A comparative study of structures comprising the thoracic outlet in 250 human cadavers and 72 surgical cases of thoracic outlet syndrome.

OBJECTIVE: We have hypothesized that variations in fibrous, muscular and osseous structures with the potential to entrap the brachial plexus occur within the thoracic outlet of the normal population; and that these variations are different in pattern and frequency from those in patients presenting with thoracic outlet syndrome (TOS). METHODS: Structural anomalies with potential for entrapping elements of the brachial plexus were examined following dissections of the posterior triangle of the neck in 250 human cadavers (N = 500 thoracic outlet dissections) and catalogued jointly by an anatomist and a thoracic surgeon. The pattern and frequency of anomalies in the 250 cadavers was compared to that encountered in 72 surgical cases of removal of the first rib for relief of symptomatic TOS (N = 72 procedures, 55 patients). RESULTS: Relevant structural variations were encountered in 46% of cadavers, exhibiting no left right or gender preference overall. When compared with the surgical group in which 100% exhibited structurally relevant anomalies, significant differences in pattern of anomalous structures and gender distribution were revealed. Anomalies posterior to the brachial plexus, ranging from fibrous bands to cervical ribs in both groups, were prevalent in the surgical group. A 'scissors-like' pattern, with neural entrapment by anterior and posterior anomalies was frequently encountered in females. CONCLUSIONS: Based on these data and embryological considerations, we propose a revised and simplified classification of impingement mechanisms within the anatomic thoracic outlet. Comparing these data to radiological imaging and observations at surgery, we offer a new perspective for the investigation and management of patients with TOS.

Bilateral rudimentary first ribs as a cause of thoracic outlet syndrome.

First rib abnormalities are an uncommon cause of thoracic outlet syndrome. Cervical ribs are a much more frequent source of thoracic outlet syndrome, and in more than 95% of these patients, the symptoms are neurologic, not vascular. Rudimentary first ribs, however, uncommonly produce exclusively neurologic symptoms and usually manifest with vascular pathology. This article reviews a case of a patient with bilateral extensively neurologic thoracic outlet syndrome symptoms arising from bilateral rudimentary first ribs. The symptoms, pathologic features, and treatment, as well as an algorithm for working up patients with thoracic outlet syndrome, are discussed. Bilateral transaxillary first rib resection was curative in this patient and is the treatment of choice for either neurologic or vascular manifestations of thoracic outlet syndrome associated with rudimentary first ribs.

Gastrointestinal function following esophagectomy for malignancy.

BACKGROUND: The frequency and causes of gastrointestinal complications following esophagectomy for malignancy are unknown. PATIENTS AND METHODS: We reviewed 295 esophagectomies performed for malignancy between January 1980 and September 1994 in order to determine the frequency and causes of early and late gastrointestinal complications. RESULTS: Compared to transhiatal and left thoracoabdominal esophagectomies, esophagectomies carried out through a right posterolateral thoracotomy with cervical esophagogastric anastomosis had a higher incidence of delayed gastric emptying (11%), pneumonia (26%), and hospital death (9%). The same operation had a higher incidence of gastroesophageal reflux (20%) and dysphagia requiring esophageal dilatation (53%). We found no independent effect of gastric drainage procedures, feeding jejunostomy, preoperative radiotherapy, pathology, or age on these outcomes. Women had no operative mortality, but a higher incidence of gastroesophageal reflux and diarrhea following esophagectomy. CONCLUSIONS: Surgical techniques aimed at improving gastric emptying following esophagectomy for cancer should improve operative morbidity and mortality.

Anterior and middle mediastinum paraganglioma: complete resection is the treatment of choice.

Paraganglioma of the mediastinum is described to be an indolent and slow-growing tumor. After a patient presented to our center, we reviewed the world literature to evaluate the prognosis of this tumor. This review showed that paragangliomas are locally invasive and have a high local recurrence rate (44/79 or 55.7%) with a true metastatic capacity (21/79 or 26.6%). The overall survival is 62.0% (49/79), but only 36.7% (29/79) of patients could be considered as free of disease, with survival time of 98.2 +/- 11.7 months (mean +/- standard error). The survival with a complete resection is 84.6% (125.7 +/- 18.7 months) versus 50.0% (71.5 +/- 13.8 months) for patients with a biopsy or a partial excision and adjuvant treatment (p < 0.01). We acknowledge the limitation of this retrospective study, but a prospective trial is not possible because of the rarity of the tumor. We want to emphasize that paraganglioma of the anterior and middle mediastinum is an aggressive tumor, and complete surgical resection, using cardiopulmonary bypass if necessary, is highly recommended.

Detection of dysplasia and carcinoma in situ by ratio fluorometry.

