358 believe that his pleural adhesion held the tear in the visceral pleura open, allowing a continuous leak with subpleural tracking. Macklin and Macklin’9 suggested that pleural adhesions which prevent part of the lung from collapsing may lead to local hyperexpansion, enabling the escape of air into the lung interstices (pulmonary interstital emphysema) and thence via the hilum into the mediastinum. After our experience in these two fatal cases we suggest that any pneumothorax of more than 72 hours’ duration should be drained slowly. If the patient begins to cough, possibly indicating the onset of pulmonary oedema, the tube should be clamped at once. If artificial ventilation proves necessary, great care should be taken in looking for a contralateral pneumothorax, and a prophylactic chest drain on the unaffected side should be considered. If a pleural adhesion prevents complete collapse in patients with continuing surgical emphysema, there may be a case for its division at thoracoscopy or for closure of the lung tear at thoracotomy. In a patient whose airway is endangered by mediastinal and severe
cervical emphysema, tracheostomy will ensure airway and release some of the interstitial air.20
We thank Dr M. W. McNicol and Dr J. F. Riordan for permission report on their patients, and Mrs B. Frost and Mrs P. Jennings for the typing.
to
REFERENCES 1. Kjaergaard, H. Acta med. scand. 1932, suppl. 43. 2. Killen, D. A., Gobbel, W. G. Spontaneous Pneumothorax. Boston, 1968. 3. Geisler, L. S., Savic, B. Prax. Pneumol. 1976, 30, 73. 4. Mills, M., Baisch, B. F. Ann. thorac, Surg. 1965, 1, 286. 5. Estafanous, F. G., et al. Anæsth. Analg. 1975, 54, 730. 6. Trapnell, D. H., Thurston, J. G. B. Lancet, 1970, i, 1367. 7. Carlson, R. I., et al. Surg. Forum, 1959, 9, 367. 8. Grant, M. J. A. New Z. med. J. 1971, 74, 250 9. Schwander, D., et al. Helv. chir. Acta, 1973, 40, 393. 10. Shanahan, M. X., et al. Anæsth. intens. Care, 1975, 3, 19. 11. Waqaruddin, M., Bernstein, A. Thorax, 1975, 30, 54. 12. Miller, W. C., et al. Am. Rev. resp. Dis. 1973, 108, 664. 13. Sautter, R. D., et al. Chest, 1971, 60, 399. 14. Humphreys, R. L., Berne, A. S. Radiology, 1970, 96, 509. 15. Childress, M. E., et al. Am. Rev. resp. Dis. 1971, 104, 119. 16. Ziskind, M. M., et al. ibid. 1965, 92, 632. 17. Ratliff, J. L., et al. Chest, 1973, 64, 654. 18. Millard, C. E. Postgrad. Med. 1971, 49, 117. 19. Macklin, M. T., Macklin, C. C. Medicine, Baltimore, 1944, 23, 281. 20. Rydell, J. R., Jennings, W. K. Archs Surg. 1955, 70, 647.
Preliminary Communications
larger 8 radiation
fields have not improved the curerate.7 Extensive disease (stage III or iv) has generally been treated with systemic chemotherapy. DeVita and his associates demonstrated that combination chemotherapy was curative in 30-40% of patients with advanced disease.9 Newer drug regimens containing doxorubicin (’Adriamycin’) appear to have further improved the results achieved with chemotherapy. 10 " This report summarises our experience with adriamy-
CHEMOTHERAPY OF LOCALISED HISTIOCYTIC LYMPHOMA THOMAS P. MILLER
STEPHEN E. JONES
Section of Hematology and Oncology, University of Arizona Health Sciences Center, Tucson, Arizona 85724, U.S.A.
Summary
22
patients
with localised
(stage
an
I or
cin-containing combination chemotherapy rather than radiotherapy as primary treatment for localised diffuse lymphoma.
