Clinical experience with carinal resection

OBJECTIVE

Pathologic processes that involve the carina pose a tremendous challenge to thoracic surgeons. Although techniques have been developed to allow primary resection and reconstruction, few institutions have accumulated sufficient experience to allow meaningful conclusions about the indications and the morbidity and mortality rates for this type of surgery.

METHODS

Since 1962, 135 patients have undergone 143 carinal resections (134 primary resection, 9 re-resection) at our institution. Indications for carinal resection included bronchogenic cancer (58 patients), other airway neoplasms (60 patients), and benign or inflammatory strictures (16 patients). Thirty-seven patients (28%) had a history of prior lung or airway surgery not involving the carina. Carinal resection without pulmonary resection was accomplished in 52 patients; 57 patients had carinal pneumonectomy (44 right, 13 left); 14 patients had carinal plus lobar resection, and 11 patients had carinal resection after pneumonectomy (9 left, 2 right). There were 15 different modes of reconstruction, based on the type and extent of resection. Techniques were used to reduce anastomotic tension.

RESULTS

The operative mortality rate in the 134 patients after primary carinal resection was 12.7%. Adult respiratory distress syndrome was responsible for 9 early deaths. Predominant predictors of operative death included postoperative mechanical ventilation (P =.001), length of resected airway (P =.03), and development of anastomotic complications (P =.04). Mortality rates varied by the type of procedure and the indication for resection. Left carinal pneumonectomy was associated with a high operative mortality rate (31%). Complications were noted in 52 patients (39%), including atrial arrhythmias (20 patients) and pneumonia (11 patients). Anastomotic complications, both early and late, were seen in a total of 23 patients (17%) and resulted in death or surgical reintervention in 21 patients (91%). The operative mortality rate for carinal re-resection was 11.1%.

CONCLUSIONS

Carinal resection with primary reconstruction may be accomplished with acceptable mortality rates, but the underlying pathologic process and chance for long-term survival must be carefully considered before the operation is recommended, especially in the case of left carinal pneumonectomy. Anastomotic complications exact a heavy toll on involved patients. Careful patient selection and meticulous anesthetic and surgical technique remain the key to minimizing morbidity and mortality rates.

Chest wall constriction after too extensive and too early operations for pectus excavatum

BACKGROUND AND METHODS

Since 1990 we have evaluated 12 children and teenagers in whom severe cardiorespiratory symptoms have developed due to failure of chest wall growth after very extensive pectus excavatum operations (removal of five or more ribs) at very early ages (< 4 years).

RESULTS

Apparently these extensive procedures have removed or prevented growth center activity, which resulted in restriction of chest wall growth with marked limitation of ventilatory function. The forced vital capacity ranged from 30% to 50% of predicted and the forced expiratory volume in 1 second from 30% to 60%. All patients are symptomatic with mild exercise and cannot compete in running games. Our protocol for critical evaluation includes exercise pulmonary function studies and axial computed tomographic reconstruction.

CONCLUSIONS

This report is an alert to recognize such patients and also to recommend delay in operative repair in small children until at least 6 to 8 years of age. The younger the patient the more limited the chest wall resection for pectus excavatum should be. Five of these patients have had a chest cavity expansion operation with encouraging early results.

The role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract: friend or foe?

OBJECTIVE

To evaluate the role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract.

DESIGN

Prospective study; institutional review board-approved clinical trial.

SETTING

Tertiary care pediatric medical center.

PATIENTS

Fifteen patients; choanal atresia in 5 patients, airway stenosis in 8 patients, hypopharyngeal stenosis in 1 patient, and esophageal stenosis in 1 patient.

OUTCOME

The efficacy and safety of mitomycin in the prevention of scar formation.

INTERVENTION

All patients underwent surgical repair of the stenotic area, followed by topical application of mitomycin (1 mL of 0.4 mg/mL) for 4 minutes.

RESULTS

Ten patients (67%) showed major improvement, 4 patients (27%) showed minor improvement, and 1 patient (7%) showed no improvement.

CONCLUSION

Topical application of mitomycin can play an effective role in the prevention and treatment of scar formation in the aerodigestive tract.

Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients

OBJECTIVE

Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. However, up to now, only scant information exists on chronic postoperative pain and discomfort in patients who underwent video-assisted thoracoscopy. Therefore, a retrospective study was performed with the aid of a self-reported questionnaire.

