Video-assisted thoracoscopic stapled wedge excision for indeterminate pulmonary nodules

Between June 1991 and July 1992, 118 patients (57 men and 61 women) underwent video-assisted thoracoscopy for indeterminate pulmonary nodules. Median age was 64 years (range 30 to 85 years). Thoracotomy was performed in 33 patients (28.0%) after thoracoscopy only because the nodule could not be located in 17 patients, was too large to safely resect in 5, appeared malignant in 4, and for technical reasons in 7. Eighty-five patients underwent thoracoscopic wedge excision. Twenty-one (24.7%) of these 85 patients also had thoracotomy--15 to perform formal lung resection for bronchogenic carcinoma, 3 for nondiagnostic abnormalities, 2 to locate a second nodule, and 1 for stapler malfunction. The remaining 64 patients (54.2%) had only video-assisted thoracoscopic wedge excision. A single wedge excision was performed in 56 patients, two in 6, and three in 2. Pathologic examination of these 74 nodules revealed a granuloma in 30, metastatic cancer in 25, hamartoma in 7, lymphoma in 1, and other benign lesions in 11. There were no deaths and only 4 (6.3%) complications in these 64 patients. The 64 patients treated by thoracoscopy only were compared with a similar group of 64 patients who had wedge excision via thoracotomy without prior thoracoscopy. Postoperative analgesic requirements were less in the patients treated by thoracoscopy. Median hospitalization in the thoracoscopy group was 3 days compared with 6 days in the thoracotomy group (p < 0.05). Median total charge for the thoracoscopy-only group was $12,898 as compared with $12,502 for patients undergoing wedge excision via thoracotomy. We conclude that thoracoscopic wedge excision is a safe and effective procedure in selected patients with an indeterminate pulmonary nodule. A significant number of patients (45.8%), however, required a thoracotomy to accomplish a safe operation or to ensure adequate staging and resection for malignancy. Although thoracoscopy reduces postoperative analgesia requirements and shortens hospital stay, total hospital charges were similar to charges for a wedge excision via thoracotomy.

Transhiatal esophagectomy for carcinoma of the esophagus

One hundred thirty-one patients (107 men and 24 women) underwent transhiatal esophagectomy for carcinoma of the esophagus. Median age was 65.3 years (range, 30 to 89 years). Signs and symptoms were present in 130 patients, which included dysphagia in 96 (73.3%) and weight loss (median, 7.7 kg) in 52 (39.7%). The cancer involved the gastroesophageal junction in 94 patients, the lower half of the intrathoracic esophagus in 25, the upper half in 10, and multiple sites in 2. An adenocarcinoma was present in 101 patients (77.1%), squamous cell carcinoma in 29 (22.1%), and adenosquamous cell in 1 (0.8%). The cancer was classified as stage 0 in 4 patients, stage I in 16, stage IIA in 26, stage IIB in 18, stage III in 65, and stage IV in 1. The stomach was used to replace the esophagus in all patients. Operative mortality was 2.3%. Anastomotic leak developed in 32 patients; 6 leaks were not clinically significant, 12 healed with drainage alone, and 14 required further surgical intervention. Follow-up ranged from 1 month to 6.7 years (median, 1.4 years). Currently, 42 patients are alive, 34 without evidence of recurrence. Overall 5-year survival was 20.8% and varied according to stage. Five-year survival was 47.5% for patients with stage I disease compared with 37.7% for patients in stage II and only 5.8% 4-year survival for patients in stage III. Cell type also influenced survival. Five-year survival for patients with adenocarcinoma was 27.1% compared with zero for patients with squamous cell carcinoma (p < 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Successful double-lung transplantation with direct bronchial artery revascularization