II)
diffuse lymphoma were treated with chemotherapy at the time of diagnosis. 14 patients received chemotherapy as the only treatment, and 8 received chemotherapy plus local irradiation. Doxorubicin-containing drug regimens were used in 20 patients. All 22 patients achieved a complete remission and remain alive with a median survival from the time of diagnosis of 27+ months. 21 patients (95%) have remained continuously free of disease with a median disease-free survival from the completion of chemotherapy of 23+ months. These findings provide a strong rationale for further clinical trials of chemotherapy alone or chemotherapy followed by regional radiotherapy for localised stages of diffuse lymphoma.
PATIENTS AND METHODS
Between November, 1971, and December, 1978, 22 patients treated for localised non-Hodgkin’s lymphoma. The orig-
were
inal
biopsy material, classified according to the scheme of Rappaport,12 showed the following histological distribution: 18 patients had diffuse histiocytic lymphoma, 2 patients had mixed histiocytic-lymphocytic lymphoma, and 2 patients had minimally nodular histiocytic lymphoma (the latter entity has a prognosis similar to D. H.L. 11). All patients were carefully staged by lymphangiography and bone-marrow core biopsy.i4’j8 peatients also underwent exploratory laparotomy.16 The extent of disease- was classified according to the criteria of the Ann
INTRODUCTION
histiocytic lymphoma (D.H.L.) is a highly malignant lymphoma characterised by rapid growth, a propensity for early dissemination through the bloodstream, and rapid recurrence after inadequate or unsuccessful treatment.I-3 Historically, the choice of treatment has been determined by the extent of disease at diagnosis. The more localised forms of the disease-i.e., lymphoma confined to one side of the diaphragm (stage I or 11)—have been treated with radiotherapy. Radiation therapy has proved curative in 45-65% of patients with very localised disease (stage 1).4-6 However, radiotherapy has been considerably less successful in patients with stage-II disease,.34 Higher dosages of radiation and DIFFUSE
.,
Arbor conference. 17 All patients received intensive intermittent combination chemotherapy. 14 patients received chemotherapy as the only therapy, and 8 patients were treated with both chemotherapy and radiation. 19 patients received the four-drug regimen, CHOP, which combines cyclophosphamide, adriamycin, vincristine, and prednisone in a schedule which is repeated every 21 days." 1 patient received HOP (adriamycin, vincristine, and prednisone) every 21 days.10 2 patients with heart-disease received combination chemotherapy without adriamycin.9 Patients treated with chemotherapy alone received between six and eleven courses of CHOP (average eight). Patients receiving both chemotherapy and radiotherapy were given involvedfield radiation with a minimum dosage of 4500 rad (range 4500-6000 rad). 5 patients received chemotherapy with two courses of CHOP before radiation therapy. Thus, 19 of 22 patients received chemotherapy as their first form of therapy. The remaining 3 patients began chemotherapy at the same
359 CLINICAL CHARACTERISTICS OF PATIENTS
RESULTS
The clinical characteristics of the 22 patients are summarised in the table. 73% had stage-II disease, and 64% had extranodal extension (E lesions). 50% of the entire group had gastrointestinal-tract involvement or bulky disease-factors which are known to influence prognosis
adversely.2 All 22 patients
___
-
I
I
*xRT=involved-field radiation therapy.
G.I.=gastrointestinal tract. I., IIe=stage I or II disease with extranodal extension.
time
as radiation therapy. At the completion of therapy all patients were restaged with particular attention to reassessing initially involved sites of disease. All patients were determined to be in complete remission. 18 No additional therapy was administered. Survival was measured from the time the patients were first seen. Disease-free survival was measured from the completion of all therapy.
