Mechanical injuries to the ipsilateral non-diseased lobes(s) during pulmonary resection--another factor causing postoperative complications.

BACKGROUND: The occurrence of complications after major pulmonary resection is known to be related to various factors. However, peri-surgical injuries to the ipsilateral non-diseased lobes(s) occurring during resection have never been mentioned in the literature. This study aimed to verify the injury in cases after lobectomy and wedge resection. METHODS: Data from eighteen patients who underwent lobectomy or wedge resection for malignant tumor between January 2003 and January 2004 were collected. All patients had pre- and postoperative examinations of alveolar-capillary membrane (A/C) permeability using 99m TC-DPTA radioaerosol. RESULTS: Ten lobectomies and eight wedge resection were performed. Using the paired t-test with each patient's pre-operative A/C permeability as his own control data, the postoperative A/C permeability of the ipsilateral non-diseased lobe(s) was found to be significantly increased. The degree of increase in the lobectomy group was the same as that in the wedge resection group. However, no significant change was found on the contralateral side in both groups. CONCLUSION: The degree of increase of permeability was the same in both groups, indicating that the effects of stretch on the surviving lung are not a contributing factor to the change in A/C permeability. The mechanical injuries during the pulmonary surgical procedure alter the permeability, which could be a possible factor causing postoperative pulmonary complications.

The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases.

BACKGROUND: Compensatory hyperhidrosis is the most troublesome side effect and the leading cause of regret with sympathetic surgery. A new classification is proposed to make the procedure more selective and to minimize the side effects and regret rate. Also, a proposed mechanism for compensatory hyperhidrosis is discussed. METHODS: Between January 2002 and July 2003, 464 patients with various sympathetic disorders underwent thoracoscopic sympathectomy/sympathicotomy (ETS) or sympathetic block by clipping (ESB) at various levels according to the authors' classification. The surgery was performed on an outpatient basis. The rates of success, compensatory hyperhidrosis, and regret were recorded. RESULTS: All the patients were followed up for 17 to 35 months. All excessive sweating was effectively stopped to varying degrees. The 25 patients with palmar hyperhidrosis who insisted on receiving ETS of T4 experienced no compensatory hyperhidrosis. Of the 54 patients with facial blushing who received ESB of T2, 23 experienced compensatory hyperhidrosis. Nine patients expressed regret and requested removal of the clips. Of the 33 patients with craniofacial hyperhidrosis who received ESB of T3, 9 experienced compensatory hyperhidrosis. Three expressed regret, and reverse procedures were performed. For 324 patients with palmar hyperhidrosis receiving ESB of T4, no compensatory hyperhidrosis was found. Only two expressed regret because of discomfort. No compensatory hyperhidrosis or regret was noted with 28 patients who received ESB of T5 for axillary sweating. There was no recurrence in the entire series. CONCLUSIONS: Different procedures are recommended for different sympathetic disorders according to the classification. The higher the level of sympathetic ganglion blockade, the higher is the regret rate. Therefore, for T2 and T3 ganglion, endoscopic thoracic sympathetic block by the clipping method is strongly recommended because of its reversibility.

Alveolar-capillary membrane permeability for early prediction of response of inhaled steroid on patients with chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVE: Glucocorticosteroid reversibility-testing is undertaken over a period of 3 months to identify whether patients with chronic obstructive pulmonary disease (COPD) would benefit from long-term inhaled corticosteroids. This study assessed whether alveolar-capillary membrane (a/c) permeability testing can be used as an early alternative test method for the same purpose. METHODS: Fourteen patients with severe and symptomatic moderate COPD (group S) were prescribed inhaled steroid 800 microg/day for 3 months. Before inhalation and 4 weeks after inhalation therapy, forced expiratory volume in 1 s (FEV(1)) and a/c permeability using (99m)Tc-DTPA were performed. FEV(1) was recorded again at the end of the third month. Another 10 patients with COPD of comparable severity (group B) prescribed with inhaled bronchodilators were examined and studied as controls. RESULTS: In group S, the permeability decreased in eight patients (group D) and increased in six patients (group I). No significant change was noted in FEV(1) at the end of the first month. However, seven patients in group D showed significant improvement in FEV(1) at the end of the third month, whereas in patients in group I no significant changes were observed. In group B, no significant change in a/c permeability was observed, although the FEV(1) increased by 12-17%. CONCLUSION: With steroid inhalation, the a/c permeability at 4 weeks predicts future changes in lung functions. Long-term inhaled corticosteroids are likely to be useful if permeability decreases. This test, which needs further validation, appears to provide much earlier prediction of response than glucocorticoid reversibility testing.

