Acquired Tracheomalacia: Detection by Expiratory CT Scan

PURPOSE

The purpose of this work was to determine whether cross-sectional area and coronal and sagittal diameter measurements of the trachea between inspiration and end-expiration on CT are significantly different between patients with acquired tracheomalacia and those without this condition.

METHOD

Inspiratory and end-expiratory CT scans of the trachea of 23 normal patients and 10 patients with acquired tracheomalacia were analyzed. Percent changes in cross-sectional area, coronal, and sagittal diameters were calculated.

RESULTS

For patients with tracheomalacia, mean percent changes in the upper and middle trachea between inspiration and expiration were 49 and 44%; mean changes in the coronal and sagittal diameters in the upper and middle tracheal were 4 and 10% and 39 and 54%, respectively. Control group mean percent changes in the upper and middle tracheal area were 12 and 14%, respectively, and mean changes in the coronal and sagittal diameters in the upper and middle trachea were 4 and 4% and 11 and 13%, respectively. Significant differences were calculated for changes in cross-sectional area and sagittal diameter between groups (p < 10-5). Based on receiver operator curve analysis, a > 18% change in the upper trachea and 28% change in the midtrachea between inspiration and expiration were observed; the probability of tracheomalacia was 89-100%. The probability of tracheomalacia was > 89%, especially if the change in sagittal diameter was > 28%.

CONCLUSION

By measuring changes in tracheal cross-sectional area and sagittal diameters between inspiratory and end-expiratory CT, a significant difference can be identified between normal patients and those with acquired tracheomalacia.

Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome

OBJECTIVE

Bronchogenic carcinoma in close proximity to or involving the carina remains a challenging problem for thoracic surgeons. The operative procedures to allow complete resection are technically demanding and can be associated with significant morbidity and mortality. Little is known about long-term survival data to guide therapy in these patients.

METHODS

We conducted a single-institution retrospective review.

RESULTS

We have performed 60 carinal resections for bronchogenic carcinoma: 18 isolated carinal resections for tumor confined to the carinal or proximal main stem bronchus; 35 carinal pneumonectomies; 5 carinal plus lobar resections, and 2 carinal resections for stump recurrence after prior pneumonectomy. Thirteen patients (22%) had a history of lung or airway surgery. The overall operative mortality was 15%, improved from the first half of the series (20%) to the second half (10%), and varied according to the type of resection performed. Adult respiratory distress syndrome was responsible for 5 early deaths, and all late deaths were related to anastomotic complications. In 34 patients, all lymph nodes were negative for metastatic disease; 15 patients had positive N1 nodes, and 11 patients had positive N2/N3 nodes. Complete follow-up was accomplished in 90%, with a mean follow-up of 59 months. The overall 5-year survival including operative mortality was 42%, with 19 absolute 5-year survivors. Survival was highest after isolated carinal resection (51%). Lymph node involvement had a strong influence on survival: patients without nodal involvement had a 5-year survival of 51%, compared with 32% for patients with N1 disease and 12% for those with N2/N3 disease.

CONCLUSIONS

This constitutes one of the largest single-institution reports on carinal resection for bronchogenic carcinoma involving the carina. Morbidity and mortality rates are acceptable. The overall survival including operative mortality is 42%. Positive N2/N3 lymph nodes may be a contraindication to surgery because of poor prognosis.

Stage III thymoma: pattern of failure after surgery and postoperative radiotherapy and its implication for future study

PURPOSE

With the conventional approach of surgery and postoperative radiotherapy for patients with Masaoka Stage III thymoma, progress has been slow for an improvement in the long-term survival rate over the past 20 years. The objective of this study was to evaluate the pattern of failure and survival after surgery and postoperative radiotherapy in Stage III thymoma and search for a new direction for better therapy outcome.

METHODS AND MATERIALS

Between 1975 and 1993, 111 patients with thymoma were treated at Massachusetts General Hospital. Of these, 32 patients were determined to have Masaoka Stage III thymoma. The initial treatment included surgery for clinically resectable disease in 25 patients and preoperative therapy for unresectable disease in 7 patients. Surgical procedure consisted of thymectomy plus resection of involved tissues. For postoperative radiotherapy (n = 23), radiation dose consisted of 45-50 Gy for close resection margins, 54 Gy for microscopically positive resection margins, and 60 Gy for grossly positive margins administered in 1.8 to 2.0 Gy of daily dose fractions, 5 fractions a week, over a period of 5 to 6.6 weeks. In preoperative radiotherapy, a dose of 40 Gy was administered in 2.0 Gy of daily dose fractions, 5 days a week. For patients with large tumor requiring more than 30% of total lung volume included in the target volume (n = 3), a preoperative radiation dose of 30 Gy was administered and an additional dose of 24-30 Gy was given to the tumor bed region after surgery for positive resection margins.