.
achieved a complete remission. All patients remain alive, with a median survival from the time of diagnosis of 27+ months (see figure). 21 patients (95%) remain continuously free of disease with a median disease-free survival from the completion of chemotherapy of 23+ months (see figure). 1 patient relapsed 3 months after completing eight courses of CHOP alone. This patient had lymphomatous involvement of the supraclavicular, cervical, and submandibular nodes in association with constitutional symptoms. At relapse recurrence was found in a single cervical lymph-node site, which was then irradiated with a complete response. She has remained free of lymphoma for 25+ months since treatment for recurrence. The toxicity and side-effects of treatment were generally mild and manageable. Leucopenia was moderate but uncomplicated by serious infection or hospital admission. Nausea, vomiting, and hair loss, although common, did not interrupt therapy. No cardiotoxicity due to adriamycin was observed.
DISCUSSION
approximately two-thirds of cases D.H.L. is disseminated at the time of diagnosis and requires immediate chemotherapy. 1 14 16 Thorough staging, including surgical evaluation, further reduces the number of patients with localised lymphoma because occult sites of disease In
detected thereby.6 14 16 However, even with careful staging and radiotherapy, 10-20% of patients develop disseminated lymphoma while undergoing radiotherapy and 30-50% of patients with localised D.H.L. ultimately relapse if radiotherapy alone is used.3-8 Changes in the management of this series of patients reflect our evolving concepts for the treatment of D.H.L. Initially, 3 patients received chemotherapy concurrently with irradiation. To prevent dissemination of localised disease, systemic chemotherapy was administered as the first form of therapy in the remaining 19 patients. In the last 14 of these patients, chemotherapy alone was given. Our experience with chemotherapy in early D.H.L. appears to be analogous to experience in Hodgkin’s disease. Chemotherapy with MOPP (mustine, vincristine, prednisone, and procarbazine) produced cures in about half of patients with advanced Hodgkin’s disease. 19 In a series from Uganda all patients with early Hodgkin’s disease (stages I and II) achieved complete regression of tumour with MOPP chemotherapy, and only 1 patient relapsed.2O Because of these results, large clinical trials are now underway in the United States to evaluate further the role of chemotherapy alone in the management of early Hodgkin’s disease. The excellent results in our series appear to be related to effective chemotherapy rather than selection of patients. As indicated in the table, this group of patients was characterised by a number of factors known to be associated with a poor prognosis.2 Systemic chemoare
A. Survival from time of
diagnosis in 22 patients with diffuse histiocytic lymphoma treated with chemotherapy with or without radiotherapy. B. Disease-free survival after completion of therapy. XRT=involved-field radiation therapy.
360
therapy occult
be effective therapy for well as clinically apparent disease, the need for extensive pretreatment staging
with
CHOP seems to
metastases as
obviating with laparotomy.b i6
.
We propose that initial systemic chemotherapy is more successful than initial radiotherapy in the treatment of localised D.H.L. The validity of this approach, and the role of radiotherapy as an adjuvant to chemotherapy, will need to be further tested in larger numbers of patients. This work was supported in part by grants CA-13162 and CA-17094 from the National Cancer Institute, Department of Health, Education and Welfare, Bethesda, Maryland.
Requests for reprints should be addressed to S. E. J. REFERENCES
4.
Jones, S. E., Fuks, Z., Kaplan,
H. S.,
Rosenberg,
S. A.
Cancer, 1973, 32,
682. 5. Lattuada, A., Bonadonna, G., Milani, F., Banfi, A., Valagussa, P., DeLena, M., Monfardini, S. in Adjuvant Therapy of Cancer (edited by S. E. Salmon and S. E. Jones); p. 537. Amsterdam, 1977. 6. Bitran, J. D., Kinzie, J., Sweet, D. L., et al. Cancer, 1977, 39, 342. 7. Fuks, Z., Kaplan, H. S. Radiology, 1973, 108, 675. 8. Glatstein, E., Portlock, C., Rosenberg, S. A., Kaplan, H. S. in Adjuvant Therapy of Cancer (edited by S. E. Salmon and S. E. Jones), p. 545.