Interaction between cigarette, alcohol and betel nut use on esophageal cancer risk in Taiwan.

OBJECTIVE: In 2003 esophageal cancer was the sixth leading cause of death among men in Taiwan, but it is the fastest increasing (70%) alimentary tract cancer. The aim of this study was to investigate the impact of different habits of betel nut chewing on esophageal squamous cell carcinoma (SCC) and its interaction with cigarette use and alcohol consumption. MATERIALS AND METHODS: All 165 cases were pathologically proven esophageal SCC patients (all male, mean age = 56.0, range = 35-92 years) diagnosed by biopsy during gastroendoscopic examinations. The control group comprised 255 subjects (all male, mean age = 54.8, range = 40-92 years) selected from patients who had visited the Otolaryngology Outpatient or Inpatient Department of KMUH owing to a benign lesion over this field. All were interviewed to collect demographic and substance use information by a trained interviewer using a standardized questionnaire. RESULTS: Smoking (aOR = 5.4, 95% CI = 2.4-12.9, PAR = 72%), alcoholic beverage drinking (aOR = 17.6, 95% CI = 9.3-35.2, PAR = 76%) and low education level are independent risk factors for esophageal cancer. Although betel nut chewers only had a borderline significant higher risk than nonchewers (aOR = 1.7; 95% CI = 0.8-3.1), those who chewed with a piece of betel inflorescence (aOR = 4.2, 95% CI = 1.4-16.0) and swallow betel-quid juice (aOR = 3.3, 95% CI = 1.3-9.3) had a significant higher risk. Significant dose-response effects were found in daily quantity of drinking and smoking. There is a synergistic effect of these three substances on the development of esophageal cancer. CONCLUSION: Betel nut chewing plays a relevant role in the development of esophageal SCC but adds to the carcinogenetic effect of smoking and alcohol drinking. Direct mucosal contact of betel juice may contribute to its carcinogenesis.

Bilateral video-assisted thoracoscopic thymectomy vs. extended transsternal thymectomy in myasthenia gravis: a prospective study.

The optimal approach to thymectomy remains controversial. This study is designed to prospectively compare the results between bilateral video-assisted thoracoscopic thymectomy (BVTx) and extended transsternal thymectomy (ETTx) in patients with myasthenia gravis (MG) without thymoma. Fifteen patients who had undergone BVTx and 16 patients who had undergone ETTx were compared for age, gender, severity of disease, preoperative duration of disease, operative time, intraoperative blood loss, postoperative complications, hospital stay, duration of chest tube drainage, thymic histopathology, pain perception by visual analog scale (VAS), remission and improvement rate, period of follow-up, and activities of daily living (ADL). Fisher's exact test, t test and paired t test were used for statistical analysis. BVTx had longer operative time and less intraoperative blood loss than that of the ETTx. Their remission rates and their degree of postoperative ADL improvement were not significantly different. However, the lowering of VAS was significantly greater in the sternotomy group at 3 months. All other parameters were not significantly different. No mortality was noted in the series. We consider BVTx as an effective alternative procedure to the transsternal approach for patients with nonthymomatous MG. As more and more people care about cosmetics, BVTx could become the future trend.

Video-assisted thoracic surgery is minimally invasive, but is it less traumatic?

