications and of the unstable patient is outlined. Diagnosis and treatment of unique problems such as coronary artery spasm and pulmonary vasoconstriction are discussed. The appendixes on adult and infant drug doses and drug serum levels are easy to use.
One of the most helpful features of this book is the extensively updated list of over 600 current and historical references. Where appropriate, common pitfalls in caring for cardiac surgery patients are pointed out and the rationale for dealing with the problems are explained. Technical points, such as securing an endotracheal tube in an infant, are carefully described and well illustrated. A few minor omissions, such as continuous pulmonary artery saturation monitoring and management of postoperative hematocrit, are evident. The only substantial deficiency is the inconsideration of economic change in medicine since the third edition. The recommendation for many radiographic and laboratory examinations as postoperatively routine is difficult to justify when cost containment is a necessity. In future editions this concern should be addressed. Despite these few deficiencies, this manual should be required reading for all levels of surgery house staff assigned to a cardiac surgery service and would be especially valuable to others involved in the care of these patients, for example, cardiologists or anesthesiologists.
Bethesda, M D
Henderson, Ryder, Marryatt: Esophageal Myotomy and Total Fundoplication Hernia Repair
vious hiatal hernia repairs and the esophagus was damaged at that previous operation. My final point concerns the preservation of the HPZ. I have not at any time preserved the HPZ. I am concerned that HPZ preservation produces a major problem in these patients. The only other study reporting this approach that I am aware of is that of McGiffin and co-workers [lo] in 1982. They operated on 8 patients and reported on 7, and 2 of the 7 required reoperation because of esophageal HPZ obstruction. I have seen 6 such patients despite the fact that I do not use that approach and have always extended the myotomy to include the HPZ. A summary of the case of 1 patient will illustrate the clinical problem. The preoperative radiological study of this particular patient showed a small hiatal hernia and diffuse spasm. He had
an extended myotomy to the apex of the chest with the HPZ preserved. The patient was asymptomatic for 6 months. However, by the time 1 saw him in consultation, he was unable to eat solids and was unable to maintain hydration. The lower esophagus could be seen dilated with an intact HPZ. This has been a difficult patient to manage. I treated him by a Heller myotomy only, extending the myotomy through the HPZ. The short-term 6-month follow-up is satisfactory. I believe that despite Dr. Ellis’s excellent experience with this approach, we still have to look at it in the long-term review, and I think it very important that we should be careful until this is an established procedure. Certainly there is adequate evidence to suggest that obstruction and dilatation of the esophagus are a major risk.
REVIEW OF RECENT BOOKS
Patient Care in Cardiac Surgery. Fourth Edition Douglas M . Behrendt, M . D . , and W. Gerald Austen, M . D . Boston, Little, Brown, 1985 280 pp, illustrated, $22.50
Reviewed by ] d i e A . Swain, M . D . This fourth-edition paperback, by two respected teachers and practitioners of cardiac surgery, continues the high quality of its predecessors. The first two chapters concisely cover preoperative and intraoperative care of the patient, including such useful items as sample orders and checklists. Particularly helpful are short sections on the management of patients on specific medications or with problems such as coagulopathy and renal failure. The final seven chapters deal with early and late postoperative care of adults and children, with cardiovascular and pulmonary systems featured in individual chapters. Management of the typical patient without complications and of the unstable patient is outlined. Diagnosis and treatment of unique problems such as coronary artery spasm and pulmonary vasoconstriction are discussed. The appendixes on adult and infant drug doses and drug serum levels are easy to use.
One of the most helpful features of this book is the extensively updated list of over 600 current and historical references. Where appropriate, common pitfalls in caring for cardiac surgery patients are pointed out and the rationale for dealing with the problems are explained. Technical points, such as securing an endotracheal tube in an infant, are carefully described and well illustrated. A few minor omissions, such as continuous pulmonary artery saturation monitoring and management of postoperative hematocrit, are evident. The only substantial deficiency is the inconsideration of economic change in medicine since the third edition. The recommendation for many radiographic and laboratory examinations as postoperatively routine is difficult to justify when cost containment is a necessity. In future editions this concern should be addressed. Despite these few deficiencies, this manual should be required reading for all levels of surgery house staff assigned to a cardiac surgery service and would be especially valuable to others involved in the care of these patients, for example, cardiologists or anesthesiologists.
Bethesda, M D