Amsterdam, 1977. 9. DeVita, V. T., Canellos, G. P., Chabner, B., Schein, P., Hubbard, S. P., Young, R. C. Lancet, 1975, ii, 248. 10. McKelvey, E. M., Gottlieb, J. A., Wilson, H. E., et al. Cancer, 1976, 38, 1484. 11. Jones, S. E., Grozea, P. N., Metz, E. N., ibid. (in the press). 12. Rappaport, H. Atlas of Tumour Pathology; section II, fasc. 8, p. 101. Armed Forces Institute of Pathology, Washington, D. C., 1966. 13. Warnke, R. A., Kim, H., Fuks, Z., Dorfman, R. F. Cancer, 1977, 40, 1229. 14. Chabner, B. A., Johnson, R. E., DeVita, V. T., Canellos, G. P., Hubbard, S. P., Johnson, S. K., Young, R. C. Cancer Treat. Rep. 1977, 61, 993. 15. Jones, S. E.J.Am. med.Ass. 1975, 234, 633. 16. Goffinet, D. R., Warnke, R., Dunnick, N. R., et al. Cancer Treat. Rep. 1977,
61, 981. Carbone, P. P., Kaplan, H. S., Musshoff, K., Smithers, D. W., Tubiana, M. Cancer Res. 1971, 31, 1858. 18. Herman, T. S., Jones, S. E. Cancer Treat. Rep. 1977, 61, 1009. 19. DeVita, V. T., Serpick, A. A., Carbone, P. P. Ann. intern. Med. 1970, 75, 17.
Jones, S. E., Fuks, Z., Bull, M., Kadin, M. E., Dorfman, R. F., Kaplan, H. S., Rosenberg, S. A., Kim, H. Cancer, 1973, 31, 806. 2. Fisher, R. I., DeVita, V. T., Johnson, B. L., Simon, R., Young, R. C. Am. J. Med. 1977, 63, 177. 3. Kushlan, P., Coleman, C. N., Glatstein, E. J., Rosenberg, S. A., Kaplan, 1.
H. S.Am.Ass.
Cancer Res. 1978, 19, 337.
881.
20. Olweny, C. L. M., Katongole-Mbidde, E., Küre, C., Lwanga, Magrath, I., Ziegler, J. L. Cancer, 1978, 42, 787.
S. K.,
Methods and Devices
RYLE’S TUBE FOR RAPID INTRAVENOUS TRANSFUSION
S. WESTABY
I. D. S. GILLIES
Departments of Surgery and Anœsthetics, Hammersmith Hospital and Royal Postgraduate Medical School, London W12 OHS
Ryle’s tube is well known for its role in nasogastric aspiration. However, a simple modification quickly transforms this, tube for use as a large-bore venous cannula ideal for very rapid transfusion and for the measurement of central venous pressure. It is very useful when torrential bleeding is encountered or anticipated after abdominal or thoracic trauma, with peptic ulceration or cesophageal varices, and during major cardiac, vascular, or hepatic operations.
A.-Cutdown in antecubital fossa with Ryle’s tubes sizes 10 FG and 12 FG introduced into veins through separate stab incisions.
METHOD
The
Ryle’s ford, Kent) is
tube cut
(’Aldon’, Aldington Laboratories Ltd., Ashto half length (21 in), and the distal end is
bevelled to facilitate its introduction into the vein. A cut-down is performed in the antecubital fossa, preferably into the median cubital vein, as this provides free access to the subclavian vein. If the cephalic vein is used, negotiation of the clavipectoral fascia may be difficult because the tube is soft. A vena commitans of the brachial artery or as a last resort the long
B. Procedure complete.
vein may also be used. Two or more tubes may be introduced through the same antecubital fossa. The skin is prepared and an incision is made over the appropriate vein, which is then stabilised between catgut ligatures while a venotomy is performed to admit the tube. The tube is passed through a separate stab incision in the skin, as shown
saphenous
FLOW OF BLOOD AND NORMAL SALINE THROUGH VARIOUS TYPES OF INTRAVENOUS CANNULae AND
3
GAUGES OF
RYLE’S TUBES*
*Ha:molysis produced is assessed by plasma-haemoglobin concentration. A control value of 6.3mg/dl was found in the bag before infusion. Infusion through the giving-set alone resulted in a plasma-hxmoglobin of 10- 2 mg/dl.