BACKGROUND: Video-assisted thoracic surgery (VATS) is a minimally invasive procedure. This study aimed to evaluate whether the procedure is less traumatic to the ipsilateral non-diseased lobe(s) than open thoracotomy (OT) during pulmonary resection by a comparison of alveolar-capillary membrane (A/C) permeability. METHODS: Wedge resections were performed in twenty-seven patients with various types of primary and secondary malignant, solitary, pulmonary nodules. Fifteen patients had OT, while 12 patients had VATS. (99 m)Tc-DTPA radioaerosol studies were performed on the day before surgery and on the third or fourth day postoperatively. The images of the ipsilateral non-diseased lobe(s) were compared. RESULTS: Postoperatively, all patients had significantly increased A/C permeability at the ipsilateral non-diseased lobe(s). However, the degree of increase in the VATS group was the same as that of the OT group. Postoperative A/C permeability of the contralateral lung was not significantly different. CONCLUSIONS: Both procedures caused injury to the ipsilateral non-diseased lobe(s) in terms of A/C permeability at the same degree. Although VATS has been considered as a minimally invasive procedure, the trauma caused by VATS to the "disease-free lung" is the same as that caused by open thoracotomy.

Color Doppler ultrasound detection and classification of the tangential hepatic vein before laparoscopic cholecystectomy.

BACKGROUND: Unexpected fatal bleeding from the gallbladder bed during laparoscopic cholecystectomy is often associated with injury to the middle hepatic vein. This paper studies whether preoperative color Doppler ultrasound is effective in reducing the risk of injury. Also a venous classification is suggested. METHODS: Between June 1999 and February 2004, 2,146 patients undergoing laparoscopic cholecystectomy by standard method received preoperative color Doppler ultrasound examinations. The closest distance between the hepatic vein and the gallbladder was studied. Also, cases of liver cirrhosis, number of conversions to open cholecystectomy, intraoperative blood loss, operative time, complications, and hospital stay were recorded (group D). At the end of the study, we retrospectively reviewed the same parameter of another 2,146 patients who received laparoscopic cholecystectomy without preoperative color Doppler ultrasound between the period of March 1995 and June 1999 (group ND). RESULTS: In group D, 108 patients had cirrhosis. Four hundred and ninety-six patients (27 cases of cirrhosis) had a closest distance of 1 mm or less between the vein and the gallbladder. There were two conversions to open cholecystectomy, but none related to gallbladder bed bleeding. In group ND, there were five conversions, including four cases of gallbladder bed bleeding from the middle hepatic vein and one case of severe adhesion. The conversion rate was significantly higher. In group ND, the mean intraoperative blood loss in the cases of liver cirrhosis was significantly greater. Also, the operative time of patients with the closest vein and gallbladder distance of 1 mm or less in group D was significantly longer. CONCLUSIONS: Color Doppler ultrasound is an effective method for detecting the presence of potential bleeders. Although the operative time will be a bit longer, the operation can be done under meticulous care and complete preparation, so that the conversion rate and the risk of fatal hemorrhage can be reduced, especially in patients with liver cirrhosis.

Thoracoscopic decortication: first-line therapy for pediatric empyema.

Video-assisted thoracoscopic surgery (VATS) has become a popular and well-refined procedure. It has several advantages over open thoracotomy in terms of invasiveness and cosmetics. The aim of this study is to consider if VATS can serve as primary management for pediatric empyema. Between October 2000 and December 2002, 13 children with empyema receiving VATS were retrospectively reviewed. Of them, 5 had tube thoracostomy before VATS intervention (group T), and 8 had VATS as the initial treatment (group V). Their mean (+/- SD) age of groups V and T were 5.75 +/- 4.43 and 4.0 +/- 1.58 years, respectively. The children of group V had a shorter length of hospital stay (group V 10.7 +/- 3.54 days; group T 28.2 +/- 8.32 days), a shorter period of chest tube drainage (group V 5 +/- 1.87 days; group T 25 +/- 11.08 days), less transfusion (group V 0.4 +/- 0.17 units; group T 0.9 +/- 0.27 units) and less radiation exposure (group V 10.3 +/- 3.49; group T 23.4 +/- 11.64). No mortality was noted in the entire series. We conclude that primary VATS is a safe, effective and definitive method which can serve as first-line therapy for children with empyema.

Constituents of areca chewing related to esophageal cancer risk in Taiwanese men.

