Percutaneous endoscopic gastrostomy risks rendering the gastric conduit unusable for esophagectomy

Surgical treatment for cancer of the esophagus most often involves replacement of the esophagus with a gastric conduit. This gastric tube relies upon the continuity of the gastroepiploic artery for its blood supply. This case report involves a patient whose gastroepiploic artery became thrombosed by a percutaneous endoscopic gastrostomy, rendering his gastric conduit unusable.

Effectiveness of Screening Aqueous Contrast Swallow in Detecting Clinically Significant Anastomotic Leaks after Esophagectomy

BACKGROUND

Aqueous contrast swallow study is recommended as a screening procedure for the evaluation of esophageal anastomotic integrity following esophagectomy. The aim of this study was to assess the accuracy of water-soluble contrast swallow screening as a predictor of clinically significant anastomotic leak in patients with esophagectomy.

PATIENTS AND METHODS

The records of 505 consecutive patients undergoing esophagectomy in Mayo Clinic from January 1991 through December 1995 were retrospectively reviewed. 464 (92%) patients had water-soluble contrast swallows performed in the early postoperative period (median postoperative day 7, range 4-11 days).

RESULTS

A total of 39 radiological leaks were obtained but only 17 of these had clinical signs of anastomotic leakage. Furthermore, 25 patients who had normal swallow study developed a clinical anastomotic leak. There were therefore 22 (4.7%) false positive and 25 (5.4%) false negative results giving values for the specificity, sensitivity and false negative error rate of the radiological examination of 94.7, 40.4, and 59.5% respectively. Aspiration of the contrast agent was noted on fluoroscopy in 30 (6.5%) patients. Only 2 (0.4%) patients developed aqueous contrast agent-caused aspiration pneumonia. There was no procedure-related mortality.

CONCLUSION

While radiological assessment of esophageal anastomoses in the early postoperative period using aqueous contrast agents appears to be a relatively safe procedure, the poor sensitivity and high false negative error rate of this technique, when performed on postoperative day 7 and in a series with clinical anastomotic leak rate of 9%, is insufficient for it to be worthwhile as a screening procedure.

Lobar torsion after pulmonary resection: presentation and outcome

OBJECTIVE

We reviewed our experience on postoperative lobar torsion.

METHODS

Between January 1972 and January 1998, 7887 patients underwent pulmonary resection at our institution. Seven (0.089%; 4 women and 3 men; median age, 68 years) patients required surgical reintervention for lobar torsion.

RESULTS

The indications for pulmonary resection were non-small cell carcinoma in 5 patients, lymphoma in 1 patient, and metastatic prostate carcinoma in 1 patient. The right upper lobe was resected in 3 patients, the left lower lobe in 2 patients, and the right middle and right lower lobe in 1 patient each. Postoperative radiographs demonstrated pulmonary infiltrates and volume loss in 5 patients and complete opacification in 2 patients. The median white blood cell count was 10.6 x 10(9) cells/L (range, 9.3-14.9 x 10(9) cells/L), and the median peak temperature was 38.4 degrees C (range, 37.8 degrees C-40.2 degrees C) during the first 48 hours postoperatively. The diagnosis of lobar torsion was made a median of 10 days (range, 2-14 days) after the initial operation; 4 patients underwent completion pneumonectomy, and 3 had lobectomy. Median hospitalization was 24 days and ranged from 10 to 56 days. There were no postoperative deaths. Complications after reoperation included respiratory failure in 2 patients, atrial arrhythmia in 2 patients, and empyema, urinary tract infection, and a transient ischemic attack in 1 patient each.

CONCLUSIONS

Lobar torsion represents a difficult diagnostic dilemma in the early postoperative period after pulmonary resection. A high index of suspicion is necessary to avoid a delay in treatment. Late diagnosis results in further pulmonary resection and prolonged hospitalization in the majority of cases.

Laparoscopic repair of large paraesophageal hiatal hernia

BACKGROUND

The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias.

METHODS

Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed.

RESULTS

Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%).

CONCLUSIONS

Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.

Surgical treatment of primary lung cancer with synchronous brain metastases

OBJECTIVES

The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial.

METHODS

From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer.

RESULTS

The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001).

CONCLUSION

Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.

Alterations of p14ARF, p53, and p73 genes involved in the E2F-1-mediated apoptotic pathways in non-small cell lung carcinoma

Overexpression of E2F-1 induces apoptosis by both a p14ARF-p53- and a p73-mediated pathway. p14ARF is the alternate tumor suppressor product of the INK4a/ARF locus that is inactivated frequently in lung carcinogenesis. Because p14ARF stabilizes p53, it has been proposed that the loss of p14ARF is functionally equivalent to a p53 mutation. We have tested this hypothesis by examining the genomic status of the unique exon 1beta of p14ARF in 53 human cell lines and 86 primary non-small cell lung carcinomas and correlated this with previously characterized alterations of p53. Homozygous deletions of p14ARF were detected in 12 of 53 (23%) cell lines and 16 of 86 (19%) primary tumors. A single cell line, but no primary tumors, harbored an intragenic mutation. The deletion of p14ARF was inversely correlated with the loss of p53 in the majority of cell lines (P = 0.02), but this relationship was not maintained among primary tumors (P = 0.5). E2F-1 can also induce p73 via a p53-independent apoptotic pathway. Although we did not observe inactivation of p73 by either mutation or DNA methylation, haploinsufficiency of p73 correlated positively with either p14ARF or p53 mutation or both (P = 0.01) in primary non-small cell lung carcinomas. These data are consistent with the current model of p14ARF and p53 interaction as a complex network rather than a simple linear pathway and indicate a possible role for an E2F-1-mediated failsafe, p53-independent, apoptotic pathway involving p73 in human lung carcinogenesis.

Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

BACKGROUND

Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed.

METHODS

All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis.

RESULTS

Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis.

CONCLUSIONS

Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.

Pneumonectomy for malignant disease: factors affecting early morbidity and mortality

OBJECTIVE

The purpose of this report is to analyze factors affecting morbidity and mortality after pneumonectomy for malignant disease.

METHODS

We retrospectively reviewed the cases of all patients who underwent pneumonectomy for malignancy at the Mayo Clinic. Between January 1, 1985, and September 30, 1998, 639 patients (469 men and 170 women) were identified. Median age was 64 years (range 20 to 86 years). Indication for pneumonectomy was primary lung cancer in 607 (95.0%) patients and metastatic disease in 32 (5.0%). Factors affecting morbidity and mortality were analyzed by univariate and multivariate analysis.

RESULTS

Cardiopulmonary complications occurred in 245 patients (38.3%; 95% confidence interval 34.6%-42.2%). Factors adversely affecting morbidity with univariate analysis included age (P <.0001), male sex (P =.04), associated respiratory (P =.02) or cardiovascular disease (P <.0001), cigarette smoking (P =.02), decreased vital capacity (P =.01), forced expiratory volume in 1 second (P <.0001), forced vital capacity (P =.002), diffusion capacity of the lung to carbon monoxide (P =.005), oxygen saturation (P <.05), arterial PO (2) (P =.007), preoperative radiation (P =.02), bronchial stump reinforcement (P =.007), crystalloid infusion (P =.01), and blood transfusion (P =.02). Factors adversely affecting morbidity with multivariate analysis included age (P =.0001), associated cardiovascular disease (P =.001), and bronchial stump reinforcement (P =.0005). There were 45 deaths (7.0%; 95% confidence intervals 5.2%-9.3%). Factors adversely affecting mortality with univariate analysis included associated cardiovascular (P <.0001) or hematologic disease (P <.005), lower preoperative serum hemoglobin level (P =.004), preoperative chemotherapy (P =.01), decreased diffusion capacity of lung to carbon monoxide (P =.002), right pneumonectomy (P =.0006), extended resection (P =.04), bronchial stump reinforcement (P =.007), and crystalloid infusion (P =.01). Factors affecting mortality with multivariate analysis included hematologic disease (P =.01), lower preoperative serum hemoglobin (P =.003), and completion pneumonectomy (P =.01).

CONCLUSION

Multiple factors adversely affected morbidity and mortality after pneumonectomy for malignant disease. Appropriate selection and meticulous perioperative care are paramount to minimize risks in those patients who require pneumonectomy.

Ivor Lewis esophagogastrectomy for esophageal cancer

BACKGROUND

To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience.

METHODS

We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995.

RESULTS

There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV.

CONCLUSIONS

Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.

