Is video-assisted thoracoscopic surgery superior to limited axillary thoracotomy in the management of spontaneous pneumothorax?

OBJECTIVE: To evaluate bullectomy and pleurectomy in the treatment of spontaneous pneumothorax (PNO) using video-assisted thoracoscopic surgery (VATS), and to compare the outcome with that of the same procedure performed using limited axillary thoracotomy (LAT). DESIGN: A retrospective case series with patient follow-up. SETTING: A Canadian tertiary care hospital. PATIENTS: The medical records of all patients with a spontaneous PNO treated by either VATS or LAT at the Ottawa Hospital - General Campus, Ottawa, Ontario, between April 1993 and August 1999 were reviewed, and the patients were subsequently interviewed. MAIN OUTCOME MEASURES: Operative details (length of operation, operative complications); postoperative details (duration of chest tube, length of hospital stay, duration of analgesia, pain, time missed from work, complications, recurrence rate); and cost (hospital and operative, socioeconomic [time missed from work]). RESULTS: Fifty patients were identified who had had surgical treatment of a spontaneous PNO. Twenty-eight patients were treated by LAT and 22 underwent VATS. The median length of follow-up was 44.6 months (range four to 81.5 months). Three patients developed a recurrent PNO - two patients after LAT and one patient after VATS. No difference was found between the two groups in the operating time or in the amount of pain experienced immediately after surgery. However, patients who underwent VATS had a shorter length of stay (P=0.002) and a shorter requirement for analgesics postoperatively (P=0.03). Overall, the total cost of VATS was no different than that for LAT; however, in terms of socioeconomic costs, patients in the VATS group missed significantly less time from work postoperatively (P=0.02). CONCLUSIONS: VATS offers a cost effective and better tolerated procedure for the management of spontaneous PNO than the time-honoured open technique.

A logical approach to the thoracic inlet: the Dartevelle approach revisited.

BACKGROUND: Traditionally, Pancoast tumors have been associated with an extremely poor outlook. Recently, Dartevelle and colleagues have noted a significant survival advantage in patients treated by wide en bloc excision. METHODS: Utilizing an illustrative case example, step by step exposure of the lung apex and first rib is provided with the Dartevelle approach. RESULTS: Safe exposure was provided by this combined transcervical and transthoracic approach. CONCLUSIONS: The Dartevelle approach appears to be the favored approach to anterior lung apex or first rib lesions. The combined efforts of an Otolaryngolist-Head and Neck Surgeon and a Thoracic Surgeon may allow for safe, wide en bloc excision of these otherwise difficult to access lesions.

Neoadjuvant chemotherapy before surgery for resectable carcinoma of the lower esophagus.

Neoadjuvant chemotherapy before surgery has been proposed to improve the outcome in patients with early lower esophageal cancer. To evaluate its effectiveness, we performed a systematic retrospective analysis of consecutive patients treated at the Ottawa Regional Cancer Center with prospective inclusion criteria. Between 1988 and 1992 patients were treated with surgery alone. From 1992 until 1997, patients were uniformly treated with neoadjuvant chemotherapy consisting of cisplatin and 5-fluorouracil. Surgical resection was then performed. Nineteen patients received neoadjuvant chemotherapy and 15 received surgery alone. Although the two arms of the study were balanced for age and sex, there were more patients in the neoadjuvant arm with squamous histology, weight loss and regional nodes at diagnosis. In the neoadjuvant arm, two patients did not have surgery because of progression or toxicity. However, complete resection rates were similar. There was no difference in overall survival or disease-free survival between the two arms (p > 0.4). Multivariate analysis revealed that only the nodal status at diagnosis was predictive of outcome. Neoadjuvant chemotherapy with this regimen does not result in improved survival over surgery alone.

Primary aortogastric fistula: a complication of ruptured aortic aneurysm.

