Less than lobar resections for bronchogenic carcinoma.

We performed less than lobar resections for peripheral clinical Stage I primary lung cancers on 170 patients treated between 1973 and 1987 at two university centers, one in Hawaii and one in Israel. Most patients were poor risks and several had FEV1 < 1 liter. There were 6 (3.5%) hospital deaths. There were 58 segmental resections, 97 wedge resections and 15 less than lobar resections not otherwise specified. Seventy-three patients (43%) are living free of cancer from 5 to 11 years postoperatively and 20 additional patients died of causes unrelated to lung cancer after 5 years; thus disease free five year survival was 54.7%. Patients with adenocarcinoma had poorer prognosis than other cell types. Twenty-three patients (13.5%) had synchronous or metachronous second primary lung cancers. Nine of these patients are long term survivors. Twenty-four patients (14.1%) developed local recurrences with or without distant metastases. This promising long term cancer-free survival and the frequency of second primary lung cancers justifies less than lobar resection for peripheral, Stage I bronchogenic carcinoma, especially in the poor risk patient.

Late rupture after dacron wrapping of aortic aneurysms.

We reviewed the entire experience in Hawaii with external wall reinforcement with Dacron graft material as a primary method of surgical treatment of aortic aneurysm. Over the past 11.5 years, 14 such procedures have been performed. Two of the aneurysms were located in the distal aortic arch, eight in the descending thoracic aorta, and four in the abdominal aorta. The operation was done in each instance as a safer alternative to resection and replacement in high-risk patients. There were two postoperative deaths, one unrelated to the surgery. To date, three of the 12 surviving patients have experienced aortic rupture at the graft site, 6 months to 3 years later. Two died of exsanguinating hemorrhage and a third survived corrective surgery. The rupture in each instance occurred through the entire wrap itself. Two of these developed aortobronchial fistulas and one an aortoesophageal fistula. The high incidence of late rupture of wrapped aneurysms, as reported here, has not been documented in the literature and raises serious questions as to the efficacy of this procedure.

Effort-related axillosubclavian vein thrombosis. A new theory of pathogenesis and a plea for direct surgical intervention.

Four cases of effort-related axillosubclavian thrombosis are described. The pathogenesis of this disorder is related to an anatomic constriction of the vein by the clavicle and first rib complex associated with repetitive trauma to the vein and resultant changes in the vein wall itself. Therapy must, therefore, not only address the superimposed thrombosis but must also provide a reliable correction of the constricting mechanism and the resultant lesion in the proximal subclavian vein. Our operative approach resulted in a full return to daily activities and no recurrence or persistence of symptoms in our series. Although early intervention is advisable, patients who present with long-standing venous occlusion should also be considered for operation. Medical therapy, consisting either of anticoagulation or thrombolytic therapy, results in an unsatisfactory clinical outcome because it does not correct the underlying mechanical abnormality.

The surgical treatment of well-differentiated carcinoma of the thyroid.

Ninety-five surgically treated patients with well-differentiated carcinoma of the thyroid with an average of 11.2 years of follow-up were reviewed. Overall complications included 13% recurrence, 3% deaths due to thyroid cancer, 3% recurrent laryngeal nerve damage, and 2% hypoparathyroidism. Statistically significant prognostic findings included lower rates of recurrence and/or death among patients who were female, without lymph node involvement, or younger than 45. In comparison with total thyroidectomy, subtotal thyroidectomy was associated with markedly higher rates of recurrence and death among Stage II+ patients. No such difference appeared among Stage I patients. No statistically significant differences or meaningful trends could be found in the recurrence or death rates for age, sex, and lymph node status-matched patients treated with total versus subtotal thyroidectomy. These findings suggest the use of age, sex, and staging criteria to decide between subtotal and total thyroidectomy in patients with localized, well-differentiated thyroid cancer. More specifically, females younger than 45 with small tumors and no clinical evidence of nodal involvement or metastases can be treated using subtotal thyroidectomy with some confidence that undue recurrence or death due to cancer will not result. This selective use of subtotal thyroidectomy would avoid the complications of total thyroidectomy, namely, bilateral recurrent laryngeal nerve trauma and hypoparathyroidism, the latter being a particularly troublesome iatrogenic disease.

Ischemic colitis after aortic aneurysmectomy.

A retrospective analysis was conducted to quantitatively assess eight suspected risk factors for the development of bowel ischemia after abdominal aortic aneurysmectomy. Eighteen patients were studied and compared with 100 randomly selected control subjects who underwent similar operations during the same time period in five Honolulu hospitals, but in whom the complication did not develop. Prolonged cross-clamp time, hypoxemia, ruptured aneurysm, hypotension, and arrhythmia (supraventricular and ventricular) occurred with significantly greater frequency among the patients with ischemia when compared with the control subjects. Age and other preexisting cardiovascular or gastrointestinal diseases did not significantly correlate with risk of postoperative colon ischemia. In addition, the technique of aortic grafting did not significantly influence the risk of development of ischemic colitis, but the number of patients in this study is too small to provide meaningful data on that point.

Surgical treatment of lung cancer in patients over the age of 70 years.

Eighty patients of 70 years of age with lung cancer have been treated since 1964. Forty-eight received no therapy or chemotherapy and/or irradiation. Mean survival was 3.5 to 10 months, and only three (6%) survived for 2 years. Twenty-two of 32 patients selected for thoracotomy underwent resection for cure (70%). The operative mortality rate was 18% for resection, and 64% of the patients survived for at least 2 years. The incidence of exploratory thoracotomy decreased in the last 5 years of the study with the introduction of more rigorous preoperative evaluation. The poor survival rate without resection and the favorable survival rate following recovery from resection support the continued use of surgical resection for lung cancer in elderly patients, despite an increased operative risk.

Surfing injuries At waikiki.

A 56-month survey of 36 hospitalized patients injured while surfing off Oahu, Hawaii, indicated that 34% of the injuries involved the head and spine. Bodysurfing involves a considerable risk of craniospinal injury if the head is driven into the sand. The most frequent injury in surfboarding is being hit by a loose board. Risk of injury in surfboarding is approximately one per 17,500 surfing days--an incidence far below most sports.