Fluorescence bronchoscopy was performed in 82 volunteers recruited from occupational groups at risk of exposure to asbestos and/or diesel fumes to determine whether differences in tissue autofluorescence between normal and malignant bronchial tissues can be used to improve the sensitivity of standard fiberoptic bronchoscopy in detecting dysplasic and carcinoma in situ (CIS). This study consisted of 25 nonsmokers, 40 exsmokers, and 17 current smokers with mean ages of 52, 55, and 49 yr, respectively. Tissue autofluorescence was induced by a blue light from an He-Cd laser coupled to the illumination channel of the bronchoscope and analyzed by a ratiofluorometer. One or more sites of moderate or severe dysplasia were found in 12% of the exsmokers and current smokers but in none of the nonsmoker volunteers. CIS was found in two of the exsmokers. The sensitivity of fluorescence bronchoscopy (86%) was found to be 50% better than that of conventional white-light bronchoscopy (52%) in detecting dysplasia and CIS. Pre- and post-bronchoscopy sputum cytology failed to detect these precancerous lesions. Our results suggest that fluorescence bronchoscopy may be an important new method that can improve the ability to detect and localize precancerous and/or CIS lesions.

Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases.

We reviewed our experience from 1979 to 1990 with 160 cases of transhiatal esophagectomy for carcinoma of the lower esophagus and cardia to evaluate trends in patient selection, management, and outcome. Patients treated in the past 6 years (n = 110) and those treated before 1985 (n = 50) were similar in terms of age and sex distribution, medical history, and weight loss. The majority of tumors seen were adenocarcinoma, with patients in the latter group having significantly lower stages. Significant decreases in anesthetic time, units of blood transfusions, chest tube insertions, length of postoperative ventilation, incidence of postoperative pneumonia, and length of hospital stay were seen during the past 6 years. Wound infections increased significantly during the same period. The decrease in the 30-day mortality rate from 6% to 0.9% was not significant. Survival rates did not differ between groups, with overall rates of 62%, 40%, and 21% at 1, 2, and 5 years, respectively.

Esophagogastrectomy and the variant left hepatic artery.

A variant left hepatic artery occurs at a rate of approximately 10%. In standard esophagogastrectomy and some proximal gastric operations this variant artery is sacrificed, which has led to reported fatalities secondary to hepatic necrosis. We report our method of esophagogastrectomy in the presence of an aberrant left hepatic artery.

Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.

Following esophagectomy, restoration of swallowing by gastric tube interposition with cervical esophagogastric anastomosis reduces morbidity and mortality associated with intrathoracic anastomoses at the expense of an increased incidence of both anastomotic leak and stricture formation. A retrospective study of 165 patients with either squamous cell carcinoma or adenocarcinoma of the distal esophagus or gastric cardia undergoing esophagogastrectomy with gastric tube interposition and cervical anastomosis at Vancouver, British Columbia, or London, Ontario, was undertaken. Forced-entry multiple logistic regression analysis of factors believed to influence anastomotic outcome was performed. Anastomotic leak occurred in 17% of patients; statistically significant correlation with low preoperative serum albumin (p = 0.005), running suture technique (p = 0.029), high intraoperative blood loss (p = 0.038), and the occurrence of postoperative delayed gastric emptying (p = 0.045) was found. Anastomotic strictures occurred in 31% of patients; a statistically significant correlation was found with preceding anastomotic leak (p = 0.001) and intraoperative blood loss (p = 0.042). Factors including preoperative radiotherapy and diabetes mellitus were not found to be significant.

DNA adducts in bronchial biopsies.

To investigate the feasibility of measuring DNA-carcinogen adducts in the lungs of non-surgical patients, endobronchial biopsies were obtained from 78 patients undergoing routine diagnostic bronchoscopy. Lung cancer was present in 37 (47%) of the patients. DNA was isolated from the tissues and analyzed by HPLC- or nuclease-PI-enriched 32P-postlabelling, using procedures selective for aromatic adducts. Chromatograms from all 28 current smokers showed a distinctive diagonal adduct zone which was present in only 24 of 40 ex-smokers and 4 of 10 lifetime non-smokers. Adduct levels and chromatographic patterns were similar in bronchial tissue from different lobes of the lung, in bronchial and alveolar tissue, and in tumor and non-tumor bronchial tissue taken from the same subject. Bronchial DNA adduct levels were strongly associated with cigarette smoking status and dropped rapidly after smoking ceased. Higher levels of DNA adducts seen in the lung-cancer patients were mainly due to cigarette smoking. Frequent alcohol intake was the only dietary factor associated with higher levels of bronchial DNA adducts. We conclude that the level of bronchial DNA adducts is strongly associated with cigarette-smoking history and with alcohol intake, but is not associated with lung cancer independently from its relation to smoking. The results indicate the feasibility of using 32P-postlabelling to detect and quantitate genetic damage in bronchial biopsy specimens.

