Postpneumonectomy and Postlobectomy Empyema

Although similar strategies are used in the management of PPE and PLE, these conditions need to be viewed as two separate entities. For the purpose of devising the appropriate management strategy, PPE should be divided into early and late, with and without mediastinal induration and extensive pleural space contamination. If at all possible, PLE should be managed as a postpneumonic empyema with prolonged chest tube drainage. The key to these conditions is prevention.

Sarcoidosis: still a mystery?

Sarcoidosis is a systemic granulomatous disease of unknown etiology. It has diverse clinical manifestations, most frequently including pulmonary disorders. It is associated with immunological abnormalities, the intricacies of which have yet to be clearly delineated. In the immunologically susceptible individual, genetic, environmental, nutritional, and socioeconomic factors may play a governing role in its development. Sarcoidosis is a diagnosis of exclusion established by clinical manifestations, radiologic findings, and histologic evidence of noncaseating epithelioid-cell granulomas in >1 organ. We will discuss parameters that are helpful in making this diagnosis.

Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients

BACKGROUND

The treatment of primary spontaneous pneumothorax in young adults has been controversial. Conventional treatment consisting of chest tube thoracostomy may be associated with morbidity at the time of tube insertion, prolonged hospitalization, and interval operation in many patients. As spontaneous pneumothorax in young adults is usually associated with apical blebs, we hypothesized that video-assisted thoracic surgical (VATS) resection of the blebs at the time of the first pneumothorax may be an effective treatment associated with low morbidity and short hospital stays.

METHODS

From July 1992 to February 2001, 156 young adults were treated for spontaneous pneumothorax. Within 12 hours of presentation to the emergency department patients underwent semielective VATS with bleb resection and pleuradesis. During follow-up patients were observed for recurrent pneumothorax.

RESULTS

There were 69 men (44%) and 87 women (56%). The median age was 19 years old (range 14 to 38 years old). Patients were predominantly tall and thin. Patients were mildly symptomatic at the time of presentation. Apical blebs were seen in all patients and the presence of blebs was confirmed in the pathologic specimen. In 23 patients bleeding was associated with bleb rupture. There were no postoperative air leaks. The mean hospital stay was 2.4 +/- 0.5 days. Follow-up ranged from 2 to 96 months (median 62 months). There were no recurrences on the index side.

CONCLUSIONS

VATS resection of apical blebs is associated with low morbidity and short hospitalization and provides an attractive alternative to the conventional treatment of initial tube thoracostomy and possible interval repeat thoracostomy or operation. VATS may be an effective first line treatment for spontaneous pneumothorax in young adults. Due to the pathophysiology of this disease, patients should be closely followed for the occurrence of pneumothorax on the contralateral side.

Percutaneous endoscopic gastrostomy before multimodality therapy in patients with esophageal cancer

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has not been widely used in esophageal cancer because of concerns about safety of dilatation, suitability of the stomach as an esophageal replacement, and potential for inoculation metastasis.

METHODS

Experience with PEG in consecutive patients presenting with new esophageal cancer from March 1991 to March 2001 was reviewed retrospectively. PEG was planned in 119 of 179 (66%) of these patients excluding those presenting moribund and those for whom early resection was planned. The PEG was placed using an endoscopic method with wire-guided endoscopic bougienage or laser ablation or both as needed. Success of placement, requirement for dilatation and ablation, PEG-related complications, tolerance of enteral feeds, and impact on therapy were evaluated.

RESULTS

PEG placement was possible in 87% of patients (103 of 119). Dilatation or laser ablation or both was required in 46% (47 of 103). There was no procedure-related mortality. Thirty-day mortality was 13.5%. Major PEG-related complications were observed in 4% (4 of 103) and minor PEG-related complications in 12% (12 of 103). PEG removal was required in 4 patients and interruption of enteral feeds required in 33 (32%). No instances of esophageal disruption or tumor inoculation metastasis were noted. PEG takedown and site closure at the time of operation was uncomplicated and use of the stomach as an esophageal substitute was possible in all 61 resected patients. Rates of anastomotic leak, stricture, and gastric emptying delay were similar to those for patients proceeding to resection without prior PEG (leak: PEG = 8% [5 of 61] versus non-PEG = 10.5% [2 of 19]), (stricture: PEG = 37% [22 of 61] versus non-PEG = 32.5% [6 of 19]), (delay: PEG = 9.8% [6 of 61] versus non-PEG = 10.5% [2 of 19]). Analysis of variables showed PEG to be significantly related to attainment of target doses of chemoradiotherapy (p = 0.034), and survival at 12 months (p = 0.02).