RESULTS

Patients with Stage III thymoma accounted for 29% (32/111 patients) of all patients. The median age was 57 years with a range from 27 to 81 years; gender ratio was 10:22 for male to female. The median follow-up time was 6 years. Histologic subtypes included well-differentiated thymic carcinoma in 19 (59%), high-grade carcinoma in 6 (19%), organoid thymoma in 4 (13%), and cortical thymoma in 3 (9%) according to the Marino and Müller-Hermelink classification. The overall survival rates were 71% and 54% at 5 and 10 years, respectively. Ten of the 25 patients who were subjected to surgery as initial treatment were found to have incomplete resection by histopathologic evaluation. The 5- and 10-year survival rates were 86% and 69% for patients (n = 15) with clear resection margins as compared with 28% and 14% for those (n = 10) with incomplete resection margins even after postoperative therapy, p = 0.002. Survival rates at 5 and 10 years were 100% and 67% for those with unresectable disease treated with preoperative radiation (n = 6) and subsequent surgery (n = 3). Recurrence was noted in 12 of 32 patients and 11 of these died of recurrent thymoma. Recurrences at pleura and tumor bed accounted for 77% of all relapses, and all pleural recurrences were observed among the patients who were treated with surgery initially.

CONCLUSION

Incomplete resection leads to poor results even with postoperative radiotherapy or chemoradiotherapy in Stage III thymoma. Pleural recurrence is also observed more often among patients treated with surgery first. These findings suggest that preoperative radiotherapy or chemoradiotherapy may result in an increase in survival by improving the rate of complete resection and reducing local and pleural recurrences.

Bronchoalveolar carcinoma: clinical, radiologic, and pathologic factors and survival

BACKGROUND

The principal feature of bronchoalveolar carcinoma is that it spreads along airways or aerogenously with multifocality, but many issues are unresolved.

METHODS

We studied 119 patients with pathologically confirmed bronchoalveolar carcinoma. Symptoms, smoking status, radiologic findings, the size of tumor, operative procedures, and complications were reviewed. We studied the pathologic features: presence or absence of aerogenous spread, patterns of growth, cell type, nuclear grade, mitosis, rate of bronchoalveolar carcinoma in adenocarcinoma, and lymphocyte infiltration. The correlation among clinical, radiologic, and pathologic findings was examined, and the factors affecting survival were analyzed.

RESULTS

Symptomatic patients had more infiltrative radiographic features, and asymptomatic patients tended to have more mass-like features (P <.0001). Tumors with radiographically infiltrating lesions tended to have mucinous histologic features (P =.006). Tumors with mass lesions by radiograph tended to have nonmucinous and sclerosing histologic features (P =.003). Aerogenous spread was seen in 94% of specimens. The presence of a variety of cell types suggested multiple clonal origin. The overall survival in those patients undergoing resection was 69.1% at 5 years and 56.5% at 10 years. The significant factors affecting survival were radiologic presence of a mass or infiltrate, pathologic findings of the presence of sclerosis, association with a scar, the rate of bronchoalveolar carcinoma in adenocarcinoma, lymphocyte infiltration grade, nodal involvement, and status of complete resection. Mitosis or nuclear grade of tumor cells did not correlate with survival.

CONCLUSIONS

Bronchoalveolar carcinoma showed good overall survival with appropriate surgical procedures. Certain radiologic or pathologic findings correlated with survival. These findings may enhance the ability to predict long-term survival.

Superior sulcus lung tumors: impact of local control on survival

OBJECTIVES

Our goal was to assess patient survival and response to treatment for superior sulcus tumors treated with combined radiation therapy and surgery when possible, or with radiation alone when surgery was not possible.

METHODS

Seventy-three patients were treated for primary non-small cell carcinoma of the superior pulmonary sulcus. Thirty-four patients received combined resection and irradiation. Thirty-nine patients who had extensive primary disease, distant metastases, or who were medically unfit for surgery were treated with radiation alone. Thirty-one patients (91%) assigned to the resection/irradiation group completed treatment. Combined therapy patients routinely received 40 Gy before the operation, with additional postoperative irradiation based on the surgical findings.

