Impact of EBUS-TBNA on modalities for tissue acquisition in patients with lung cancer.

BACKGROUND: The impact of the introduction of Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) on the use of diagnostic modalities for tissue acquisition in patients with lung cancer is unknown. METHODS: A retrospective review of 328 consecutive patients diagnosed with lung cancer at a university teaching hospital, where they first presented in London in 2007, 2009 and 2011. EBUS was introduced in 2008. RESULTS: In total, 316 patients were included in the analysis. Comparing 2007 with 2011 data, there has been a significant reduction in standard bronchoscopy (P < 0.0001) and mediastinoscopy (P = 0.02). The proportion of cases diagnosed by EBUS-TBNA significantly increased from 0% in 2007 to 26.7% in 2009 and 25.4% in 2011 (P < 0.0001). In the same period there has also been an increased trend in the proportion of patients going directly to surgery without pathological confirmation with a 9.6% increase in diagnoses obtained at thoracotomy (P = 0.0526). CONCLUSION: The use of diagnostic modalities that provide information on diagnosis and staging in a single intervention are increasing. At our hospital, the use of EBUS-TBNA for providing a lung cancer diagnosis is increasing and this has led to a significant reduction in standard bronchoscopies and mediastinoscopies. These changes in practice may have implications for future service provision, training and commissioning.

Parsonnet score is a good predictor of the duration of intensive care unit stay following cardiac surgery.

OBJECTIVE: To investigate the value of the Parsonnet score (PS) in identifying preoperatively patients that are likely to spend < 24 hours on the intensive care unit (ICU) following cardiac surgery. METHOD: Prospectively collected data on 5591 patients were analysed. PS, mortality, the length of stay on the ICU (ICU-LOS), number of patients with clinical evidence of stroke, need for haemofiltration, resternotomy for bleeding, tracheostomy, and use of intra-aortic balloon pump were documented as outcomes. A receiver operating characteristic (ROC) curve constructed using PS as a predictor of ICU stay < 24 hours identified a PS of 10 as the best cut off point that would predict ICU-LOS < 24 hours. The patients were therefore stratified by PS into two groups, those with a PS of 0 to 9 (PS 0-9) and those with a PS of 10 and above (PS 10+). RESULTS: The ROC curve constructed using PS as a predictor of ICU stay < 24 hours had an area under the curve of 0.70 (0.01). The maximum efficiency of the test was at a sensitivity of 0.68. This corresponded to PS 10. The positive predictive value of the test at this score was 90.5%. Patients with PS 0-9 had a mean ICU stay of 1.49 days, while patients with PS 10+ had a mean ICU stay of 2.89 days (p = 0.01). The risk of stroke, use of intra-aortic balloon pump, requirement for haemofiltration, need for tracheostomy, and risk of resternotomy for bleeding were each significantly less in patients with PS 0-9 versus those with a score of PS 10+ (p < 0.01 in all cases). The risk of a single complication was 4.7% (PS 0-9) v 15.2% (PS 10+) (p < 0.01). CONCLUSION: PS is an impartial and objective method of predicting postoperative complications and ICU stay < 24 hours. This is of value in selecting a cohort of patients likely to maintain a smooth flow of patients through the cardiothoracic unit when resources are limited to a few free ICU beds.

Primary esophageal repair for Boerhaave's syndrome.

BACKGROUND: Boerhaave's syndrome is the most sinister cause of esophageal perforation. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. METHODS: We present a series of 21 patients seen in our unit in the 10 years 1987 to 1996. Esophageal repair was performed in 17 (81%) of them. After the resuscitation of the patient in the intensive care unit, our strategy is primary esophageal repair with a single layer of interrupted absorbable sutures combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy. The majority of patients (12/21) were referred more than 24 hours after perforation. RESULTS: The mean age of the patients was 60+/-17 years. The mean stay in the intensive care unit was 1.6+/-1.8 days and the median hospital stay, 14 days. There were three deaths, an overall mortality rate of 14.3%. CONCLUSIONS: When combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy, primary esophageal repair for Boerhaave's syndrome gives an acceptable mortality and should not be reserved for patients seen within 24 hours after spontaneous rupture.

Iatrogenic oesophageal perforations: a clinical review.

Thirty patients with iatrogenically induced perforation of the oesophagus were managed in our unit between January 1986 and December 1996. Thirteen (43%) of these injuries were referred after upper gastrointestinal endoscopy performed by physicians. Ten (33%) cases were referred by ENT surgeons and general surgeons referred 7 (23%) cases. Of these patients, 15 (50%) had no abnormality of the oesophagus found before perforation. Only 18 (60%) of patients were referred within 24 h of injury. The mean duration of care required in the intensive care unit was 1.5 days +/- 2.5 days and the mean inpatient hospital stay 26.5 days +/- 22.1 days. The mortality was 10% (three cases). Oesophageal perforation remains a serious life-threatening injury. The early diagnosis of this uncommon condition requires a high index of suspicion as the symptoms are often non-specific. Identification of the site of perforation is necessary as the management of cervical and thoracic perforations differs considerably. Early referral combined with appropriate therapy would appear to result in a better outcome than previously published data. It is therefore suggested that patients with this relatively rare condition should be referred as soon as possible to a centre with expertise in its management.

