Giant Primary Liposarcoma of the Thoracic Esophagus

Primary liposarcomas of the mediastinum are unusual tumors. We report herein a case of a 64 year-old man; who presented a liposarcoma involving the mediastinum and the neck. A complete resection was performed and we had a free-disease survival result of eighteen months

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy.

BACKGROUND: The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy. METHODS: This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS. RESULTS: In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant. CONCLUSIONS: Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.

A unique congenital mediastinal malformation.

We report a case of a 35-year-old patient presenting with a unique asymptomatic malformation associating extralobar pulmonary sequestration communicating with a bronchogenic cyst of the esophageal wall via the aortopulmonary window, dextroisomerism, and complete agenesia of the left pericardium. Despite computed tomography (CT) scan and magnetic resonance imaging (MRI), the diagnosis could not be established before left thoracotomy. The sequestrated lobe and bronchogenic cyst were then successfully resected.

Surgical treatment of primary sarcoma of the lung.

OBJECTIVE: To study the results of surgical treatment of primary lung sarcoma. METHODS: Between 1982 and 1998, we performed 18 macroscopically complete resections for primary sarcomas of the lung. The records of all patients were reviewed, as were pathological slides. Presence of symptoms, tumour size (more or less than 5 cm), complete resection, TNM stage and histology grade were analyzed for predictors of survival. RESULTS: Patients comprised 11 women and seven men whose age ranged from 19 to 73 years (mean 50 years). Mean tumour diameter was 8.05 cm (range 2.5-15 cm) There were one grade 1, eight grade 2 and nine grade 3 tumours. Tumours in two patients were unresectable at first presentation, and another was of doubtful resectability according to computed tomography scan. These three patients received pre-operative chemotherapy, with a partial response in the two unresectable patients allowing macroscopically complete resection in both cases. We performed 12 lobectomies (extended to the chest wall in two cases and to the diaphragm in two cases) and six pneumonectomies (extended to the chest wall in one case and the superior vena cava in one case). Operative and 30 days post-operative mortality were nil. Resection margins were invaded in two cases. Six patients received post-operative chemo- or radiotherapy and three others underwent repeat resections for pulmonary sarcoma recurrence. No patients were lost to follow-up. Pulmonary sarcomas recurred in eight patients (44%) leading to death in five cases after a mean period of 17 months. Overall median survival was 48 months, and actuarial 5-year survival 43%. Only TNM stage correlated with significantly increased survival. CONCLUSION: As complete resection is the best therapeutic option for obtaining an acceptable survival rate in primary pulmonary sarcoma, pre-operative chemotherapy can be a useful adjunct in increasing the resectability of these tumours.

Perforation of Barrett's ulcer: a challenge in esophageal surgery.

BACKGROUND: Barrett's ulcer, which develops within Barrett's esophagus, is frequently responsible for bleeding. Perforation is a rare complication constituting a great challenge for diagnosis and management. METHODS: Three personal cases and 31 published reports of perforated Barrett's ulcer were reviewed retrospectively. The site of perforation, clinical presentation, management, and outcome were assessed. RESULTS: The clinical presentation proved to be heterogeneous and was determined by the site of perforation: this was the pleural cavity (20% of cases), mediastinum (20%), left atrium (16.6%), tracheobronchial tract (13.3%), aorta (13.3%), pericardium (10%), or pulmonary vein (6.6%). Early esophagectomy and esophageal diversion-exclusion were the most frequent procedures, and overall mortality was 45%. CONCLUSIONS: The poor prognosis of perforated Barrett's ulcer should be improved by earlier diagnosis and adequate emergent operation. Although early esophagectomy constitutes the recommended procedure, esophageal diversion-exclusion, which allows control of both sepsis and bleeding, is also of interest.

Pericardoscopy for primary management of pericardial effusion in cancer patients.

