Surgical management of symptomatic pulmonary aspergilloma.

Pulmonary aspergilloma is a potentially life-threatening disease resulting from the colonization of lung cavities by the ubiquitous fungus Aspergillus fumigatus. Complex aspergilloma, characterized by thick-walled cavities with surrounding parenchymal inflammation, is a risk factor for increased morbidity and mortality. Fifteen patients with symptomatic aspergilloma underwent major thoracic procedures at North Carolina Memorial Hospital between January 1, 1972, and December 31, 1983. Twelve of the patients had hemoptysis; in 7 it was recurrent and in 5, life threatening. Tuberculosis and sarcoidosis were the most common underlying causes of lung disease, and more than half of the patients had other coexistent serious medical illness. Eleven of the 15 patients were seen with complex aspergilloma; all of the 4 major complications and the 2 deaths occurred in these patients. Bronchopleural fistula with persistent air space was the most common serious complication, and required thoracoplasty in 3 patients. Nine patients, including 5 with complex aspergilloma, had no postoperative complications, and there were no recurrent symptoms in any of the 13 operative survivors over a mean follow-up of five years. It is concluded that aggressive pulmonary resection can provide effective long-term palliation in critically ill patients with symptomatic pulmonary aspergilloma.

Esophagogastrectomy as palliative treatment for esophageal carcinoma: results obtained in the setting of a thoracic surgery residency program.

The palliative treatment of esophageal carcinoma has included intubation, bypass, dilation, irradiation, and esophagogastrectomy. The last has been criticized by some on the basis of high operative morbidity and mortality. To assess the success of this method at our institution, we reviewed the 60 consecutive resections performed for carcinoma of the esophagus from January, 1972, through June, 1983. Forty-six patients had squamous cell tumors and 14, adenocarcinomas. There were 47 men and 13 women, and the mean age was 59.9 years (range, 38.5 to 78.9 years). The most frequent preoperative findings included dysphagia (55), weight loss (34), chest pain (22), and vomiting (49). Fifty (83%) out of the 60 resections were performed by the resident staff under the supervision of an attending surgeon. Four patients died within 30 days of operation, an operative mortality of 6.7%. Immediate causes of death included respiratory failure, myocardial infarction, hemorrhage, and renal failure. One of the patients who died and 3 of the survivors had an anastomotic leak. There were 27 additional complications in 24 patients: respiratory problems (8), arrhythmias (5), pleural effusion (4), gastric outlet obstruction (2), wound infection (2), and 1 each of pulmonary embolus, acute brain syndrome, congestive heart failure, myocardial infarction, chylothorax, and empyema. The one-, two-, three-, and five-year actuarial survival rates were 46%, 27%, 10%, and 5%, respectively. Mean survival for the 46 patients dead at the time of this study was 13.5 months. Outpatient follow-up data were available on 53 (95%) of the operative survivors and showed an absence of dysphagia in 87.5% during most of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Major pulmonary resection for suspected but unconfirmed malignancy.

Thoracotomy is not infrequently performed in patients with suspected pulmonary carcinoma but with no histological or cytological confirmation of malignancy. The intraoperative decision to proceed with major pulmonary resection (lobectomy or pneumonectomy) is difficult if a large or central lesion precludes total excisional biopsy. Incisional or needle biopsies violate the principles of good cancer surgery, and the results may be inconclusive if the tumor is missed and areas of associated inflammation or necrosis are sampled. Between January 1, 1970, and December 31, 1980, 303 patients underwent thoracotomy for suspected but unconfirmed malignancy. One hundred twenty-two had a minor resection only, 79 had a major resection (lobectomy or pneumonectomy) after a diagnosis was established by frozen section, and 102 had a major resection without a definitive diagnosis of cancer. Carcinoma subsequently was found in 68% (69) of this group of 102 patients, and benign lesions were identified in the remaining 32% (33), all of whom underwent lobectomy. The diagnoses in these 33 patients included seven granulomas, three hamartomas, nine instances of tuberculosis, and fourteen instances of fibrosis, inflammation, or cystic degeneration. The 2 thirty-day operative deaths in this group of 102 patients occurred among the 69 with malignant disease; 1 died of hemorrhage following pneumonectomy and 1, of respiratory insufficiency after lobectomy. In all 303 patients, there was no difference in operative mortality (p less than 0.01) between lobectomy (2%) and a lesser resection (1.6%). In a patient with a suspicious but inaccessible pulmonary lesion, lobectomy can be performed safely without violating the principles of cancer surgery. This recommendation should probably not be extended to lesions requiring pneumonectomy, because of the increased rates of morbidity and mortality associated with that procedure.

