Aggressive metastasectomy for pulmonic sarcomatous metastases: a follow-up study

Pulmonary metastases are the primary cause of death due to bone and soft tissue sarcomas. We have previously shown that an aggressive approach and a new technique of multiple pulmonary metastasectomies have resulted in improved survival for patients with pulmonary metastases. In this follow-up study, an expanded database of patients was retrospectively analyzed to determine survivability as well as to evaluate potential prognostic indicators. Forty-nine patients, 26 of whom had osteogenic sarcoma (OGS), were evaluated. A number of patients had been referred from other institutions where their disease had been considered inoperable because it was extensive or recurrent. Using lateral thoracotomies exclusively, employment of a laser technique, and excision of minimal pulmonary parenchymal tissue, we performed aggressive metastasectomy. A mean of 3.0 thoracotomies was performed, in which an average of 10.2 nodules per thoracotomy were excised. Operative morbidity and mortality were minimal. The disease-free interval, the number of nodules resected, the number of thoracotomies performed, and the size of the nodules were evaluated as potential prognostic indicators. Statistically significant correlation could be established only for the size of the nodules resected. The 5-year survival rate for all patients was 39%; it was 24% for patients with OGS and 71% for those without OGS. Aggressive surgical resection of pulmonary metastases from bone and soft tissue sarcoma should be considered when there is control of local disease, no evidence of extrapulmonary metastasis, and adequate post-resection pulmonary reserve. The presence of bilateral, extensive, or recurrent disease is not a contraindication to thoracotomy. Aggressive resection of multiple nodules and improved chemotherapy appear to prolong survival of these patients when compared with survival rates of historical control subjects.

A new approach to the resection of pulmonary osteosarcoma metastases. Results of aggressive metastasectomy

Pulmonary metastases are the primary cause of death from bone and soft-tissue sarcoma. Recognition that even multiple resections of metastases can improve survival has led to a more aggressive surgical approach to these patients. The authors instituted an aggressive approach and a new technique and retrospectively analyzed the results of multiple, pulmonary metastasectomies for pulmonary metastases in 34 patients, 21 of whom had osteogenic sarcoma (OGS). A number of cases were referred from other institutions, where they had been considered inoperable because of extensive or recurrent disease. Using lateral thoracotomies, laser technique with minimal parenchymal excision, and thin gloves for palpation, aggressive metastectomy was carried out. A mean of 3.1 thoracotomies were performed, with an average of 10.6 nodules resected per thoracotomy. Operative morbidity and mortality were minimal. Evaluation of potential prognostic factors revealed no statistically significant survival difference on the basis of disease-free interval (DFI), number of nodules resected, number of thoracotomies, or size of largest nodule resected. There was a clear trend toward decreased survival of patients with larger nodules (greater than 2 cm), but because of the small number of patients in this group, no firm conclusions can be drawn. Five-year survival was 49% for the study group as a whole, and 39% for the OGS patients. Aggressive surgical resection of pulmonary metastases from bone and soft-tissue sarcoma should be considered when there is control of local disease, no evidence of extrapulmonary metastasis, and adequate postresection pulmonary reserve. The presence of bilateral, extensive, or recurrent disease is not a contraindication to thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative management of small-bowel obstruction with endoscopic long intestinal tube placement

Intestinal obstruction remains a major cause of morbidity and mortality in surgical patients. We reviewed the records of 77 patients with mechanical small-bowel obstruction who were treated with endoscopically and fluoroscopically placed Leonard long intestinal tube decompression. Most patients (59%) had failed a trial of nasogastric tube or Miller-Abbott tube decompression. Overall, 29 per cent of patients were able to resolve their obstruction with Leonard tube decompression alone. Subdivision of patients on the basis of the etiology of their obstruction demonstrated a much higher rate of success for tube decompression in adhesive obstruction (37%) versus malignant obstruction (12%) or inflammatory obstruction (no successes). Patients with radiographic and clinical evidence of complete intestinal obstruction were significantly less likely to respond to long intestinal tube treatment (13%). The long intestinal tube was easily passed in all patients. There were no complications of the intubation procedure in our series, and the incidence of tube-related complications was four per cent. We conclude that an initial period of long intestinal tube decompression allows a significant percentage of patients with mechanical small-bowel obstruction to be treated nonoperatively, particularly if a partial obstruction from postoperative adhesions is present. Patients who have failed a trial of nasogastric tube decompression and are poor operative risks should also be considered for long intestinal tube placement.