Thoracoscopic debridement of empyema thoracis.

BACKGROUND: The primary treatment of empyema thoracis remains intercostal tube drainage together with antibiotics. Failure of primary treatment has until recently been an indication for thoracotomy and decortication. Video-assisted thoracoscopic debridement (VATD) has increased the available treatment options but requires validation. METHODS: A retrospective analysis was undertaken of 44 consecutive patients who presented for surgical treatment of empyema thoracis over a 3-year period. RESULTS: Two patients were unsuitable for VATD and were treated with open decortication (OD). Thirty patients were successfully treated by VATD. Two patients were converted to OD at the first operation, and 10 patients required OD as a second procedure. The mean duration of preoperative symptoms before referral was 37.6 +/- 11.8 days (VATD) and 40.1 +/- 11.6 days (OD) (p = not significant). The mean duration of hospitalization before transfer was 13.7 +/- 2.4 days (VATD) and 11.5 +/- 3.4 days (OD) (p = not significant). Intercostal drainage was required for 4.0 +/- 0.3 days (VATD) and 8.5 +/- 2.0 days (OD) (p = 0.004). The postoperative hospital stay was 5.3 +/- 0.4 days (VATD) and 10.3 +/- 2.1 days (OD) (p = 0.001). CONCLUSIONS: Primary surgical therapy with VATD should be considered for all patients with pleural empyema, irrespective of the duration of symptoms. This approach does not preclude OD as a secondary procedure or conversion to OD after initial thoracoscopic assessment. The major advantages of VATD over OD are a shorter duration of postoperative intercostal drainage and reduced postoperative hospitalization.

Homograft as a conduit for superior vena cava syndrome.

This report outlines the management of a 30-year-old man with severe multiresistant mycobacterium tuberculosis of his right lung. Despite medical therapy he had open tuberculosis with positive sputum smears. A right pneumonectomy was undertaken, but due to distorted hilar anatomy, the superior vena cava was resected. Postoperatively, superior vena cava syndrome developed and failure of venous drainage was demonstrated by bilateral arum venography and computed tomographic scanning. The superior vena cava syndrome was successfully relieved using an aortic homograft as a superior vena cava replacement instead of a spiral vein graft or a prosthetic conduit.

Effect of cardiopulmonary bypass perfusion protocols on gut tissue oxygenation and blood flow.

BACKGROUND: Previous studies in patients undergoing cardiopulmonary bypass (CPB) have documented gastric mucosal hypoperfusion and hypoxia. This study examines the influence of the CPB protocol on the adequacy of gut blood flow and oxygenation. METHODS: Twenty-four patients were prospectively randomized into one of four CPB groups: nonpulsatile hypothermic (NP 28); pulsatile hypothermic (P 28); non-pulsatile normothermic (NP 37); and pulsatile normothermic (P 37). Gastric wall blood flow was assessed using laser Doppler flow measurement and gastric mucosal oxygenation (intramucosal pH), using tonometry. RESULTS: After 10 minutes of CPB, the NP 28 group had the greatest reduction in gastric wall blood flow (-60.6% +/- 3.8%) compared with baseline (p < 0.05). Thirty minutes into CPB, the P 37 group had less gastric mucosal hypoperfusion (-9.7% +/- 10.3%) than the NP 28 patients (-53.0% +/- 8.6%; p < 0.05). All groups showed a hyperemic response immediately after CPB. No significant differences between the four groups were found for gastric mucosal oxygenation during or after CPB. A progressive decline occurred in this variable during the period 3 to 4 hours after CPB. At this time, total-body oxygen consumption and extraction were at their maximum. CONCLUSIONS: This study found that perfusion protocol can influence mucosal blood flow, but other overriding factors that operate during and after CPB act to cause mucosal hypoxia. These findings, particularly the timing of mucosal hypoxia, may have implications for centers contemplating early extubation or "fast tracking" of patients after CPB.

Forty-five-degree two-stage venous cannula: advantages over standard two-stage venous cannulation.

We present a 45-degree two-stage venous cannula that confers advantage to the surgeon using cardiopulmonary bypass. This cannula exits the mediastinum under the transverse bar of the sternal retractor, leaving the rostral end of the sternal incision free of apparatus. It allows for lifting of the heart with minimal effect on venous return and does not interfere with the radially laid out sutures of an aortic valve replacement using an interrupted suture technique.