Emeritus Faculty, Acad Council, Cardiothoracic Surgery
Fellowship, Yale - New Haven Hospital
Residency, Yale - New Haven Hospital (1960)
MD, Vanderbilt University, Medicine (1953)
Carcinoma of the esophagus is a highly lethal disease in which surgical resection is part of every treatment regimen carried out with curative intent. The development of surgical resection of the esophagus for carcinoma has been a long and tortuous one. Its evolution depended not only on a thorough knowledge of surgical anatomy and technique, but also on important developments in endoscopy, radiology, anesthesia, nutrition, pulmonary physiology, and intensive care.
View details for PubMedID 10689533
View details for PubMedID 9506184
To determine the usefulness of radioaerosol ventilation scans for the detection and localization of air leaks from the lungs or bronchial tree.Selected patients with suspected air leaks underwent ventilation scans. Retrospective analysis of data was carried out.Twenty-eight hospitalized patients were included in the study.Ventilation scintigraphy using 99mTc-DTPA (technetium aerosol) was carried out in patients with air leaks.Of the total group, there were 50% true-positive scans, 36% true-negative scans, and 14% false-negative scans giving a sensitivity of 78%, specificity of 100%, and accuracy of 86%.99mTc-DTPA ventilation scintigraphy is useful in some patients with air leaks from the lung or tracheobronchial tree and may help to guide surgical intervention should this become necessary.
View details for Web of Science ID A1997WH30400011
View details for PubMedID 9041970
Lung cancer is the leading cause of cancer death in both men and women in the United States. Although lung cancer has been treated aggressively by surgery, radiation therapy, and chemotherapy, alone or in combination, survival is still in the 12% to 15% range at 5 years. All curative treatment plans for patients with non-small cell lung cancer include resectional surgery. Despite the dismal outlook there is hope, because improvements in outcome for patients undergoing surgical treatment have been realized. Definite progress has been made in reducing operative mortality and morbidity, helping to increase long-term survival. Advances that have contributed to these successes include improved preoperative evaluation in staging and patient selection criteria, the use of newer techniques such as video-assisted or open limited resections in selected instances, and the use of neoadjuvant therapy. These topics are addressed here, as are techniques for locally advanced tumors and options for palliation.
View details for PubMedID 9363152
A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs ("blind" placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.
View details for Web of Science ID A1995RX49400009
View details for PubMedID 8787258
To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine.A randomized, prospective, double-blind study.A university-affiliated medical center.Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy.Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period.Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia.Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.
View details for Web of Science ID A1995TB74600009
View details for PubMedID 8547554
It can be difficult to localize or even lateralize the site of persistent bronchopleural fistula in patients who have undergone thoracotomy. If the site of persistent air leak can be identified noninvasively, it may be possible to repair the leak with thoracoscopic techniques and thereby avoid repeat thoracotomy. This article reports experience using 99mTc-DTPA ventilation scintigraphy to localize persistent bronchopleural fistulas in six patients. The site of bronchopleural fistula was identified in four patients. In the other two patients, no leak was identified, and the clinical course confirmed that a significant bronchopleural fistula did not exist.
View details for Web of Science ID A1994NK51400027
View details for PubMedID 8176473
A method for detecting air leak when using a double-lumen endobronchial tube is described. The ventilatory circuit is directly attached to the lumen of the ventilated lung. A balloon is fitted snugly over the open lumen of the tube to the nonventilated lung. If lung separation is incomplete, the balloon will inflate with each ventilation.
View details for Web of Science ID A1993LH44100048
View details for PubMedID 8512424
Sixteen consenting patients scheduled for elective thoracotomy were enrolled into a randomized trial of epidural morphine and hydromorphone. Each patient had a lumbar epidural catheter placed preoperatively for the purpose of post-thoracotomy analgesia. Shortly before the end of the operative procedure each patient received 5 mg of morphine and 0.75 mg of hydromorphone via the epidural catheter. Blood was sampled at regular intervals following the opiate administration and patients were randomized to 1 of 7 cervical CSF sampling times. Blood and CSF samples were assayed for morphine and hydromorphone concentration to determine blood and CSF pharmacokinetic profiles. A maximum blood morphine concentration of 60 +/- 25 ng/ml (mean +/- S.D.) was obtained at 11 +/- 6 min (mean +/- S.D.). The blood hydromorphone peak of 14 +/- 13 ng/ml (mean +/- S.D.) occurred 8 +/- 6 min (mean +/- S.D.). The mean peak CSF opioid concentrations of 1581 ng/ml for morphine and 309 ng/ml for hydromorphone occurred 60 min after epidural administration. The blood and CSF pharmacokinetic profiles for morphine and hydromorphone are presented. These profiles are similar for the two drugs after lumbar epidural administration.