Two most common types of areca chewing are noted in Taiwan: raw betel fruit with Piper betle inflorescence or folded in betel leaf. Piper betle inflorescence contains carcinogens, whereas betel leaf includes anticarcinogenic agents. One hundred and twenty-six esophageal squamous-cell-carcinoma patients and 279 healthy controls, all men, were analyzed. Areca chewers were 4.4 times (95% CI, 2.2-8.8) more likely to develop esophageal cancer than non-chewers. Sixty-five of the patients were areca chewers, of which, 61 (93.9%) chewed areca with Piper betle inflorescence, none chewed it with betel leaf and four (6.1%) chewed both. Of the 24 controls who were chewers, 10 (41.7%), three (12.5%) and 11 (45.8%) chewed areca with Piper betle inflorescence, betel leaf, and both, respectively. Multivariate analysis showed that subjects who chewed areca with Piper betle inflorescence were 24.4 times (95% CI 3.9-154.4) more likely to develop esophageal cancer than those who chewed areca with betel leaf or with both leaf and inflorescence. Our epidemiologic findings suggest parts of the same Piper plant contains carcinogenic and anticarcinogenic substances.

Fiber-optic bronchoscopic classification of inhalation injury: prediction of acute lung injury.

BACKGROUND: Fiber-optic bronchoscopy is widely used for the early diagnosis of inhalation injury. However, there is no current bronchoscopic classification of inhalation injury for the prediction of acute lung injury (ALI). Our goal was to devise such a classification. METHODS: Between February 1993 and January 2002, 167 patients with highly suspicious inhalation injuries were collected. All patients received fiber-optic bronchoscopy within 24 h after their accident. In total, 108 patients were diagnosed as positive under direct inspection. The patients were divided into three groups (G(1), G(2), and G(3)) according to the depth of mucosal damage. Six patients were found to be positive by biopsy and were assigned to group Gb. Of these 114 positive cases, 27 developed ALI. Meanwhile, 53 patients were diagnosed as negative; these patients were assigned to group G(0). RESULTS: After analysis, the following results were noted: G(0) (n = 53), two ALI (3.8%); G(1) (n = 49), two ALI (4%); G(2) (n = 46), 15 ALI (33%); G(3)(n = 13),10 ALI (77%); Gb (n = 6), no ALI. We discovered that the deeper the mucosal injuries, the higher the rate of ALI. There were no deaths related to the procedure. CONCLUSIONS: Fiber-optic bronchoscopy is a safe and effective method for the early diagnosis of inhalation injuries. Also, it is a good predictor of ALL. We hope that in the near future, this classification will serve as a treatment guideline for the early prevention of ALI. The more severe the damage, the more alert clinicians need to be to improve the patient's chances for survival.

Relationship between site of oesophageal cancer and areca chewing and smoking in Taiwan.

Among 309 male patients, those who had heavily consumed betel and tobacco were more likely than nonchewers (OR=2.91; 95% CI=1.36-6.25) and nonsmokers (OR=2.49; 95% CI=1.02-6.08) to develop cancer in the upper and middle third of the oesophagus, respectively; the effects of alcohol did not dominate in any third.

Genetic polymorphisms of cytochrome P4501A1 and oesophageal squamous-cell carcinoma in Taiwan.

Several in vitro studies have demonstrated that genetic polymorphisms result in functionally significant changes in cytochrome p4501A1 (either CYP1A1 MspI or exon 7) but the few epidemiologic studies of these polymorphisms in oesophageal squamous-cell carcinoma have been inconclusive. These inconclusive results motivated us to further examine the relationship between CYP1A1 MspI and exon 7 polymorphisms and risk of oesophageal cancer. In total, 146 cases of oesophageal squamous-cell-carcinoma and 324 control cases (a total of 470 cases) were genotyped from records at three Taiwan hospitals. No significant association was noted for the CYP1A1 MspI polymorphism variable between carcinoma and control cases. In contrast, the frequency of Ile/Ile, Ile/Val, and Val/Val in exon 7 was 68 (46.6%), 62 (42.5%), and 16 (11.0%) in carcinoma cases and 179 (55.3%), 127 (39.2%), and 18 (5.6%) in control cases, respectively. After factoring out other potential contributing factors, patients with Val/Val showed a 2.48 (95% CT=1.15-5.34) greater risk of developing oesophageal cancer than those with Ile/Ile. A slightly (albeit not significantly) greater risk was identified in subjects with Ile/Val (OR=1.34; 95% CI=0.86-2.07). These findings suggest that an exon 7 polymorphism, not a MspI polymorphism, in CYP1A1 may be pivotal in the development of oesophageal cancer.