Selective application of fundoplication in achalasia.

Although esophagomyotomy alone may effectively relieve dysphagia in patients with achalasia, utilization of a complementary fundoplication procedure should be considered for selected patients. Fundoplication is a sensible addition to myotomy in circumstances that suggest high risk for the development of reflux esophagitis. Also, in complicated achalasia, relief of esophageal obstruction by simple myotomy may not be achieved safely. Identification of those pathological features associated with achalasia that merit consideration of fundoplication should improve operative results and reduce morbidity. This paper examines the application of a complementary fundoplication procedure in the operative management of 21 patients with achalasia over a ten-year period.

Effects of therapy with cholestyramine on progression of coronary arteriosclerosis: results of the NHLBI Type II Coronary Intervention Study.

In the National Heart, Lung and Blood Institute Type II Coronary Intervention Study, patients with Type II hyperlipoproteinemia and coronary artery disease (CAD) were placed on a low-fat, low-cholesterol diet and then were randomly allocated to receive either 6 g cholestyramine four times daily or placebo. This double-blind study evaluated the effects of cholestyramine on the progression of CAD as assessed by angiography. Diet alone reduced the low-density lipoprotein cholesterol 6% in both groups. After randomization, low-density lipoprotein cholesterol decreased another 5% in the placebo group and 26% in the cholestyramine-treated group. Coronary angiography was performed in 116 patients before and after 5 years of treatment. CAD progressed in 49% (28 of 57) of the placebo-treated patients vs 32% (19 of 59) of the cholestyramine-treated patients (p less than .05). When only definite progression was considered, 35% (20 of 57) of the placebo-treated patients vs 25% (15 of 59) of the cholestyramine-treated patients exhibited definite progression; the difference was not statistically significant. However, when this analysis was performed with adjustment for baseline inequalities of risk factors, effect of treatment was more pronounced. Of lesions causing 50% or greater stenosis at baseline, 33% of placebo-treated and 12% of cholestyramine-treated patients manifested lesion progression (p less than .05). Similar analyses with other end points (percent of baseline lesions that progressed, lesions that progressed to occlusion, lesions that regressed, size of lesion change, and all cardiovascular end points) all favored the cholestyramine-treated group, but were not statistically significant. Thus, although the sample size does not allow a definitive conclusion to be drawn, this study suggests that cholestyramine treatment retards the rate of progression of CAD in patients with Type II hyperlipoproteinemia.

The influence of changes in lipid values induced by cholestyramine and diet on progression of coronary artery disease: results of NHLBI Type II Coronary Intervention Study.

The National Heart, Lung and Blood Institute Type II Coronary Intervention Study, a double-blind, placebo-controlled trial, evaluated the efficacy of reduction in cholesterol levels induced by cholestyramine on progression of coronary artery disease (CAD). The rate of CAD progression in patients treated with cholestyramine plus diet was compared with that of patients treated with placebo plus diet. CAD progression was defined angiographically. Significant decrease in total cholesterol (TC) and low-density lipoprotein cholesterol (LDLc) and increases in high-density lipoprotein cholesterol (HDLc), as well as in HDLc/TC and HDLc/LDLc ratios, were observed with cholestyramine. HDLc change was due to increase in HDL2A and HDL2B. When the relationship between CAD progression and lipid changes was examined independent of specific treatment group, a significant inverse relationship was found between progression at 5 years and the combination of an increase in HDLc and a decrease in LDLc; changes in HDLc/TC and HDLc/LDLc were the best predictors of CAD change. While the testing of these relationships independent of treatment group was not part of the initial study design, the trends were observed in both the placebo-treated and cholestyramine-treated groups. Moreover, with multivariate analysis, the effect of cholestyramine treatment on CAD progression was eliminated by adding changes in HDLc/TC to the regression model. These findings support the hypothesis that increases in HDLc and decreases in TC (or LDLc) can prevent or delay CAD progression.

An unusual complication of naso-enteral feeding with small-diameter feeding tubes.

The occurrence of nasotracheal intubation with feeding tubes of various types is well known but poorly documented. The small-diameter feeding tubes currently available for enteral hyperalimentation may be more prone to this complication because of their small size and the rigid guide wire which is required for placement. A high index of suspicion when placing these tubes in patients at risk, use of the wire guide to pass the nasopharynx only, and x-ray verification of tube location prior to usage should avert this potentially life-threatening mistake.