Double-lung transplantation with tracheal anastomosis has previously resulted in unacceptable ischemic complications of airway healing. Three patients underwent double-lung transplantation at our institution in 1986 and 1987, and 2 of these required later retransplantation because of airway complications. Recently, we began to perform direct revascularization of the bronchial arteries at their origin on the donor descending thoracic aorta, using recipient internal thoracic artery. Eight patients (2 male and 6 female patients; ages, 10-51 years) underwent nine double-lung transplantations with revascularization. The preoperative diagnoses in these patients were cystic fibrosis (2 patients), atrial septal defect and Eisenmenger's syndrome (1 patient), lymphagioleiomyomatosis (1 patient), bronchiectasis (1 patient), alpha 1-antitrypsin deficiency (1 patient), and primary pulmonary hypertension (2 patients); 1 underwent retransplantation because of pulmonary emboli. There have been no significant airway complications in any patient. Two patients died early postoperatively, 1 of early pulmonary dysfunction (at 1 day postoperatively) and 1 of subarachnoid hemorrhage (at 16 days postoperatively; tracheal healing was excellent in this patient). Follow-up in the remaining 6 patients ranged from 5 to 9 months. Internal thoracic artery angiography was performed on seven grafts, which documented patency of the internal thoracic artery in all seven and bronchial artery perfusion in six. Bronchoscopic examinations have demonstrated excellent airway healing in all six of these grafts, with no dehiscence, granulation, or narrowing of the trachea or distal bronchi. Ulceration of the tracheal anastomosis developed anteriorly in the remaining patient, which has resolved. We conclude that double-lung transplantation is an acceptable therapeutic approach when combined with bronchial artery revascularization, and early airway healing has been excellent.(ABSTRACT TRUNCATED AT 250 WORDS)

Equipment for thoracoscopy

The combining of miniaturized video technology with thoracoscopy now allows surgeons to perform a variety of thoracic procedures percutaneously. Both rigid and flexible video thoracoscopes are available. The rigid endoscope has a camera located proximally at the eye-piece and is capable of excellent resolution. However, visualization of the entire pleural cavity is difficult because of the rigid chest wall. Placing the video camera at the distal end of a flexible thoracoscope, as in the electronic video thoracoscope (EVE-L; Fujinon, Wayne, NJ), yields better visualization of these relatively inaccessible areas. However, disadvantages of the flexible thoracoscope include increased expense and complexity, reduced resolution as compared to rigid systems, and the need for a strobed light source, thus making video-assisted surgery more difficult. Thoracoscopic wedge excisions of the lung are now possible because of the adaptation of gastrointestinal staplers for percutaneous use. The initial design consisted of a reloadable 30-mm disposable stapler. Newer models, however, have a longer staple line and some are reusable. Future refinements may allow the head of the instrument to articulate, thus permitting it to be applied to the lung at various angles. Thoracoscopic ports that provide an air-tight seal are available but are not essential; therefore, standard thoracotomy instruments can be utilized through small open incisions. Specialized disposable thoracoscopic instruments are also available, including scissors, dissectors, and fan retractors. It is hoped that the future will bring improved optics, better staplers, and refined percutaneous instrumentation.

Determinants of survival and recovery of left ventricular function after aortic valve replacement

To determine factors that influence survival and recovery of ventricular function in patients undergoing aortic valve replacement in the current surgical era, baseline risk factors related to outcome were analyzed in 1,012 consecutive patients undergoing aortic valve replacement between 1983 and 1990. Forty-two percent of patients underwent concomitant coronary bypass. Observed survival probabilities (expressed as 30-day/5-year) were 0.97/0.81 overall, 0.99/0.89 for patients aged less than 70 years, and 0.95/0.74 for patients aged 70 years or greater. Advanced age (p < 0.0001), decreased ejection fraction (p < 0.0001), extent of coronary disease (p < 0.006), smaller prosthetic valve (p < 0.03), and advanced New York Heart Association class (p < 0.04) were incremental risk factors for mortality. In patients with preoperative ventricular dysfunction (ejection fraction < or = 0.45), ejection fraction measured 1.4 years after aortic valve replacement improved in 72% and the mean increment in ejection fraction was 0.175 (95% confidence interval, 0.154 to 0.195). The increment in ejection fraction was greater in female patients than in male patients (p < 0.02) and greater in patients without than with coronary disease (p < 0.02). Female sex (p < 0.02) and lesser extent of coronary disease (p < 0.05) were independent predictors of change in ejection fraction. In all patients, early improvement in ejection fraction conveyed an independent subsequent survival benefit (p < 0.0001). The results of aortic valve replacement in the current era are excellent, and the majority of patients with ventricular dysfunction demonstrate significant improvement. Early improvement in ejection fraction, influenced by coexistent coronary artery disease and sex-associated factors, importantly affects subsequent survival.