OBJECTIVE: To assess the usefulness of pericardoscopy via the subxyphoid route for the diagnosis and treatment of pericardial effusion in patients with a history of cancer. METHODS: All patients with a recent or remote history of cancer and a pericardial effusion of unknown origin requiring drainage for diagnostic and therapeutic purposes were included in the study. They underwent complete exploration and cleansing of the pericardial cavity. Abnormal structures or deposits were biopsied under direct visual control, with a 24 cm long rigid pericardoscope. RESULTS: Between 1985 and 1998, pericardoscopy was completed in 112 of the 114 patients included (feasibility 98%), resulting in the immediate relief of symptoms in all the cases. Peri-operative mortality was 3.5%, and post-operative morbidity, 6.1%. After pericardioscopy pericardial effusions were considered malignant in 43 cases. One more case (2.3%) due to a false negative result of pericardioscopy was diagnosed during follow-up. Overall, 44 of the 114 patients (38.6%) had a malignant effusion, and 70 (61.4%), a non-malignant effusion according the follow up. In 10 of the 44 patients with a malignant pericardial effusion (22.7%), pericardoscopy corrected the results of cytological pericardial fluid studies and pericardial window biopsy, both false negatives. The sensitivities of cytological studies of the pericardial fluid, pathological examinations of pericardial window biopsy and pericardioscopy were 75, 65 and 97%, respectively. One patient with a malignant effusion had a non-symptomatic recurrence 1 month after pericardioscopy (2.3%). CONCLUSION: We recommend pericardioscopy to ascertain the malignant nature of the effusion and to diminish the recurrence rate, this avoiding repeat procedures in patients with a short life expectancy.

Is computed tomography guided biopsy still necessary for the diagnosis of adrenal masses in patients with resectable non-small-cell lung cancer?

OBJECTIVES: This study was undertaken: (1) to evaluate the usefulness of unenhanced computed tomography (CT), magnetic resonance imaging (MRI) and CT guided biopsy for the characterization of adrenal masses in patients with operable non-small-cell lung cancer (NSCLC) and (2) to evaluate the situations in which CT guided biopsy is absolutely necessary before potentially curative resection of NSCLC. METHODS: Consecutive patients with operable NSCLC underwent unenhanced adrenal CT with density measurements of any adrenal mass over 1 cm in diameter. An adrenal mass was considered as an adenoma when its density was below 10 Hounsfield Units and a metastasis when its density exceeded 10 Hounsfield Units. Then patients underwent MRI, the signal on the T2 weighted images from the enlarged gland was classified adenoma or metastasis in comparison with that from the liver parenchyma. CT guided biopsy was performed after a pheochromocytoma was eliminated. Unenhanced CT attenuation values and signal intensity values on MRI were correlated with histopathologic results. RESULTS: Of the 443 patients, 32 had an adrenal mass consisting of adrenal metastases in 18 cases and adenomas in 14 cases. On CT, 3/14 (21%) of the adenomas were misdiagnosed as metastases (their densities exceeded 10 Hounsfield Units) and 2/18 (11%) of the metastases were misdiagnosed as adenomas (their densities were below 10 Hounsfield Units). On MRI, none of the metastases were misdiagnosed as an adenoma (100% sensitivity) but 7/14 (50%) of the adenomas were misdiagnosed as metastases (signal superior to that of liver). Overall, a diagnostic certainty of metastasis could not be obtained in 25/32 patients (78%). CT guided biopsy with 100% sensitivity and specificity corrected all the inaccurate results of CT and MRI without any morbidity. CONCLUSION: Despite extensive morphological evaluation with unenhanced CT and conventional MRI, CT guided biopsy is necessary for most patients referred to surgery for an operable NSCLC and an adrenal mass.

Long-term cardiovascular consequences of undiagnosed intralobar pulmonary sequestration.

We report the case of a patient with a congenital aortic valve stenosis associated with a long-term undiagnosed intralobar pulmonary sequestration. The important blood flow through the aberrant artery led to progressive congestive heart failure and severe hemoptysis at the age of 25 years. We demonstrate the regression of cardiac symptoms and left ventricular diameter after surgical resection of the sequestration.

Adrenalectomy for a solitary adrenal metastasis from lung cancer.