Aortic aneurysms in children and young adults with tuberous sclerosis: report of two cases and review of the literature

Abdominal aortic aneurysms (AAAs) in children and young adults are rare; some have been observed in patients with tuberous sclerosis (TS). We report two cases and review the literature. A 9-year-old girl with TS was diagnosed with a 3-cm calcified AAA, and a 41-year-old man with TS was diagnosed with a 7.5-cm thoracic aortic aneurysm (TAA). Both patients underwent open repair with a tube polyester graft without complication. They are both doing well at 7 and 8 years after surgery. Pathologic evaluation revealed medial atrophy and focal medial disruption in the aortic wall in both patients. With our two cases, 15 patients with TS and aneurysms have been reported; 12 had AAA, and four had TAA (one patient had both). Three AAAs and two TAAs ruptured. Six patients died because of aneurysmal disease. There is an association between TS and aortic aneurysms. Patients should be screened for aortic aneurysms at the time TS is diagnosed and annually thereafter. Because of the high risk of rupture, early elective repair is suggested. New aortic aneurysms after repair may also develop.

Surgical treatment of hepatic and pulmonary metastases from colon cancer

BACKGROUND

Surgical resection of isolated hepatic or pulmonary metastases secondary to colorectal cancer has been shown to yield acceptable long-term survival. However, results are inconclusive for surgical resection of both hepatic and pulmonary metastases.

METHODS

We reviewed the records of all patients who underwent surgical resection of both hepatic and pulmonary metastases from colorectal cancer between 1980 and 1998.

RESULTS

A total of 58 patients underwent resection of both hepatic and pulmonary metastases secondary to colorectal cancer. All patients had local control of their primary cancer before metastasectomy. There were no operative deaths. Morbidity occurred in 12% of patients. Follow-up was complete in all patients, with a median duration of 62 months (range, 6 to 201 months). The 5- and 10-year survivals were 30% and 16%, respectively. A premetastasectomy carcinoembryonic antigen level greater than 5 ng/mL increased the risk of early death (p = 0.029). Neither the number of pulmonary lesions nor the time interval between the primary surgery and the metastasectomy had a significant impact on survival (p = 0.67). At 5 years, 55% of patients were free of disease. Four patients had lymph node involvement at the time of pulmonary resection and all 4 patients died within 22 months of their pulmonary metastasectomy.

CONCLUSIONS

Resection of both hepatic and pulmonary metastases secondary to colorectal cancer in highly selected patients is safe and results in long-term survival. Thoracic lymph node involvement and elevated carcinoembryonic antigen levels before pulmonary metastasectomy are associated with reduced survival.

Management of postpneumonectomy empyema and bronchopleural fistula

Empyema after pneumonectomy is often associated with a bronchopleural fistula (BDF) and has a significant mortality. Management options include systemic antibiotics and observation, adequate pleural drainage, appropriate parenteral antibiotics, removal of necrotic tissue, and obliteration of residual pleural space. We prefer to treat the empyema with the procedure originally described by Clagett and Geraci in 1963. They demonstrated that postpneumonectomy empyema could be successfully treated by open pleural drainage, frequent wet-to-dry dressing changes, and when the thorax was clean, secondary chest wall closure with obliteration of the pleural cavity with an antibiotic solution. Failure was most often caused by a persistent or recurrent fistula. Because of this, when a BPF is present, the original Clagett technique was modified to include transposition of a well-vascularized muscle to cover the stump at the time of open drainage to prevent further ischemia and necrosis. Our preference is intrathoracic transposition of extrathoracic skeletal muscle. The goals of therapy for postpneumonectomy empyema remain a healthy patient with a a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients by using the Clagett procedure and intrathoracic muscle transposition when a BPF is present.

Esophageal reconstruction for benign disease: self-assessment of functional outcome and quality of life

BACKGROUND

Little information exists regarding functional outcome and quality of life after esophagectomy and subsequent esophageal reconstruction for benign disease as evaluated by the patients themselves.

METHODS

Eighty-one patients completed a combined two-part questionnaire regarding esophageal function and quality of life (MOS SF-36) a median of 9.8 years (range, 10 months to 18.9 years) after esophageal reconstruction for benign disease. There were 43 men (53.1%) and 38 women (46.9%). Median age at time of esophageal reconstruction was 51 years (range, 6 to 78 years). Intestinal continuity was established with stomach in 58 patients (71.6%), colon in 16 patients (19.8%), and small bowel in 7 patients (8.6%).

RESULTS

Dysphagia to solids was present in 48 patients (59.3%) and 27 patients (33.3%) required at least one postoperative dilatation. Heartburn was present in 50 patients (61.7%) which required medication for control in 37 patients (45.7%). The number of meals per day was three to four in 58 patients (71.6%), more than four in 15 patients (18.5%), less than three in 6 patients (7.4%), and unknown in 2 patients (2.5%). The size of each meal was smaller than preoperatively in 46 patients (56.8%), larger in 22 patients (27.2%), unchanged in 12 patients (14.8%), and unknown in 1 patient (1.2%). The number of bowel movements per day increased in 37 patients (45.7%), was unchanged in 36 patients (44.4%), and decreased in 8 patients (9.9%). Resection for perforation was associated with smaller postoperative meals compared with resection for stricture (p < 0.05). Age, sex, and type of esophageal reconstruction did not affect late functional outcome. Regarding quality of life, physical functioning, social functioning, and health perception were decreased (p < 0.05). No significant change was observed in role-physical, mental health, bodily pain, energy/fatigue, and role-emotional scores.

CONCLUSIONS

Self-assessment of postoperative esophageal symptoms after esophagectomy and reconstruction for benign disease demonstrates that symptoms are frequently present at long-term follow-up and unaffected by the type of reconstruction.

Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results

BACKGROUND

Esophagectomy for benign disease is performed infrequently. We reviewed the Mayo Clinic's experience with patients who required esophageal reconstruction for benign esophageal disease.

METHODS

From March 1956 to October 1997, all patients who required resection and reconstruction for a benign condition of the esophagus were reviewed.

RESULTS

There were 255 patients (141 male, 114 female). Median age was 55 years (range, 2 to 100). The original diagnosis was an esophageal stricture in 108 patients (42%), primary motility disorder in 84 (33%), perforation in 36 (14%), hiatal hernia in 18 (7%), and other in 9 (4.0%). Reconstruction was with stomach in 168 patients (66%), colon in 70 (27%), and small bowel in 17 (7%). The anastomosis was intrathoracic in 144 patients (57%) and cervical in 111 (43%). There were 13 postoperative deaths (mortality 5%); 142 patients (56%) had at least one complication. Median hospitalization was 14 days (range, 6-95 days). Follow-up was complete in 226 patients (88.6%) for a median of 52 months (range, 1 month to 29 years). A total of 175 patients (77.4%) were improved. Functional results were classified as excellent in 72 patients (31.8%), good in 23 (10.2%), fair in 80 (35.4%), and poor in 51 (22.6%).

CONCLUSIONS

Esophageal reconstruction for benign disease resulted in functional improvement in a majority of patients. It can be done with low mortality and acceptable morbidity. Early morbidity is adversely affected by the diagnosis of perforation and the route through which the conduit is placed. Late functional outcome is adversely affected by the diagnosis of paraesophageal hernia and a cervical anastomosis.

Bronchobiliary fistula: principles of management

Bronchobiliary fistula is an uncommon entity. Recently, we encountered 2 patients with this problem. Both were treated successfully with resection of the involved pulmonary tissue and interposition of viable tissue between the lung and the fistulous tract. This approach, although invasive, provided a rapid resolution of the patients' problem.

Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure

BACKGROUND

Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperfusion, we reviewed our experience with direct fenestration of the aorta.

METHODS

A retrospective analysis of all consecutive aortic fenestrations performed between January 1, 1979, and December 31, 1999, was performed. Fourteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three type A and 11 type B patients. In the acute dissection group (n = 7), indications for surgery were malperfusion in six patients (leg ischemia, 4; renal ischemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), thoracoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1.

RESULTS

Emergency aortic fenestration was performed in seven patients (surgically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacement was performed in four patients, combined with ascending aortic replacement (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acute fenestration was performed for organ malperfusion after prior proximal aortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (descending thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and pararenal aorta, 1). Concomitant aortic replacement was performed in six patients (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was successful at restoring flow in all 10 patients with malperfusion. Operative mortality for emergency fenestration was 43% (3/7). The three deaths that occurred were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm formations at the fenestration site.

CONCLUSION

Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality. Elective fenestration combined with aortic replacement can be performed safely in chronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits.

Role of surgical resection in broncholithiasis

BACKGROUND

Broncholithiasis is an uncommon problem with life-threatening complications. The purpose of this study was to update our experience in patients with broncholithiasis managed by surgical intervention.

METHODS

From January 1984 to January 1998, 118 patients were diagnosed with broncholithiasis at our institution. We reviewed the medical records of those patients who underwent surgical treatment.