Epiphrenic diverticulum: results of surgical treatment

From 1975 to 1991, 112 patients (64 men and 48 women) were found to have an epiphrenic diverticulum. Symptoms were absent or minimal in 71 patients and incapacitating in 41. All patients with minimal symptoms were managed conservatively; 35 were available for follow-up, which ranged from 1 to 25 years (median, 9 years). None of these 35 patients had clinically significant progression of symptoms. Surgical repair was done in 33 patients with incapacitating symptoms. Achalasia was present in 8 of the surgical patients (24.2%), diffuse esophageal spasm in 3 (9.1%), hypertensive lower esophageal sphincter alone in 1 (3.0%), and nonspecific motor abnormalities of the esophageal body in 7 (21.2%). Diverticulectomy and esophagomyotomy were performed in 22 patients, diverticulectomy alone in 7, esophageal resection in 3, and esophagomyotomy alone in 1. Concomitant hiatal hernia repair was done in 6 patients. Complications occurred in 11 patients; 6 had esophageal leaks. There were three operative deaths (9.1%), all occurring in patients with abnormal manometry. Follow-up was complete in 29 patients and ranged from 4 months to 15 years (median, 6.9 years). Long-term results were excellent in 14 patients (48.2%), good in 8 (27.6%), fair in 5 (17.2%), and poor in 2 (6.9%). We conclude that operation has significant risks and is not warranted in patients with minimal symptoms because progression is unlikely. Surgical treatment, however, is advisable in patients with incapacitating symptoms because most operative survivors will have long-term symptomatic palliation.

Ischemia of the interventricular septum. A mechanism of right ventricular failure during mechanical left ventricular assist

Right ventricular failure has been noted in up to 25% of patients requiring a left ventricular assist device. Altered septal motion or function is one proposed mechanism of right ventricular failure during left heart bypass. We studied the effect of regional ischemia and reperfusion of the interventricular septum on right ventricular function during complete left heart bypass. In six calves the septal perforating branches of the proximal left anterior descending coronary artery were isolated for intermittent occlusion. Complete left heart bypass was established with a Pierce-Donachy left ventricular assist device. Right and left ventricular function were studied with two-dimensional echocardiography and with intraventricular pressure monitors. Establishment of left heart bypass did not significantly affect right ventricular developed pressure, right ventricular end-diastolic area, or right ventricular fractional change in area. Left heart bypass significantly (p less than 0.001) decreased percent systolic septal wall thickening. Septal ischemia during left heart bypass resulted in a decrease in right ventricular developed pressure (p = 0.09), significant increase in right ventricular end-diastolic area (p = 0.002) and significant decrease in right ventricular fractional change in area (p less than 0.001), and a further decrease in interventricular septal wall thickening (p = 0.016). The interventricular septum became thin with flattening of its normal contour. Septal reperfusion resulted in right ventricular recovery with significant improvement in all factors (p less than 0.02). Similar results were documented during a second episode of septal ischemia with recovery after septal reperfusion. In some cases, septal ischemia may be an important factor in the development of right ventricular failure during left heart bypass.