Identification of internal carotid artery stenosis in coronary artery bypass candidates.

Identification of stenotic internal carotid arteries in neurologically asymptomatic coronary artery bypass candidates is difficult. We correlated carotid arteriograms with carotid bruits in 422 vessels and demonstrated a sensitivity of 79% and a specificity of 65% with regard to the bruit's identification of vessels with a 50% or more reduction in angiographic diameter. The noninvasive duplex scan, used in conjunction with Fast Fourier Transform spectral analysis, had a sensitivity and a specificity of 90% in this same regard. Since there is only a 6% incidence of significant internal carotid stenosis in bypass candidates, Bayes' theorem used in conjunction with our findings showed that a carotid bruit was an incorrect predictor of internal carotid stenosis 87% of the time. The duplex scan was somewhat better, but still inaccurate 64% of the time. Thus neither parameter alone has a high enough predictive value to determine whether preoperative carotid angiography is necessary. However, if one limits duplex scanning to patients with a carotid bruit, the predictive value is raised to 92%. At the same time, there is minimal increase in the number of undiagnosed patients. Thus far this combined approach is recommended for preoperative evaluation of patients scheduled for coronary artery bypass.

Intractable dysphagia following placement of Angelchik prosthesis for reflux esophagitis.

In 1979, Angelchik and Cohen [1] reported a series of 46 patients in whom a Silastic prosthesis was used to control gastroesophageal reflux. The initial results were good, and to date, no long-term complications have been noted. We discuss a patient whom severe dysphagia developed following placement of an Angelchik prosthesis. Preoperative evaluation revealed no motor abnormality and no stricture, but there was acute angulation of the gastroesophageal junction. The prosthesis was removed through a left thoracotomy, and a Belsey repair resulted in good relief of symptoms.

The cervical approach to esophageal leiomyomas.

Intramural leiomyoma is the most common benign esophageal tumor. The treatment of choice is enucleation without mucosal encroachment. Esophageal resection with reconstruction is rarely necessary, obviating the need for wide exposure. This report demonstrates the technical simplicity of the cervical approach to leiomyomata of the proximal thoracic esophagus. The operative technique avoids the morbidity of the commonly employed thoracotomy incision and deserves consideration in the treatment of accessible lesions.

Reliability of assessing change with sequential coronary angiography.

Data are presented from a study evaluating the reliability of sequential angiography in estimating changes in coronary lesions. Three panels of three expert angiographers each read on two separate, independent occasions 18 sets of paired angiograms taken 24 months apart. All readers were blinded to the temporal sequence of the films, clinical data, and ventriculography information. The need for simultaneous viewing and reading of the two films, for training sessions, and for allowance to be made for apparent differences arising from boundary definitions prior to final analysis was demonstrated. Under stringent conditions (determination of change based on agreement of at least two out of three panels of physicians) it was possible to ascertain change in coronary atherosclerosis from sequential sets of coronary angiograms with good reliability. However, single-panel readings yielded an unacceptable overestimate of the number of patients with lesion changes.

National Heart, Lung, and Blood Institute type II Coronary Intervention Study: design, methods, and baseline characteristics.

The Type II Coronary Intervention Study (Type II Study) is a double-blind, randomized, placebo-controlled clinical trial conducted by the Division of Intramural Research of the National Heart, Lung, and Blood Institute of Bethesda, Maryland. The study was designed to evaluate the 5-year treatment effect of cholestyramine on low density lipoprotein (LDL) cholesterol and on lesions in the coronary arteries. One hundred forty-three patients with Type II hyperlipoproteinemia (elevated LDL cholesterol) and coronary artery disease (CAD) were entered into the study between 1972 and 1976. Patients were stratified by sex and extent of coronary disease as defined angiographically and were randomly allocated to a daily dosage of 24 g cholestyramine and diet (treatment group) or placebo and diet (control group). Changes in the coronary arteries were evaluated by sequential coronary angiography carried out before and after five years of treatment. This report describes the trial design and baseline characteristics of the study patients.

Subarachnoid-pleural fistula: unusual complication of thoracotomy.

A case of subarachnoid-pleural fistula caused by a traction injury of the intercostal neurovascular bundle during thoracotomy is presented. Headaches, air within the ventricles of the brain, and clear drainage from the chest catheter should alert the surgeon to the presence of a subarachnoid-pleural fistula. If spontaneous closure of the fistula does not occur after a brief trial of chest catheter drainage, early operative intervention is advised.