RESULTS

Overall survival at 5 years was 19% and disease-specific survival was 20% for all patients. Overall survival and disease-specific survival at 5 years for the resection/irradiation group were 33% and 38%, respectively. Significant indicators of poor prognosis included unresected primary disease, low performance score, T4 stage, or positive node status. Eighty-two percent of the patients who received irradiation alone were treated with palliative intent. Freedom from local-regional progression, achieved initially in 66% of these patients, was associated with a median survival of 8 months. Median survival for 7 patients considered for definitive irradiation was 25 months. During the first 18 months, distant failures occurred in approximately 35% of patients in each treatment group.

CONCLUSIONS

Selection of medically fit patients with resectable disease for combined surgery and aggressive radiation therapy resulted in a high likelihood of local control. Overall survival for the resection/irradiation group was significantly poorer for patients with T4 stage, nodal disease, or Horner's syndrome. Distant metastases eventually developed in 56% of patients undergoing resection. Median survival in the resection/irradiation group was significantly prolonged for those patients who could tolerate high-dose radiation treatment.

Surgical treatment of primary pulmonary sarcomas

OBJECTIVE

We sought to identify the long-term prognosis after surgical treatment for primary pulmonary sarcoma.

METHODS

Twenty-three patients were retrospectively identified as having been treated surgically for primary pulmonary sarcoma between 1981 and 1996. The records of all patients were reviewed, and the histopathology reexamined by a pathologist.

RESULTS

Fifteen patients were male and eight female; their ages ranged from 20 to 78 (mean 51) years. Tumors measured between 0.9 and 12.0 (mean 5.2) cm across the greatest diameter. The histologic diagnoses were malignant fibrous histiocytoma (8, three grade 1 or 2, two grade 3), synovial sarcoma (4), malignant schwannoma (3), leiomyosarcoma (3), and one case each of angiosarcoma, intimal sarcoma, epitheloid hemangioendothelioma, fibrosarcoma and primitive neuroectodermal tumor. Three patients were found to be unresectable. All three underwent radiation and chemotherapy. Lobectomies or bilobectomies were performed in 13 patients including two sleeve resections, one carinal resection, and one chest wall resection. Four patients underwent radical pneumonectomies. Three patients with invasion of the pulmonary artery, pulmonary veins or atrial wall underwent extended resections with the use of cardiopulmonary bypass. In two, a homograft was used to reconstruct the right ventricular outflow tract. Of the resected patients, six had a positive resection margin, and four had at least one positive lymph node in the specimen. Three patients underwent repeat pulmonary resections for recurrences. Eleven patients received postoperative chemotherapy and eight had radiation therapy. Follow-up was available on 22 patients, and ranged from 2 to 183 (mean 48) months; 14 patients are disease free, six died of disease, one died of surgical complications (operative mortality 5%), and two are alive with disease. Actuarial 3- and 5-year survival of the resected patients was 69%. Size and grade were not found to be correlated with significantly increased survival, but completeness of resection was (P<0.05).

CONCLUSIONS

Resection of primary pulmonary sarcomas can produce an acceptable survival rate if the resection is complete. Cardiopulmonary bypass can be a useful adjunct when tumors involve a resectable area of the heart or great vessels.

Long-segment colon interposition for acquired esophageal disease

BACKGROUND

Long-segment colon interposition has been used for esophageal replacement for acquired esophageal disease. The indications for use, morbidity, and functional results of these conduits have been debated.

METHODS

We reviewed the medical records, office visits, and operative reports of patients undergoing long colon interposition for acquired esophageal disease at our institution from 1956 to 1997.

RESULTS

Long colon interposition was performed in 52 patients for caustic injury (n = 20), gastroesophageal disease (n = 16), previous irradiation (n = 8), primary motility disorders (n = 4), and acquired absence of the esophagus (n = 4). From 1976 to 1997, acquired diseases accounted for 62% of long colon interposition. The left colon was used in 46 patients and the right colon in 6. The in-hospital mortality rate was 4%. Early complications included graft ischemia in 5 patients, anastomotic leak in 3, and small bowel obstruction in 1. Late complications included anastomotic stenosis requiring dilation in 26 patients, with 2 requiring surgical revision, and bile reflux requiring surgical diversion in 1 patient. Swallowing function was excellent in 24% of patients, good in 66%, and poor in 10%.

CONCLUSIONS

Long colon interposition can be performed safely, with acceptable long-term functional results in patients with acquired esophageal disease.

Clinical experience with carinal resection

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inhaled nitric oxide for adult respiratory distress syndrome after pulmonary resection

BACKGROUND

The adult respiratory distress syndrome (ARDS) developing after pulmonary resection is usually a lethal complication. The etiology of this serious complication remains unknown despite many theories. Intubation, aspiration bronchoscopy, antibiotics, and diuresis have been the mainstays of treatment. Mortality rates from ARDS after pneumonectomy have been reported as high as 90% to 100%.

