Oropharyngeal dysphagia after cardiac operations.

BACKGROUND: As many as 15% of hospitalized patients have oropharyngeal dysphagia. The incidence and causes of postoperative oropharyngeal dysphagia (OD) in patients having cardiac operations are poorly documented and the best treatment is uncertain. We undertook a study to evaluate OD in patients having cardiac operations. METHODS: As part of a quality improvement project, all patients operated on in 1998 and 1999 were monitored for the signs or symptoms of OD. Patients with OD had diagnostic and therapeutic interventions to limit adverse outcomes. At the end of the 2-year evaluation period, patient risk factors, diagnoses, results of interventions, and outcomes were measured. RESULTS: Thirty-one out of 1,042, patients (3%) had OD. OD is more common in older patients (p < 0.0001) with diabetes (p = 0.02), renal insufficiency (p = 0.012), hyperlipidemia (p = 0.046), and preoperative congestive heart failure (p < 0.0001), and in those having noncoronary artery bypass procedures (p < 0.0001). One patient with OD died from respiratory arrest, presumably secondary to aspiration. Modified barium swallow (MBS) identified oral dysphagia in 2 patients, pharyngeal dysphagia in 7 patients, and both oral and pharyngeal dysphagia in 17 patients. One patient had a structural defect (cervical osteophyte) causing dysphagia and 4 patients had no identifiable cause of dysphagia on MBS. Postoperative neurologic complications are more common in patients with OD. Ten of 31 patients (32%) with OD had some new neurologic complication after operation compared with 36 of 1,011 (3.5%) who had a postoperative neurologic problem without OD. In 19 patients with OD no cause for swallowing difficulty was identified. Specifically, no metabolic, myopathic, or infectious abnormalities were identified in any patient with OD. Hospital charges were significantly increased in patients with OD ($69,320 versus $36,087, p < 0.0001). Therapy consisting of modification of eating behavior and swallowing technique and in some severe cases enteral or parenteral feeding was successful in all patients except 1, but 4 patients required more than 4 months of supportive care before return to oral feeding was possible. CONCLUSIONS: OD is associated with increased cost and morbidity. Older patients with diabetes, preoperative heart failure, and renal insufficiency are at increased risk for OD. Early recognition and intervention is likely to result in satisfactory outcome but may be associated with a protracted postoperative course.

Long-term angiographic results of coronary endarterectomy.

BACKGROUND: To evaluate the long-term patency of endarterectomized coronary vessels, we studied patients having recatheterization after coronary artery bypass grafting. METHODS: Forty-one clinical and angiographic variables were analyzed in 97 study patients who had coronary endarterectomy (CE) and in 154 control patients who did not have CE but who had repeat catheterization after coronary artery bypass grafting. RESULTS: Ninety-seven patients had 132 CEs. The right coronary artery was the most commonly endarterectomized vessel (73 of the 132 endarterectomized vessels). At a mean of 7.1 years of follow-up, significantly fewer bypass grafts to endarterectomized vessels were patent compared with nonendarterectomized vessels (40% of endarterectomized vessels compared with 58% of nonendarterectomized vessels in study patients and 65% in control patients, p = 0.0003). The only predictor of long-term CE graft patency is age-adjusted body surface area (p = 0.0068). Patency in grafts to nonendarterectomized vessels is diminished by hypertension (p = 0.046) and current cigarette use (p = 0.024) and improved by use of mammary artery grafting (p < 0.0001). CONCLUSIONS: These results show that long-term patency in bypass grafts to endarterectomized vessels is less common than in nonendarterectomized vessels and that this patency is related to larger body size. Patency in nonendarterectomized vessels is reduced by risks of arteriosclerosis. This suggests that CE should be used with caution in smaller patients and that aggressive control of risk factors for atherogenesis is particularly important in patients who have CE. On the basis of these results, we speculate that the extent of disease is advanced in patients who require CE.

Impact of revised stage classification of lung cancer on survival: a military experience.

STUDY OBJECTIVES: This report reviews results of surgical management of lung cancer at a military medical center using the revised 1997 stage classification and determines the impact of the revised system on survival rates. It also compares our results with the recent reports from Japan and from a large, multinational study involving several institutions. DESIGN: Retrospective review. SETTING: Department of Cardiothoracic Surgery, Walter Reed Army Medical Center (WRAMC), Washington, DC. PATIENTS OR PARTICIPANTS: Active military members, their dependents, and eligible retired military members who were admitted to WRAMC for surgical treatment of lung cancer between January 1984 and December 1996. METHODS: Records of all patients who had surgical resection with intent to cure were reviewed. Data extracted included clinical and pathologic stages according to the 1997 revised stage classification. Survival probabilities for the stages were calculated by the Kaplan-Meier actuarial method. The log rank test was used to compare survival rates between stages and stage subsets. A p value < 0.05 was considered statistically significant. MEASUREMENTS AND RESULTS: Five hundred fifty-two of the 1,398 patients with primary lung cancers underwent curative surgical resection (39.5%). The operative mortality was 2%. Using the revised 1997 stage classification, the survival rate for stage IA was 77%; IB, 62%; IIA, 57%; IIB, 47%; IIIA, 28%; IIIB, 20%; and IV, 0%. The overall actuarial 5-year and 10-year survival rates were 58% and 45%, respectively (median survival, 3.3 years; mean survival 3.9+/-0.1 years). CONCLUSIONS: Our results confirm the justification for the recent revisions in the staging system of lung cancer; however, there are still discrepancies that cannot be explained.