An aortogastric fistula which resulted from rupture of an atherosclerotic aneurysm of the descending and supraceliac aortic segments is reported. The diagnosis was suspected preoperatively on the basis of CT and angiographic examinations. Vascular replacement was accomplished without difficulty, but a fatal outcome eventually occurred because of failure of local repair of the gastric defect. Relevant literature on primary aortoenteric fistulas has been reviewed, with particular emphasis on reports detailing management of the alimentary tract perforations. We now believe that resection should be strongly considered in situations where both resection and local repair of the enteric defect are options.

Quality-of-life following thoracotomy for lung cancer.

Contrary to the issues of perioperative morbidity and survival following surgery for lung cancer, little attention has been given to quality-of-life. To address this, quality-of-life was assessed preoperatively and 1, 3, 6 and 9 months postoperatively in a cohort of 117 consecutive subjects who underwent thoracotomy with a certain or presumptive diagnosis of lung cancer. Those with cancer (n = 91) confirmed at thoracotomy were contrasted to those without (n = 26). Moderate to severe dyspnea, reported in 14% preoperatively, increased to 34% at 1 and 3 months (p < 0.005) but returned to approximately 10% at 6 and 9 months. Similarly, activities of daily living were impaired in 11% preoperatively; this disability increased to 21% at 1 month (p < 0.005), and returned to baseline at 6 and 9 months. Those with cancer compared to those without a postoperative diagnosis of cancer had similar quality-of-life preoperatively but deteriorated more in the postoperative period. This study demonstrates that important deterioration in quality-of-life occurs during the first 3 months postoperatively in those with a final diagnosis of cancer but improvement back to baseline can be expected thereafter.

Benign bronchoesophageal fistulas.

Two cases of benign bronchoesophageal fistula are presented which are representative of both congenital and acquired forms. The presentation of this relatively rare condition is characterized by recurrent cough especially after drinking liquids and is easily diagnosed by esophagogram. A high index of suspicion is required in all cases of recurrent cough and lung suppuration in order for this condition to be recognized. Benign bronchoesophageal fistulas are rare but the symptoms are often classic and the diagnosis is made easily once proper investigation is undertaken. Bronchoesophageal fistulas may be either congenital or acquired, with the latter being more common. The treatment is usually straightforward and prognosis is excellent for long-term survival. We present two cases of benign bronchoesophageal fistula.

Specific active immunochemotherapy in lung cancer: a survival study.

A radomized clinical trial of chemotherapy, immunization and immunochemotherapy among 55 patients with stages I and II carcinoma of the lung is reported. The survival rate in the immunized groups was significantly better (P = 0.001) than that in the nonimmunized groups. The results are discussed in the light of the reactivity of the patients to the specific cancer antigen.

Immunochemotherapy of lung cancer.

After surgical resection of their primary lung cancer, 33 patients were randomized into one of three groups. The first received high-dose methotrexate once per month with citrovorum rescue, for 3 months. The second group were immunized monthly with a homogenate of Freund's complete adjuvant and carefully characterized soluble antigen derived from allogeneic lung cancer cells of appropriate histology, for 3 months. The third group received a combination of methotrexate and immunization monthly, for 3 months. Each patient was monitored immunologically before, during, and after the treatment period, by use of delayed hypersensitivity reactions to recall and cancer antigens, in vitro lymphocyte response to mitogens, and mixed lymphocyte blocking factor activity. The group that received methotrexate showed little change in skin reactivity, a reduction of blocking factor activity, and significant rebound overshoot in in vitro lymphocyte performance. The immunized group showed a tendency to production of blocking factor activity, striking conversion and enhancement of skin reactivity, and little change in in vitro lymphocyte performance. The immunochemotherapy group showed dramatic increases in specific skin reactivity to cancer antigens, up to 2 years after treatment, in vitro lymphocyte rebound overshoot, and reduction of blocking factor activity production. Classic life table analysis of the probability of freedom from metastases in patients with stage-I cancer indicate that the disease-free interval in patients who received methotrexate is longer than in historic and concomitant controls but not as long as in those who received immunization. The best group appear to be those who received combination immunochemotherapy. We emphasize that the small numbers in this pilot study do not yet allow firm conclusions to be made.