METHODS

In 1991, nitric oxide became clinically available. We instituted an aggressive program to treat patients with ARDS after pulmonary resection. Patients were intubated and treated with standard supportive measures plus inhaled nitric oxide at 10 to 20 parts/million. While being ventilated, all patients had postural changes to improve ventilation/perfusion matching and management of secretions. Systemic steroids were given to half of the patients.

RESULTS

Ten consecutive patients after pulmonary resection with severe ARDS (ARDS score = 3.1+/-0.04) were treated. The mean ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen at initiation of treatment was 95+/-13 mm Hg (mean +/- SEM) and improved immediately to 128+/-24 mm Hg, a 31%+/-8% improvement (p<0.05). The ratio improved steadily over the ensuing 96 hours. Chest x-rays improved in all patients and normalized in 8. No adverse reactions to nitric oxide were observed.

CONCLUSIONS

We recommend the following treatment regimen for this lethal complication: intubation at the first radiographic sign of ARDS; immediate institution of inhaled nitric oxide (10 to 20 parts per million); aspiration bronchoscopy and postural changes to improve management of secretions and ventilation/perfusion matching; diuresis and antibiotics; and consideration of the addition of intravenous steroid therapy.

Slide tracheoplasty for long-segment tracheal stenosis

OBJECTIVE

To introduce a novel surgical technique for the repair of congenital long-segment tracheal stenosis.

DESIGN

Retrospective case series.

SETTING

Tertiary-care hospital.

PATIENTS

Three children ranging in age from 3 months to 3 years, all with complete tracheal rings, the stenotic segments representing between 36% and 49% of the total tracheal length. One patient had an anomalous right upper lobe bronchus and an associated pulmonary artery sling.

INTERVENTION

Slide tracheoplasty reconstruction.

MAIN OUTCOME MEASURE(S)

Postoperative clinical status as evidenced by day and site of extubation, duration of hospitalization, number of bronchoscopic examinations performed before discharge, and subsequent need for urgent bronchoscopic examinations, which reflects the adequacy of the reconstructed airway.

RESULTS

Two patients were extubated on the day of surgery, 1 intraoperatively; the child with the pulmonary artery sling required 3 days of elective intubation for postoperative ventilatory support. The duration of hospitalization ranged from 8 to 10 days. All patients underwent elective bronchoscopy once before discharge; none had granuloma formation. Follow-up ranged from 1 to 4 1/2 years. One patient required a single urgent bronchoscopic examination in addition to planned surveillance endoscopy. Growth of the reconstructed hemitracheal rings is demonstrable.

CONCLUSIONS

Slide tracheoplasty achieves successful tracheal reconstruction using the patient's own tracheal tissues. Advantages of this method include the potential avoidance of cardiopulmonary bypass, immediate or early postoperative extubation, and the near-complete absence of granulation tissue formation. The latter obviates the need for multiple postoperative bronchoscopic examinations, as has been reported in tracheoplasty procedures using either costal cartilage or pericardium.

Reoperative tracheal resection and reconstruction for unsuccessful repair of postintubation stenosis

OBJECTIVE

Our objective was to analyze characteristics and results of redo tracheal resection and reconstruction.

METHODS

Seventy-five patients were operated on between 1966 and 1997 after unsuccessful initial repairs for postintubation tracheal stenosis.

RESULTS

Sixteen of these patients came from a group of 32 patients with unsuccessful repair among the 450 primary resections and reconstructions performed at our institution. Fifty-nine patients were referred to us after unsuccessful initial repair elsewhere. Initial management was a T-tube or tracheotomy in 39 patients. The length of repeat resection ranged from 1.0 cm to 5.5 cm (mean 3.5 cm). A laryngeal release was used in 19 patients (25%) to reduce anastomotic tension. Complications occurred in 29 patients (39%) and were most frequent in the group requiring laryngeal release (12/19, 63.2%). Overall outcome was good in 59 patients (78.6%) and satisfactory in 10 (13.3%). The repair was unsuccessful in four patients (5.3%), and two patients died (2.6%).

CONCLUSIONS

Despite difficulties encountered in reoperative surgery after failed tracheal reconstruction for postintubation stenosis, successful outcome may be achieved in a large number of cases.

Induction therapy for esophageal cancer with paclitaxel and hyperfractionated radiotherapy: a phase I and II study

OBJECTIVE

Induction chemoradiotherapy followed by surgery may improve survival rates among patients with esophageal carcinoma. We designed a novel intense induction regimen with paclitaxel and high-dose hyperfractionated radiotherapy to maximize complete response rates.

