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OBJECTIVE: The aim of this study was to review the results of off-pump (OPCAB) versus conventional on-pump coronary artery bypass surgery (CCAB) in high-risk patients. METHODS: In a cohort of patients with an additive EuroSCORE >/= 6, 67 underwent OPCAB and 112 underwent CCAB. RESULTS: Thirty-day postoperative death and stroke rates were 7.5 % and 6.0 % for the OPCAB group, and 5.4 % ( P = 0.75) and 8.0 % ( P = 0.77) for the CCAB group, respectively. No significant differences were observed for other major outcome endpoints other than cardiac troponin I (OPCAB: 117 +/- 428 ng/ml vs. CCAB: 58 +/- 99 ng/ml, P = 0.028), a result which was probably due to preoperative massive myocardial infarction in two very high-risk patients who underwent OPCAB. A similar outcome was also observed among propensity score-matched pairs. Congestive heart failure ( P = 0.006, OR: 6.366, 95 % CI: 1.682 - 24.093) and baseline cardiac index ( P = 0.018, OR: 0.171, 95 % CI: 0.040 - 0.735) were independent predictors of 30-day postoperative mortality. CONCLUSIONS: OPCAB can be safely performed in high-risk patients with results as satisfactory as those achieved with CCAB.

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AIM: Oxyhemodynamic parameters have been shown to have a relevant impact on the immediate postoperative outcome after major surgery, but it is not known their specific impact on the outcome after elective repair of abdominal aortic aneurysm (AAA). METHODS: One-hundred and forty-one patients underwent elective open repair of infrarenal AAA and hemodynamic parameters were monitored perioperatively. RESULTS: One patient (0.7%) died postoperatively, 23 (16.3%) experienced a myocardial ischemic event and 9 of them (6.4%) had a myocardial infarction. Baseline oxygen delivery was not predictive of such myocardial ischemic events. Thirty-three patients (23.4%) suffered severe postoperative complications. The median baseline oxygen delivery was 429.5 mL/min/m2 among patients who had severe postoperative complications, whereas it was 505.5 mL/min/m2 among those who did not have severe complications (p=0.03). However, this parameter did not retain its significance at multivariate analysis. When only the preoperative variables were included in the logistic regression model, the Glasgow Aneurysm Score (P=0.004, Oddsratio 1.94, 95% C.I. 1.24-3.05) was the only predictor of severe postoperative complications. The Glasgow Aneurysm Score was significantly correlated with baseline oxygen delivery (P=-0.256, P=0.003). CONCLUSIONS: Baseline oxygen delivery is associated with an increased risk of severe postoperative complications after elective open repair of AAA. The value of preoperative optimization of oxygen delivery should be evaluated in this patient population.

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OBJECTIVE: To evaluate five risk scoring methods in predicting the immediate postoperative outcome after elective open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective evaluation of the Eagle score, Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score in a consecutive series of patients. PATIENTS: Two hundred and eighty-six consecutive patients undergoing elective infrarenal aortic aneurysm repair. RESULTS: Nine patients (3.1%) died in hospital and another 35 (12%) experienced severe postoperative complications. For the Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.749 (p=0.01), 0.777 (p=0.008), 0.788 (p=0.006) and 0.794 (p=0.005), respectively. The Eagle risk score was less accurate for predicting in-hospital mortality. The risk-scoring systems did not perform well in predicting post-operative complications, but multivariate analysis showed that the modified Leiden score was an independent predictor of postoperative complications. CONCLUSION: All scoring systems predict, with reasonable accuracy, the risk of in-hospital death in patients undergoing elective open repair of AAA, whereas the accuracy in predicting severe postoperative complications is less.

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BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.

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Uniformity of myocardial protection during retrograde blood cardioplegia is still a controversial area. We conducted a study on electron microscopic changes in the myocardium during mild hypothermic retrograde cardioplegia (31-32 degrees C) in 12 patients undergoing coronary artery bypass grafting. Biopsies for electron microscopy were taken from the right and left ventricular myocardium before and at the end of aortic cross-clamping and after 15 min reperfusion. The intercellular junctions, intracellular and extracellular oedema, mitochondria, capillaries, nuclei and myofibrils were analysed separately in each specimen, using a semiquantative method with scoring from 0 (unchanged) to 3 (severe changes), and the total scores were correlated with the severity of right and left coronary artery disease and with ischaemia time during aortic cross-clamping. Mild to moderate ultrastructural changes occurred in the myocardium during the cardiopolegia, most typically myofibrillar injury and oedema. These changes increased during aortic cross-clamping and reperfusion, especially in the right ventricle. The total ultrastructural score for the right ventricle correlated negatively with the severity of right coronary artery disease at the end of cross-clamping. No such correlation was found in the left ventricle. Apart from one case of perioperative myocardial infarction, the clinical outcome was unproblematic. Myocardial structure thus was by and large well preserved during mild hypothermic retrograde blood cardioplegia, with the right ventricle seemingly somewhat less protected than the left.