BACKGROUND: Several case reports have shown that patients with truly solitary adrenal gland metastases can undergo resection with long-term survival. METHODS: We assessed consecutive patients with operable or operated non-small cell lung cancer in whom the presence of a unilateral solitary adrenal metastasis was confirmed histologically. Synchronous homolateral adrenal metastases were resected at the same time as the non-small cell lung carcinoma through a transphrenic approach. Synchronous contralateral or metachronous adrenal metastases were resected through an elective approach. RESULTS: Of 598 patients with operable or operated non-small cell lung carcinoma, 11 had a unilateral solitary adrenal gland metastasis and underwent adrenalectomy with no additional mortality or morbidity. One patient died of late postoperative complications and 7 patients died of other distant metastases between 4 and 24 months after adrenalectomy. Two patients are still alive and free of recurrent disease and 1 patient is still alive with brain metastasis 66, 6, and 10 months, respectively, after adrenalectomy. CONCLUSIONS: In the absence of selection criteria to identify the subgroup of patients who will benefit from surgical resection, we suggest the resection of synchronous lesions in patients without N2 involvement and the careful selection of patients with metachronous adrenal metastases according to the evolution of their disease.

Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections.

OBJECTIVE: To review the results of the different modalities of treatment of acute necrotizing pancreatitis that have been used by a single team during a 6-year period to assess the technique and indications of an endoscopic method of retroperitoneal drainage that is routinely performed for the management of peripancreatic necrosis. DESIGN AND SETTING: Retrospective study of 53 patients in a tertiary care center. RESULTS: All patients had signs of peripancreatic necrosis on initial computed tomography scan, 20 patients experienced organ failure during the first 7 days of the disease, and bacterial contamination was proved in 22 (56%) of 39 samples of peripancreatic necrosis. Methods of treatment included supportive therapy alone (group 1), percutaneous drainage (group 2), endoscopic retroperitoneal drainage (group 3), and laparotomy and transperitoneal drainage (group 4). Mortality and mean hospital stay were as follows: group 1, 0% and 23 days; group 2, 20% and 89 days; group 3, 10% and 62 days; and group 4, 33% and 86 days. Percutaneous drainage was beneficial in only 3 cases of sterile collection. Two local complications were related to the method of endoscopic drainage. Primary laparotomy was not routinely performed except in patients with an intraperitoneal complication. Overall mortality was 13.2%; mortality was significantly higher in patients with an infected necrosis (32%). CONCLUSIONS: The use of endoscopic retroperitoneal drainage seemed to be a significant factor in the observed improvement by providing a reliable drainage of the peripancreatic areas and avoiding the opening of the peritoneal cavity. This surgical approach is not exclusive and may be combined with a secondary laparotomy when needed. The preferred indications of this method are heterogeneous collections of necrosis with bacterial contamination.

Postpneumonectomy interatrial right-to-left shunt: successful percutaneous treatment.

This report describes the case of a 67-year-old man in whom atrial right-to-left shunt developed after a right pneumonectomy, leading to dyspnea with severe arterial desaturation. Transcatheter occlusion of the patent foramen ovale was successfully performed using a buttoned device. Review of literature and mechanisms of these atrial right-to-left shunts are discussed.

Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis.

OBJECTIVES: To evaluate the efficacy of arterial embolization (EMB) in the management of bleeding pancreatic pseudocysts or pseudoaneurysms and to assess the possible indication for secondary surgery. DESIGN: Retrospective review with a mean follow-up of 60 months (range, 18-125 months). SETTING: Tertiary care center, university hospital. PATIENTS: The medical records of 14 patients who were referred to the hospital with bleeding pancreatic pseudocysts and/or pseudoaneurysms related to chronic pancreatitis, between 1983 and 1994, were reviewed. The clinical presentation was major bleeding in 10 patients (gastrointestinal or intraperitoneal) and chronic signs in 4. INTERVENTION: Celiac and superior mesenteric angiography with EMB attempt in all patients. MAIN OUTCOME MEASURES: The immediate effect on bleeding and the long-term safety of arterial EMB. RESULTS: Embolization failed in 3 patients and surgery was needed (1 patient died). Embolization was successful in 11 patients, but 2 complications occurred (duodenal necrosis and aortic thrombosis) (1 patient died). Among the 10 patients whose bleeding stopped, an intentional pancreatectomy was performed 4 times (all patients are alive). The 6 other patients did not undergo a further pancreatic operation due to unfavorable local or general condition. None of them had recurrent bleeding, 3 of them died later of extrapancreatic diseases. Overall, early mortality was 14%, with deaths occurring only in unsuccessful or complicated EMB cases. CONCLUSIONS: The immediate effectiveness of arterial EMB is undeniable but depends on the expertise of the radiologist. When EMB is successful, further surgery should be reserved for patients in good general condition who have other complications of chronic pancreatitis that are not amenable to minimally invasive techniques.