RESULTS

There were 47 patients (19 men and 28 women). Median age was 58 years (range, 18 to 90 years). Indications for operation were symptoms in 44 patients and abnormal roentgenograms in 3 patients. Operative procedures included lung resection in 30 patients, broncholithectomy with or without bronchoplasty in 16, and segmental bronchial resection in 1 patient. There were no operative deaths. Postoperative complications occurred in 16 patients (34%). Follow-up was complete in 46 patients (98%) and ranged from 11 to 165 months (median, 74 months). The 15-year actuarial survival did not differ significantly from that of a matched control group (p = 0.774). At follow-up, 28 patients (68.3%) were asymptomatic. Symptoms continued in 12 patients. Recurrent or persistent disease was documented in 6 patients (14.6%). The site of recurrence was in a new location in 3 patients, a previous site in 2, and unknown in 1 patient. Subsequent management included observation in 3 patients, bronchoscopic removal in 2, and bilobectomy in 1 patient.

CONCLUSIONS

Surgical resection for broncholithiasis is an effective method of management for this disease and can be done with low mortality and morbidity. Progression of the disease may lead to recurrence and further surgical intervention.

Primary non-Hodgkin's lymphoma of the lung

BACKGROUND

Primary non-Hodgkin's lymphoma of the lung is a rare entity. Although the prognosis is favorable, clinical features, prognostic factors, and patient management have not been clearly defined.

METHODS

We reviewed retrospectively the records of 48 patients operated on for primary pulmonary non-Hodgkin's lymphoma. The study group consisted of 21 male (44%) and 27 female (56%) patients with a mean age of 61.8 years. Thirty-seven and a half percent of patients were asymptomatic, and 62.5% were seen with pulmonary symptoms, systemic symptoms, or both. A definitive diagnosis was obtained by thoracotomy in 90% of patients, thoracoscopy in 8%, and anterior mediastinotomy in 2%.

RESULTS

Complete surgical resection was possible in 19 patients (40%). A mucosa-associated lymphoid tissue lymphoma (MALT) was found in 35 patients and lymphoma that was not of this type, in 13. The 1-year, 5-year, and 10-year survival rates were 91%, 68%, and 53%, respectively in the group with mucosa-associated lymphoid tissue lymphoma and 85%, 65%, and 64% in the group with lymphoma that was not of the mucosa-associated lymphoid tissue type. None of the prognostic factors studied (mode of presentation, smoking history, bilateral disease, postoperative stage, complete resection, adjuvant chemotherapy, histology) significantly influenced patient survival.

CONCLUSIONS

Primary non-Hodgkin's lymphoma of the lung occurs with nonspecific clinical features. Although patient survival is good, prognostic factors could not be identified.

The STS National Database: current changes and challenges for the new millennium. Committee to Establish a National Database in Cardiothoracic Surgery, The Society of Thoracic Surgeons

BACKGROUND

The Society of Thoracic Surgeons (STS) established the National Database (NDB) for Cardiac Surgery in 1989. Since then it has grown to be the largest database of its kind in medicine. The NDB has been one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery.

METHODS AND RESULTS

This report explains the numerous changes in the NDB and its structure that have occurred over the past 2 years. It highlights the benefits of these changes, both to the individual member participants and to the STS overall. Additionally, the vision changes to the NDB and reporting structure are identified. The individuals who have participated in this effort since 1989 are acknowledged, and the STS owes an enormous debt of gratitude to each of them.

CONCLUSIONS

Because of their collective efforts, the goal to establish the STS NDB as a "gold standard" worldwide for process and outcomes analysis related to cardiothoracic surgery is becoming a reality.

Aortic-origin reconstruction of the great vessels: risk factors of early and late complications

OBJECTIVE

Great vessel reconstruction for arterial occlusive disease has been shown to be a durable procedure. The purpose of this report is the examination of the influence of cause and risk factors on outcomes for the identification of patients who may be better treated with endovascular techniques or other surgical approaches.

METHODS

Data for patients who underwent aortic-origin great vessel reconstruction between 1988 and 1998 were reviewed. The data were analyzed with Fisher exact test, life-table analysis, and log-rank test.

RESULTS

Ninety-two vessels underwent revascularization in 58 patients (15 men, 43 women; mean age, 54 years; age range, 20 to 82 years). Etiology was atherosclerosis obliterans (n = 40; 69%), Takayasu's arteritis (n = 13; 22%), radiation arteritis (RA; n = 4; 7%), and mediastinal fibrosis (n = 1; 2%). The symptoms were cerebrovascular (n = 25), upper extremity (n = 8), or both (n = 23), and two patients were asymptomatic. The bypass grafting was performed with single-limb synthetic grafts (n = 23) or grafts plus side arms (n = 28). Seven patients underwent innominate endarterectomy. The mean follow-up period was 45 months (range, 0 to 126 months). The perioperative stroke (n = 4; 7%) and death (n = 2; 3%) rates were not related to the cause of disease. The patients with creatinine levels of 2 or more (n = 4) had a combined perioperative stroke/death rate of 50% (vs 7% for patients with healthy creatinine levels; P <.05). The patients with hypercoagulable states (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33% vs 4% for patients without hypercoagulable states; P <.05) and an increased late thrombosis rate. The primary and secondary graft patency rates at 5 years were 80% +/- 7% and 91% +/- 5%, respectively. Patients with RA had a greater risk of stroke or death at 3 years (33% free of stroke or death vs 79% for patients with atherosclerosis obliterans and 92% for patients with Takayasu's arteritis; P =.02) and an increased major late infection rate (50% vs 2% for all others; P =.01).

CONCLUSION

Patients with thrombophilia and renal insufficiency have increased perioperative stroke and stroke/death rates, respectively. Patients with RA have an increased incidence rate of late major infection, which directly contributes to an increased rate of stroke or death. Patients with thrombophilia have an increased rate of late graft thrombosis. These patient conditions should be approached cautiously, and some patients may benefit from endovascular therapy.

Extended resections for lung cancer. How far is too far?

Pulmonary resection is the preferred treatment for patients with lung cancer. Half of all patients, however, have signs of unresectability at the time of diagnosis. Contraindication to pulmonary resection is based on cell type, the extent of the disease, and the patient's overall general medical condition. Invasion of the chest wall by bronchogenic carcinoma is not rare. The diagnostic importance of this findings, however, has been controversial. Early reports had regarded thoracic wall invasion as a uniformly ominous sign, while recent reports have been more optimistic, especially when lymph nodes were not metastatically involved. Chest wall resection should be preceeded by mediastinoscopy. If lymph nodes are negative, excision is generally performed en bloc with pulmonary resection. After the thorax is entered and the cancer is found to be invading the chest wall, wide resection of the chest wall with attached lung is performed. Generally, the line of resection should encompass the area of invasion by several centimeters. The lung with attached chest wall is then allowed to fall back into the pleural cavity, where the appropriate pulmonary resection is performed. If the chest wall defect is less than 5 cm in diameter, no reconstruction of the defect is required. If, however the defect is larger and structural, stability is required. The defect should be reconstructed with a prosthetic material, such as the various meshes, metals, or soft tissue patches, and reinforced with a muscle flap. If the wound is contaminated from an intrathoracic source, prosthetic material should be avoided and reconstruction with a muscle flap alone is preferred. Muscles commonly used include serratus anterior, pectoralis major, latissimus dorsi, and occasionaly, rectus abdominus. Because the omentum lacks structural stabilitly, it should be considered a back-up alternative procedure. Operative mortality is usually related to the extent of pulmonary resection rather than the extent of chest wall resection. Five-year survival approaches 50% for patients with T3N0M0 lesions. For patients with either N1 or N2 neoplasms, 5-year survial is less than 10%. Postoperative radiation therapy appears to have no effect on surival.

Inflammatory pseudotumors of the lung

BACKGROUND

Inflammatory pseudotumors of the lung are rare and often present a dilemma for the surgeon at time of operation. We reviewed our experience with patients who have this unusual pathology.

METHODS

Between February 1946 and September 1993, 56,400 general thoracic surgical procedures were performed at the Mayo Clinic. Twenty-three patients (0.04%) had resection of an inflammatory pseudotumor of the lung. There were 12 women and 11 men. Median age was 47 years (range, 5 to 77 years). Six patients (26%) were less than 18 years old. All pathologic specimens were re-reviewed, and the diagnosis of inflammatory pseudotumor was confirmed. Eighteen patients (78%) were symptomatic which included cough in 12, weight loss in 4, fever in 4, and fatigue in 4. Four patients had prior incomplete resections performed elsewhere and underwent re-resection because of growth of residual pseudotumor. Wedge excision was performed in 7 patients, lobectomy in 6, pneumonectomy in 6, chest wall resection in 2, segmentectomy in 1, and bilobectomy in 1. Complete resection was accomplished in 18 patients (78%). Median tumor size was 4.0 cm (range, 1 to 15 cm). There were no operative deaths. Follow-up was complete in all patients and ranged from 3 to 27 years (median, 9 years).