Long-term results of aortic valve replacement with nonviable homografts

Between 1965 and 1972, 250 patients (186 men and 64 women; median age, 48 years) underwent aortic valve replacement with homografts preserved with beta-propiolactone (98 patients) or irradiation (152 patients); operative mortality was 6% (15 patients). Follow-up to death, reoperation, or recent evaluation was completed in 95% of patients, and median follow-up time was 11.4 years. Thromboembolic events occurred in two patients (0.21 events/100 patients/yr). Risk of reoperation was 22% at 5 years, 62% at 10 years, 85% at 15 years, and 95% at 20 years. Factors associated with increased risk of reoperation were young age, male sex, native aortic valve insufficiency, previous aortic valve surgery, history of endocarditis, and larger homograft size. Survival at 5, 10, 15, and 20 years was 85%, 66%, 53%, and 38%, respectively. Late survival was diminished in older patients and those with native aortic valve insufficiency and coronary artery disease. Aortic valve replacement with nonviable homografts has a high risk of late tissue degeneration and need for reoperation. However, the incidence of thromboemboli is minimal, and grafts can be replaced with low risk (4.5%) so that overall patient survival is similar to that observed with other bioprosthetic or mechanical heart valves.

Bronchoalveolar carcinoma: factors affecting survival

One hundred thirty-four consecutive patients (65 men and 69 women) underwent pulmonary resection for bronchoalveolar carcinoma. Mean age was 65 years. Lobectomy was done in 100 patients, pneumonectomy in 10, segmentectomy in 5, and wedge excision in 19. Only 10 patients had lymph node metastases (7.5%). The neoplasm was solitary in 111 patients (82.8%); 97 were in stage I, 4 were in stage II, 9 were in stage IIIa, and 1 was in stage IIIb. There were two operative deaths (1.5%). Thirty-nine complications occurred in 31 patients. Median follow-up was 5.1 years. Recurrent bronchoalveolar carcinoma developed in 45 patients. Five- and 10-year survival for patients in stage I was 75.2% and 62.0%, respectively. Survival for patients with T1 N0 M0 neoplasms was identical to expected survival and was 90.5% at 5 years, as compared with 55.4% for patients with T2 N0 M0 disease, only 35.9% for patients with multiple bilateral disease, and 0.0% for patients with bilateral disease (p less than 0.0001). Other significant factors adversely affecting survival included the presence of signs and symptoms, diffuse malignant invasion, mucin-producing tumors, and the histological absence of scar. We conclude that bronchoalveolar carcinoma has a unique natural history that is more influenced by local neoplastic processes than by lymph node metastases. Early aggressive pulmonary resection is safe and offers the potential for cure. The presence of bilateral cancer, however, is ominous.

Histologic comparison of experimental coronary artery bypass grafts. Similarity of in situ and free internal mammary artery grafts

This study compares patency and histologic structure of in situ internal mammary artery grafts, free internal mammary artery grafts, stripped, free internal mammary artery grafts, and stripped, free superficial femoral artery grafts (a muscular artery model) in a canine model of coronary artery bypass. Twenty-four adult mongrel dogs underwent bypass of the circumflex coronary artery with one of the above grafts. Three months postoperatively, graft patency was assessed by angiogram, and postmortem specimens were studied by intraluminal injection of a dilute barium solution proximal to the graft. Proximal, mid, and distal segments of each graft were examined microscopically. In situ internal mammary artery grafts and free internal mammary artery grafts were not significantly different in regard to patency, vascular wall cellular structure, or perfusion of the vasa vasorum. The stripped, free internal mammary artery group had a higher incidence of thrombosis, intimal thickening, and medial injury than the pedicled (in situ and free internal mammary artery) grafts. This difference may be due to early vascular wall ischemia as a result of poor early perfusion of the vasa vasorum. The stripped, free superficial femoral artery grafts were all patent, but all had adventitial injury.

Pulmonary aspergilloma. Results of surgical treatment

Between 1953 and 1984, 53 patients (40 male and 13 female) underwent thoracotomy for treatment of pulmonary aspergilloma. The median age was 58 years (range 4 to 86 years). Either underlying lung disease or immunologic risk factors were present in 49 patients (92%). Twenty-one patients (31%) had simple aspergilloma and 32 (47%) had complex aspergilloma. The most common indication for operation was an indeterminate mass, hemoptysis, or severe cough. Lobectomy, wedge excision, and pneumonectomy were the most frequent operations. Complications occurred in 78% of patients with complex aspergilloma and in 33% of patients with simple aspergilloma (p = 0.002). Operative mortality was 5% (one death) in patients with simple aspergilloma and 34% (11 deaths) in patients with complex aspergilloma (p = 0.01). Cause of death was respiratory failure in four patients, underlying pulmonary disease in three, aspergillosis in two, and other conditions in three. At follow-up, 84% of operative survivors with simple aspergilloma were alive and well compared with 43% of those with complex aspergilloma. Although operative mortality in patients with complex aspergilloma was high, 67% of the survivors had a good long-term result in terms of absence of symptoms, but they frequently died of underlying disease. In contrast, operation in patients with simple aspergilloma was done with low risk, and approximately 90% of survivors had a good late result. Late appearance of contralateral disease did occur and argues for rigorous postoperative surveillance.

