A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy.

Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.

Curative lung metastectomy and complete pathological response after neo-adjuvant GEMOX chemotherapy for relapse fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma. It is commonly reported in the younger population with no underlying chronic liver disease and free of viral Hepatitis B and C. Local recurrence and distant metastasis are common despite better prognosis compared to conventional hepatocellular carcinoma. Complete surgical resection is associated with higher median survival and is the mainstay treatment option for localized FL-HCC. Multi-modality therapies such as TACE can be used to downstage upfront unresectable FL-HCC. Complete response with GEMOX chemotherapy has been reported in advanced metastatic FL-HCC and should be considered in upfront unresectable or metastatic disease. We present a case of biopsied proven relapse FL-HCC with oligo- left lung metastasis who successfully underwent a left lung lobectomy after neo-adjuvant GEMOX chemotherapy, and is disease free at 24 months follow up.

Surgical repair of pulmonary vein injury from blunt trauma.

Pulmonary vein deceleration injury is rare and patients can be deceptively stable for a period after injury. Quick diagnosis and transfer to the operating theatre is the only way to treat this potentially lethal injury successfully. Techniques of repair are a useful addition to the cardiovascular surgeon's repertoire.

Tumour necrosis factor-alpha production stimulated by heat shock protein 70 and its inhibition in circulating dendritic cells and cells eluted from mucosal tissues in Crohn's disease.

Summaryand interleukin (IL)-12 by dendritic cells (DC) from patients with Crohn's disease. TNF-alpha concentration was increased significantly when DC from Crohn's disease were stimulated with HSP70 or CD40L and this was associated with signalling by the extracellular signal regulated kinase (ERK) 1/2 and p38 mitogen activated protein (MAP) kinase pathway. IL-12 production was also increased when DC were stimulated with HSP70. Cells eluted from inflamed intestinal mucosa from Crohn's disease, stimulated with HSP70, CD40L or lipopolysaccharide produced significantly greater TNF-alpha and IL-12 concentrations than cells from uninflamed mucosa. Significant inhibition of TNF-alpha production was demonstrated when DC from peripheral blood mononuclear cells or cells eluted from intestinal mucosa of Crohn's disease were treated with either the HSP70 inhibitory peptide (aa 457-496) or peptides derived from CD40 and CD40L. These inhibitory peptides target the CD40-CD40L and the emerging CD40-HSP70 co-stimulatory pathway. Our findings offer a novel strategy to prevent excessive production of TNF-alpha in Crohn's disease.

Genetic determinants of the pre- and post-azathioprine therapy thiopurine methyltransferase activity phenotype.

Thiopurine drug therapy has been reported to lead to a variable increase in red cell TPMT activity that may alter effective dose and therapeutic outcome. The aim of this study was to correlate Variable Number Tandem Repeat (VNTR) in the promoter region of the TPMT gene with induction of red cell TPMT activity in patients treated with azathioprine (AZA). In 58 patients, TPMT activity measured at 3 months was not significantly induced on average above pre-therapy levels. Individual patients showed variation in TPMT activity pre- and post-AZA therapy, however changes in TPMT activity were not predicted by VNTR configuration. In conclusion, TPMT promoter VNTRs are unlikely to play a significant role in changes in TPMT activity in response to AZA therapy.

Small-bowel barium follow-through is rarely required in patients with a normal ileoscopy and terminal ileal biopsy and a normal or unremarkable colonoscopy.

BACKGROUND: There is an increase of reliance on ileoscopy in preference to small-bowel barium follow-through in the diagnosis of terminal ileal Crohn disease. In this study the role of small-bowel barium follow-through after a normal or unremarkable ileocolonoscopy was investigated. METHODS: A retrospective analysis of all patients who had a colonoscopy followed by a small-bowel barium follow-through over a 7-year period was performed. Patients with a previously established diagnosis of inflammatory bowel disease and those who had colonoscopic evidence of inflammatory bowel disease were excluded. RESULTS: Of the 96 patients who had a normal ileoscopy and normal or unremarkable colonoscopy, 3 had abnormalities detected at small-bowel barium follow-through. Two patients had abnormal terminal ileal biopsies, although the terminal ileum appeared macroscopically normal. The small-bowel barium follow-through helped to establish the diagnosis of Crohn disease. The other patient presented changes consistent with a previously established diagnosis. Of the 47 patients who had a normal or unremarkable total colonoscopy without ileoscopy, I had abnormalities detected at small-bowel barium follow-through consistent with a previously established diagnosis. CONCLUSIONS: Small-bowel barium follow-through is rarely required in patients who have had a normal ileoscopy and terminal ileum biopsy and a normal or unremarkable colonoscopy. It should only be performed if there is a very high index of suspicion of small-bowel pathology. In patients with suspected Crohn disease, it is important to take terminal ileum biopsies even if the ileum appears macroscopically normal at ileoscopy.