METHODS

Forty patients with esophageal cancer were treated in a phase I and II trial of induction chemotherapy (cisplatin, 5-fluorouracil, and paclitaxel) at three dosage levels (75, 125, and 100 mg/m2) and concurrent hyperfractionated radiotherapy (45 Gy to the mediastinum, 58.5 Gy to the tumor). The mean age was 62 years, and 32 patients (80%) had adenocarcinoma. Twenty-eight of 40 (70%) patients had locally advanced tumors (T3, or stage IIB or greater).

RESULTS

The average hospitalization for induction treatment was 17 days. Toxicity was substantial, with esophagitis necessitating nutritional support the most common complication. The maximum tolerated dose of paclitaxel was 100 mg/m2. Two patients died during induction treatment. Thirty-six patients (90%) underwent resection. The median length of stay was 10 days, and two patients died after the operation. Fourteen of 36 patients (39%) had a pathologic complete response. Patients who received all prescribed chemotherapy had a higher pathologic complete response rate (50%) than did patients who required dose reduction (17%; p = 0.076). The 2-year survival rate was 61% (95% CI 35% to 86%) with a median follow-up of 11.9 months.

CONCLUSIONS

Paclitaxel at a dose of 100 mg/m2 appears to have acceptable toxicity. The high pathologic complete response rate in this regimen is encouraging, but it is associated with substantial toxicity. The toxicity of this regimen is not acceptable and will require substantial reduction in the radiation component. Survival data are too short-term to confirm enhanced survival.

Bronchopulmonary carcinoid tumors associated with Cushing's syndrome: a more aggressive variant of typical carcinoid

OBJECTIVES

Our objectives were to delineate the clinicopathologic characteristics of adrenocorticotropin-secreting bronchopulmonary carcinoid tumors causing Cushing's syndrome and to derive from these findings a rational approach to diagnosis and surgical management of this unusual condition.

METHODS

We conducted a retrospective, chart-review analysis of seven consecutive patients treated at the Massachusetts General Hospital over a 16-year period.

RESULTS

The patients uniformly had symptoms of marked hypercortisolism, and the underlying lung lesions remained clinically occult for a mean of 24 months. Standard endocrine testing was misleading in 83% of patients, reinforcing the need for an alternative diagnostic strategy based on petrosal sinus catheterization and computed tomography of the chest. Although 72% of the tumors were typical carcinoids by standard criteria, 57% demonstrated microscopic evidence of local invasiveness, and 43% were associated with mediastinal lymph node metastases. Eighty-six percent of patients have been cured by pulmonary resection a mean of 59 months after the operation, but 50% of these required a second operation for resection of involved lymph nodes after an initial relapse.

CONCLUSIONS

These data suggest that adrenocorticotropin-secreting bronchopulmonary carcinoid tumors represent a distinct, more aggressive subtype of the usual, typical carcinoid. The high rate of lymphatic and local spread demands a surgical approach consisting of anatomic resection and routine mediastinal lymph node dissection.

Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality

BACKGROUND

Cost containment is a reality in thoracic surgery. Patient care pathways have proved effective in cardiac surgery to reduce length of stay and control costs.

METHODS

A multidisciplinary team formulated a pulmonary lobectomy patient care pathway to standardize care, reduce length of stay and costs, and maintain quality. Variance codes were developed to collect data prospectively on reasons for prolonged stay. A patient satisfaction survey was instituted to learn patients' responses to their hospitalization.

RESULTS

One hundred forty-seven patients underwent lobectomy in 1995 before institution of the pathway with a mean length of stay of 10.6 days and a mean cost of $16,063. The lobectomy pathway was instituted at the beginning of 1996. One hundred thirty patients underwent lobectomy in 1996 with a mean length of stay of 7.5 days (p = 0.03) and a mean cost of $14,792 (p = 0.47). Readmission and mortality rates were unchanged. Eighty-eight of 130 patients (68%) were able to be discharged by the target length of stay of 7 days in 1996 as opposed to 76 of 147 patients (52%) in 1995. The most common reason for delayed discharge was inadequate pain control. The majority of patients felt prepared for discharge by the seventh postoperative day (70 of 96 patients, 73%).

CONCLUSIONS

The institution of a lobectomy patient care pathway appeared to reduce length of stay and costs. The pathway provided a framework to begin systematic quality control measures to enhance patient care.

Postpneumonectomy syndrome: another twist

This report describes the clinical, radiographic, and surgical findings in a patient with a rare postoperative complication, the postpneumonectomy syndrome. To our knowledge, it is the first reported case of postpneumonectomy syndrome after left pneumonectomy in a patient with a left-sided aortic arch.