RESULTS

Overall 5-year survival was 91%. Nineteen patients are currently alive. Cause of death in the remaining 4 patients was unrelated to pseudotumor. The pseudotumor recurred in 3 of the 5 patients who had incomplete resection; 2 have had subsequent complete excision with no evidence of recurrence 8 and 9 years later.

CONCLUSIONS

We conclude that inflammatory pseudotumors of the lung are rare. They often occur in children, can grow to a large size, and are often locally invasive, requiring significant pulmonary resection. Complete resection, when possible, is safe and leads to excellent survival. Pseudotumors, which recur, should be re-resected.

Early and long-term results of prosthetic chest wall reconstruction

OBJECTIVE

The purpose of this report is to evaluate our results in patients who underwent prosthetic bony reconstruction after chest wall resection.

METHODS

We retrospectively reviewed all patients who underwent chest wall resection and reconstruction with prosthetic material at the Mayo Clinic.

RESULTS

From January 1, 1977, to December 31, 1992, 197 patients (109 male patients and 88 female patients) underwent chest wall resection and reconstruction with prosthetic material. Median age was 59 years (range, 11-86 years). The indication for resection was recurrent chest wall malignancy in 65 patients (33.0%), primary chest wall malignancy in 62 patients (31.5%), contiguous lung or breast carcinoma in 58 patients (29.4%), and other reasons in 12 patients (6.1%). Three patients (1.5%) each had an open draining wound. This review covers 2 time periods. Sixty-four patients (32.5%) underwent reconstruction with polypropylene mesh during the period from 1977 to 1986. One hundred thirty-three patients (67.5%) underwent reconstruction with polytetrafluoroethylene from 1984 to 1992. Soft tissue coverage was achieved with transposed muscle in 116 patients (58.9%), local tissue in 81 patients (41.1%), and omentum in 3 patients (1.5%). There were 8 deaths (operative mortality rate, 4.1%). Ninety-one patients (46.2%) experienced complications. Seromas occurred in 14 patients (7.1%). Wound infections occurred in 9 patients (4.6%; 5 patients with polypropylene mesh and 4 patients with polytetrafluoroethylene). The prosthesis was removed in all 5 patients with polypropylene mesh and in none of the patients with polytetrafluoroethylene. Follow-up was complete in 179 operative survivors (94.7%) and ranged from 1 to 204 months (median, 26 months). A well-healed asymptomatic wound was present in 127 patients (70.9%).

CONCLUSIONS

Chest wall resection and reconstruction with prosthetic material will yield satisfactory results in most patients. Little difference exists between polypropylene mesh and polytetrafluoroethylene.

Mycotic vascular infections of large arteries with Mycobacterium bovis after intravesical bacillus Calmette-Guérin therapy: case report

Disseminated infection after intravesical bacille Calmette-Guérin instillation for bladder cancer is a rare but potential complication. Vascular infection is an additional serious complication but is seldom reported. We present the first report of a small series of patients with vascular infections after intravesical bacille Calmette-Guérin instillation, and we review the related literature.

Results of reoperation on the upper esophageal sphincter

OBJECTIVE

Reoperation on the upper esophageal sphincter is infrequent. We reviewed our experience in patients who underwent reoperation on the upper esophageal sphincter.

METHODS

This is a retrospective report of accumulative series from 2 separate institutions.

RESULTS

From September 1, 1976, to February 28, 1997, 37 patients underwent reoperation on the upper esophageal sphincter for recurrent or persistent obstructive symptoms. There were 29 men and 8 women. The median age was 69 years (range, 38-87 years). The original indication for the operation was a pharyngoesophageal (Zenker's) diverticulum in 33 patients (89.2%), oculopharyngeal dystrophy in 3 patients (8.1%), and muscular dystrophy in 1 patient (2.7%). One prior upper esophageal sphincter operation had been performed in 26 patients (70.3%), two operations in 9 patients (24. 3%), and three operations in 2 patients (5.4%). All patients were symptomatic; 35 patients (94.6%) had dysphagia; 23 patients (62.2%) had regurgitation; and 12 patients (32.4%) had episodes of aspiration. Thirty of the patients (91.0%) with Zenker's diverticulum were found to have a recurrent or persistent diverticulum at reoperation. A diverticulectomy and cricopharyngeal myotomy were performed in 23 patients (62.2%); cricopharyngeal myotomy alone, in 7 patients (18.9%); diverticulopexy and cricopharyngeal myotomy, in 6 patients (16.2%); and diverticulectomy alone, in 1 patient (2.7%). There were no operative deaths. Complications developed in 10 patients (27.0%). Follow-up was complete in 34 patients (91.9%) and ranged from 2 to 149 months (median, 39 mo). Thirty-two patients (94.1%) were improved. Functional results were classified as excellent in 26 patients (76. 5%), good in 2 patients (5.9%), fair in 4 patients (11.7%), and poor in 2 patients (5.9%).

CONCLUSIONS

Reoperation for patients who have persistent or recurrent symptoms after an operation on the upper esophageal sphincter is associated with acceptable morbidity and mortality rates. Resolution of symptoms occurs in most patients.

Uncut Collis-Nissen fundoplication: learning curve and long-term results

BACKGROUND

Between September 1985 and July 1990, the first 100 consecutive patients (50 female and 50 male) undergoing primary uncut Collis-Nissen fundoplication performed by one surgeon were reviewed.

METHODS

Median age was 62 years and ranged from 19 to 89 years. Indications for repair included gastroesophageal reflux in 56 patients, obstructive symptoms in 34, and a combination of both in 10. An upper gastrointestinal endoscopy was performed in 99 patients; all were abnormal. Esophagitis was documented in 53 patients, large diaphragmatic hernia in 36, stenosis in 18, "Cameron's erosions" in 17, Barrett's disease in 13, and other findings in 9 patients. An abnormal upper gastrointestinal series was demonstrated in 96 of 97 patients evaluated. Motility studies were performed in 95 patients, and 11 had abnormal peristalsis. All procedures were performed through a left thoracotomy.

RESULTS

Complications occurred in 23 patients and included respiratory failure in 6, atrial fibrillation in 3, atelectasis in 3, pneumonia in 2, myocardial infarction in 2, and chylothorax, severe dysphagia, early breakdown of repair, cardiac tamponade, hematuria, spinal headache, and intraoperative perforation by dilator in 1 each. There were 2 postoperative deaths, both cardiac in origin. Median hospitalization was 8 days (range, 6 to 76 days). The first 25 patients had 10 complications (40%) and 2 deaths (8%). The remaining 75 patients had 13 complications (17%) and no deaths (mortality, p = 0.06; morbidity, p = 0.03). Follow-up was complete in all patients for a median of 100 months (range, 3 to 138 months). Eighty-six of the 98 operative survivors are currently alive. At last follow-up, excellent functional results were observed in 58 patients (59%), good in 24 (25%), fair in 8 (8%), poor in 7 (7%), and unknown in 1 (1%).

CONCLUSION

We conclude that the uncut Collis-Nissen fundoplication provides good to excellent long-term results in 84% of patients. Operative mortality and morbidity is acceptable but is associated with a learning curve.

Leiomyosarcoma of the esophagus: results of surgical treatment

BACKGROUND

This study examined the results of surgical treatment of leiomyosarcoma of the esophagus.

METHODS

Between January 1920 and December 1996, 17 patients (9 men and 8 women) with leiomyosarcoma of the esophagus were treated surgically at the Mayo Clinic. Median age was 58 years and ranged from 26 to 76 years. Symptoms included dysphagia in 11 patients (64.7%) and odynophagia in 6 (35.3%). The tumor was located in the middle third of the esophagus in 10 patients (58.8%) and in the cervical esophagus in 7 (41.2%). Procedures performed included esophagogastrectomy in 9 patients (Ivor Lewis in 5, left thoracoabdominal in 3, and transhiatal in 1), enucleation in 3, transgastric excision in 1, and exploration without resection in 4.

RESULTS

The procedure was considered curative in 11 patients (64.7%). There was one operative death (mortality, 5.9%). Complications occurred in 3 patients (17.6%) and included anastomotic leak in 2 and bleeding requiring reoperation in 1. Growth pattern was infiltrating in 7, polypoid in 5, and intramural in 5. Histologically, the tumor was grade 1 in 6 patients, grade 2 in 2, grade 3 in 7, and grade 4 in 2. The tumor was postsurgically classified as stage I in 2 patients, stage IIA in 7, stage IIB in 1, stage IIIA in 5, stage IV in 1, and unknown in 1. Six patients (35.3%) received adjuvant treatment. Follow-up was complete in 16 patients (94.1%) and ranged from 1 to 182 months (median, 48 months). Five- and 10-year actuarial survivals were 47.0% and 31.0%, respectively. Seven patients (41.2%) are currently alive (median survival, 72 months); all underwent curative resection. Factors affecting survival included completeness of resection, growth pattern, postsurgical stage, tumor grade, and tumor location (p < 0.05).