Video-assisted thoracoscopic sympathetic ramicotomy for hyperhidrosis--a way to reduce the complications.

Endoscopic resectional surgery of sympathetic nerves is now the most acceptable method to treat palmar hyperhidrosis, though the resection of the sympathetic trunk and ganglia can result in the irreversible compensatory hyperhidrosis. The ideal way to treat the palmar hyperhidrosis, without the undesirable complication of the compensatory hyperhidrosis, is still pending. We adapt endoscopic cutting of the second and third sympathetic rami without injury to the sympathetic ganglia and trunk, and find that it is a good way to reduce the complications. Most importantly, it has a cure rate comparable with the conventional technique. The longer operation time and the higher operation risk are the drawbacks.

Video-assisted thoracoscopic management of mediastinal tumors.

BACKGROUND: Many successful attempts at removing benign mediastinal tumors with the video-assisted thoracoscopic technique have been reported, but no formal report has been published regarding malignant mediastinal tumors treated with this technique. We report our preliminary experience with video-assisted thoracoscopic removal of mediastinal tumors, benign or malignant. METHODS: Seven patients with mediastinal tumors treated with video-assisted thoracoscopic surgery were reviewed from January 1999 to April 2000. Their tumor pathologies included benign or malignant thymoma, neurilemmoma, and teratoma. RESULTS: The mean operation time was 240 minutes. The mean blood loss was 173 mL. The mean insertion time of chest tubes was 3 days. The mean admission time was 6 days. No deaths occurred during the study. Morbidity occurred in 2 patients. No tumor recurrence has been seen during the mean follow-up of 7 months. CONCLUSIONS: The short-term results support the feasibility of VATS in managing technically resectable mediastinal tumors. Yet the long-term prognosis for the malignant lesions is deferred and needs further study.

Risk of betel chewing for oesophageal cancer in Taiwan.

Among 104 cases of squamous-cell oesophageal carcinoma patients and 277 controls in Taiwan, after adjusting for cigarette smoking, alcohol consumption, and other confounders, we found that subjects who chewed from 1 to 495 betel-year and more than 495 betel-years (about 20 betel quid per day for 20 years) had 3.6-fold (95% Cl = 1.3-10.1) and 9.2-fold risk (95% Cl = 1.8-46.7), respectively, of developing oesophageal cancer, compared to those who did not chew betel.

The heterogeneity in risk factors of lung cancer and the difference of histologic distribution between genders in Taiwan.

OBJECTIVE: The difference in histologic patterns of lung cancer between men and women in Taiwan may be associated with the heterogeneity in causal factors of lung cancer between the sexes. A sex- and age-matched case-control study was designed to investigate such a relationship. METHODS: Cases consisted of 236 male and 291 female incident cases with newly diagnosed and histologically confirmed primary carcinoma of the lung, and were compared to one or two individually matched controls. RESULTS: Cigarette smoking, occupations, and previous tuberculosis history were found to independently correlate with an elevated risk of squamous/small cell carcinoma and adenocarcinoma for male patients. However, there was little difference in the effect of these risk factors except smoking. The use of fume extractors in the kitchen, and the habit of waiting to fry after the fumes were emitted, separately explained the majority of the attributable fraction of female squamous/small cell carcinoma (28.2%) and adenocarcinoma (47.7%). With the exception of a kitchen with fume extractors and a clinical history of tuberculosis, the environmental causal factors of lung cancer were heterogeneous between these two histologic cell groups. CONCLUSIONS: Our results suggested that the causal factors of lung cancer might be specific for the type of tumor concerned. The gender-specific risk factors of lung cancer could partly explain the difference in cell-type distribution between men and women.