cervical emphysema, tracheostomy will ensure airway and release some of the interstitial air.20
We thank Dr M. W. McNicol and Dr J. F. Riordan for permission report on their patients, and Mrs B. Frost and Mrs P. Jennings for the typing.
to
REFERENCES 1. Kjaergaard, H. Acta med. scand. 1932, suppl. 43. 2. Killen, D. A., Gobbel, W. G. Spontaneous Pneumothorax. Boston, 1968. 3. Geisler, L. S., Savic, B. Prax. Pneumol. 1976, 30, 73. 4. Mills, M., Baisch, B. F. Ann. thorac, Surg. 1965, 1, 286. 5. Estafanous, F. G., et al. Anæsth. Analg. 1975, 54, 730. 6. Trapnell, D. H., Thurston, J. G. B. Lancet, 1970, i, 1367. 7. Carlson, R. I., et al. Surg. Forum, 1959, 9, 367. 8. Grant, M. J. A. New Z. med. J. 1971, 74, 250 9. Schwander, D., et al. Helv. chir. Acta, 1973, 40, 393. 10. Shanahan, M. X., et al. Anæsth. intens. Care, 1975, 3, 19. 11. Waqaruddin, M., Bernstein, A. Thorax, 1975, 30, 54. 12. Miller, W. C., et al. Am. Rev. resp. Dis. 1973, 108, 664. 13. Sautter, R. D., et al. Chest, 1971, 60, 399. 14. Humphreys, R. L., Berne, A. S. Radiology, 1970, 96, 509. 15. Childress, M. E., et al. Am. Rev. resp. Dis. 1971, 104, 119. 16. Ziskind, M. M., et al. ibid. 1965, 92, 632. 17. Ratliff, J. L., et al. Chest, 1973, 64, 654. 18. Millard, C. E. Postgrad. Med. 1971, 49, 117. 19. Macklin, M. T., Macklin, C. C. Medicine, Baltimore, 1944, 23, 281. 20. Rydell, J. R., Jennings, W. K. Archs Surg. 1955, 70, 647.
Preliminary Communications
larger 8 radiation
fields have not improved the curerate.7 Extensive disease (stage III or iv) has generally been treated with systemic chemotherapy. DeVita and his associates demonstrated that combination chemotherapy was curative in 30-40% of patients with advanced disease.9 Newer drug regimens containing doxorubicin (’Adriamycin’) appear to have further improved the results achieved with chemotherapy. 10 " This report summarises our experience with adriamy-
CHEMOTHERAPY OF LOCALISED HISTIOCYTIC LYMPHOMA THOMAS P. MILLER
STEPHEN E. JONES
Section of Hematology and Oncology, University of Arizona Health Sciences Center, Tucson, Arizona 85724, U.S.A.
Summary
22
patients
with localised
(stage
an
I or
cin-containing combination chemotherapy rather than radiotherapy as primary treatment for localised diffuse lymphoma.
II)
diffuse lymphoma were treated with chemotherapy at the time of diagnosis. 14 patients received chemotherapy as the only treatment, and 8 received chemotherapy plus local irradiation. Doxorubicin-containing drug regimens were used in 20 patients. All 22 patients achieved a complete remission and remain alive with a median survival from the time of diagnosis of 27+ months. 21 patients (95%) have remained continuously free of disease with a median disease-free survival from the completion of chemotherapy of 23+ months. These findings provide a strong rationale for further clinical trials of chemotherapy alone or chemotherapy followed by regional radiotherapy for localised stages of diffuse lymphoma.