CONCLUSIONS

We conclude that leiomyosarcoma of the esophagus is rare. Complete resection provides long-term survival.

Zenker's diverticulum in the elderly: is operation justified?

BACKGROUND

Surgical correction of symptomatic Zenker's diverticulum is effective; however, elderly symptomatic patients may be denied surgical intervention because of perceived increased risks.

METHODS

To address this concern, we reviewed 75 patients (46 men and 29 women) found to have this condition during the past two decades.

RESULTS

Median age was 79 years (range, 75 to 91 years). Preoperative symptoms included dysphagia in 69 patients (92%), regurgitation in 61 (81%), pneumonia in 9 (12%), halitosis in 3 (4%), and weight loss in 1 (1%). Gastroesophageal reflux symptoms were noted in 27 patients (36%). Diagnosis was made by barium swallow in 63 patients, esophagoscopy in 5, and a combination of both in 7. Surgical procedures included both diverticulectomy and myotomy in 57 patients (76%), myotomy alone in 9 (12%), diverticulopexy and myotomy in 5 (7%), and diverticulectomy alone in 4 (5%). There was no in-hospital mortality. Complications occurred in 8 patients (11%) and included esophagocutaneous fistula in 4, pneumonia and urinary tract infection in 1, and wound infection, myocardial infarction, and persistent diverticulum in 1 each. Follow-up was available in 72 patients (96%) and ranged from 8 days to 17 years (median, 3.3 years). At follow-up, 64 patients (88%) were asymptomatic and 4 (6%) were improved with minimal symptoms. The remaining 4 patients (6%) have had varying degrees of dysphagia and all have been treated with periodic esophageal dilations.

CONCLUSIONS

Operation for symptomatic Zenker's diverticulum in the elderly is safe and effective and will result in resolution of symptoms and improved quality of life in most patients.

Allelic deletion analysis of the FHIT gene predicts poor survival in non-small cell lung cancer

The fragile histidine triad (FHIT) gene at chromosome 3p14.2 is a candidate tumor suppressor gene linked to cancers of the lung, breast, colon, pancreas, and head and neck. Reports of frequent allelic deletion and abnormal transcripts in primary lung tumors plus recent evidence that it is targeted by tobacco smoke carcinogens suggest that it plays an important role in lung carcinogenesis. Non-small cell lung carcinoma still maintains a poor 5-year survival rate with the stage of disease at presentation as a major determinant of prognosis. We examined for allelic deletion at the FHIT locus in a series of 106 non-small cell lung carcinomas for which a full clinical, epidemiological, and 5-year survival profile was available. We found an allelic deletion frequency of 38% at one or two intragenic microsatellites. Allelic deletion of FHIT was related to tumor histology with 4 of 20 adenocarcinomas (20%) displaying loss of heterozygosity (LOH) compared with 12 of 22 (55%) nonadenocarcinomas (P = 0.03). We found that 63% of tumors with LOH of FHIT also had p53 missense mutations whereas only 26% with LOH had wild type p53 negative sequence (P = 0.02). We also found a significant trend toward poorer survival in patients with LOH of at least one locus of the FHIT gene (log rank, P = 0.01). This survival correlation is independent of tumor stage, size, histological subtype, degree of differentiation, and p53 mutation status. Our data support the hypothesis that the loss of the FHIT contributes to the molecular pathogenesis of human lung cancer and is an indicator of poor prognosis.

p21waf1/cip1 and transforming growth factor beta 1 protein expression correlate with survival in non-small cell lung cancer

p21waf1/cip1 encodes a cyclin-dependent kinase inhibitor that is transcriptionally activated by the p53 tumor suppressor gene, transforming growth factor beta 1 (TGF-beta 1), AP2, and other pathways. Because p21waf1/cip1, p53, and TGF-beta 1 all regulate apoptosis and the cell cycle, we tested the hypothesis that their relative protein levels would correlate with biological features including the survival of non-small cell lung cancer (NSCLC) patients. We conducted an immunohistochemical analysis of p21waf1/cip1 and TGF-beta 1 and identified four patient groups with distinct survival outcomes. Concordant p21waf1/cip1 and TGF-beta 1 expression (i.e., either high p21waf1/cip1 and high TGF-beta 1 expression or low p21waf1/cip1 and low TGF-beta 1 expression) predicted 70% disease-free survival at 2000 days of follow-up. Discordant p21waf1/cip1 and TGF-beta 1 expression (i.e., either high p21waf1/cip1 and low TGF-beta 1 expression or low p21waf1/cip1 and high TGF-beta 1 expression) predicted 35% disease-free survival (P = 0.0003; log-rank test). These survival relationships were not attributable to differences in grade, stage, or p53 status. Although current models do not fully explain these complex interactions, most of these data fit a paradigm whereby TGF-beta 1 regulation determines NSCLC survival. In addition to the survival correlation, we found that high p21waf1/cip1 protein expression correlated with high tumor grade (P = 0.014). There is little evidence that p21waf1/cip1 protein levels accurately predict p53 mutation status in NSCLC; specifically, 20 of 48 (42%) tumors with p53 mutations contained high levels of p21waf1/cip1 protein. These findings indicate that p21waf1/cip1 immunohistochemical analysis may provide useful information concerning the biological properties of NSCLC.

Early experience and learning curve associated with laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic approach for hiatal hernia repair is relatively new. Information on the learning curve is limited.

METHODS

From January 1994 to September 1996, 280 patients underwent antireflux surgery at our institution. A laparoscopic repair was attempted in 60 patients (21.4%). There were 38 men and 22 women. Median age was 49 years (range 21 to 78 years). Indications for operation were gastroesophageal reflux in 59 patients and a large paraesophageal hernia in one. A Nissen fundoplication was performed in all patients; 53 (88.3%) had concomitant hiatal hernia repair.

RESULTS

In eight patients (13.3%) the operation was converted to an open procedure. Median operative time for the 52 patients who had laparoscopic repair was 215 minutes (range 104 to 320 minutes). There were no deaths. Complications occurred in five patients (9.6%). Median hospitalization was 2 days (range 1 to 5 days). Median operative time and median hospitalization were significantly longer in the first 26 patients than in the subsequent 25 patients (248 vs 203 minutes and 2 days vs 1 day, respectively; p = 0.03). Seven of the first 30 patients (23.3%) required laparotomy as compared with two of the second 30 (6.7%) (p = 0.07). Follow-up in the 51 patients who had laparoscopic fundoplication for reflux was complete in 50 (98.0%) and ranged from 7 to 38 months (median 13 months). Functional results were classified as excellent in 34 patients (68.0%), good in 6 (12.0%), fair in 7 (14.0%), and poor in 3 (6.0%). Three patients were reoperated on for recurrent reflux symptoms at 5, 5, and 11 months.

CONCLUSIONS

We conclude that laparoscopic Nissen fundoplication can be performed safely. The operative time, hospitalization, and conversion rate to laparotomy are higher during the early part of the experience, but all are reduced after the learning curve.

Reconstruction of the superior vena cava: benefits of postoperative surveillance and secondary endovascular interventions

PURPOSE

Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown.

METHODS

During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted.

RESULTS

No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively.

CONCLUSION

Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts.

Effectiveness of postoperative irradiation in stage IIIA non-small cell lung cancer according to regression tree analyses of recurrence risks

BACKGROUND

In the setting of grossly resected stage IIIA (N2 involvement) non-small cell lung carcinoma, the role of adjuvant postoperative thoracic radiation therapy (TRT) remains controversial. This study was initiated to subcategorize these patients into high-, intermediate-, and low-risk groups with respect to local recurrence and survival rates, and to determine whether there were certain subgroups of patients who were particularly likely or unlikely to benefit from postoperative TRT.

METHODS

Two hundred twenty-four patients were studied. A regression tree analysis was used to separate patients who had undergone operation alone into groups that had a high, intermediate, or low risk of local recurrence and death. The effect of adjuvant postoperative TRT then was examined in each of these groups.

RESULTS

The use of adjuvant postoperative TRT (compared with operation alone) was associated with an improvement in freedom from local recurrence and survival for patients who had an intermediate or high risk of local recurrence and death. However, the greatest level of improvement in freedom from local recurrence (p < 0.0001) and survival (p = 0.0002) associated with the use of adjuvant postoperative TRT was in the high-risk group. Similarly, but of lesser magnitude, the intermediate-risk group had improved freedom from local recurrence and survival rates with the use of adjuvant post-operative TRT (p = 0.002 and p = 0.01, respectively). For the low-risk group, the freedom from local recurrence and survival rates were not statistically different between the patients who received adjuvant postoperative TRT and those who underwent observation.