Thoracic outlet syndrome. Thoracic surgery perspective.

We have attempted throughout this review to identify the issues surrounding thoracic outlet syndrome as well as to highlight their origins. It should be clear that many aspects of TOS remain controversial from the definition of the entity through pathogenesis, diagnosis, and treatment. The conflicts surrounding TOS are underlined most poignantly in the many letters to the editor of the New England Journal of Medicine in response to Urschel's 1972 publication. It is incumbent upon those of us who treat patients with TOS to dispel the ignorance surrounding this syndrome with astute, accurate, and reproducible observations. We must clearly define TOS as a clinical entity such that we may analyze the characteristics of the patients we treat. We must continue to search for innovative and specific diagnostic criteria. We must quantitatively and reproducibly measure subjective end points of pain severity and quality of life. The use of these methods will provide yardsticks for therapeutic success and act as determinants for the natural history of TOS. The objectives of treatment will remain the alleviation of symptoms and the restoration of function. We have applied these principles to the formulation of a protocol in which we record, in a prospective manner, both routine and innovative clinical parameters. With quantification of subjective end points, we may be able to correlate clinical presentation with outcome. We also may be able to define with some accuracy this entity we call thoracic outlet syndrome.

Chest-wall tumours.

Between August 1984 and October 1988, 7 women and 16 men underwent chest-wall resection. The 23 patients ranged in age from 17 to 79 years. Resection was done for benign lesions in 9 patients, for recurrent chest-wall sarcoma in 4 and for carcinoma involving the chest wall in 10. The number of ribs resected ranged from none to six. Prosthetic material was required for reconstruction in eight patients. There were no operative deaths and no flail segments developed postoperatively. Three patients have since died of metastatic disease, one has died of unrelated causes but with no residual disease and the remainder were alive and well at follow-up intervals ranging from 11 to 60 months. Aggressive resection, including a wide margin of healthy tissue, provides the best chance for recurrence-free survival for patients with many types of chest-wall tumour. Resection can be performed with low morbidity and satisfactory cosmetic results.

Left main bronchial-esophageal fistula: a complication of bronchial artery embolization.

Left bronchial-esophageal fistula is a rare complication of bronchial artery embolization. A case is presented with pathologic correlation. The pathophysiology of this complication is discussed as well as recommendations on how it may possibly be avoided.

Pulmonary capillary blood volume in emphysema.

We determined single breath diffusing capacity (DLCO) and pulmonary capillary blood volume (Vc) in a total of 110 patients, who were being evaluated for resectional lung surgery for a localized tumor or lesion. Pathologic assessment of emphysema was obtained in 55 cases who had resection of a lung or an upper lobe, based on a standard reference panel for emphysema grading. In 86 cases, the extent of emphysema was quantitated by computed tomography (CT) of the chest. There was a significant negative correlation between Vc and emphysema assessed by either pathology or CT (r = about -0.5, p less than 0.001) similar to the correlation between DLCO and the extent of emphysema. Results of Vc were significantly lower in cases with moderate emphysema (pathologic grade greater than or equal to 30) than those with no emphysema (grade less than or equal to 5) (p less than 0.001) or mild emphysema (grade 10 to 25) (p less than 0.05), and they were significantly lower (p less than 0.05) in the group with mild emphysema compared with the group with no emphysema on pathologic assessment similar to DLCO results. Although Vc was reduced in emphysema, determination of Vc did not result in improved discrimination in separating cases with emphysema from those without emphysema when compared with DLCO.

Effect of routine fibrin glue use on the duration of air leaks after lobectomy.

The effectiveness of fibrin glue as a sealant to reduce postoperative air leaks after pulmonary lobectomy was evaluated in 28 consecutive patients between November 1988 and May 1989. A fibrin glue spray was used in 14 patients, and 14 patients served as controls. Assignment of either group was made before thoracotomy. Nine male and 5 female patients with a mean age of 63.8 years were in the fibrin glue experimental group, and 8 male and 6 female patients with a mean age of 59 years, in the control group. An equal number of complete and incomplete fissures were in each group. All fissures were handled in the same way (stapled). Two milliliters of fibrin glue was applied through a double-syringe delivery system and sprayed on the staple line and any cut surface of the inflated lung just before thoracotomy closure. The fibrin glue-treated group had a mean air leak duration of 2.3 +/- 3.7 days, chest tube drains for 6 +/- 4.1 days, and a postoperative hospitalization of 9.8 +/- 3.1 days. The control group had a mean air leak duration of 3.3 +/- 3.3 days (p = 0.94), chest tube drains for 5.9 +/- 3.9 days (p = 0.95), and a postoperative hospitalization of 11.5 +/- 3.9 days (p = 0.21). We conclude that the routine use of a fixed quantity of fibrin glue is not effective in reducing the duration of air leaks, chest tube drainage, or hospitalization after uncomplicated pulmonary lobectomy.