METHODS

Two hundred and thirteen patients (of whom 79 females) with a mean age of 48 (range 15-88) years were operated on for a total of 225 procedures. Thoracoscopy was performed for pneumothorax (n=70), pulmonary nodules (n=44), interstitial lung diseases (n=20), pleural effusion (n=20), and empyema (n=19). Various indications included therapeutic or diagnostic procedures in bullous disease, mediastinal tumors, carcinoma, inflammatory lung disease, hyperhidrosis mani and bronchiectasis.

RESULTS

Mean drainage time was 6.0+/-4.7 days and hospital stay 8.4+/-6.6 days. One patient died on the ninth postoperative day after lobectomy for bronchial carcinoma due to cardiac failure, five patients needed a short period of reintubation due to acute respiratory failure. In two patients, thoracoscopic reoperation was necessary for closure of bronchopleural fistula. The self-reported questionnaire was returned by 173 (81%) of all patients within a mean follow-up of 18 (3-38) months. More than half of the patients (53%) reported no thoracic pain as early as 2 weeks after the procedure. At 2 weeks after the operation, 13% of patients suffered from localized pain and 31% from diffuse discomfort. Twelve percent needed pain medication regularly, and 3% occasionally. At 6 months postoperatively, three quarters of the patients had no complaints, 5% suffered from scar pain, and 20% had diffuse chest discomfort. One year after the procedure, 86% of the patients had no complaints, 9% suffered from minimal pain, and 5% from moderate pain. Two years after the procedure, 96% of the patients had no complaints at all. One hundred and twenty-five of the 140 patients (89%) working preoperatively went back to work within 2 weeks after the operation. Fifteen patients did not work between 3 and 16 weeks; 14 due to chest pain, one due to shoulder pain.

CONCLUSION

Video-assisted thoracoscopy permits very early recovery with rapid reintegration into the working process. Long-term complaints after videothoracoscopy are rare.

Congenital lung malformations?antenatal and postnatal evaluation and management

We reviewed our institutional experience with pulmonary resection for congenital bronchopulmonary malformations and analysed the management and outcome of pregnancies with a prenatal diagnosis of congenital lung malformations. Between January 1993 and December 2003, 31 patients underwent evaluation and pulmonary resection for bronchopulmonary malformations. Common clinical presentations were respiratory distress (9), respiratory infections/pneumonias (22), and dyspnoea (9). Diagnostic modalities included chest radiography, CT scan (22), MRI scan (7), arteriography (1), and bronchoscopy (5). There were 13 congenital cystic adenomatoid malformations (CCAM), six pulmonary sequestrations, three bronchogenic cysts, and nine congenital lobar emphysemas (CLE). Fifteen patients who underwent resection were diagnosed by antenatal ultrasound. No foetus had hydrops or associated malformations. No pregnancy was terminated. There was no foetal demise. Regression of the sonographic appearance was observed in six cases. Amniotic puncture was required for hydramnios in three cases. Eight emergency resections were performed (CCAM 4; CLE 3; Bronchogenic cyst 1). Surgical procedures included 24 lobectomies, one right middle lobectomy with a wedge resection of the right lower lobe, one completion right lower lobectomy, four sequestrectomies, one mediastinal mass excision and one wedge resection for a bronchogenic cyst. There were no deaths. Postoperative complications included: persistent air leak (n=2; one requiring completion lobectomy) and pneumothorax (1). Persistent mild symptoms were present in five patients, at long-term follow-up. Congenital cystic adenomatoid malformation and congenital lobar emphysema were the commonest congenital anomalies. Congenital lung malformations are increasingly diagnosed antenatally, sometimes necessitating emergent surgical resection. The natural history is variable. All infants with a prenatal diagnosis require postnatal evaluation. Patients should be evaluated for associated disorders. The presence of mass effects is an indication for therapeutic decompression. The risk of pulmonary compression, infection and malignant degeneration makes resection imperative, even in asymptomatic patients. Lobectomy is the procedure of choice, is well tolerated, and leads to excellent outcomes.

Regenerative medicine as applied to general surgery

The present review illustrates the state of the art of regenerative medicine (RM) as applied to surgical diseases and demonstrates that this field has the potential to address some of the unmet needs in surgery. RM is a multidisciplinary field whose purpose is to regenerate in vivo or ex vivo human cells, tissues, or organs to restore or establish normal function through exploitation of the potential to regenerate, which is intrinsic to human cells, tissues, and organs. RM uses cells and/or specially designed biomaterials to reach its goals and RM-based therapies are already in use in several clinical trials in most fields of surgery. The main challenges for investigators are threefold: Creation of an appropriate microenvironment ex vivo that is able to sustain cell physiology and function in order to generate the desired cells or body parts; identification and appropriate manipulation of cells that have the potential to generate parenchymal, stromal and vascular components on demand, both in vivo and ex vivo; and production of smart materials that are able to drive cell fate.

Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11%). These 39 patients had been symptomatic for an average of 134 months. They were all taking H2-blocking agents (21%) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisone (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antireflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.

Predictors of change in postoperative pulmonary function in adolescent idiopathic scoliosis: a prospective study of 254 patients

STUDY DESIGN

A multicenter study of prospectively collected pulmonary function testing and radiographic measures in patients surgically treated for adolescent idiopathic scoliosis (AIS).

OBJECTIVE

The objectives of this study were 1) to identify the factors that determine pulmonary function more than 2 years after surgery for AIS; and 2) to determine what factors, if any, can predict an increase or decrease in the percent predicted 2-year pulmonary function.

SUMMARY OF BACKGROUND DATA

Thoracic spinal deformity can lead to significant pulmonary impairment. Studies have shown that patients with AIS experienced a significantly greater improvement in pulmonary function at 2 years after surgery when treated with a posterior approach compared to an anterior approach.

METHODS

Pulmonary function testing (PFT) and radiographic examination of 254 patients with AIS were completed prospectively. Demographic data, associations between radiographic measurements of spinal deformity, and the results of spirometry underwent correlation analysis and subsequent step-wise multiple regression analysis.

RESULTS

The variables found to be significant predictors of 2-year pulmonary function (FVC, FEV1, TLC) include: preop PFT (R = 0.20-0.39), having an open thoracotomy (as opposed to thoracoscopic or posterior) (R = 0.07-0.09), surgical time (R = 0.03-0.07), and thoracoplasty (R = 0.02-0.04). These models explain 40 to 51% of the variance in 2-year PFT. For patients undergoing open thoracotomy with a thoracoplasty, approximately 54% had a 15% decrease, or more, in percent predicted PFT. This compared with 11% and 15%, respectively of patients who either had posterior or thoracoscopic procedures with no thoracoplasty that had a 15% decrease or more in percent predicted PFT.

CONCLUSION

Aside from preoperative PFT values, open anterior approaches predict the largest percent of variance in 2-year PFT. Additionally, a clinically significant reduction in the predicted 2-year pulmonary function is more likely when performing a thoracoplasty. The magnitude of the effects for both these variables, however, is modest. This may facilitate the decision-making process as regards to operative intervention.

The risk of sudden infant death from gastroesophageal reflux

Gastroesophageal reflux (GER) has been a suspected cause of infant deaths and sudden infant death syndrome (SIDS). We examined our 10-year experience with 499 consecutive infants 6 months of age or less who had extended (18 to 24 hours) esophageal pH monitoring performed to evaluate for GER. The data extracted from the esophageal pH records included the pH score, the pattern of GER (type I, II, or III), and the mean duration of reflux during sleep (ZMD). All infants were followed to determine the occurrence and cause of death during the first year of life. Of the 19 deaths found in the series, three were classified as SIDS and two were in-hospital deaths caused by reflux-induced aspiration. All five of these infants who died had a prolonged ZMD (greater than 3.8 minutes) and received either basic medical (n = 4) or no (n = 1) antireflux therapy. Four infants also had the type I pattern of GER. There was a 9.1% (4/44; 95% confidence limits, 2.5% to 21.7%) incidence of reflux-related or SIDS deaths in infants with type I GER and a prolonged ZMD who were treated nonoperatively, compared with none (0/83, P = .03) in the same group of infants treated with antireflux surgery. The incidence of SIDS was higher in infants with type I GER and a prolonged ZMD who were treated nonoperatively (3/44, 6.8%) compared with all other infants treated nonoperatively (0/265, 0%; P = .003).(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of CO2 laser surgery of the aerodigestive tract: experience of 4416 cases

The CO2 laser was first introduced for surgery of the aerodigestive tract in 1971. Since that time, great advances in application have been made in both the adult and pediatric population. Recent reports of isolated complications have appeared in the literature. However, a realistic complication rate in a large series of patients has yet to be reported. This report relates the combined experience of the authors in a total of 4416 cases during the 11-year period from 1971 to 1982. There were nine instances of complications, representing a complication rate of 0.2%. These complications provided a unique learning experience for the authors, and led to the establishment of certain basic principles that should be followed in all laser operations. This survey indicates that the CO2 laser is a safe, extremely useful surgical modality in the aerodigestive tract.