CONCLUSIONS

PEG in esophageal cancer is safe and useful and does not compromise the stomach or esophagogastric anastomosis. Further study is required to define the efficacy of PEG as a means of nutritional support and its impact on survival.

Video-assisted thoracic surgery lobectomy for stage I lung cancer

BACKGROUND

The technique, safety, and oncologic efficacy of video-assisted thoracic surgery (VATS) lobectomy are controversial. Issues include operative time, lymph node yield, conversion to thoracotomy, resource utilization, recurrence, complications, and survival.

METHODS

From January 1995 to December 2001, 179 patients underwent VATS lobectomy for preoperative stage I lung cancer (T1N0, 118 patients; T2N0, 61 patients). Mean age was 64.34 years (range, 38 to 87); 91 were female and 88 were male. Contraindications to VATS lobectomy included any suggestion of hilar, endobronchial, or central lesions. Video-assisted thoracic surgery lobectomy was performed using three ports, partial anatomic hilar dissection, and mediastinal node dissection.

RESULTS

Distribution of lobectomies was as follows: left upper lobe, 50 patients; left lower lobe, 27 patients; right upper lobe, 33 patients; right upper and right middle lobe, 29 patients; right middle lobe, 9 patients; right lower lobe, 30 patients; right middle lobe and right lower lobe, 1 patient. Mean operative time was 75 +/- 6 minutes. Mean lymph node yield was 11 +/- 5 nodes. Pathologic upstaging was noted in 14 of the 179 patients (7.8%). Mean hospitalization was 4.1 days (range, 2 days to 4 months). There were no conversions to thoracotomy and there was 1 death (1 of 179, 0.05%). Complications included air leak in 24 of 179 (13.4%), subcutaneous emphysema in 4 of 179 (2.2%), pneumonia in 10 of 179 (5.6%), wound infection in 5 of 179 (2.8%), respiratory failure in 3 of 179 (1.7%), pulmonary embolism in 2 of 179 (1.1%), and myocardial infarction in 1 of 179 (0.5%). At a mean follow-up of 37 months, local recurrence rate was 0.013 per person per year. Actuarial recurrence-free survival was 88% and 85% at 36 and 60 months respectively.

CONCLUSIONS

For carefully selected patients VATS lobectomy for early stage lung cancer is a safe and effective strategy. Long-term follow-up is required to fully evaluate recurrence and survival.

Biliary web--a rare cause of extrahepatic biliary obstruction

A case of an isolated mucosal web of the common hepatic duct is presented. Such extrahepatic biliary webs are extremely rare causes of biliary obstruction, likely congenital in nature, but presenting in later life due to the initial patency of these webs in allowing bile drainage from the liver. The relevant literature is reviewed; diagnostic and therapeutic aspects are discussed.

Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique

The current surgical literature has not clearly demonstrated an optimal technique for abdominal closure. Prospective randomized studies published between 1980 and 1998 were analyzed and the relevant data derived from those studies were pooled for statistical evaluation. The outcome variables of dehiscence, infection, hernia formation, suture sinus formation, and pain were studied and the probability of their occurrence in association with different techniques was calculated. In relation to the outcome features of dehiscence and infection no statistically significant difference was seen when absorbable suture material was compared with nonabsorbable material. In regard to the probability of hernia formation no statistically significant difference was seen when monofilament absorbable material was compared with nonabsorbable material. There was, however, a higher incidence of hernia formation when braided absorbable suture material was used. In addition there was a higher incidence of incision pain and suture sinus formation when nonabsorbable suture material was used. Absorbable monofilament suture material is superior to both absorbable braided and nonabsorbable suture for abdominal fascial closure. A continuous mass (all-layer) closure with absorbable monofilament suture material is the optimal technique for fascial closure after laparotomy.