Impact of new radiotherapy modalities on the surgical management of cancer of the esophagus and cardia.

At the Cancer Control Agency of British Columbia, 483 patients with cancer of the esophagus and cardia were seen from 1970-1980. Four hundred and one out of 483 (83%) had tumors larger than 5 cm (T2) and in 288/483 (60%) the disease had extended beyond the esophageal wall (T3). The overall 5-year survival rate was only 9% for all patients treated by external irradiation. The 5-year survival for a selected group having esophagectomy was 20%. Most patients died of persistent cancer at the primary site (83%); the cause of death was aspiration pneumonia (82%) due to obstruction caused by the persistent cancer. Our most recent experience using intracavitary irradiation either prior to or after external irradiation in 211 patients has been safe and simple and preliminary analysis of treatment results suggests that it has improved the therapeutic ratio. The analysis of quality of life at 6 months following therapy as it relates to performance status, swallowing ability, weight, and pain indicated significant improvement in all of these parameters. Of 171 patients, 33% were still alive at 1 year, 26% at 2 years, and 19% at 3 years following treatment. Of 43 patients suitable for preoperative irradiation, only 26 patients were actually resected and 19 of them are still alive with no evidence of disease, 8 to 30 months. The rationale and technical aspects of the combined treatment are described in detail. Treatment results, complications and an outline for future programs based on this experience are also described.

Pathologic findings in total esophagectomy specimens after intracavitary and external-beam radiotherapy.

Pathologic findings in 21 esophagectomy specimens from patients having preoperative combined intracavitary radiotherapy (ICR) and external-beam radiotherapy (EBR) are described. Eleven patients received 1500 cGY ICR and 4000 cGy EBR (Group 1) and ten patients received 1500 cGy plus 2000 to 3000 cGy EBR (Group 2). Effectiveness of radiotherapy was expressed as the ratio between depth of radiation effect and depth of tumor invasion. Depth was expressed as one of four levels: Level I, not deeper than the muscularis mucosa; Level 2, involving but not deeper than submucosa; Level 3, involving but not deeper than muscularis propria; and Level 4, involving periesophageal soft tissue. The depth of radiation damage to tumor cells was comparable between the two groups. However, residual tumor was present in the periesophageal tissue in only one of 11 patients after high-dose EBR compared to of ten patients with lower dose EBR (P less than 0.01, chi-square test). A ratio of one between radiation effect and depth of tumor invasion was present in six patients receiving high-dose EBR and one patient receiving lower dose EBR (P less than 0.05). The authors conclude that ICR combined with EBR affords good local tumor control in the majority of patients. Higher doses of EBR give a better radiation effect in deeper layers of the esophageal wall. The ratio between depth of radiation effect and tumor invasion provides a simple and objective approach to the pathologic analysis of esophagectomy specimens.

Mediastinal lymph node necrosis: a newly recognized complication of mediastinoscopy.

Eight cases of partial mediastinal lymph node necrosis identified at thoracotomy two to 17 days after cervical mediastinoscopy are described. In 6 cases, the involved nodes were grossly abnormal at operation, requiring frozen section interpretation. In the first 2 patients, the areas of nodal infarction were misinterpreted as necrotic tumor. Permanent sections from all 8 patients showed no evidence of tumor in the infarcted nodes. Factors predisposing to nodal infarction included right-sided tumor, central tumor, and large mediastinoscopic biopsy specimens. In all instances, the infarcted nodes were subcarinal and/or main bronchial. In 2 patients, left recurrent laryngeal nerve palsy occurred after mediastinoscopy. Necrosis in distal nodal areas should be recognized as a complication of thorough mediastinoscopic sampling, presumably due to interruption of arteries supplying these nodes. Awareness of this phenomenon by surgeons and pathologists may avert falsely positive gross or microscopic diagnoses of metastatic malignancy at thoracotomy.

Management of massive hemoptysis secondary to catheter-induced perforation of the pulmonary artery during cardiopulmonary bypass.

Pulmonary artery perforation by flow-directed catheters is associated with high mortality, particularly in heparinized patients. We report a recent case and discuss recognition and management.

Tracheal tear during laryngopharyngectomy and transhiatal oesophagectomy: a case report.

A case is reported of a tracheal tear developing during laryngopharyngectomy and transhiatal oesophagectomy. Ventilation and oxygenation were managed by removing the tracheostomy tube and advancing a straight cuffed armoured tube via the tracheostomy into one main stem bronchus and applying CPAP to the other bronchus via a Foley catheter. Following gastrointestinal reconstruction, the membranous tracheal tear was repaired via a right lateral thoracotomy.