Kyphoscoliosis and bronchial torsion.

STUDY OBJECTIVE: Severe idiopathic scoliosis is associated with respiratory failure. This usually is secondary to restrictive airway disease and reduced vital capacity. Patients may also suffer from an increase in airway resistance when severe kyphoscoliosis is present. SETTING: Three patients (two of whom required assisted ventilation) with varying degrees of kyphoscoliosis presented with moderate to severe breathing difficulties. INTERVENTION: Bronchoscopic examination of these patients showed evidence of torsion with secondary obstruction of the central airways. RESULTS: The airway obstruction was notable for its slit-like appearance, for the normality of the mucosa at the site of the obstruction, for the relative ease through which an instrument could traverse the obstruction, and once the retained secretions had been cleared, for the preservation of normal anatomy of the distal airways. The insertion of metal prostheses to stent the areas of obstruction prompted an impressive improvement in respiratory status, radiologic findings, and spirometric criteria in each case. Improvement has been maintained over a maximum follow-up period of 4 years. CONCLUSION: Severe kyphoscoliosis can lead to bronchial torsion and obstruction of the central airways. Patients should be assessed by bronchoscopy to exclude this deformity or any other cause of obstruction. The use of a metal endobronchial stent has been effective in both the immediate and long-term period.

Pneumothorax in AIDS: case reviews and proposed clinical management.

BACKGROUND: Pneumothorax is a not uncommon complication of advanced HIV infection, and may prove difficult to manage in view of its recalcitrant and recurrent nature. In this group where immunosuppression and reduced life expectancy are a feature, standard protocols are often abandoned in favour of a more conservative approach. This is often unsuccessful. METHODS: Patients attending the Department of Genitourinary Medicine, Chelsea and Westminster Hospital who sustained pneumothorax between 1988 and 1992 were identified retrospectively and their notes reviewed. RESULTS: Fifteen patients were identified of whom three had post-procedural pneumothoraces. In the remaining 12 patients, 10 had previously had Pneumocystic carinii pneumonia (PCP), whilst all 12 had some evidence to suggest current PCP (seven proven, five presumptive). In those six patients with a single, unilateral pneumothorax, four were managed successfully with intercostal drainage alone (one patient died early, one required pleurectomy). In those with recurrent pneumothoraces or pneumothoraces that did not respond to prolonged intercostal drainage, failure of medical treatment was judged to have occurred and surgery was performed. Overall, conservative management failed in 7/11 patients. Conversely surgery resulted in resolution in 7/7 with recurrence seen in one individual. Median survival was similar in the two groups. CONCLUSIONS: Pneumothorax in patients with AIDS is associated with a high rate of intercurrent PCP; a low threshold for treating this infection presumptively is indicated. Intercostal drainage was successful in patients with a single, unilateral pneumothorax. However, in patients with recurrent or bilateral pneumothorax extended periods on intercostal drainage were uniformly unsuccessful. Early surgical referral should be considered in this group.

Alternatives to allogeneic blood use in surgery: acute normovolemic hemodilution and preoperative autologous donation.

Acute normovolemic hemodilution (ANH) is a common blood conservation strategy in elective surgical procedures. Moderate ANH is safe in patients > 60 years of age; ANH is not recommended for patients who have coronary artery disease, significant anemia, renal disease, severe hepatic disease, pulmonary emphysema, or obstructive lung disease. Preservation of oxygen delivery during ANH depends on the maintenance of normovolemia to avoid decompensation and falling cardiac output. Preoperative autologous donation (PAD) as a blood conservation strategy has the advantage of protecting the patient from risks associated with allogenic transfusion, but it is expensive and time consuming. No protocols have established a preference for either ANH or PAD; an early study suggested that ANH is less expensive and more effectively preserves blood components, but other researchers warn that the methodology for ANH remains unresolved.

Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Distal circulatory support for thoracic aortic operations: effects on intracranial pressure.