PATIENTS AND METHODS
Between November, 1971, and December, 1978, 22 patients treated for localised non-Hodgkin’s lymphoma. The orig-
were
inal
biopsy material, classified according to the scheme of Rappaport,12 showed the following histological distribution: 18 patients had diffuse histiocytic lymphoma, 2 patients had mixed histiocytic-lymphocytic lymphoma, and 2 patients had minimally nodular histiocytic lymphoma (the latter entity has a prognosis similar to D. H.L. 11). All patients were carefully staged by lymphangiography and bone-marrow core biopsy.i4’j8 peatients also underwent exploratory laparotomy.16 The extent of disease- was classified according to the criteria of the Ann
INTRODUCTION
histiocytic lymphoma (D.H.L.) is a highly malignant lymphoma characterised by rapid growth, a propensity for early dissemination through the bloodstream, and rapid recurrence after inadequate or unsuccessful treatment.I-3 Historically, the choice of treatment has been determined by the extent of disease at diagnosis. The more localised forms of the disease-i.e., lymphoma confined to one side of the diaphragm (stage I or 11)—have been treated with radiotherapy. Radiation therapy has proved curative in 45-65% of patients with very localised disease (stage 1).4-6 However, radiotherapy has been considerably less successful in patients with stage-II disease,.34 Higher dosages of radiation and DIFFUSE
.,
Arbor conference. 17 All patients received intensive intermittent combination chemotherapy. 14 patients received chemotherapy as the only therapy, and 8 patients were treated with both chemotherapy and radiation. 19 patients received the four-drug regimen, CHOP, which combines cyclophosphamide, adriamycin, vincristine, and prednisone in a schedule which is repeated every 21 days." 1 patient received HOP (adriamycin, vincristine, and prednisone) every 21 days.10 2 patients with heart-disease received combination chemotherapy without adriamycin.9 Patients treated with chemotherapy alone received between six and eleven courses of CHOP (average eight). Patients receiving both chemotherapy and radiotherapy were given involvedfield radiation with a minimum dosage of 4500 rad (range 4500-6000 rad). 5 patients received chemotherapy with two courses of CHOP before radiation therapy. Thus, 19 of 22 patients received chemotherapy as their first form of therapy. The remaining 3 patients began chemotherapy at the same
359 CLINICAL CHARACTERISTICS OF PATIENTS
RESULTS
The clinical characteristics of the 22 patients are summarised in the table. 73% had stage-II disease, and 64% had extranodal extension (E lesions). 50% of the entire group had gastrointestinal-tract involvement or bulky disease-factors which are known to influence prognosis
adversely.2 All 22 patients
___
-
I
I
*xRT=involved-field radiation therapy.
G.I.=gastrointestinal tract. I., IIe=stage I or II disease with extranodal extension.
time
as radiation therapy. At the completion of therapy all patients were restaged with particular attention to reassessing initially involved sites of disease. All patients were determined to be in complete remission. 18 No additional therapy was administered. Survival was measured from the time the patients were first seen. Disease-free survival was measured from the completion of all therapy.
.
achieved a complete remission. All patients remain alive, with a median survival from the time of diagnosis of 27+ months (see figure). 21 patients (95%) remain continuously free of disease with a median disease-free survival from the completion of chemotherapy of 23+ months (see figure). 1 patient relapsed 3 months after completing eight courses of CHOP alone. This patient had lymphomatous involvement of the supraclavicular, cervical, and submandibular nodes in association with constitutional symptoms. At relapse recurrence was found in a single cervical lymph-node site, which was then irradiated with a complete response. She has remained free of lymphoma for 25+ months since treatment for recurrence. The toxicity and side-effects of treatment were generally mild and manageable. Leucopenia was moderate but uncomplicated by serious infection or hospital admission. Nausea, vomiting, and hair loss, although common, did not interrupt therapy. No cardiotoxicity due to adriamycin was observed.
