Blunt cardiac injury: case report of salvaged traumatic right atrial rupture.

The incidence of cardiac rupture following blunt trauma is rare, occurring in 0.3%-0.5% of all blunt trauma patients. It can be fatal at the trauma scene, and is frequently missed in the emergency room setting. The severity of a cardiac trauma is based on the mechanism and degree of the force applied. The objective of this study was to report the case of a 32-year-old male patient who was involved in a motor vehicle collision and presented to the emergency room with signs of hypovolemic shock. The patient was found to have severe chest trauma associated with massive hemothorax requiring immediate intervention. The patient had an emergent thoracotomy revealing a right atrial injury. Repair of the atrial injury reversed the state of shock. The patient was discharged after 35 days of hospitalization in good condition.

Modification and implementation of NCCN guidelines on non-small cell lung cancer in the Middle East and North Africa region.

A lung cancer committee from the Middle East and North Africa (MENA) region was established to modify the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) on Non-Small Cell Lung Cancer to create a platform for standard care in the region. The committee comprised different experts in thoracic oncology from the region, including the disciplines of medical and clinical oncology, radiation oncology, thoracic surgery, pulmonary medicine, radiology, and pathology. The committee reviewed version 2 of the 2009 NCCN Guidelines on Non-Small Cell Lung Cancer and identified recommendations requiring modification for the region using published evidence and relevant experience. These suggested modifications were discussed among the group and with a United States-based NCCN expert for approval. The recommended modifications, with justification and references, were categorized based on the NCCN Guidelines flow. This article describes these recommended modifications. The process of adapting the first NCCN-based guidelines in the region is a step toward helping to improve lung cancer care in the region and encouraging networking and collaboration.

Transcervical gastric tube drainage facilitates patient mobility and reduces the risk of pulmonary complications after esophagectomy.

BACKGROUND: Standard nasogastric decompression following esophagectomy is associated with reduced patient comfort and mobility and impaired hypopharyngeal function--predisposing the patient to sinusitis, pharyngitis, and the risk of aspiration. In this study, we evaluate the results of the transcervical gastric tube drainage in the setting of esophagectomy. METHODS: Transcervical gastric tube decompression was performed on 145 consecutive patients undergoing open esophagectomy between 2003 and 2007. Postoperative outcome variables include morbidity, mortality, esophagostomy duration, and length of stay. RESULTS: There were 107 males and 38 females (median age = 66; range = 37-87). Perioperative mortality was 2.8%. Major complications included five anastomotic leaks (3.4%), ten pneumonias (6.9%), two myocardial infarctions (1.4%), and the need for reoperation in four patients (bleeding, dehiscence). Median duration of transcervical drainage was 8 days. No tubes were dislodged prematurely. There were no bleeding complications. Four patients developed cellulitis near the cervical gastric tube site and were treated successfully with antibiotics and/or tube removal. CONCLUSIONS: Transcervical gastric decompression can be performed safely with minimal complication risk. Inadvertent tube removal was not encountered in this series. The use of this technique may help to promote accelerated patient mobilization, greater patient comfort, and a durable means of gastric decompression.

Laparoscopic clam shell partial fundoplication achieves effective reflux control with reduced postoperative dysphagia and gas bloating.

BACKGROUND: We describe a novel laparoscopic "clam shell" partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease. We hypothesize that this clam-shell-like mechanism allows a dynamic rather than rigid circumferential antireflux barrier allowing effective reflux control (compared with partial fundoplication) with reduced occurrence of postoperative dysphagia, gas bloating and vagal nerve injury (compared with Nissen fundoplication). METHODS: Between November 2002 and May 2006, 140 patients (82 female; mean age, 53 years) underwent this laparoscopic clam shell fundoplication procedure for medically recalcitrant gastroesophageal reflux disease (n = 94) or large paraesophageal hernias (n = 46). Preoperative invasive studies (endoscopy, manometry, pH monitoring) and noninvasive studies (barium swallow and radionuclide gastroesophageal motility) revealed esophageal dysmotility in 26 patients. Routine barium swallow and radionuclide studies were performed 6 months postoperatively and then at yearly intervals. RESULTS: There was no mortality or conversions to open procedures. Mean operative time was 45 minutes; median hospital stay was 1 day (range, 1 to 4). Overall control of reflux symptoms was seen in 95% of patients. Postoperative gas bloating and significant dysphagia occurred in only 11% and 6% of patients, respectively. Three patients (2%) experienced postoperative complications (pneumonia, 2; pleural effusion requiring drainage, 1). Postoperative studies demonstrated reflux in 8 patients (5%) and the presence of small hiatal hernias in 5 patients (4%) during a mean follow-up 19 months (range, 7 to 42). Twenty five patients (17%) underwent postoperative esophageal dilation (median dilations, 1; range, 1 to 3) for dysphagia (11 of these patients had preoperative esophageal dysmotility). Five patients underwent repeat fundoplication (recurrent reflux, 2; gas bloating, 1; dysphagia, 2). CONCLUSIONS: Clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas bloating.

Margin and local recurrence after sublobar resection of non-small cell lung cancer.