Spinal cord ischemia can result from aortic clamping during thoracic aortic operations. The perfusion gradient for spinal cord perfusion is positively influenced by distal aortic pressure and negatively influenced by intracranial pressure (ICP). Hemodynamic and ICP changes were examined in a swine model of descending thoracic aortic surgery where distal aortic perfusion was achieved under one of three conditions: (1) clamping without support, (2) a passive aortofemoral shunt, or (3) a left atrium-femoral artery bypass system. With aortic clamping alone, ICP increased from 9.8 +/- 2.2 mm Hg to 15.2 +/- 2.8 mm Hg (p < 0.05). With passive shunting, ICP was decreased to 13.8 +/- 3.0 mm Hg, which was still significantly elevated above baseline. However, with active bypass, ICP remained at control level (9.8 +/- 2.2 mm Hg). Mean distal aortic pressure, which was 82 +/- 10 mm Hg in the control state, decreased to 20 +/- 0.5 mm Hg with clamping alone and to 39 +/- 9 mm Hg with passive shunting, whereas with active support, a distal pressure of 64 +/- 8 mm Hg was achieved. In contrast to passive shunting, active distal bypass results in maintenance of ICP at baseline levels and results in distal aortic pressure significantly greater than that achieved with either aortic clamping alone or passive shunting. Thus, active distal circulatory support produces the greatest salutary effect on the two determinants of the spinal cord perfusion pressure gradient: ICP and distal aortic pressure. This support modality may be the best adjunctive technique to maintain the spinal cord perfusion gradient and hence minimize the risk of ischemic injury.

The non-functioning pleuro-peritoneal shunt: revise or replace?

Pleural malignancy commonly leads to troublesome and recurrent effusion. Cure is not possible and effective palliation is important for the 2-3 months median survival following diagnosis. We have previously emphasised the role of pleuro-peritoneal shunts (PPS) in this situation. A number of shunts (11%) malfunction and we have revised our policy as to how best to deal with this problem. We studied our 70 patients who required the insertion of 71 PPS over seven years: there were 8 cases (11%) of non-functioning shunts necessitating re-exploration. In two cases the shunt was blocked due to infection which may have been present prior to insertion of the shunt. In these cases the shunt was removed and drainage was performed. In one shunt non-function was due to obstruction of the pleural limb and it was re-positioned successfully. The remaining five shunts were found to be blocked by fibrinous tissue. Replacement of two of these led to a functioning shunt until the death of the patients, while the three shunts which were revised failed to function. One shunt became infected and was removed and the other two became blocked again. Following subsequent replacement the function was restored until the death of the two patients. We conclude that non-functioning pleuro-peritoneal shunts should be replaced rather than revised to avoid subsequent complications.

Review of blood transfusion practices in thoracic surgery.

Between September 1, 1989, and August 31, 1990, 516 patients were admitted to the Royal Brompton National Heart and Lung Hospital for thoracic operations. A prospective audit recorded the nature and extent of operation, the histologic diagnosis, and the number of units of blood prepared and transfused during hospitalization. Cross-matched blood was requested in 243 patients but only 16.1% of these received transfusion. In total, 1,295 units of whole blood or red cell concentrate were cross-matched and made immediately available in the operating suite at the time of operation. Only 322 units were administered (cross-match to transfusion ratio of 4.02:1). Almost half of the patients who received transfusions received 2 units or less, a third received 3 or 4 units, 10% between 5 and 10 units, and 8.4% required more than 10 units during their hospital stay. The nature and extent of resection was an indicator of the need for transfusion. Other important predisposing factors included a previous thoracic operation, resection for inflammatory disease, decortication of empyema thoracis, chest wall resection, or thoracoplasty. Other thoracic procedures such as pleurodesis, pleurectomy, open lung biopsy, pectus correction, operation for bullous lung disease, and mediastinoscopy had a negligible transfusion requirement. The data suggest that understanding risk factors for transfusion requirements of patients undergoing thoracic surgical procedures should optimize present resources. This is critical when exploiting the limited availability of donated blood and blood products. Similarly, anticipation of transfusion requirements takes best advantage of manpower within the blood bank and minimizes unnecessary and avoidable blood wastage and expenditure.

Surgical management of non-small-cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease).