Peripheral venous monitoring with acute blood volume alteration: cuff-occluded rate of rise of peripheral venous pressure

We investigated the use of a new peripheral hemodynamic monitoring technique, the cuff-occluded rate of rise of peripheral venous pressure (CORRP), in the assessment of volume status in fluid overload. Seven adult mongrel dogs were given a general anesthetic, and monitoring lines were inserted. The animals were then subjected to an incremental volume overload of approximately 13% of estimated initial blood volume at 5-min intervals until a total volume infusion nearly equal to the animal's initial blood volume was reached. Comparison of the various monitoring techniques (e.g., cardiac output, CVP, systemic BP, pulmonary wedge pressure) demonstrated that the peripheral measurement of CORRP had better correlation with known administered volume (r = .96) than any of the other variables. The sensitivity of each of the variables in assessing small amounts of volume overload was also studied. The volume of crystalloid infusion necessary to cause a clinically significant change (defined as greater than 2 SD above the baseline mean) was compared for each of the monitoring variables. CORRP was equivalent to the other variables in sensing early volume overload. In summary, in the anesthetized animal model CORRP appears to be a sensitive, minimally invasive method of assessing volume status in acute volume overload. The efficacy of CORRP in a canine hemorrhagic shock and reperfusion model had previously been demonstrated. This technique could be clinically applicable in situations such as trauma with hemorrhagic shock, intraoperative volume changes, and in the assessment of intravascular volume after resuscitation.

Diagnostic open-lung biopsy after bone marrow transplantation

The development of pulmonary infiltrates is an ominous sign in the immunocompromised host (ICH). Selection of the best diagnostic and therapeutic approach is often difficult, and in part depends on the risk-to-benefit ratio of various diagnostic modalities, such as bronchoscopy, bronchioalveolar lavage, percutaneous needle biopsy, and open-lung biopsy (OLB). We reviewed our experience with OLB and bronchoscopy in a predominantly pediatric bone marrow transplantation population, and attempted to assess the frequency with which OLB results directed a therapeutic change, as well as the clinical results of any such therapeutic alteration. A retrospective chart review was conducted of 87 bone marrow transplantation recipients undergoing diagnostic OLB from 1975 to 1986. Bronchoscopic and OLB cultures, histopathologic studies, serological data, and autopsy results were all carefully examined. An assessment of therapeutic alteration as a result of OLB was made, and clinical changes attributable to an OLB-directed therapeutic alteration were sought. Ninety-four OLBs and 37 bronchoscopic examinations were performed in 87 patients. All patients had undergone bone marrow transplantation, most often for leukemia (58/87) or aplastic anemia (13/87). The mean interval from bone marrow transplantation to OLB was 106 days. There were no intraoperative complications, but minor postoperative surgical complications were frequent (incidence, 21%). Postoperative mortality, defined as a death occurring within 30 days of surgery, was 45% (39/87). Seventy-four percent of the patients (64/87) died during the course of the study, at a mean of 43 days after OLB. Most OLBs (60%) yielded a specific diagnosis, defined as the establishment of a precise cause for the infiltrate.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative therapy of gallbladder disease in patients with cystic fibrosis

We retrospectively studied 20 patients with cystic fibrosis who underwent surgery for gallbladder disease from 1973 to 1986. A long delay between the onset of symptoms and the diagnosis was noted (mean 7.4 months). This delay was attributed to masking of the symptoms of biliary disease by the malabsorption and pulmonary symptoms seen in this patient population. There was a notable lack of common bile duct disease in our patients as well as in those reported in the literature. This may have been due to a combination of factors: the increased viscosity of the mucus, the small caliber of the gallbladder and ductal system, and the hypotonicity of the gallbladder. We do not recommend routine intraoperative cholangiography in patients with cystic fibrosis and gallbladder disease. Cystic fibrosis is a disease with progressive pulmonary deterioration. Cholecystectomy can be performed in these patients with relative safety if careful preoperative and postoperative care is provided. We recommend early operative intervention in the patient with gallbladder disease and cystic fibrosis.

Hemangiomatosis of the colon and peritoneum: case report and management discussion

A 3-month-old infant presented with ascites, anemia, minimal rectal bleeding, and thrombocytopenia. He was found to have several hundred small cavernous hemangiomas of the colon and peritoneal surfaces. Treatment consisted of laser surgery, subtotal colectomy, and steroids. A brief review of the literature on intestinal hemangiomatosis is included as well as the complications of the disease and current therapy.