Management of malignant esophagorespiratory fistula

Esophagorespiratory communication developed in 46 patients among 570 with esophageal cancer. Therapy was basically palliative and aimed at mechanical interruption of the fistula, restoration of esophageal continuity, and avoidance of external tubes and appliances. Supportive therapy, gastrostomy, tracheostomy, and esophageal exclusion and diversion procedures resulted in little prolongation of life and poor palliation of the patient. Permanent endoesophageal intubation with tubes of the Celestin variety resulted in best palliation with minimal operative risk for most terminal patients. Colon bypass and occasional resection can accomplish the same goal and possibly provide long-term survival in good-risk, young patients with small tumors.

Complications to tracheostomy and long-term intubation: a follow-up study

Hospital records of 79 patients treated with tracheostomy or long-term intubation from 1969 to 1971 were reviewed, and the 43 surviving patients were examined by laryngoscopy, x-ray and spirometry for complications subsequent to these treatments. Early complications included one tube occlusion and one case of postextubation stridor in each group, one dislocated tube, one bilateral pneumothorax, and one case of fatal innominate arterial hemorrhage in the tracheostomy group, and two cases of atelectasis in the long-term intubation group. Necropsy findings included necrotic ulcers in the larynx of intubated patients and eroded tracheal mucosa in both groups. Late complications in surviving patients were prolonged hoarseness in six patients treated with prolonged intubation, two of whom had also had tracheostomy. Radiologically verified tracheal stenosis (40-60%), four at the stoma level and one at the cuff level, all occurred in the tracheostomy group.

Morphine administration in horses anaesthetized for upper respiratory tract surgery

OBJECTIVE

To determine the effect of morphine administration on commonly monitored cardio-respiratory variables and recovery quality in horses undergoing anaesthesia and surgery.

STUDY DESIGN

Prospective, randomized clinical study.

ANIMALS

Thirty-eight thoroughbred horses, 32 geldings and six mares, 3-13 years old, weighing 411-600 kg.

MATERIALS AND METHODS

A standard anaesthetic technique was used. Twenty minutes after induction of anaesthesia horses received 0.1 mg kg(-1) (0.1 m) or 0.2 mg kg(-1) (0.2 m) morphine by intravenous injection. A control group did not receive morphine. Heart rate, respiratory rate (fr), mean arterial pressure (MAP) and blood gases were measured before morphine administration and every 10 minutes thereafter. Horses were positioned for 35 minutes in right lateral recumbency for tension palatoplasty by cautery and were then moved into dorsal recumbency for additional intraluminal surgery comprising one or more of aryepiglottic fold resection, sub-epiglottal mucosal resection, ventriculectomy and cordectomy. A subjective recovery score from 0 (worst) to 5 (best) was assigned by a single observer who was unaware of treatment group. Two-way repeated measures anova, one-way anova, Kruskal-Wallis test, Mann-Whitney test, Pearson and Spearman correlation coefficients, and chi-squared tests were used to analyse the data where appropriate.

RESULTS

Arterial partial pressure of oxygen (PaO(2)) decreased significantly over time and was significantly lower in horses that received morphine. One horse in the control group and two horses in each of the morphine groups had a PaO(2) <13 kPa. No other significant cardiopulmonary effects were detected. Recovery scores [median (range)] were higher in morphine recipients: 4 (2-5) in 0.1 m, 4 (3-5) in 0.2 m compared with 3 (2-4) in the control group.

CONCLUSIONS AND CLINICAL RELEVANCE

The lower PaO(2) in morphine recipients did not appear to be of clinical significance in healthy horses because the number of horses with a low PaO(2) was similar between groups. The quality of recovery was significantly better in morphine recipients. These results indicate that morphine may be considered for use in clinical cases although further work is required to assess the analgesic properties of the drug in this species.

Review of pediatric airway malacia and its management, with emphasis on stenting

Malacia of the pediatric airway presents itself in a variety of clinical circumstances. Pediatric airway stenting is a more recent treatment modality. Complications may necessitate stent removal. This is usually performed bronchoscopically. We were forced to surgically remove a complicated airway stent. The Palmaz stent had been inserted for bronchomalacia presenting after interrupted aortic arch surgery in a 4-month old child with DiGeorge syndrome. This prompted us to review pediatric airway malacia, its management options and long-term outcomes, in an attempt to crystallize the current status of this relatively uncommon and difficult issue. The role of stents is analysed.