DISCUSSION
approximately two-thirds of cases D.H.L. is disseminated at the time of diagnosis and requires immediate chemotherapy. 1 14 16 Thorough staging, including surgical evaluation, further reduces the number of patients with localised lymphoma because occult sites of disease In
detected thereby.6 14 16 However, even with careful staging and radiotherapy, 10-20% of patients develop disseminated lymphoma while undergoing radiotherapy and 30-50% of patients with localised D.H.L. ultimately relapse if radiotherapy alone is used.3-8 Changes in the management of this series of patients reflect our evolving concepts for the treatment of D.H.L. Initially, 3 patients received chemotherapy concurrently with irradiation. To prevent dissemination of localised disease, systemic chemotherapy was administered as the first form of therapy in the remaining 19 patients. In the last 14 of these patients, chemotherapy alone was given. Our experience with chemotherapy in early D.H.L. appears to be analogous to experience in Hodgkin’s disease. Chemotherapy with MOPP (mustine, vincristine, prednisone, and procarbazine) produced cures in about half of patients with advanced Hodgkin’s disease. 19 In a series from Uganda all patients with early Hodgkin’s disease (stages I and II) achieved complete regression of tumour with MOPP chemotherapy, and only 1 patient relapsed.2O Because of these results, large clinical trials are now underway in the United States to evaluate further the role of chemotherapy alone in the management of early Hodgkin’s disease. The excellent results in our series appear to be related to effective chemotherapy rather than selection of patients. As indicated in the table, this group of patients was characterised by a number of factors known to be associated with a poor prognosis.2 Systemic chemoare
A. Survival from time of
diagnosis in 22 patients with diffuse histiocytic lymphoma treated with chemotherapy with or without radiotherapy. B. Disease-free survival after completion of therapy. XRT=involved-field radiation therapy.
360
therapy occult
be effective therapy for well as clinically apparent disease, the need for extensive pretreatment staging
with
CHOP seems to
metastases as
obviating with laparotomy.b i6
.
We propose that initial systemic chemotherapy is more successful than initial radiotherapy in the treatment of localised D.H.L. The validity of this approach, and the role of radiotherapy as an adjuvant to chemotherapy, will need to be further tested in larger numbers of patients. This work was supported in part by grants CA-13162 and CA-17094 from the National Cancer Institute, Department of Health, Education and Welfare, Bethesda, Maryland.
Requests for reprints should be addressed to S. E. J. REFERENCES
4.
Jones, S. E., Fuks, Z., Kaplan,
H. S.,
Rosenberg,
S. A.
Cancer, 1973, 32,
682. 5. Lattuada, A., Bonadonna, G., Milani, F., Banfi, A., Valagussa, P., DeLena, M., Monfardini, S. in Adjuvant Therapy of Cancer (edited by S. E. Salmon and S. E. Jones); p. 537. Amsterdam, 1977. 6. Bitran, J. D., Kinzie, J., Sweet, D. L., et al. Cancer, 1977, 39, 342. 7. Fuks, Z., Kaplan, H. S. Radiology, 1973, 108, 675. 8. Glatstein, E., Portlock, C., Rosenberg, S. A., Kaplan, H. S. in Adjuvant Therapy of Cancer (edited by S. E. Salmon and S. E. Jones), p. 545.