CONCLUSIONS

Patients with non-small cell lung carcinoma involving ipsilateral mediastinal lymph nodes (stage IIIA) who undergo gross resection and who are at either high or intermediate risk for local recurrence and death are likely to benefit from adjuvant postoperative irradiation. The role of radiation therapy in low-risk patients is unclear. Prospective confirmation of these observations is warranted.

The impact of surgical adjuvant thoracic radiation therapy for patients with nonsmall cell lung carcinoma with ipsilateral mediastinal lymph node involvement

BACKGROUND

Previous nonsmall cell lung carcinoma studies have shown that patients with ipsilateral mediastinal (N2) lymph node involvement who underwent surgical resection have a greater local recurrence rate than those with less lymph node involvement (N0, N1). Therefore, it was hypothesized that complete surgical clearance of subclinical lymph node disease is difficult in N2 patients and that adjuvant postoperative thoracic radiotherapy (TRT) may be beneficial.

METHODS

A retrospective review was performed to determine the local recurrence and survival rates for patients with N2 disease undergoing complete surgical resection with or without adjuvant TRT. Between 1987 and 1993 at the Mayo Clinic, 224 patients underwent complete resection of N2 nonsmall cell lung carcinoma. More than one mediastinal lymph node station was sampled in 98% of patients; 39% then received adjuvant TRT (median dose, 50.4 grays).

RESULTS

The median follow-up time was 3.5 years for the patients who were alive at the time of the analysis. The surgery alone versus surgery plus TRT groups were well balanced with respect to gender, age, histology, tumor grade, number of mediastinal lymph node stations dissected or involved, and involved N1 lymph node number. There were slightly more patients with right lower lobe lesions (compared with other lobes), patients with multiple lobe involvement, and patients with only one N2 lymph node involved in the surgery alone group. After treatment with surgery alone, the actuarial 4-year local recurrence rate was 60%, compared with 17% for treatment with adjuvant TRT (P < 0.0001). The actuarial 4-year survival rate was 22% for treatment with surgery alone, compared with 43% for treatment with adjuvant TRT (P = 0.005). On multivariate analysis, the addition of TRT (P = 0.0001), absence of superior mediastinal lymph node involvement (P = 0.005), and fewer N1 lymph nodes involved (P = 0.02) were independently associated with improved survival rate.

CONCLUSIONS

This study, which to the authors' knowledge is the largest evaluating adjuvant TRT in N2 nonsmall cell lung carcinoma, suggests that adjuvant TRT may improve local control and survival.

Esophageal resection for cancer of the esophagus: long-term function and quality of life

BACKGROUND

Information on function and quality of life of long-term survivors after esophageal resection for carcinoma is limited.

METHODS

Between 1972 and 1990, 359 patients underwent esophagectomy for stage I or II esophageal carcinoma at Mayo Clinic. We evaluated long-term function and quality of life in 107 of these patients (81 men and 26 women) who survived 5 or more years. Median age at operation was 62 years (range, 30 to 81 years). The operation performed was an Ivor Lewis resection in 77 patients (72%), transhiatal esophagectomy in 14 (13%), extended esophagectomy in 4 (4%), thoracoabdominal esophagectomy in 4 (4%), and other in 8 (7%). Adenocarcinoma was present in 72 patients (67%), squamous cell carcinoma in 28 (26%), and other in 7 (7%). Thirty-four patients (32%) were in postsurgical stage I, 65 (61%) in stage IIA, and 8 (8%) in stage IIB. Median survival was 10.2 years (range, 5.0 to 23.2 years). Follow-up was complete for all patients.

RESULTS

Gastroesophageal reflux was present in 64 patients (60%), symptoms of dumping in 53 (50%), and dysphagia to solid food in 27 (25%). Seventeen patients (16%) were asymptomatic. Factors affecting late functional outcome were analyzed. Patients who had a cervical anastomosis had significantly fewer reflux symptoms (p < 0.05). Dumping syndrome occurred more frequently in younger patients (p < 0.05) and women (p < 0.01). Quality of life was assessed separately by the Medical Outcomes Study 36-Item Short-Form Health Survey and compared with the national norm. Scores measuring physical functioning were decreased (p < 0.01). Scores measuring ability to work, social interaction, daily activities, emotional dysfunction, perception of health, and levels of energy were similar. Mental health scores were higher (p < 0.05).

CONCLUSIONS

We conclude that long-term functional outcome after esophagectomy for esophageal carcinoma is affected by age, sex, and type of reconstruction. Quality of life as judged by the patients is similar to the national norm.

Long-term results after reoperation for failed antireflux procedures

From January 1960 to June 1995, 185 patients underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease. There were 102 men and 83 women. Median age was 58 years (range 20 to 84 years). A single previous antireflux operation had been performed in 147 patients, two in 33, and three in 5. The median interval between the reoperation and the previous operation was 36 months (range 1 to 291 months). Indications for reoperation were symptoms in 184 patients and a large paraesophageal hernia in one patients. The surgical approach was by means of a thoracotomy in 133 patients (71.9%), laparotomy in 27 (14.6%), and a thoracoabdominal incision in 25 (13.5%). A Nissen fundoplication was performed in 107 patients (57.8%), Belsey fundoplication in 47 (25.4%), truncal vagotomy and antrectomy with Roux-en-Y reconstruction in 17 (9.2%), anatomic hernia repair in 12 (6.5%), and Hill gastropexy in 2 (1.1%). A Collis gastroplasty was added to the fundoplication in 116 patients (62.7%), and a pyloroplasty was performed in 17 (9.2%). There was one operative death (0.5%). Complications occurred in 47 patients (25.4%). Median postoperative hospitalization was 9 days (range 5 to 58 days). Follow-up was complete in 156 patients (84.3%) and ranged from 3 to 283 months (median 44 months). Improvement occurred in 137 patients (87.8%). Functional results were classified as excellent in 65 patients (41.6%), good in 29 (18.6%), fair in 43 (27.6%), and poor in 19 (12.2%). No single operative approach or procedure proved to be functionally superior. We conclude that reoperation with esophageal preservation after a failed antireflux procedure will result in significant functional benefit and can be performed with low mortality and acceptable morbidity. The type of repair should be tailored to the individual patient.

Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience

PURPOSE

Graft-related complications must be factored into the long-term morbidity and mortality rates of abdominal aortic aneurysm (AAA) repair. However, the true incidence may be underestimated because some patients do not return to the original surgical center when a problem arises.

METHODS

To minimize referral bias and loss to follow-up, we studied all patients who underwent AAA repair between 1957 and 1990 in a geographically defined community where all AAA operations were performed and followed by a single surgical practice. All patients who remained alive were asked to have their aortic grafts imaged.

RESULTS

Among 307 patients who underwent AAA repair, 29 patients (9.4%) had a graft-related complication. At a mean follow-up of 5.8 years (range, < 30 days to 36 years), the most common complication was anastomotic pseudoaneurysm (3.0%), followed by graft thrombosis (2.0%), graft-enteric erosion/fistula (1.6%), graft infection (1.3%), anastomotic hemorrhage (1.3%), colon ischemia (0.7%), and atheroembolism (0.3%). Complications were recognized within 30 days after surgery in eight patients (2.6%) and at late follow-up in 21 patients (6.8%). These complications were observed at a median follow-up of 6.1 years for anastomotic pseudoaneurysm, 4.3 years for graft-enteric erosion, and 0.15 years for graft infection. Kaplan-Meier 5- and 10-year survival free estimates were 98% and 96% for anastomotic pseudoaneurysm, 98% and 95% for combined graft-enteric erosion/infection, and 98% and 97% for graft thrombosis.

CONCLUSIONS

This 36-year population-based study confirms that the vast majority of patients who undergo standard surgical repair of an abdominal aortic aneurysm remain free of any significant graft-related complication during their remaining lifetime.

Malignant fibrous histiocytoma of the lung. Report of four cases and review of the literature

BACKGROUND

Primary malignant fibrous histiocytoma (MFH) of the lung is a rare clinical entity. Only 23 reports of 49 cases have been reported in the literature. Surgery was the primary mode of therapy, with high rates of local and distant recurrence reported. The role of radiation therapy and chemotherapy has never been clearly defined.

METHODS

The records of the Mayo Clinic in Scottsdale and Rochester from 1970 to 1990 were reviewed for cases of primary pulmonary MFH. A review of the literature was also undertaken.

RESULTS

Four cases from the Mayo records and 49 cases from a review of the literature were identified. Eight patients were alive at 5 years from diagnosis; all had been treated with surgery as the primary modality. No definite relationship between histologic subtype of MFH and survival could be identified and no definite role of radiation therapy or chemotherapy could be defined.

CONCLUSIONS

MFH of the lung should be treated by surgical resection if technically feasible. The role of adjuvant therapy remains undefined.

