A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection.

OBJECTIVE: Practice varies as to whether or not suction is applied to under-water seal drains following lung surgery. We tested the null hypothesis that there is no difference with respect to air leak duration. METHODS: Patients undergoing thoracotomy or video assisted thoracoscopic surgery for lobectomy or wedge resection had either low-pressure suction or no suction applied to their underwater seal bottles postoperatively. Patients were allocated using minimization, a method of unbiased allocation ensuring balance between the arms of a trial with respect to known or suspected confounding factors. The trial was powered for duration of air leak. If an air leak persisted on the 7th post-operative day, the surgeon determined further management. Kaplan-Meier survival analysis of air leak duration and a log rank test were performed on an intention-to-treat basis, with observations censored at 144h (6 complete days). RESULTS: Of the 254 patients that entered the trial, data were available for analysis for 239 (123 no-suction and 116 suction). There was no significant difference in the cumulative persistence of air leaks between the two groups (P=0.62) and inspection of the Kaplan-Meier curves suggests that any difference is negligible. CONCLUSIONS: Applying suction to the underwater seal drains following lung surgery makes no difference in terms of air leak duration. In the light of this finding we have adopted a uniform policy of no suction being applied to the underwater seal, from the time of surgery, unless a specific clinical judgment is made to use it. The anticipated gains are that this will reduce work and cost and aid mobilization.

Angina with a normal coronary angiogram caused by amyloidosis.

A case of severe intractable angina pectoris with normal angiography is presented. Following video assisted thoracic sympathectomy the patient died of heart failure. Microvascular cardiac amyloidosis was diagnosed at the postmortem examination. This report alerts clinicians to this possible diagnosis when treating patients with severe angina when no cause is found and discusses the poor prognosis in such cases.

Intercostal drain migration post esophagectomy.

A 38-year-old man underwent an Ivor-Lewis esophagectomy for a squamous carcinoma at the lower third of his esophagus. On the fifth postoperative day one liter of turbid fluid appeared from the intercostal drain and there was a right-sided pleural effusion on the chest radiograph. A contrast swallow demonstrated a leak at the distal part of the gastric staple line. This leak was managed conservatively and subsequent contrast swallows failed to show any leakage despite the persistent drainage from the drain. At gastroscopy, the intercostal drain was seen to have eroded through the stomach wall. The drain was repositioned and the patient was discharged from hospital 5 days later. We believe this to be the first report of an intercostal drain migration into the stomach after an elective esophagectomy.

Bronchogastric fistula successfully treated with the insertion of a covered bronchial stent.

We present what we believe to be the first case of a bronchogastric fistula successfully treated with a plastic-covered metallic bronchial stent. This developed 5 years after a transhiatal oesophagectomy with gastric pull-up for carcinoma of the oesophagus. The successful outcome in this case suggests that this method of treatment should be considered in patients in whom this post-operative complication cannot be managed easily by other means.

Laudable pus - lardaceous kidneys.

Amyloidosis frequently affects the kidney leading to proteinuria and loss of function. In cases of AA (reactive/inflammatory) amyloidosis, it is sometimes possible to quench the stimulus to chronic inflammation and by so doing stop further elaboration and deposition of amyloid fibrils. We describe the case of a man with a long-standing empyema who developed nephrotic syndrome and renal impairment. The empyema was resected and shortly afterwards proteinuria disappeared and renal function improved. Strenuous efforts are mandatory to locate and definitively treat underlying inflammatory foci in AA amyloidosis.

Removal of migrating pectus bars by video-assisted thoracoscopy.

Surgical correction of pectus excavatum deformity with the use of a metal bar strut provides a good cosmetic result with a low complication rate. Reports of pectus bar migration are rare but we report three cases of bar migration which required thoracoscopic removal.

[(18)F]Fluorodeoxyglucose positron emission tomography and its prognostic value in lung cancer.

OBJECTIVE: Positron emission tomography (PET) is being increasingly used as an accurate and non-invasive modality in diagnosis, staging and post-therapy assessment in patients with lung cancer. In this study, we examine whether the uptake of [(18)F]fluorodeoxyglucose (FDG), a marker of increased glucose metabolism in neoplastic cells, is of prognostic value in patients with primary lung cancer. METHODS: We have retrospectively analyzed 77 patients (mean age, 63. 0 years; male/female ratio, 53:24) with primary lung cancers who underwent whole body and localized thoracic PET as part of their diagnostic and staging procedures prior to consideration of surgical resection. The standardized uptake value (SUV) of injected FDG for each primary lesion was correlated with tumour histology and the patient's clinical outcome. RESULTS: A SUV of 20 or greater was found to be of significant prognostic value. The chance of survival (with 95% confidence intervals (CI)) at 12 months post-surgery for the various SUV groups was as follows: 75.2% (59.6-85.5) for SUV<10; 67.5% (29.0-88.2) for SUV 10-<12; 63.6% (29.7-84.5) for SUV 12-<15; 66.7% (19.5-90.4) for SUV 15-<20; 16.7% (0.01-0.52) for SUV>20. A SUV of 20 or more is associated with a 4.66 times increase in hazard, compared with lower levels of SUV. We found no significant correlation between tumour histology and SUV. CONCLUSION: We have previously reported on the significant advantages of PET in the staging and surgical care of patients with lung cancer. The present study adds further support for an additional prognostic role for PET in the management of thoracic malignancy as determined by the amount of labelled-FDG taken up by the primary lesion.