A prospective study of the technical feasibility of ileoscopy at colonoscopy.

BACKGROUND: Despite a well-documented diagnostic yield, ileoscopy at colonoscopy is not performed routinely. This is due to the perceived difficulty in intubating the ileocaecal valve, added procedure time and a lack of acceptance regarding diagnostic yield. Therefore, we conducted a study to investigate the technical feasibility of ileoscopy at colonoscopy. METHODS: Ileoscopy was studied prospectively in 120 patients undergoing diagnostic colonoscopy. After identification of the caecum, ileoscopy was attempted by one of four techniques. The time taken to pass from caecum to terminal ileum, the patient position, use of Hyoscine-n-butyl bromide and any ileal abnormalities were recorded in each case. RESULTS: Ileoscopy was successful in 117/120 (97%) cases with a median time of 55 s taken to intubate the ileo-caecal valve. A 'down and left' technique was used in most cases (74.4%). Switching the patient to supine aided ileoscopy in 24 cases (20.4%) and Hyoscine-n-butyl bromide was considered helpful in 25 (21.4%). Overall, the terminal ileum was abnormal in 24 of 117 (20.5%) patients. CONCLUSIONS: Ileoscopy can be achieved in nearly all patients undergoing diagnostic colonoscopy and the added procedure time is short. Added time, technical difficulty and limited yield are not valid reasons for choosing not to perform ileoscopy.

Clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia.

OBJECTIVES: Ideal treatment for achalasia permanently eliminates the dysfunctional lower oesophageal sphincter, relieving dysphagia and regurgitation. The aim of this study was to review the results in a series of patients undergoing video-imaged thoracoscopic Heller's myotomy (THM). METHODS: Records of all patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire together with oesophageal manometry and/or 24 h pH monitoring when clinically indicated. RESULTS: Twenty-five consecutive patients (13 males, 12 females, mean age 40.3+/-19.9 years) suffering from grade 4 dysphagia underwent THM between 1993 and 2001. Preoperative mean lower oesophageal sphincter (LOS) pressure was 42.6+/-6.3 mmHg. Seven patients (28%) had undergone previous pneumatic dilatations. There were no hospital deaths and no oesophageal perforations. Length of hospital stay was 4.3+/-1.8 days. One patient died 3 years after surgery from unrelated causes. At follow-up of 5.4+/-2.1 years, freedom from any reintervention was 95.8% (23/24). Eleven patients (45.8%) were asymptomatic. In patients with residual or recurrent symptoms (n=13), their severity was significantly reduced from the preoperative period (dysphagia score 1.7+/-0.8 versus 4+/-0; P

Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation.

OBJECTIVE: Sequential lung volume reduction (LVR) is thought to provide additional and prolonged benefit compared with unilateral LVR. We tested this hypothesis by reviewing physiological, subjective and survival outcome data on patients who underwent sequential or unilateral LVR. METHODS: LVR was performed as a unilateral video-assisted thoracoscopic surgery (VATS) procedure, with bilateral reduction being undertaken in a staged manner. Pulmonary function data were collected prospectively. A telephone survey of patients and general practitioners was used to determine quality of life and survival. RESULTS: Fifty patients underwent LVR. Twenty-one patients had staged reduction of the contra-lateral lung at a median interval of 9 months. Pre-operatively, patients undergoing sequential LVR were not significantly different from patients undergoing unilateral LVR: forced expiratory volume in 1 s (FEV1) 23% predicted vs. 27% predicted, KCO 40% vs. 45%, total lung capacity (TLC) 124% vs. 121%, residual volume (RV) 217% vs. 214%, health score 34.5 vs. 30.8. After single-side LVR, both groups demonstrated equivalent and significant improvement in spirometric and subjective health scores: FEV1 +15% predicted (P<0.01), TLC -5% (P=0.03), health score +80% (P<0.01). Patients undergoing sequential reduction demonstrated no further significant improvements using either an intragroup comparison with their pre-second operation values or an intergroup comparison with the unilateral LVR patients. However, sequential LVR appeared to prolong the benefits experienced after the initial surgery by 1 year. Overall, 12 patients (24%) died during follow-up with no survival difference between the two groups (P=0.65). CONCLUSION: Sequential LVR is a safe strategy. Undertaking LVR to the second side does not further improve spirometric or subjective performance but does prolong the benefits achieved with the initial reduction.