Pediatric tracheal problems

Awareness of the special problems of airway repair in children and precise application of principles of tracheal and laryngotracheal surgery are necessary for success in treating acquired pediatric airway lesions. Long segment congenital lesions require special techniques, which are still evolving.

Postintubation tracheal stenosis

Resection and reconstruction are the treatments of choice for postintubation tracheal stenosis, attested to by 94% good or satisfactory results in over 500 patients. Accurate diagnosis, appropriate patient selection, and experienced and precise surgical care are important in these treatments.

Management of idiopathic tracheal stenosis

Idiopathic laryngotracheal stenosis usually occurs in women, produces stenosis of 1 to 3 cm, is densely collagenous, and is unaccompanied by systemic disease. It may be successfully managed by one stage resection and reconstruction, most often including a portion of the lower larynx.

Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management

OBJECTIVE

Postpneumonectomy bronchopleural fistula remains a morbid complication after pneumonectomy. The incidence, risk factors, and management of postpneumonectomy bronchopleural fistula were evaluated in 256 consecutive patients who underwent pneumonectomy with a standardized suture closure of the bronchus.

METHODS

Pneumonectomy was performed for lung cancer in 198 cases, for other malignancy in 20 cases, and for benign causes in 38 cases. The bronchial stump was closed with interrupted simple sutures to emphasize a long, membranous wall flap. All stumps were covered by autologous tissue.

RESULTS

The incidence of postpneumonectomy bronchopleural fistula was 3.1%. Risk factors for bronchopleural fistula were the need for postoperative ventilation (p = 0.0001) and right pneumonectomy (p = 0.04). Five patients had bronchopleural fistulas as a result of pulmonary complications necessitating ventilation; the cause in the remaining three cases appeared to be technical. Reclosure was successful in five cases (mean postoperative day 12); in one case a pinhole fistula was healed by drainage alone. Two (25%) of the eight patients who had bronchopleural fistulas died.

CONCLUSIONS

Careful, sutured closure of the main bronchus with a tissue buttress after pneumonectomy yields excellent results. The most significant risk factor for bronchopleural fistula is a pulmonary complication necessitating ventilation. Contrary to previous reports, reclosure is usually successful even if performed late.

Post intubation tracheal stenosis

Although the etiology of post intubation tracheal stenosis has been well defined and methods for its prevention clarified, the lesions continue to occur and to be the most common indication for tracheal reconstruction. These lesions with specific characteristics at various levels--such as cuff and stomal--present with the signs and symptoms of airway obstruction. They are best handled in an emergency with systematic dilation. Under certain circumstances surgical repair is best deferred using repetitive dilations or intubation through an appropriately located stoma. Preferred management is surgical resection with primary reconstruction. Special techniques are necessary in cases in which larynx is also involved. With diagnostic precision and meticulous surgical technique, good or satisfactory results were obtained in nearly 94% of 503 surgically treated patients. Best results are obtained at an initial corrective operation performed by an experienced operator.

Bronchoplasty in the management of low-grade airway neoplasms and benign bronchial stenoses

BACKGROUND

Parenchyma-sparing bronchoplastic procedures have altered the management of benign bronchial stenoses and low-grade neoplasms of the airway. Reliable techniques are available to allow sleeve resection of any lobe or the main bronchus and thus maximize preservation of lung parenchyma.

METHODS

Between 1972 and 1995 we performed 100 bronchoplastic procedures on 99 patients. Seventy-eight patients had low-grade or benign tumors including carcinoid, mucoepidermoid, and fibrous histiocytomas. Seven patients had inflammatory lesions including histoplasmosis and tuberculosis. Two patients had idiopathic stenosis. Thirteen patients had stenoses due to prior trauma or previous operation. Resection involved the bronchus alone in 51 cases. Sleeve lobectomies were done in 49 patients.

RESULTS

There were two postoperative deaths in complicated patients. Major complications occurred in 3 patients. Sixteen patients presented preoperatively with postobstructive pneumonia but had no major postoperative complications. Long-term follow-up (mean, 88 months) reveals only one instance of tumor recurrence (adenoidcystic carcinoma) and progressive stenosis in 1 patient with idiopathic stenosis.

CONCLUSIONS

Lung-sparing bronchoplastic operations are the procedures of choice in anatomically suited patients with low-grade malignant tumors of the airway and benign bronchial stenosis.