Video-assisted talc pleurodesis for malignant pleural effusions utilizing local anesthesia and I.V. sedation.

METHODS: Twenty-four consecutive patients aged 36 to 84 years (mean, 63.3+/-12.9 years) underwent video-assisted talc pleurodesis (VATP) for malignant pleural effusion (MPE) utilizing local anesthesia with IV sedation at the Walter Reed Army Medical Center. The VATP procedure was performed in the operating room with the patient in the lateral decubitus position breathing spontaneously through a face mask with 4 L/min of oxygen. Anesthesia was achieved by intercostal nerve block using a 50/50 mixture of 1% lidocaine with epinephrine and 0.5% bupivacaine hydrochloride (Marcaine) supplemented with local infiltration of the access (Surgiport) sites as necessary. Sedation was achieved with propofol, and pleurodesis was performed with 3 to 8 g (average, 5 g) of sterile talc insufflated through a talc atomizer. RESULTS: The mean operating time was 44.3+/-14.9 min (range, 23 to 75 min). The average number of days of chest tube drainage was 2.9+/-1.2 days (range, 1 to 5 days). Patients stayed on the cardiothoracic ward for an average of 4.4+/-1.3 days before discharge home or transfer to a medical oncology ward. Seventeen of the 24 patients (71%) had excellent results, 4 patients (17%) had good results, and 3 patients (12%) had poor results. The three patients with poor results all had primary lung cancer as their underlying malignancy. The overall actuarial survival was 66% at 6 months, 48% at 12 months, and 32% at 24 months with a mean survival of 9 months. There was one operative death in an 84-year-old patient with primary lung cancer. Twelve of the 24 patients are alive 4 to 30 months after VATP. CONCLUSIONS: VATP, performed under local anesthesia, is a safe and highly effective method of managing MPE.

The results of modern surgical therapy for multiple primary lung cancers.

STUDY OBJECTIVES: The purpose of this report is to review our experience with multiple primary lung cancers (MPLC) at the Walter Reed Army Medical Center, Washington, DC, and to determine the outcome of our surgical management of this complex problem. PATIENTS AND METHODS: The data from the Lung Cancer Registry on patients with MPLC from January 1984 to December 1995 were reviewed. We used the criteria of Martini and Melamed modified by Antakli for the diagnosis of synchronous and metachronous MPLC. Survival probabilities were calculated by the Kaplan-Meier actuarial method with the dates of resection as the starting point and included deaths from all causes. The log rank test was used to compare survival rates between groups and Wilcoxon rank sum test was used to compare the intervals between the first and the second metachronous cancers. A p value of 0.05 was considered statistically significant. RESULTS: Fifty-two patients, consisting of 51 patients who had "curative" pulmonary resections and 1 patient who had radiation therapy for previous primary lung cancer, developed second or third primary lung cancers. Thirty-seven patients developed metachronous cancers within 1 to 15 years of the first operation (median, 24 months) while 15 patients had synchronous cancers (10 unilateral, 5 bilateral). The probability of cancer-free interval among patients with metachronous cancers was 41% at 3 years, 16% at 5 years, and 3% at 10 years. Two of the 36 patients who had pulmonary resection for the second metachronous cancer died in the perioperative period (operative mortality, 5.6%), and one patient had radiation therapy for the second metachronous cancer. There were no deaths among patients with synchronous cancers. The actuarial 5-year survival for second metachronous cancers was 37% and for synchronous cancers was 0%. CONCLUSIONS: We conclude that an aggressive surgical approach is safe and justified in most patients with MPLC, especially patients with metachronous cancers, while patients with synchronous lung cancers have poorer prognosis. The operative morbidity and mortality are acceptable and long-term survival is possible in many patients with metachronous lung cancer.

Resection of chest wall and central veins for invasive cutaneous aspergillus infection in an immunocompromised patient.

Primary cutaneous invasive Aspergillus infection at a Hickman catheter site led to chest wall involvement and central venous suppurative thrombophlebitis in a patient with relapsed acute myelogenous leukemia. Therapy included high-dose amphotericin B, serial wound debridements pending bone marrow recovery, and definitive resection of the infected chest wall and thrombosed internal jugular, subclavian, and innominate veins. To our knowledge, this procedure for control of invasive fungal infection has not been reported previously.

A laboratory model for studying blast overpressure injury.

Blast injury remains an important source of trauma in both civilian and military settings. We have studied a recently developed blast wave generator to evaluate its effectiveness for laboratory study of blast injury. In order to determine the reliability of the device and the pathology of the lesions caused by the short duration (0.5-1.0 msec), and high intensity (60-375 psi) pressure wave, laboratory rats were exposed to the pressure waves generated by the machine. The animals were divided into three groups: the first exposed to midthoracic blasts, the second to abdominal blasts, and a group of controls exposed to a gentle stream of gas. Group I showed gross and microscopic evidence of lung blast injury of "rib imprint" hemorrhages, intra-alveolar hemorrhage, marked increase in lung weight, prolonged apnea, and bradycardia. Group II showed typical blunt abdominal trauma at the closest ranges, but characteristic submucosal hemorrhages up to 4.0 cm from the blast nozzle. In both groups, a protective effect was seen in heavier animals. The blast wave generator permits reproducible blast injury in the laboratory that is safer and faster than current methods. The lung and bowel lesions induced are grossly and microscopically similar to injuries of blast exposure seen in clinical patients.