Between 1979 and 1989, 876 patients with non-small-cell lung carcinoma were referred to our unit for surgical treatment. One hundred forty-six patients were judged not suitable for surgical treatment on clinical, radiologic, or bronchoscopic findings. Cervical mediastinoscopy or anterior mediastinotomy (or both) showed that 151 patients had mediastinal involvement by invasion or metastases into the ipsilateral (N2 disease) or contralateral (N3 disease) superior mediastinal lymph nodes and were therefore deemed inoperable. Except for one patient who had involvement of a single nodal station at mediastinoscopy, all other patients (n = 578) undergoing thoracotomy were thought, on the basis of computed tomographic scan or mediastinal exploration (or both) not to have N2 disease. Despite our efforts to avoid surgery on patients with N2 disease, at thoracotomy routine mediastinal node dissection disclosed that 149 patients had unsuspected N2 disease. Resection was possible in 130 (87.3%) by pneumonectomy (n = 72), bilobectomy (n = 7), lobectomy (n = 49), or lesser resection (n = 2). In three patients the resection was incomplete (2.3%), but in 127 a complete resection was performed (85%). Histologic examination in these 149 patients showed that 72 tumors were squamous cell carcinoma, 54 adenocarcinoma, 14 large-cell carcinoma, and 9 of mixed type. Eight patients died in the hospital after thoracotomy. Adjuvant therapy was not used after complete resection. Complete follow-up was obtained in 134 patients and the mean follow-up period was 27.25 months (1 to 116 months). The actuarial 5-year survival for those having complete resection was 20.1%. There was a statistically significant difference favoring long-term survival in those patients with squamous cell carcinoma (p < 0.01) and those in whom only one nodal station was involved (p < 0.05). Neither the extent of resection nor the involvement of any specific nodal station influenced long-term survival. Despite rigorous preoperative investigations, routine mediastinal node dissection demonstrated mediastinal node metastasis for the first time at thoracotomy in 26% of our patients. We believe resection is justified in these patients, who have already necessarily incurred the morbidity and mortality of thoracotomy, so long as complete resection is possible.

The significance of pulmonary nodules detected on CT staging for lung cancer.

Small pulmonary nodules of soft tissue density are often found during computed tomography for the staging of lung cancer, but CT cannot reliably distinguish benign from malignant uncalcified pulmonary nodules. The purpose of this study was to assess the significance of pulmonary nodules discovered on staging CT. 551 patients with lung cancer who had a staging CT and who were considered operable were studied. Eighty-eight patients (16%) were found to have small non-calcified pulmonary nodules. Adequate follow-up was possible in 25 patients who had a total of 36 nodules. Twenty-five nodules (70%) were subsequently confirmed to be benign, four (11%) were malignant and the nature of seven (19%) could not be determined. The high prevalence of benign nodules in this population should be taken into account when staging lung cancer.

Use of the Denver pleuroperitoneal shunt in the treatment of chylothorax secondary to filariasis.

A 57 year old woman developed a chylothorax as a result of having had filariasis as a child. This failed to respond to conservative measures but was successfully managed by means of a Denver pleuroperitoneal shunt.

Oesophageal obstruction during nasogastric feeding.

Although complications of enteral feeding are usually minor, we report an unusual and serious case of oesophageal obstruction after feeding with osmolite, a commonly used polymeric enteral feeding preparation. The patient described underwent rigid oesophagoscopy to remove the feed which had solidified and blocked the entire oesophageal lumen. The procedure resulted in oesophageal perforation which needed surgical repair by thoracolaparotomy and was followed by a difficult postoperative course. In vitro tests showed that all commonly used feeds containing casein (osmolite, ensure, ensure plus, paediasure, fortison, and pulmocare) solidified at a pH of less than 5. Clinifeed (containing dried skim milk) and peptamen (containing peptides) remained liquid at a pH of less than 1. Solidified feed could be liquefied by the addition of pepsin or pancrex V (a pancreatic enzyme formulation). We conclude that solidification could occur in all feeds containing casein and that alternative feeds should be considered in patients with increased gastric acidity. In addition, pepsin or pancrex V could be used to liquefy solidified feed.

Esophagogastrectomy via left thoracophrenotomy.

Esophagogastrectomy is generally considered to be the treatment of choice for resectable tumors of the esophagus. Although many approaches and techniques have been advocated, since April 1983 we have used a left thoracophrenotomy approach for most lesions of the lower two thirds of the esophagus and gastric cardia. Stapling instruments have been used for mobilization of the stomach and fashioning of the esophagogastric anastomosis. One-hundred fifteen patients undergoing resection of malignant tumors with this technique were retrospectively reviewed. Perioperative mortality was 8.7% (10/115). The rate of anastomotic leakage was 1.7% (2/115), and benign narrowing of the anastomosis requiring dilation developed in 16 patients. The rate of recurrent anastomotic tumor was 4.3%. Eighteen patients had complications, and the mean postoperative hospital stay was 13 days. Survival at 3 years was 22.1%. During the period of study, 22 patients underwent esophageal resection by some other approach; the reasons for this are described. The advantages of the left thoracophrenotomy approach are discussed.

Recent surgical experience for pulmonary tuberculosis.

Lung resection for pulmonary tuberculosis is unusual today. Over a 10-year-period 31 patients with pulmonary tuberculosis underwent thoracotomy at this Regional Centre. Five of these were for complications of known tuberculosis; two subsequently proved to be complications of pulmonary tuberculosis, and the remainder were for suspected malignancy. The clinical features, radiology, microbiology, and pathology are reviewed and the contemporary role of the surgeon in the management of pulmonary tuberculosis is examined.