Survival and function after sleeve lobectomy for lung cancer

Between 1962 and 1991, 72 patients (mean age 63.4 years) underwent sleeve lobectomy for primary lung cancer. Thirty-seven patients had adequate lung function and 35 were deemed unsuitable for pneumonectomy on the basis of inadequate pulmonary reserve (n = 31) or cardiac risk factors (n = 4). Squamous cell carcinomas (68%) and adenocarcinomas (26%) predominated. Upper lobectomy was performed in 48 patients, lower and middle lobectomy in 13, and right upper and middle bilobectomy in 11. Hospital mortality was 4% (3/72) and compares with a hospital mortality of 9% in 56 consecutive pneumonectomies between 1986 and 1990. Major complications occurred in 11% (bronchopleural fistula 1, persistent atelectasis 4, pneumonia 4). Adjusted actuarial survival after sleeve lobectomy at 1 and 5 years was 84% and 42%, compared with 76% and 44% after pneumonectomy. Five-year survival after lower and middle lobectomy in 13 patients (52%) was similar to that after upper lobectomy (46%), suggesting that in carefully selected patients the concept of sleeve lobectomy can be applied to all pulmonary lobes. N1 disease and compromised lung function were associated with lower survival (N1 38% vs N0 57%; compromised 20% vs adequate 55%). Comparison of preoperative and postoperative lung function and quantitative ventilation-perfusion isotope studies substantiated the preservation of pulmonary function in this group of patients. Sleeve lobectomy is the procedure of choice for anatomically suitable carcinomas or when reduced pulmonary reserve precludes extensive resection.

Reinforced primary repair of thoracic esophageal perforation

BACKGROUND

Treatment of esophageal perforation, especially when diagnosed late, remains controversial.

METHODS

Twenty-eight patients were treated for thoracic esophageal perforation with reinforced primary repair regardless of time of presentation.

RESULTS

Fifteen patients were treated early (< 24 hours) with no deaths. Two had contained postoperative leaks, which healed. Thirteen were treated late (mean, 5.5 days) with four deaths (3 with healed repairs). Postoperative leaks occurred in 7 patients; of the leaks, 4 healed, 2 became a controlled fistula, and 1 required reoperation. Primary healing with preservation of the native esophagus was achieved in 25 patients (89%). Among the 18 patients without evidence of sepsis preoperatively, post-operative leaks developed in 2 (11%). Ten patients had evidence of sepsis preoperatively, and postoperative leaks developed in 7 (70%).

CONCLUSIONS

Patients who present with sepsis have an increased risk of postoperative leak and therefore should have the repair buttressed. Overall mortality was 14% and no deaths were due to persistent leaks or mediastinal sepsis. Reinforced primary repair retains the native esophagus and avoids the need for later reconstructive operations. In the absence of a nondilatable stricture or cancer, reinforced primary repair should be performed for most thoracic esophageal perforations, early or late.

[Resection and reconstruction of the carina in children and adolescents]

While resection of tracheobronchial segments has become a standard operation in adults, lesions of the carina in children are rare and their treatment is technically more demanding. Since 1980, 8 patients aged 8 to 19 years underwent surgical reconstruction of the carina. The indications were tumors in 5 and non-neoplastic lesions in 3. In 3 patients with tumor (2) and advanced histoplasmosis (1), resection of the carina was combined with parenchymal resection. The principles of operative repair include complete resection, with frozen section confirmation in tumors, particular emphasis on adequate mobilization of the airway in children to reduce anastomotic tension, and use of anesthetic techniques that facilitate early extubation. One patient (12.5%) died after complex airway reconstruction for extensive mediastinal fibrosis. Residual malacia in a patient with postpneumonectomy syndrome required successful re-resection. Seven patients remain free of anastomotic stricture and tumor recurrence during a mean follow-up of 62 months (range 5 to 132 months), with expected preservation of lung function. Late bronchoscopy in 5 patients 6 months to 11 years after operation demonstrated growth of the luminal diameter and patent anastomoses. Carinal reconstruction in children is occasionally required, succeeds in general, and does not result in late problems at the anastomosis.