BACKGROUND: Local recurrence is a major concern after sublobar resection (SR) of non-small cell lung cancer (NSCLC). We postulate that a large proportion of local recurrence is related to inadequate resection margins. This report analyzes local recurrence after SR of stage I NSCLC. Stratification based on distance of the tumor (<1 cm vs >or=1 cm) to the staple line was performed. METHODS: We reviewed 81 NSCLC patients (44 female) who underwent operation over an 89-month period (January 1997 to June 2004). Mean forced expiratory volume in one second percentiles (FEV1) was 57%. Mean age was 70 (46-86) years. There were 55 wedge and 26 segmental resections. There were 41 tumors with a margin <1 cm and 40 with a margin >or=1 cm. Local recurrence was defined as recurrence within the ipsilateral lung or pulmonary hilum. RESULTS: There were no perioperative deaths. Mean follow-up was 20 months. Margin distance significantly impacted local recurrence; 6 of 41 patients (14.6%) developed local recurrence in the group with margin less than 1 cm versus 3 of 40 patients (7.5%) in the group with margin equal to or more than 1 cm (P = .04). Of the 41 patients with margins <1 cm, segmentectomy was used in 7 (17%), whereas in the 40 patients with the >or=1 cm margins, segmentectomy was used in 19 (47.5%). CONCLUSIONS: Margin is an important consideration after SR of NSCLC. Wedge resection is frequently associated with margins less than 1 cm and a high risk for locoregional recurrence. Segmentectomy appears to be a better choice of SR when this is chosen as therapy.

Outcomes of sublobar resection versus lobectomy for stage I non-small cell lung cancer: a 13-year analysis.

BACKGROUND: The appropriate use of sublobar resection versus lobectomy for stage I non-small cell lung cancer continues to be debated. A long-term analysis of the outcomes of these resections for stage I non-small cell lung cancer in a high-volume tertiary referral university hospital center was performed. METHODS: The outcomes of all stage I non-small cell lung cancer patients (n = 784) undergoing resection were analyzed from our lung cancer registry from 1990 to 2003. Lobectomy was the standard of care for patients with adequate cardiopulmonary reserve. Sublobar resection was reserved for patients with cardiopulmonary impairment prohibiting lobectomy. Predictors of overall survival and disease-free survival were evaluated. Statistical analyses included Kaplan-Meier estimates of survival, log-rank tests of survival differences, and multivariate Cox proportional hazards models. RESULTS: Lobectomy was used for 577 patients and sublobar resection for 207 patients. The median age was 70 years (range, 31 to 107 years). The median follow-up of patients remaining alive was 31 months. Compared with lobectomy, sublobar resection had no significant impact on disease-free survival, with a hazard ratio of 1.20 (95% confidence interval, 0.90 to 1.61; p = 0.24). Sublobar resection had a statistically significant association with overall survival when compared with lobectomy, with an increased hazard ratio of 1.39 (95% confidence interval, 1.11 to 1.75; p = 0.004). Twenty-eight percent of lobectomy patients experienced disease recurrence in that time compared with 29% of the sublobar patients. Seventy-two percent of the recurrences in the lobectomy cohort were distant metastasis versus 52% of the sublobar group recurrences (p = 0.0204). CONCLUSIONS: Although sublobar resection is thought to be associated with increased incidence of local recurrence when compared with lobectomy, we found no difference in disease-free survival between the two types of resection for stage IA patients but slightly worse disease-free survival for stage IB.

Efficacy of laparoscopic fundoplication in controlling pulmonary symptoms associated with gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease (GERD)-induced pulmonary symptoms (PS) can be difficult to control. The effectiveness of laparoscopic fundoplication (LF) in controlling PS among patients with medically recalcitrant GERD is poorly documented. We evaluated our results in controlling important PS in patients with GERD undergoing LF. METHODS: Seventy-four patients (28 men, 46 women) were identified with clinically important PS from a prospective cohort of 155 patients undergoing elective LF for recalcitrant GERD. Median age was 52.5 years (range, 29-84 years). Sixty-seven (91%) patients were taking proton pump inhibitors at the time of operation. Quality of life by using the SF36 physical (PCS) and mental (MCS) component summary scores (normal, 50) and heartburn severity by using the health-related quality of life (HRQOL) (best score, 0; worst score, 45) were measured. RESULTS: All 74 patients with PS survived operation, and minor morbidity occurred in 5 (7%) patients. Median hospital stay was 2 days (range, 1-6 days), and return to normal activity was seen at 2.2 weeks (range, 1-8 weeks). Median follow-up was 12 months. PS were improved significantly (P < .01) for hoarseness (62% to 17.6%), bronchospasm (60% to 9.5%), and aspiration (22% to 1.4%). Before LF, 11 (14.9%) patients required bronchodilators or oral steroids. Postoperatively such therapy was required in only 3 (4.2%) patients (P = .019), with no patient requiring oral steroids. Patients with poorer control of their GERD on the basis of high HRQOL scores had significantly more PS after operation. CONCLUSIONS: A significant number of patients with medically recalcitrant GERD (46% from our prospective database) have important PS. LF can improve PS, decrease requirement for pulmonary medications, as well as improve typical reflux symptoms and quality of life.

New therapeutic approaches for early stage non-small cell lung cancer.

Surgical resection remains the mainstay of therapy for early stage non-small cell lung cancer (NSCLC). Unfortunately, many patients present with advanced stage disease, and many with resectable early stage disease are unable to tolerate pulmonary resection because of compromised cardiopulmonary function. This article reviews the standard and some alternative therapies that are being introduced into clinical practice for early stage NSCLC. New therapies such as sublobar resection with brachytherapy, radiofrequency ablation and stereotactic radiosurgery offer some hope for those patients who are deemed poor candidates for curative resection.