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Mitral prosthetic replacement via a right thoracotomy on beating heart under normothermic bypass offers a safe alternative to redo median sternotomy in this high-risk group. Operative access is facilitated and procedural time reduced. Complication rates are low and perioperative mortality is lower than that generally reported with conventional surgery.

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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.

Primary small-cell cancer of the esophagus is a rare tumor that disseminates early with a uniformly poor prognosis if untreated. Sixteen patients with malignant dysphagia referred to the Thoracic Surgical Unit, City Hospital, Edinburgh, within a 10-year period had a diagnosis of primary small-cell cancer of the esophagus. Seven patients underwent subtotal esophagectomy or esophagogastrectomy, either alone or with adjuvant chemotherapy or radiotherapy, with a mean survival of 20 months (standard deviation 35.4 months, range 2 weeks to 96 months). The remaining nine patients had disseminated disease when they were first seen and were treated symptomatically by intubation alone (1 patient), intubation and palliative chemotherapy or radiotherapy (3 patients), palliative chemotherapy (2 patients), palliative radiotherapy (1 patient), or no therapy (2 patients), with a mean survival of 4.8 months (standard deviation 2.6 months, range 2 to 9 months). Patients seen with this aggressive tumor should be assessed urgently for evidence of metastatic spread and then offered resection in combination with chemotherapy if they are otherwise fit for operation. This treatment regimen has given us one long-term survivor (96 months) who, we believe, is the only patient to have been cured of this condition. Patients seen with disseminated disease should have symptomatic treatment of the dysphagia combined with palliative chemotherapy.

In order to determine the effect of obesity on the results of coronary artery bypass graft (CABG) surgery, we compared 250 obese patients undergoing CABG procedures between 1984 and 1987 with 250 age- and sex-matched controls of normal body mass index (BMI) undergoing CABG in the same period. The obese group had a greater incidence of diabetes mellitus (p less than 0.02), hypertension (p less than 0.05), hyperlipidaemia (p less than 0.05), and left main stem coronary artery disease (p less than 0.001). No differences were identified in the surgery performed, but obesity was associated with prolonged total bypass time (p less than 0.05). Operative mortality was 0.8% in both groups. Multivariate analysis demonstrated obesity to be an independent risk factor for perioperative morbidity (p less than 0.05). Univariate: respiratory (p less than 0.01); leg wound (p less than 0.001); myocardial infarction (p less than 0.02); arrhythmias (p less than 0.02); sternal dehiscence (p less than 0.02). At a mean follow-up time of 36.9 months obese patients exhibited a greater incidence of significant recurrent angina (p less than 0.01), which was associated with further weight gain (mean 12.2 kg; linear correlation: p less than 0.001, r = 0.891). Although in CABG surgery operative mortality is not increased in obese patients, aggressive pre- and postoperative weight control is indicated to reduce both perioperative morbidity and the incidence of recurrent angina.

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Bleeding time, platelet count and haematocrit were performed in 64 normal, anaemic and polycythaemic subjects with normal renal function and platelet counts over 100 B× 10⁹/l. There was a significant inverse correlation between the bleeding time and haematocrit (r = -0.47) and an inverse correlation of the haematocrit and platelet count (r = -0.46). We suggest that the effect of the haematocrit on the bleeding time could explain the shorter bleeding time in men compared to women, and the shorter bleeding time in subjects with arterial disease, in whom an increased haematocrit is commonly found.