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The present study was undertaken to analyse the extent of apoptosis in operated small cell lung carcinoma (SCLC) by using in situ labelling of the oligonucleosomal DNA fragments by terminal transferase. The extent of apoptosis was compared with the cell proliferation activity, as determined by Ki-67 immunohistochemistry; with the volume density of necrosis (per cent), as determined by the morphometric point counting method; and with the occurrence of immunohistochemically detectable p53 and bcl-2 proteins. By in situ labelling, remarkably high apoptotic indices (from 0.08 to 8.10 per cent) were seen in SCLC. A high percentage of SCLSs also showed an exceptionally high proliferation activity. Aberrant accumulation of p53 protein was seen in 37.5 per cent and bel-2 overexpression in 50 per cent of SCLCs. Necrosis was seen in 82.5 per cent of SCLCs. The extent of apoptosis was inversely related to the extent of tumour necrosis (P = 0.05) and to p53 protein accumulation (P = 0.008). A positive association was found between the extent of apoptosis and bel-2 immunoreactivity (P = 0.02). The apoptotic indices (per cent) correlated with the age (P < 0.05) and total smoking time of the patients (P = 0.06).

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The objectives were to evaluate the prognosis in resected lung cancer and to observe if perioperative blood transfusion adversely affects the prognosis. Of 208 patients with resection for lung cancer in 1978-1980, all but five were smokers: 127 had squamous cell and 81 non-squamous cell carcinoma. Stage I disease was found in 143 patients. (69%), stage II in 18 (9%) and stage IIIa in 47 (23%). Five-year survival was 52% in stage I, 29% in stage II and 7% in stage IIIa tumour; the respective 10-year rates were 37, 19 and 3%. Patients given perioperative blood transfusion (n = 95) had poorer prognosis than the non-transfused patients. According to Cox multivariate analysis, however, the relative risk of death was only slightly increased by perioperative transfusion (p = 0.07). In patients with stage II or IIIa carcinoma at diagnosis, this relative risk was 2.17 and 4.99 times higher than in stage I (p = 0.004 and p = 0.0001). Long-term survival thus was related to extent of the disease at diagnosis rather than to numbers of blood transfusions.

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This study was undertaken to determine the extent of apoptosis in lung carcinoma and to evaluate it as a prognostic marker. A series of 75 lung carcinomas (47 squamous cell carcinomas, 24 adenocarcinomas, 3 small cell carcinomas, and 1 large cell carcinoma) was analyzed for the extent of apoptosis by using the 3' end-labeling method of DNA in tissue sections. Apoptosis was correlated with the rate of cell proliferation, the immunohistochemically detectable p53 and bcl-2, the extent of tumor necrosis, and the survival data. The end-labeling method allowed a precise evaluation of the extent of apoptosis. In tumor tissue, the number of apoptotic bodies was roughly 2-fold greater than the number of apoptotic cells, whereas in nonneoplastic control tissues, the ratio was 1:1. The apoptotic indexes (percentages of apoptotic cells and bodies among tumor cells) were slightly higher in adenocarcinoma than in squamous cell carcinoma. There was no association between the extent of apoptosis and the expression of proliferating cell nuclear antigen or p53. On the other hand, tumor necrosis correlated significantly with proliferating cell nuclear antigen and p53 positivity (P = 0.00025 and 0.00087, respectively). Surprisingly, the extent of apoptosis was also found to be independent of the expression of bcl-2. Patients with apoptotic indexes greater than 1.5% had significantly shorter survival time than patients with apoptotic indexes equal to 1.50% or less (P < 0.01 by log rank). Aberrant p53 positivity also predicted a poor prognosis (P < 0.002 by log rank). By multivariate analysis, enhanced apoptosis showed a 1.9-fold risk (P = 0.04), and p53 positivity showed a 2.3-fold risk (P = 0.005) for a shortened survival. We conclude that both enhanced apoptosis and p53 positivity are independent prognostic markers in non-small cell lung carcinoma, predicting shortened survival time of the patients.