Treatment of invasive thymoma with single-agent ifosfamide.

PURPOSE: To evaluate single-agent ifosfamide in the treatment of invasive thymoma. PATIENTS AND METHODS: Fifteen patients (eight male and seven female) with histologically confirmed invasive thymoma were treated. The median age was 48 years (range, 23 to 76 years). Four patients had stage III disease, seven patients had stage IVa disease, and four patients had stage IVb disease. The most common histologic type was lymphoepithelial. Seven patients had received prior treatment, including one patient who received chemotherapy. Ifosfamide 1.5 g/m(2) was given on days 1 to 5, with mesna as a uroprotector. RESULTS: Thirteen patients were assessable for response. Five complete responses (38.5%; 95% confidence interval [CI], 17.7% to 64.5%) and one partial response (7.7%; 95% CI, 1.4% to 33.3%) were seen. The median duration of complete response was 66+ months (range, 25 to 87 months), and the estimated survival rate 5 years after ifosfamide treatment was 57% (SE, 32% to 79%). The most frequent toxicities were nausea, vomiting, and leucopenia, but these were well tolerated. CONCLUSION: Single-agent ifosfamide possesses significant activity against invasive thymoma and is comparable to currently used combination regimens. The inclusion of ifosfamide in combination therapy, particularly in place of cyclophosphamide in regimens such as cisplatin, doxorubicin, and cyclophosphamide, needs to be evaluated.

Self-expanding metallic stents in the management of pyloric dysfunction after gastric pull-up operations.

The purpose of this paper is to report the use and benefits of self-expanding metallic stents employed in pyloric dysfunction. Four patients treated with oesophagectomy and gastric pull-up for oesophageal carcinoma failed to respond to balloon dilatation for pyloric dysfunction. Three of the patients were thought to have residual tumour at sites remote from the pylorus prior to stenting, but the fourth, who had undergone surgery 8 years previously, was thought to be cured. All were treated with self-expanding metallic stents. All four patients responded well with resolution of their symptoms. Over a mean follow-up of 6 months there has been no recurrence of symptoms. Stent insertion represents a potentially valuable method of treatment in patients with post-surgical pyloric dysfunction in whom simple balloon dilatation has failed.

Evaluation of fluorine-18-fluorodeoxyglucose whole body positron emission tomography imaging in the staging of lung cancer.

BACKGROUND: Surgical resection of lung cancer remains the treatment of choice in appropriately staged disease, but conventional imaging techniques have limitations. Positron emission tomography (PET) may improve staging accuracy. METHODS: We studied whole body and localized thoracic PET in staging lung cancer. Standardized uptake value was calculated for the primary lesion. Ninety-seven patients under consideration for surgical resection were included. PET, computed tomography, and clinical staging were compared to stage at operation, biopsy, or final outcome. Mean follow up was 17.5 months. RESULTS: PET detected all primary lung cancers with two false-positive primary sites. Sensitivity and specificity for N2 and N3 mediastinal disease was 20% and 89.9% for computed tomography and 70.6% and 97% for PET. PET correctly altered stage in 26.8%, nodal stage in 13.4%, and detected distant metastases in 16.5%. PET missed 7 of 10 cerebral metastases. PET altered management in 37% of patients. PET staging (p<0.0001) and standardized uptake value (p<0.001) were the best predictors of time to death apart from operative staging. CONCLUSIONS: PET provides significant staging and prognostic information in lung cancer patients considered operable by standard criteria. Routine use of PET will prevent unnecessary operation and may be cost effective.

Recurrence of stage I thymoma 32 years after total excision.

Malignant thymomas are invasive and recur frequently, but noninvasive thymomas rarely do so. We report on a case of recurrent thymoma in a 50-year-old white man, 32 years after total excision of a stage I thymoma. We stress the importance of long-term follow-up in all patients.

Pulmonary artery sarcoma mimicking pulmonary embolism: successful surgical intervention.

Because of its rarity and the similarity of its presentation to that of pulmonary thromboembolic disease, the diagnosis of pulmonary artery sarcoma is often not considered early in patients presenting with recurrent or chronic pulmonary emboli. We present a case of pulmonary artery sarcoma that was treated as pulmonary embolism for 3 years before surgical resection was carried out. Two years after the resection the patient is well with no clinical or radiologic evidence of recurrent or metastatic disease.

Metallic endoprostheses for malignant tracheobronchial obstruction: initial experience.

PURPOSE: To assess the efficacy of the Wallstent endoprosthesis in malignant tracheobronchial obstruction. METHODS: Seven patients with irresectable carcinoma of the bronchus were treated with nine Wallstent endoprostheses. The procedures were performed under endoscopic and fluoroscopic guidance. Wallstent endoprostheses ranging from 8-16 mm in diameter and 26-49 mm in length were deployed after balloon dilatation of the strictures. RESULTS: All stents were successfully deployed in the desired positions. There was one procedural complication and one procedure related death. Three patients showed significant improvement in respiratory status after stenting. At a mean follow-up of 5.1 months, there has been no stent migration, fracture, or collapse. One patient had proximal tumor overgrowth that was treated with additional stent insertion. One patient died after a bout of massive hemoptysis 3 months poststenting and it was difficult to tell whether this was related to the endoprosthesis. CONCLUSION: The use of the Wallstent endoprosthesis in malignant tracheobronchial obstruction is technically feasible.