Cervical thymectomy in the treatment of myasthenia gravis.

Treatment modalities in myasthenia gravis consist of surgery, chemotherapy and plasmapheresis. Thymectomy can be accomplished either through a median sternotomy or through a small, transverse cervical incision. Forty patients who underwent cervical thymectomy for non-thymomatous myasthenia gravis were studied retrospectively. Twenty-six patients (65%) showed a favourable response to thymectomy and there were statistically significant improvements in myasthenic symptoms and reductions in medication requirements. Age, sex, duration of symptoms and thymic histology were not predictive of response to thymectomy. Operative mortality was zero and operative morbidity was minimal. During the last 6 years, only two of 22 patients required admission to the intensive care unit postoperatively. The postoperative hospital stay ranged from 2 to 23 days. Cervical thymectomy does not preclude later sternotomy in those patients who fail to respond favourably. We therefore recommend cervical thymectomy as the initial surgical procedure in the treatment of non-thymomatous myasthenia gravis.

Anastomotic narrowing after esophagogastrectomy with the EEA stapling device.

We studied a series of 176 patients undergoing esophageal resection with the aid of the EEA surgical stapling device (Auto Suture U.K. Limited, Great Britain) during a period of 7 1/2 years. A total of 160 patients (91%) were operated on for malignant disease. Operative death occurred in 15 patients (8.5%), and there were three anastomotic leaks (1.7%). The prevalence of dysphagia caused by both benign and malignant strictures after esophageal resection in which the EEA stapler was used was 17.4%. The rate of benign anastomotic narrowing in discharged patients was 12.5%. Anastomotic stricture resulting from recurrent tumor caused dysphagia in 6.2% of the patients undergoing resection for malignant disease. The highest rate of benign anastomotic narrowing occurred in patients who had undergone esophageal resection for benign, nondilatable strictures. In these patients, the prevalence of benign anastomotic narrowing was 37.5%, compared with 9.6% in the patients undergoing resection for malignant disease (p less than 0.001). An additional trend was noted: The smaller the stapling head used to construct the anastomosis, the higher the prevalence of benign anastomotic narrowing; however, a statistically significant difference could not be documented. Ninety-five percent of patients with benign anastomotic narrowings complained of dysphagia within the first 6 months after the operation; 79% of these patients required two or fewer dilatations to relieve the dysphagia. Dysphagia after esophageal resection with the aid of EEA stapler occurred in just over one of six patients. The usual cause of the dysphagia was benign anastomotic narrowing, which responds well to dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

Oesophagogastrectomy in patients over 70.

Although the results of oesophageal resection for benign and malignant disease are well documented, the risk of operative death and long term survival in patients over the age of 70 is not well defined. The outcome has been reviewed for 46 patients (23 male, 23 female) aged 70 years or more (mean 74 years) undergoing oesophageal resection during a period of seven years; 16 patients were 75 years or over. All resections were performed with the EEA stapler, except for one cervical anastomosis that was stitched by hand. In 42 patients resection was for malignancy. Six patients died within 30 days of operation or during the initial hospital stay, giving an operative mortality of 13%. Only one of the 16 patients aged 75 years or more died. Cardiopulmonary complications accounted for most of the operative deaths. Patients were scored retrospectively by a multifactual risk factor. Patients who left hospital had a mean preoperative score of 3.66, compared with 15.2 for those who died. Use of such a score may help to improve selection for surgery in this age group. It is concluded that oesophagogastrectomy may be performed in selected patients over the age of 70 years with acceptable mortality, morbidity, and length of hospital stay.

Carcinoma of the bronchus with unsuspected microscopic resection-line involvement.

In a series of 560 pulmonary resections for bronchial carcinoma, unsuspected microscopic tumor was present at the bronchial resection margin in 26 patients (4.5%). Adjuvant chemotherapy or radiotherapy was given in two patients. In follow-up times ranging from 1 to 72 months (mean, 22 months), 58% of patients were alive and free of recurrent disease. Twelve patients underwent periodic surveillance bronchoscopy in an attempt to identify early local recurrence. Eighty-three percent of these patients were alive and disease-free in follow-up times from 4 to 72 months (mean, 29.7 months). Only one choscopies. It was concluded that microscopic residual resection-line tumor does not preclude prolonged survival and that no benefit from surveillance bronchoscopy could be demonstrated in this small patient sample.