Diaphragmatic hernia and associated anemia: response to surgical treatment

From 1985 to 1993, 49 patients (35 women and 14 men) with diaphragmatic hernia and associated anemia underwent surgical repair. The median age was 64.5 years (range 24 to 84 years). Hematologic and gastroenterologic evaluations revealed no other potential cause of bleeding. Each patient had a diaphragmatic hernia. The median time between the diagnosis of anemia and surgical repair was 36 months (range 1 to 334 months). Forty-five patients (91.8%) had received replacement therapy, including iron for 43 and blood transfusions for 32 (median 6 units; range 2 to 70 units). Forty-six patients (93.9%) had symptoms: heartburn in 28, early satiety with bloating in 19, regurgitation in 11, dysphagia in 7, and aspiration in 4. Preoperative upper gastrointestinal endoscopic evaluation demonstrated gastric erosions at the level of the hiatus in 22 patients (44.9%), esophagitis in 7, stenosis in 1, and Barrett's disease in 1. An uncut Collis-Nissen fundoplication was performed in 44 patients, Belsey fundoplication in 2, a cut Collis-Nissen fundoplication, Nissen fundoplication, and Hill repair in 1 each. There was one operative death (2% mortality). Complications occurred in 18 patients (36.7%). Follow-up was complete and ranged from 4 to 103 months (median 63 months). Forty-five patients (91.8%) had resolution of their anemia. Functional results were excellent in 40 patients (81.6%), good in 2 (4.1%), fair in 4 (8.2%), and poor in 3 (6.1%). In most patients with diaphragmatic hernia and associated anemia refractory to medical treatment, surgical repair can result in successful resolution of the anemia.

Postoperative chylothorax

Between July 1987 and May 1995, 11,315 patients underwent general thoracic surgical procedures at our institution. In 47 of these patients (0.42%), postoperative chylothorax developed. There were 32 men and 15 women with a median age of 65 years (range 21 to 88 years). Initial operation was for esophageal disease in 27 patients, pulmonary disease in 13, mediastinal mass in six, and thoracic aortic aneurysm in one. All patients were initially treated with hyperalimentation, cessation of oral intake, medium chain triglyceride diet, or a combination. Nonoperative therapy was successful in 13 cases (27.7%), and oral intake was resumed a median of 7 days later (range 2 to 15 days). Reoperation was required in the remaining 34 cases. The reoperation rate varied according to the type of initial operation. Twenty-four of the 27 patients (88.9%) who had undergone an esophageal operation required reoperation, versus only five of 13 patients (38.5%) who had undergone pulmonary resection (p < 0.001). Lymphangiography was performed in 16 patients and identified the site of the leak in 13. The thoracic duct was ligated in 32 of the 34 patients who required reoperation (94%). The remaining two patients were treated with mechanical pleurodesis and fibrin glue. Reoperation was successful in 31 of the 34 patients (91.2%). The single death among the 47 patients (2.1%) occurred in the reoperated group. Complications occurred in 18 patients (38.3%). Factors that predicted the need for reoperation were initial esophageal operation and average daily postoperative drainage greater than 1000 ml/day for 7 days. We conclude that postoperative chylothorax is an infrequent complication. Some cases can be managed without operation; however, we recommend early reoperation when drainage is greater than 1000 ml/day or if the chylous fistula occurs after an esophageal operation. The fistula can usually be controlled by ligation of the thoracic duct.

Surgical management of bronchiectasis

BACKGROUND

The prevalence of bronchiectasis has decreased significantly over recent decades. We reviewed the morbidity, mortality, and outcome of surgical treatment for pulmonary bronchiectasis in the modern era of antibiotic therapy.

METHODS

From January 1976 through January 1993, 134 patients (55 male and 79 female patients) underwent pulmonary resection for bronchiectasis. The mean age was 48.4 years (range, 4 to 89 years). The indication for operation was failure of medical therapy in 85 patients (63.4%), hemoptysis in 26 (19.4%), lung abscess in 12 (9.0%), and a nondiagnostic mass in 11 (8.2%). Mean duration of symptoms was 6 years (range, 1 to 60 years) and included a productive cough in 104 patients, fetid sputum in 91, recurrent infections in 81, and hemoptysis in 56. Thirteen patients (9.7%) had no prior symptoms and presented with either hemoptysis, lung abscess, or unresolved pneumonia. The disease was bilateral in 26 patients (19.4%) and mainly confined to the lower lobe in 75 (56.0%). The mean number of segments involved was 4.4 (range, one to 14 segments). Surgical treatment included lobectomy in 86 patients (64.2%), pneumonectomy in 21 (15.7%), wedge resection or segmentectomy in 18 (13.4%), and a combination of these approaches in 9 (6.7%). Disease was considered completely resected in 108 patients (80.6%).

RESULTS

The operative mortality rate was 2.2% and the morbidity rate was 24.6%. The mean follow-up in 103 patients was 6 years (range, 1 to 16 years). Overall, 61 patients (59.2%) were asymptomatic after operation. Symptoms were improved in 30 patients (29.1%) and unchanged in 12 (11.7%). Complete resection resulted in a significantly better result than incomplete resection (p < 0.05).

CONCLUSIONS

Pulmonary resection for bronchiectasis can be done with low mortality and morbidity. When possible, complete resection should be performed.

Chest-wall reconstruction: an account of 500 consecutive patients

Our experience with 500 consecutive chest-wall reconstructions over the past 18 years is reviewed. Of the 500 patients, 286 were male and 214 were female. Their ages ranged from 1 day to 85 years (average 55 years). Among the patients, 275 had chest-wall tumors, 142 had infected median sternotomies, 119 had radiation necrosis, and 121 had combinations of the three. Skeletal resection of the chest wall was done in 443 patients. An average of 3.9 ribs were resected in 241 patients. Total or partial sternectomies were performed in 231 patients. Four-hundred and seven patients underwent 611 muscle flaps: 355 pectoralis major, 141 latissimus dorsi, and 115 others, including serratus anterior, rectus abdominis, and external oblique. The omentum was transposed in 51 patients. Chest-wall skeletal defects were closed with polytetrafluoroethylene soft-tissue patch in 116 patients, polypropylene mesh in 55, and autogenous rib in 13. The 500 patients underwent an average of 2.3 operations. Hospitalization averaged 21 days. There were 15 perioperative deaths. Twenty-three patients required tracheostomy. The average duration of follow-up was 57 months. There were 229 late deaths; the cause of death was cancer in 147 patients, cardiac in 49, pulmonary in 7, and other in 26. Four-hundred and three of the 485 patients (83.1 percent) who were alive 30 days after the operation had excellent results and had a healed, asymptomatic chest wall at the time of death or last follow-up. We conclude that chest-wall reconstruction is safe, durable, and associated with long-term survival.

Lung resection in patients with compromised pulmonary function

BACKGROUND

Some patients are denied curative pulmonary resection for lung carcinoma because of pulmonary insufficiency. To identify factors that affect postoperative morbidity and mortality, we reviewed 85 consecutive patients (53 men and 32 women) with a preoperative forced expiratory volume in 1 second of less than 1.2 L who underwent pulmonary resection for lung cancer between January 1986 and December 1990.

METHODS

Median age was 70 years (range, 49 to 82 years). Sixty patients (71%) had been previously denied operation because of pulmonary insufficiency. Preoperative pulmonary function demonstrated a median preoperative forced expiratory volume in 1 second of 1.0 L (44% of predicted normal; range, 0.5 to 1.2 L) and a diffusing capacity of the lung for carbon monoxide of 60% of predicted normal (range, 22% to 104%).

RESULTS

Pneumonectomy was done in 6 patients (7.1%), bilobectomy in 6 (7.1%), lobectomy in 38 (44.7%), segmentectomy in 12 (14.1%), and wedge excision in 29 (27.1%). The median predicted postoperative forced expiratory volume in 1 second was 0.83 L (34% of predicted normal; range, 0.45 to 1.14 L), and the median predicted postoperative diffusing capacity of the lung for carbon monoxide was 48% of predicted normal (range, 19% to 87%). Seventy-two patients (85%) received postoperative epidural analgesia. Median hospitalization was 15 days (range, 5 to 66 days). Operative mortality was 2.4%, and complications occurred in 49%. We did not identify any factors that predicted postoperative morbidity and mortality. Median follow-up was 3.2 years (range, 0.2 to 9 years). Seven patients (8%) required supplemental home oxygen. A predicted postoperative percent forced expiratory volume in 1 second less than 43% correlated with the need for home oxygen (p < 0.05). Overall 5-year survival was 44.0%. Survival for stage I cancer was 54.2%; stage II, 33.1%; and stage IIIa, 21.3%.

CONCLUSIONS

We conclude that some patients with lung cancer and compromised pulmonary function can safely undergo pulmonary resection if selected appropriately.