Is general thoracic surgical practice evidence based?

BACKGROUND

In evidence-based medicine clinical decisions are based on experimental evidence of treatment efficacy. There are no data on the extent to which general thoracic surgical practice is evidence based.

METHODS

A list of 50 thoracic surgical treatments was derived from the operating room log of one surgeon practicing at both a tertiary care cancer center and an affiliated community general hospital. Minor diagnostic procedures and procedures performed as part of experimental protocols were excluded. For each treatment a Medline search was done to obtain the best published evidence supporting the treatment's efficacy. The evidence was then placed in one of three categories developed by the Oxford Centre for Evidence-Based Medicine: (1) evidence from randomized controlled trials (RCTs); (2) convincing non-experimental evidence; and (3) interventions without substantial evidence.

RESULTS

Category 1 evidence supported 7 of 50 thoracic surgical treatments. Category 2 evidence supported 32 treatments, and 11 treatments were without substantial supportive evidence.

CONCLUSIONS

The majority of commonly performed general thoracic surgical procedures are supported by nonexperimental evidence. Although there are many obstacles to the performance of surgical randomized controlled trials, the limitations of nonrandomized studies are such that continued emphasis on randomized controlled trials in general thoracic surgery is warranted. This study could serve as a baseline reference for future assessments of evidence-based medicine in general thoracic surgical practice.

Tracheoesophageal compression from aortic arch anomalies: analysis of 30 operatively treated children

During a 16-year period (1976 to 1992), 30 children underwent surgery for tracheoesophageal compression caused by aortic arch anomalies. The age range was 3 days to 12 years (median, 3 months); 19 (63%) were male, and 20 (67%) were white. Of the 30 patients, 10 had a double aortic arch (the left was atretic in 6), 5 had a left-sided arch with an aberrant right subclavian artery (4) or innominate artery (1), and 15 had a right-sided arch with an aberrant left subclavian artery (14) or with mirror-image branching (1). There was no mortality during hospitalization or within 30 days of surgery. The left ductus arteriosus was divided in 26 of the 30 patients. Among the 10 patients with a double aortic arch, division of the atretic left arch (6), the lesser left arch (3), or the lesser right arch (1) was carried out. All 4 patients with a left arch and aberrant right subclavian artery had division of the artery. Of 14 patients with a right arch and aberrant left subclavian artery, only 3 underwent division of the artery. Of the 30 patients, anterior arteriopexy was performed in 9 (30%), and reoperation for persistent symptoms was necessary in 4 (13%). The second operation usually consisted of aortopexy or tracheopexy. Of the 4 patients with associated cardiac anomalies, 2 underwent simultaneous cardiac repair. The duration of hospital stay for the 30 patients ranged from 4 to 148 days (median, 6 days). Excluded from this series are patients with vascular rings who were asymptomatic and patients with the pulmonary vascular sling syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

The Cardiac Surgery Advanced Life Support Course (CALS): Delivering Significant Improvements in Emergency Cardiothoracic Care

BACKGROUND

A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients.

METHODS

Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints.

RESULTS

The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011).

CONCLUSIONS

Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.

Utility of three-dimensional computed tomography in general thoracic surgery

It is important for general thoracic surgeons to understand the relationship between tumors and surrounding organs during surgery; however, many anatomical variations are possible in the thorax, which can complicate this goal. Multidetector computed tomography (MDCT) is the latest technical breakthrough in CT imaging. MDCT permits rapid scanning of large areas of the body with multiple detectors, thereby allowing for simultaneous acquisition of an increased number of transaxial CT slices, which reduce motion artifacts. Three-dimensional (3D) rendering involves the creation of two-dimensional images that convey the 3D relationship of objects. The 3D reconstruction allows for enormous quantity of data to be utilized intuitively and effectively. The final images can reveal various lesions or organs of interest with high anatomical detail and accuracy to the general thoracic surgeon, which is helpful in performing safer surgeries. Surgeries for the following can benefit from this technology: lung lobectomy or segmentectomy, pulmonary sequestration, cardiovascular malformation, tracheobronchial tree, mediastinum, and chest wall. This article reviews the utility of 3D-MDCT imaging in the field of general thoracic surgery.

Effects of antireflux procedures on respiratory symptoms

BACKGROUND

Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience.

METHODS

Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18.

RESULTS

Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in-respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement (p < 0.05).

CONCLUSIONS

Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.