Selective management of blunt splenic trauma

During a recent 8-year period, 235 patients with documented blunt splenic trauma were treated. After exclusion of 39 patients with early deaths (19 dead on arrival, nine died in emergency room, and 11 died in operating room), the 196 remaining patients were treated in accordance with an evolving selective management program. Definitive management included splenectomy in 117 patients (59.7%), repair in 32 (16.3%), and nonoperative treatment in 47 (24%). A spectrum of blunt splenic trauma, as manifested by the degree of associated injuries (Injury Severity Scores), hemodynamic status, and blood transfusion requirements, was identified and permitted application of a rational selective management program that proved safe and effective for all age groups. Comparative analysis of the three methods of treatment demonstrated differences that were more a reflection of the overall magnitude of total bodily injury sustained rather than the specific manner in which any injured spleen was managed. Retrospective analysis of 19 nonoperative management failures enabled establishment of the following selection criteria for nonoperative management: absolute hemodynamic stability; minimal or lack of peritoneal findings; and maximal transfusion requirement of 2 units for the splenic injury. With operative management, splenorrhaphy is preferred, but it was often precluded by associated life-threatening injuries or by technical limitations. Of 42 attempted splenic repairs, ten (24%) were abandoned intraoperatively. There were no late failures of repair. In many cases of blunt splenic trauma, splenectomy still remains the most appropriate course of action.

The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma

Analysis of 164 percutaneous chest tube thoracostomies performed as a standardized technical procedure in the management of 129 blunt trauma victims demonstrated an overall complication rate of 9.1% (15 of 164). Three complications (1.8%) were related to problems of insertion, and four (2.4%) represented the problem of pneumothorax after chest tube removal. The remaining eight complications (4.9%) were associated with positive bacterial cultures, two (1.2%) of which represented clinical empyema. Both cases of empyema had either prolonged chest tube placement (23 and 15 days) or multiple chest tubes (two and three) on the same side. Percutaneous chest tube thoracostomy remains an important facet in the management of certain types of blunt thoracic trauma. Associated risks can best be minimized with adherence to a standardized technique and management protocol.

Penetration of cefazolin into normal and osteomyelitic canine cortical bone

The ability of cefazolin to cross the capillary membrane and its concentrations in the interstitial fluid spaces were studied in normal and osteomyelitic canine bone. The maximum extraction after a single capillary passage and the net extraction after 3 min, determined with triple-tracer indicator-dilution techniques, demonstrated that cefazolin readily traversed the capillaries of normal and osteomyelitic bone. These studies suggest that the altered pathophysiology of osteomyelitic tissue and the complex diffusional characteristics of cefazolin enhanced the ability of this agent to cross the endothelial cells lining the capillaries of osteomyelitic bone. Volume of distribution studies demonstrated that cefazolin was distributed in the plasma and interstitial fluid spaces of normal cortical bone. Although these spaces were increased 330 and 941% in osteomyelitic tissue, the distribution of cefazolin increased proportionally. There was a direct correlation between the calculated concentrations of cefazolin in the interstitial fluid spaces of normal and osteomyelitic cortical bone and the simultaneous serum levels in animals in which a steady-state equilibrium had been achieved. These studies suggest that a physiological barrier or concentration gradient for cefazolin does not exist in normal or osteomyelitic bone. Cefazolin can cross the capillary membranes of bone and achieve bactericidal concentrations in the interstitial fluid space of normal and osteomyelitic tissue.