The American Psychoanalytic Association: a decade of change

The American Psychoanalytic Association in the last decade has undergone the most extensive organizational changes in its history. Efforts at inclusion, outreach, and democratization have halted a decline in candidates, active members, and cultural influence and led to a vibrant, growing organization, as new professional groups have gradually been included in the association's training programs. The goal of increasing training opportunities for minority candidates has only partially been achieved. A recent effort to offer affiliate status to psychotherapists and students has begun, though with modest results. Alliances with otherpsychoanalytic groups have led to creation of the Psychoanalytic Consortium and steady progress toward external accreditation of institutes and licensure of psychoanalysts. In the interest of unification there is a need to develop pathways of affiliation and membership for independent institutes and societies that desire to join the association. Democracy has in large measure already been enhanced at the national level. Deliberations are now transparent, and an invigorated Executive Committee willingly shares power with the Executive Council. Candidates now are deeply involved in the governance of Board and Council and their committees. But only when all members and candidates enjoy full voting rights and all members are able to serve as officers and Executive Councilors will the decades-long effort to democratize the association be concluded.

Fecal impaction causing megarectum-producing colorectal catastrophes. A report of two cases

PURPOSE

Massive fecal impaction leading to surgical catastrophes has rarely been reported. We present 2 such patients to remind physicians that neglected accumulation of fecal matter in the rectum may lead to ischemia and perforation of the colon and rectum.

METHODS

Report of 2 patients and a MEDLINE search of the literature.

RESULTS

In the 1st case massive fecal impaction produced an abdominal compartment syndrome and rectal necrosis. In the 2nd patient fecal impaction resulted in colonic obstruction and ischemia. In both, an operation was life-saving.

CONCLUSION

Neglected fecal impaction may lead to a megarectum causing an abdominal compartment syndrome and colorectal obstruction, perforation or necrosis. Measures to prevent fecal impaction are of paramount importance and prompt manual disimpaction before the above complications develop is mandatory. Appropriate operative treatment may be life-saving.

Liver enzymes are commonly elevated following laparoscopic cholecystectomy: is elevated intra-abdominal pressure the cause?

BACKGROUND

A previous study disclosed 'unexplained' disturbances in postoperative liver function tests (LFTs) in up to 80% of 67 patients undergoing laparoscopic cholecystectomy (LC). No cause for these elevations was documented. Our objective was to assess the incidence, cause and clinical significance of 'unexplained' disturbances in liver enzymes following LC.

PATIENTS AND METHODS

A retrospective chart review of 270 patients who underwent LC and 64 patients undergoing open cholecystectomy (OC) was conducted.

EXCLUSION CRITERIA

any preoperative abnormality in bilirubin or liver enzyme levels, history of chronic liver disease, gallbladder empyema, gangrene or perforation, any evidence or suggestion of choledocholithiasis or other ductal pathology on preoperative or intraoperative imaging or surgical exploration. Preoperatively and on postoperative day 1, alanine transaminase (ALT), alkaline phosphatase and bilirubin levels were measured. There 'unexplained' disturbances were defined as a 50% increase from preoperative values and/or above the normal range. At LC the pneumoperitoneum was maintained at a pressure not exceeding 15 mm Hg.

RESULTS

In the groups undergoing OC and LC the respective early elevations in bilirubin occurred in 5 and 9% of patients (NS), and in alkaline phosphatase in 0 and 4% patients (NS). Postoperative ALT was elevated in 15% of patients following OC and in 34% after LC (p = 0. 004). 'Unexplained' LFT disturbances were not associated with any morbidity.

CONCLUSIONS

'Unexplained' disturbances in ALT following LC occur in 34% of the patients and appear to be clinically nonsignificant. It is suggested that the reason for this phenomenon is the pneumoperitoneum-related intra-abdominal hypertension; the only variable not present in the OC group.