Management of postpneumonectomy empyema and bronchopleural fistula

Postpneumonectomy empyema with or without fistula is a serious complication. Management includes drainage, antibiotherapy, debridement closure of the bronchopleural fistula when present, and obliteration of the residual pleural space. Excellent results can be obtained in most patients using the Clagett procedure and its modification. A detailed description of each step of the surgical treatment of postpneumonectomy empyema and associated bronchopleural fistula is provided.

Barretts's esophagus: does an antireflux procedure reduce the need for endoscopic surveillance?

Barrett's esophagus, a premalignant condition associated with chronic gastroesophageal reflux, carries an approximate 40-fold increase in the incidence of adenocarcinoma. Between 1975 and 1994, 113 patients with Barrett's esophagus underwent antireflux procedures at the Mayo Clinic. The antireflux procedure was performed more than 3 months after the diagnosis of Barrett's disease in 39 patients (34.5%) and during the initial preoperative evaluation in 74 (65.5%). Uncut Collis-Nissen fundoplication was performed in 69 patients (61.1%), Nissen fundoplication was performed in 16 (14.2%), cut Collis-Nissen fundoplication was performed in 12 (10.6%), Belsey repair was performed in nine (8.0%), Collis-Belsey repair was performed in six (5.3%), and Nissen fundoplication with an anterior gastropexy was performed in one (0.9%). There was one operative death (0.9% mortality). Morbidity occurred in 41 patients (36.3%), including cardiac arrhythmia in eight (7.0%), pneumonia in six (5.3%), empyema in five (4.4%), hemorrhage in four (3.6%), myocardial infarction in two (1.8%), and wound dehiscence, wound infection, perforated duodenal ulcer, and postoperative leak in one each (0.9%). Median follow-up for the 112 survivors of operation was 6.5 years (range 4 months to 18.2 years). Excellent or good alleviation of symptoms was obtained in 92 patients (82.2%). Ninety-nine patients (88.4%) are currently alive and 13 (11.6%) have died. Three patients (2.7%) subsequently had adenocarcinoma of the esophagus after the antireflux procedure at 13, 25, and 39 months; two of these died of cancer. The incidence of esophageal carcinoma in this select group of patients was one in 273.8 patient-years of follow-up. We conclude that although antireflux procedures in patients with Barrett's esophagus result in long-term control of reflux symptoms, the possibility of esophageal cancer still exists. Endoscopic surveillance should therefore be recommended.

Inflammatory abdominal aortic aneurysms: a case-control study

PURPOSE

This study was designed to identify significant differences in the clinical and radiologic characteristics and outcome between patients with inflammatory and noninflammatory abdominal aortic aneurysms (AAAs).

METHODS

We reviewed 29 consecutive patients who underwent repair of an inflammatory AAA between 1985 and 1994. This group was matched in a case-control fashion by date of surgery and by the performing surgeon to a group of 58 patients who underwent repair of noninflammatory AAAs.

RESULTS

The two groups had comparable characteristics of age, gender, and cardiovascular risk factors. Patients with inflammatory AAAs were significantly more symptomatic than those with noninflammatory AAAs (93% vs 9%, p < 0.001), were more likely to have a family history of aneurysms (17% vs 1.5%, p = 0.007), and tended to be current smokers (45% vs 24%, p = 0.049). The most significant laboratory difference was an elevated sedimentation rate in patients with inflammatory AAAs (mean, 53 mm/hr vs 12 mm/hr, p < 0.00001). Inflammatory AAAs also were significantly larger than noninflammatory AAAs at presentation (6.8 cm vs 5.9 cm, p < 0.05). Although operative mortality was low in both groups, patients with an inflammatory AAA tended to have higher morbidity, including sepsis (p < 0.01) and renal failure (p = 0.04). Five-year survival rates, however, were similar for the two groups (79% for inflammatory and 83% for noninflammatory AAAs). On follow-up computed tomographic scans, the retroperitoneal inflammatory process resolved completely in 53% of the patients, but 47% of patients had persistent inflammation that involved the ureters in 32% and resulted in long-term solitary or bilateral renal atrophy in 47%.

CONCLUSIONS

This case-control study provides preliminary evidence that inflammatory AAAs may have a relatively strong familial connection and that current smoking may play an important role in the inflammatory response. The study also documents that persistent retroperitoneal inflammation may be more prevalent than has been previously reported, and stresses the need for an improved understanding of the pathogenesis and long-term management of inflammatory AAAs.

Mainstem bronchial sleeve resection with pulmonary preservation

BACKGROUND

Resection of a mainstem bronchus with pulmonary preservation is a therapeutic option when disease is limited to the mainstem bronchus. We reviewed our experience with this procedure to determine the operative morbidity, mortality, and long-term outcome.

METHODS

From January 1965 through January 1995, 22 patients (13 male, 9 female) underwent circumferential mainstem bronchial sleeve resection without removal of pulmonary parenchyma. Median age was 37 years (range, 12 to 70 years). The right mainstem bronchus was involved in 12 patients and the left, in 10. Nineteen patients (86%) were symptomatic; symptoms included cough in 5, dyspnea in 5, wheeze in 3, hemoptysis in 3, and a combination of these in 3. Conventional tomography was done in 8 patients and identified every lesion. Bronchoscopy was diagnostic in all patients. Resection was for cancer in 15 patients (68%), benign stricture in 5 (23%), and an impacted broncholith in 2 (9%). The cancer was a carcinoid in 9 patients, a mucoepidermoid carcinoma in 3, squamous cell carcinoma in 2, and adenoid cystic carcinoma in 1. Fourteen patients were postsurgically classified as stage IIIA (T3 NO MO) and 1 patient as stage IIIB (T4 N2 M0). The median length of the resected bronchus was 2.0 cm (range, 1.0 to 4.0 cm). Two patients required hilar release maneuvers. The bronchial anastomosis was reinforced with pleura in 10 patients, pericardium in 2, and serratus anterior muscle in 1.

RESULTS

There were no operative deaths. Three patients (14%) had postoperative complications. Follow-up was complete and ranged from 6 months to 25.7 years (median follow-up, 10.2 years). Twenty-one patients are currently alive. All patients are asymptomatic except 1 patient, who required a stent for an anastomotic stricture. No patient has had recurrence of cancer.

CONCLUSIONS

In properly selected patients, mainstem bronchial sleeve resection with lung preservation can be performed safely and provides excellent relief of symptoms with good long-term survival.

Video-assisted thoracic surgical procedures: the Mayo experience

OBJECTIVE

To describe an initial 3-year experience with video-assisted thoracic surgical procedures (VATS) at Mayo Clinic Rochester.

DESIGN

We review the cumulative data on 771 VATS performed between June 1, 1991, and May 31, 1994, and assess the applications for this technique.

MATERIAL AND METHODS

The indications for VATS, our techniques used, and the associated mortality and morbidity are summarized. In addition, the frequency of conversion of VATS to open procedures and the reasons for choosing this strategy are discussed.

RESULTS

The 771 study patients (401 male and 370 female patients) had a median age of 62 years (range, 7 to 96). For all VATS. we used one-lung general anesthesia, without carbon dioxide insufflation. Indications for performing VATS were a pulmonary nodule in 333 patients, pleural effusion in 208, pulmonary infiltrate in 117, pneumothorax in 51, mediastinal mass in 22, pleural mass in 17, air leak in 13, and other in 10. The procedure was a wedge excision in 352 patients, examination of the pleural cavity in 128, pleural biopsy in 86, talc pleurodesis in 85, wedge excision and mechanical pleurodesis in 46, decortication in 27, excision of a mediastinal mass in 12, sympathectomy in 4, and other in 16. The rate of conversion of VATS to thoracotomy was 33.1% and did not change throughout the period of the study. The most common reasons for conversion were to complete a resection of a malignant lesion or to remove a deep nodule. The overall operative mortality was 1.9%. Complications occurred in 43 patients (8.3%) who underwent VATS without conversion to an open procedure and included prolonged air leak in 14, respiratory failure in 8, pneumothorax in 6, and atrial fibrillation in 5. The median hospitalization was 5 days (range, 1 to 104).

CONCLUSION

VATS is safe and useful for selected thoracic conditions. We favor conversion to thoracotomy when curative resection of a malignant lesion is intended.

Management of spontaneous pneumothorax during pregnancy: case report and review of the literature

Spontaneous pneumothorax rarely occurs during pregnancy. Only 22 nonmalignancy-related cases have been previously published. Herein we report a case of recurrent spontaneous pneumothorax during the third trimester of pregnancy that necessitated surgical intervention. At thoracotomy, a large bulla was excised from the lower lobe of the right lung; abrasive pleurodesis was subsequently done. Postoperatively, the patient had regular contractions, which were successfully stopped with intravenous administration of magnesium sulfate. Indications, procedures, and pre-cautions for operative intervention during pregnancy are discussed.