Lifetime environmental exposure to tobacco smoke and primary lung cancer of non-smoking Taiwanese women.

BACKGROUND: For a female population with a high lung cancer mortality rate, such as Taiwanese women, who smoke relatively rarely, but live in an environment with high male smoking prevalence, the risk and population burden of lung cancer due to environmental tobacco smoke (ETS) are relatively important. METHODS: An age-matched case-control study was designed to investigate the effects of cumulative environmental exposure to tobacco smoke during childhood and adult life on lung cancer risk among non-smoking women in Taiwan. Information on passive smoking from all possible sources and life periods were obtained from interviews with 268 and 445 lifetime non-smoking cases and controls. Conditional logistic regression and synergism 'S' index were applied to the data to assess the independent and joint effects of passive smoking in different life stages while controlling for possible confounding variables. RESULTS: Risks of contracting lung cancer among women near-distantly exposed to the highest level of ETS in childhood (>20 smoker-years) and in adult life (>40 smoker-years) were 1.8-fold (95% CI: 1.2-2.9) and 2.2-fold (95% CI: 1.4-3.7) higher than that among women being never exposed to ETS, and the two variables accounted for about 37% of tumours in this non-smoking female population. Children were found to be more susceptible to ETS than adults and such early exposure was found to modify the effect of subsequent tobacco smoke exposure in adult life based on an additive interaction model. CONCLUSIONS: Environmental tobacco smoke exposure occurring in childhood potentiates the effect of high doses of exposure in adult life in determining the development of lung cancer. Smoking prohibition would be expected to protect about 37% of non-smoking Taiwanese women against lung cancer.

Chinese food cooking and lung cancer in women nonsmokers.

Cigarette smoking cannot fully explain the epidemiologic characteristics of lung cancer in Taiwanese women, who smoke rarely but have lung cancer relatively often. In a previous study, the authors suspected that exposure to fumes from cooking oils was an important risk factor for lung cancer in Taiwanese women nonsmokers in the Republic of China. In a new case-control study conducted in 1993-1996, they further explored the association of oil fumes with lung cancer in women. Two sets of controls were used concurrently. The subjects were 131 nonsmoking incident cases with newly diagnosed and histologically confirmed primary carcinoma of the lung, 252 hospital controls hospitalized for causes unrelated to diseases of smoking, and 262 community controls; all controls were women nonsmokers matched by age and date of interview. Details on cooking conditions and habits were collected, in addition to other epidemiologic data. Lung cancer risk increased with the number of meals per day to about threefold for women who cooked these meals each day. The risk was also greater if women usually waited until fumes were emitted from the cooking oil before they began cooking (adjusted odds ratios = 2.0-2.6) and if they did not use a fume extractor (adjusted odds ratios = 3.2-12.2). These results suggest that a proportion of lung cancer may be attributable to the habit of waiting until the cooking oil has been heated to a high temperature before cooking the food.

Histopathologic studies of gastric mucosa following gastric substitution in benign and malignant esophageal disease.

Gastric interposition was performed and prospectively studied in 9 patients with esophageal cancer, 1 patient with esophageal neurofibroma and 5 with corrosive esophageal stricture. The postoperative follow-up periods were between 6 to 68 months with a mean of 28.6 months. The subjects were then endoscopically reviewed. Twelve of them were macroscopically normal. The others exhibited signs of inflammation and hyperemia. Mucosal biopsies were obtained at the upper and lower third of the graft. The histologic findings were compared with those of the preoperative specimens. Among the 15 post-operative specimens, only minute histologic changes were seen. Three patients whose proximal grafts showed inflammatory signs revealed congestion. Another 2 patients exhibited granulocyte infiltration in the mucosa of the distal third. The mucosal structure of the remaining 10 patients was similar to that of the preoperative graft. In conclusion, the macroscopic and microscopic changes were few and minimal although there were alterations in function, physiology and location of the stomach.

Spontaneous haemothorax: an unusual presentation of primary lung cancer.

An unusual case of spontaneous haemothorax caused by a subpleural primary lung cancer is reported. Tumour invasion of the pulmonary vessels and visceral pleura was the possible cause.