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PURPOSE: The predictive value of staging of primary lung cancer by CT and thoracotomy with respect to survival was assessed in a series of 151 consecutive patients. MATERIAL AND METHODS: The new international staging system for lung cancer was used, with an additional indeterminate stage employed for cases in which a definite classification was impossible by CT. RESULTS: The survival rate curves for the stage groups assessed at CT and thoracotomy showed moderate to good parallelism. The patients with tumor stage I at thoracotomy but indeterminate or IIIa at CT had a significantly lower survival rate than those scored stage I at both. It was concluded that a sign of tumor spread obtained at any of the investigations should lead to an active approach, increasing the radicality of surgery or omitting noncurative operations.

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Ultrastructural changes in myocardial tissue were studied in 21 patients undergoing elective aorta-coronary bypass operation. The patients were randomized into two groups, with 10 of them receiving continuous retrograde warm and 11 continuous retrograde mild hypothermic blood cardioplegia. Biopsy specimens for electron microscopy were taken from the apical part of the left ventricle before and at the end of the aortic crossclamp period and after reperfusion of the myocardium. The ultrastructural changes were analyzed with use of a semiquantitative scoring system and classified as mild, moderate, or severe. Slight ultrastructural changes were found in both groups even before the aortic crossclamp period. At the end of the aortic crossclamp period the most prominent ultrastructural changes were mitochondrial swelling, damage of capillary endothelium, and clearing of the nucleoplasm or margination of chromatin, but some enlargement in intercalated discs was also discernible. Reperfusion of the myocardium for 15 minutes somewhat further increased the overall score of the ultrastructural changes. Two patients in the warm cardioplegia group had a perioperative myocardial infarction, and this may be one reason for the higher postoperative creatine kinase MB efflux in this patient group. Despite this finding, no major differences in the ultrastructural changes between the two cardioplegia groups could be observed. We conclude that only mild to moderate and principally reversible ultrastructural changes occur in myocardium during continuous retrograde warm and mild hypothermic blood cardioplegia for coronary bypass operation.

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OBJECTIVE: The goal of this study was to assess the effects of a combination of glucose-insulin-potassium (GIK) and the amino acids aspartate and glutamate upon perioperative hemodynamics in coronary surgery patients with unstable angina and/or compromised left ventricular function. DESIGN: Prospective, randomized, and double-blind clinical study. SETTING: Operating theatre and intensive care unit (ICU) of a university hospital. PATIENTS: 44 coronary artery bypass graft (CABG) patients with unstable angina and/or compromised left ventricular function. INTERVENTIONS: 22 patients (group A) were given 1l of an infusion with 250g glucose, 100 I.U. fast-acting human insulin, 72 mmol potassium, 32 mmol magnesium, 20 mmol phosphate, 65 mmol aspartate, and 65 mmol glutamate, while another 22 patients (group C) were given 1l of an infusion with 50 g glucose, 72 mmol potassium, 32 mmol magnesium, and 8 mmol phosphate. The infusion rate was 1.2 ml/kg/h from the anesthesia induction onward to the commencement of cardiopulmonary bypass, when it was reduced to 0.8 ml/kg/h. When 11 had been infused, but not later than 4 a.m., the infusion was continued by giving 10% glucose at the same rate to both groups. Additional insulin (median: 14.2 I.U., range: 0-41.5) or saline was given during bypass to the A and C patients, respectively. A blood cardioplegia technique containing aspartate and glutamate was used in both groups. RESULTS: At aortic cannulation, the cardiac index (CI) had increased from the pre-anesthetic level by 15.3% (mean) (SD: 31.7%) in group A and decreased by 7.7% (15.1%) in C patients, p = 0.0069. Also the changes in stroke index (SI; p = 0.022), left (LVSWI; p = 0.0037) and right ventricular stroke work index (RVSWI; p = 0.0097) were more favorable in group A. Despite longer aortic cross-clamp, p = 0.031, and perfusion times, p = 0.042, in A patients, the change in cardiac index was also better in this group after bypass: At decannulation, the difference between mean values was 31.8%, p = 0.0001, and at arrival in the ICU it was 16.1%, p = 0.028. The same was also seen 8 h postoperatively and on the 1st and 2nd postoperative mornings; p = 0.034, 0.040, and 0.037, respectively (Wilcoxon test). Favorable changes were seen for the A patients also regarding SI at decannulation (p = 0.0002) and after 8 h (p = 0.017); LVSWI at decannulation (p = 0.0002), at arrival in the ICU (p = 0.0023), and after 8 h (p = 0.0011); and RVSWI at decannulation (p = 0.0027), at the ICU (p = 0.021), after 8 h (p = 0.014), and on the 1st postoperative morning (p = 0.039). However, the response to a hemodynamic loading test (6% hydroxyethyl starch 5 ml/kg) was similar in the 2 groups, and there was no difference in the need for inotropic support. CONCLUSIONS: Amino acid-enriched GIK infusion improves hemodynamic function in CABG patients with unstable angina and/or compromised left ventricular function.