View details for Web of Science ID A1991FJ99300003
View details for PubMedID 1713663
View details for Web of Science ID A1991BV79P00020
Forty-four patients were treated with a continuous infusion of lumbar epidural hydromorphone (0.05%) after thoracic operations. Postoperatively, visual analog pain scores were obtained. On postoperative day 1 and 2, more than 90% of the patients experienced either no pain (visual analog pain scale = 0) or mild pain (visual analog pain score = 1 to 3) at rest. The incidence of side effects (hypoventilation, pruritus, and nausea) was less than reported with other epidurally administered opioids. Continuous infusion of lumbar epidural hydromorphone produced safe, predictable analgesia after thoracotomy.
View details for Web of Science ID A1990EL24100006
View details for PubMedID 1700682
From 1973 through 1987, a total of 140 patients underwent 184 operations for removal of metastatic tumors to the lungs. The number of lesions removed ranged form one to 30. Of the patients, 44% had solitary lesions. Overall 3-year survival was 62.6%, and 5-year survival was 48.2%. In all primary tumors except melanoma and breast cancer, 3-year survival was greater than 50% and 5-year survival was greater than 40%. With rare exceptions, the operation of choice for unilateral lesions was ipsilateral thoracotomy, and for bilateral lesions it was median sternotomy. Adequate conservative resection was the rule. There were three pneumonectomies, 25 lobectomies, 71 single wedge resections, 38 multiple unilateral wedge resections, and 47 bilateral wedge resections. There were no postoperative hospital deaths. Cox covariate analysis demonstrated improved survival in patients whose largest lesion was less than 1.5 cm in diameter and with disease-free interval longer than 1 year, but survival was not related to number of lesions or age of patient. An aggressive surgical approach is justified in patients with most primary tumors and a limited number of lung metastases less than 1.5 cm in diameter. Resection of metastases from melanoma and breast cancer should be accomplished after other sites of metastatic disease have been ruled out by the most stringent criteria.
View details for Web of Science ID A1990EB83100023
View details for PubMedID 2222179
The most common neoplasms of the anterior mediastinum are thymomas, lymphomas, and germ cell tumors. Surgical exploration was the routine approach to the diagnosis and management of these tumors. This is no longer true. The appropriate initial treatment of these neoplasms varies from surgical resection to radiation therapy to systemic chemotherapy. Except for the small well-encapsulated anterior mediastinal mass, it is imperative that a definitive tissue diagnosis be obtained before initiating treatment. An overview of these tumors and the specific approaches to their treatment are detailed.
View details for Web of Science ID A1990DZ57600009
View details for PubMedID 2237088
View details for Web of Science ID A1989BQ45T00093
Endobronchial brachytherapy is being used with increased frequency in the treatment of recurrent neoplastic obstruction of the major airways, alone or in combination with Nd-YAG laser ablation of the occluding tumor mass. Currently available catheter systems are not reliable with respect to accurate and simple bronchoscopic guidance during placement. Flexibility, wall strength and radiation transmission characteristics are not optimized. We describe a system that meets these goals which has been designed and tested in our department. It is composed of an external handle, deflecting guidewire, and catheter specially modified for endobronchial brachytherapy, with a tip that can be maneuvered in any direction with one hand from outside the patient. Major advantages of the system are ease of concurrent bronchoscopy and catheter guidance, good dosimetric characteristics of the catheter, reasonable cost, and ready availability for adaptation to various techniques of endobronchial brachytherapy.
View details for Web of Science ID A1988P791200028
View details for PubMedID 3403325
View details for PubMedID 17165356