Amsterdam, 1977. 9. DeVita, V. T., Canellos, G. P., Chabner, B., Schein, P., Hubbard, S. P., Young, R. C. Lancet, 1975, ii, 248. 10. McKelvey, E. M., Gottlieb, J. A., Wilson, H. E., et al. Cancer, 1976, 38, 1484. 11. Jones, S. E., Grozea, P. N., Metz, E. N., ibid. (in the press). 12. Rappaport, H. Atlas of Tumour Pathology; section II, fasc. 8, p. 101. Armed Forces Institute of Pathology, Washington, D. C., 1966. 13. Warnke, R. A., Kim, H., Fuks, Z., Dorfman, R. F. Cancer, 1977, 40, 1229. 14. Chabner, B. A., Johnson, R. E., DeVita, V. T., Canellos, G. P., Hubbard, S. P., Johnson, S. K., Young, R. C. Cancer Treat. Rep. 1977, 61, 993. 15. Jones, S. E.J.Am. med.Ass. 1975, 234, 633. 16. Goffinet, D. R., Warnke, R., Dunnick, N. R., et al. Cancer Treat. Rep. 1977,
61, 981. Carbone, P. P., Kaplan, H. S., Musshoff, K., Smithers, D. W., Tubiana, M. Cancer Res. 1971, 31, 1858. 18. Herman, T. S., Jones, S. E. Cancer Treat. Rep. 1977, 61, 1009. 19. DeVita, V. T., Serpick, A. A., Carbone, P. P. Ann. intern. Med. 1970, 75, 17.
Jones, S. E., Fuks, Z., Bull, M., Kadin, M. E., Dorfman, R. F., Kaplan, H. S., Rosenberg, S. A., Kim, H. Cancer, 1973, 31, 806. 2. Fisher, R. I., DeVita, V. T., Johnson, B. L., Simon, R., Young, R. C. Am. J. Med. 1977, 63, 177. 3. Kushlan, P., Coleman, C. N., Glatstein, E. J., Rosenberg, S. A., Kaplan, 1.
H. S.Am.Ass.
Cancer Res. 1978, 19, 337.
881.
20. Olweny, C. L. M., Katongole-Mbidde, E., Küre, C., Lwanga, Magrath, I., Ziegler, J. L. Cancer, 1978, 42, 787.
S. K.,
Methods and Devices
RYLE’S TUBE FOR RAPID INTRAVENOUS TRANSFUSION
S. WESTABY
I. D. S. GILLIES
Departments of Surgery and Anœsthetics, Hammersmith Hospital and Royal Postgraduate Medical School, London W12 OHS
Ryle’s tube is well known for its role in nasogastric aspiration. However, a simple modification quickly transforms this, tube for use as a large-bore venous cannula ideal for very rapid transfusion and for the measurement of central venous pressure. It is very useful when torrential bleeding is encountered or anticipated after abdominal or thoracic trauma, with peptic ulceration or cesophageal varices, and during major cardiac, vascular, or hepatic operations.
A.-Cutdown in antecubital fossa with Ryle’s tubes sizes 10 FG and 12 FG introduced into veins through separate stab incisions.
METHOD
The
Ryle’s ford, Kent) is
tube cut
(’Aldon’, Aldington Laboratories Ltd., Ashto half length (21 in), and the distal end is
bevelled to facilitate its introduction into the vein. A cut-down is performed in the antecubital fossa, preferably into the median cubital vein, as this provides free access to the subclavian vein. If the cephalic vein is used, negotiation of the clavipectoral fascia may be difficult because the tube is soft. A vena commitans of the brachial artery or as a last resort the long
B. Procedure complete.
vein may also be used. Two or more tubes may be introduced through the same antecubital fossa. The skin is prepared and an incision is made over the appropriate vein, which is then stabilised between catgut ligatures while a venotomy is performed to admit the tube. The tube is passed through a separate stab incision in the skin, as shown
saphenous
FLOW OF BLOOD AND NORMAL SALINE THROUGH VARIOUS TYPES OF INTRAVENOUS CANNULae AND
3
GAUGES OF
RYLE’S TUBES*
*Ha:molysis produced is assessed by plasma-haemoglobin concentration. A control value of 6.3mg/dl was found in the bag before infusion. Infusion through the giving-set alone resulted in a plasma-hxmoglobin of 10- 2 mg/dl.