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In order to assess the accuracy of CT in predicting the resectability of lung cancer, a prospective study was performed on 96 patients undergoing thoracotomy. The tumors were classified preoperatively according to the TNM classification and the new international staging system for lung cancer, and scored as being resectable by lobectomy or pulmectomy, potentially resectable by lobectomy or pulmectomy, or nonresectable. Of the tumors predicted to be resectable or potentially resectable, 86.6% and 63% were radically resected, respectively, and the need for lobectomy versus pulmectomy was correctly estimated in 81.3% of them. The insufficiency of CT for defining lymph node metastases and infiltrative tumor growth was considered a marked disadvantage of the method.

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To investigate whether the assessment of resectability of lung cancer can be reliably made on the basis of computed tomography (CT), the thoracic CT scans of 96 lung cancer patients who were operated on, and in whom the tumour was classified to be of stage III at preoperative CT or at thoracotomy, were analysed. Of the patients, 58 underwent complete resection of the tumour, whereas thoracotomy resulted in non-complete resection or exploration only in 38 cases. Overlapping of the CT findings in the groups of complete and non-successful resection was observed. The majority of tumours with apparent growth to the carina, trachea, oesophagus or great vessels at CT were completely resected. Tumours that only bordered on the pleura could not be distinguished from those with pleural invasion. Mediastinal lymph node enlargement did not always mean metastatic spread. We conclude that there is no definite sign that identifies non-resectability of lung tumours, and a certain proportion of non-curative thoracotomies must be accepted.

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In order to assess the value of computed tomography (CT) of the mediastinum, upper abdomen and head in the assessment of resectability of lung cancer, the CT findings of 262 patients, of whom 198 underwent thoracotomy, were analyzed retrospectively and the stagings obtained at CT and thoracotomy were compared. Mediastinal CT reliably predicted resectability when there was no evidence of mediastinal involvement. However, it was often impossible to determine whether tumour with apparent mediastinal infiltration on CT was resectable or not. The sole finding of lymph node enlargement did not permit differentiation of benign from malignant lymphadenopathy when the lymph node diameter was less than 25 mm and the lymphadenopathy was confined to one lymph node station. Upper abdominal metastases were found in 6.1% and brain metastases in 4.6% of patients and neither the histological type nor other features of the tumour were found to be useful predictors of their presence. The large number of non-specific findings decreased the utility of abdominal CT. The appropriate strategy for the pre-operative evaluation of patients with lung cancer is discussed.

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The pulmonary chromium content was determined by plasma atomic emission spectrometer (DCP-AES) from 53 lung cancer and 43 control patients, and compared with smoking habits, severity of emphysema and occupational history. The chromium content from the lung cancer patients was higher than that from the smoking (P less than 0.025) or nonsmoking control patients (6.4 +/- 4.3, 4.0 +/- 4.0, and 2.2 +/- 0.6 microgram/g dry weight, respectively). A positive correlation between the pulmonary chromium and smoking time (P less than 0.025) and the severity of emphysema (P less than 0.001) was found in the control but not in the cancer patients. The difference in the pulmonary chromium content was greatest between those lung cancer and control patients who were light smokers or had mild emphysema. This group of lung cancer patients included subjects with occupational exposure to chromium. The possibility of occupational cancer should be considered especially with light smokers. The grade of emphysema and metals such as chromium accumulating from tobacco could serve as objective indicators of smoking.

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All 205 patients operated on for primary pulmonary cancer at Oulu University Hospital in 1975-1977 were followed up for 10 years to evaluate the prognostic influence of factors such as lymph-node invasion, size of tumour and histologic type. Preoperative mediastinoscopy was performed on 186 patients (91.2%), and revealed no mediastinal metastases in 182. Nevertheless N 2 (mediastinal) lymph nodes were found in 36 cases at operation and N 1 (perihilar or ipsilateral) nodes in 42. Despite lobectomy or pneumonectomy, all 32 patients (17.2%) with false-negative mediastinoscopy died within a year (mean 7.2 months) of operation. Pneumonectomy was performed in 67 cases (29 right, 38 left), lobectomy or bilobectomy in 125 and exploratory thoracotomy in the remainder. Most of the tumours were epidermoid carcinoma (53.7%). Adenocarcinoma was present in 20%, and large-cell carcinoma and oat-cell carcinoma each in 11.7%. Survival rates were significantly higher in patients without vs. those with lymph-node metastases and in epidermoid or adenocarcinoma vs. small-cell carcinoma.

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