Treatment strategies for bronchopleural fistula

Successful management of chronic postoperative bronchopleural fistula remains a challenge for thoracic surgeons. Forty-two patients (33 referred from other institutions) were treated for major postoperative bronchopleural fistula since 1978. Factors associated with bronchopleural fistula included right pneumonectomy (n = 23), left pneumonectomy (n = 8), long bronchial stump (n = 16), pneumonia (n = 13), radiation therapy (n = 12), stapled bronchial closure (n = 8), prolonged mechanical ventilation (n = 7), recurrent carcinoma (n = 6), and tuberculosis (n = 2). Patients had undergone an average of 3.3 surgical procedures to correct their bronchopleural fistulas during a mean interval of 24 months before our treatment. Bronchopleural fistulas were located in the right main bronchial stump (n = 23), left main bronchial stump (n = 8), right lobar bronchial stumps (n = 10), and tracheobronchial anastomosis (n = 1). Thirty-five patients were treated by suture closure of the bronchial stump, buttressed with vascularized pedicle flaps of omentum (n = 19), muscle (n = 13), or pleura (n = 2). In seven cases, direct suture closure was not possible, and omental (n = 6) or muscle (n = 1) flaps were sutured over the bronchopleural fistula. Suture closure without pedicle coverage was performed successfully in one case. Initial repair of the fistula was successful in 23 of 25 patients treated with omentum, in nine of 14 patients treated with muscle and in neither of two patients treated with pleural flaps. In nine patients with persistent or recurrent bronchopleural fistula after our initial repair, four underwent a second procedure (three successful) and five were managed with drainage only. The fistula was successfully closed in 11 of 12 patients who had received high-dose radiation therapy (nine with omentum). Overall, successful closure of bronchopleural fistula was achieved in 36 of 42 patients (86%). Four in-hospital deaths resulted from pneumonia and sepsis, two in patients with recurrent bronchopleural fistula after pleural flap closure. In 16 patients the empyema cavity was obliterated during definitive repair of the fistula. The cavity resolved with drainage in four others, nine had draining cavities at follow-up, and one was lost to follow-up. Ten patients required a total of 17 Clagett procedures and one had a delayed myoplasty. Direct surgical repair of chronic bronchopleural fistula may be achieved in most patients after adequate pleural drainage by suture closure and aggressive transposition of vascularized pedicle flaps. Omentum is particularly effective in buttressing the closure of bronchopleural fistulas.

Postintubation tracheal stenosis. Treatment and results

A total of 503 patients underwent 521 tracheal resections and reconstructions for postintubation stenosis from 1965 through 1992. Fifty-three had had prior attempts at surgical resection, 51 others had undergone various forms of tracheal or laryngeal repair, and 45 had had laser treatment. There were 251 cuff lesions, 178 stomal lesions, 38 at both levels, and 36 of indeterminate origin. Sixty-two patients with major laryngeal injuries required complete resection of anterior cricoid cartilage and anastomosis of trachea to thyroid cartilage, and 117 had tracheal anastomosis to the cricoid. A cervical approach was used in 350, cervicomediastinal in 145, and transthoracic in 8. Length of resection was 1.0 to 7.5 cm. Forty-nine had laryngeal release to reduce anastomotic tension. A total of 471 patients (93.7%) had good (87.5%) or satisfactory (6.2%) results. Eighteen of 37 whose operation failed underwent a second reconstruction. Eighteen required postoperative tracheostomy or T-tube insertion for extensive or multilevel disease. Twelve died (2.4%). The most common complication, suture line granulations (9.7%), has almost vanished with the use of absorbable sutures. Wound infection occurred in 15 (3%) and glottic dysfunction in 11 (2.2%). Five had postoperative innominate artery hemorrhage. Resection and reconstruction offer optimal treatment for postintubation tracheal stenosis.

Reconstructive airway operation after irradiation

After a patient died of anastomotic necrosis following a tracheal resection for the management of recurrent thyroid cancer invading the trachea, which had been treated 6 years previously by thyroid lobectomy and 4,800 cGy of radiation to control known residual disease, we explored methods to promote the healing of tissues damaged by irradiation. Between 1979 and 1992, 22 patients underwent major airway resection and reconstruction after receiving large doses of radiation. The average dose was 4,979 +/- 1,113 cGy (range, 3,150 to 6,840 cGy); the number of fractions, 20 to 38; and the average dose per fraction, 180 cGy (range, 150 to 200 cGy). The interval between irradiation and surgical treatment was 42 +/- 105 months (range, 1 to 480 months). Seven cervical, eight midtracheal, and five carinal resections were performed, as well as two mainstem sleeve resections. Omentum was used to protect the anastomosis in 15 patients (68%), a pericardial fat pad was used in 2, and pleura was used in 2. In 3 patients, sternohyoid muscle was placed between the anastomosis and a major vascular structure, but without a tissue wrap. Two patients (9.0%) died postoperatively. Anastomotic dehiscence was the cause of death in a patient treated for lymphoma, and adult respiratory distress syndrome was the cause in the other patient; this patient had undergone carinal pneumonectomy. Complications developed in 8 patients (36%). Two cervical dehiscences were treated by T-tube placement, 2 patients suffered wound infection, and 1 patient each suffered a myocardial infarction, dysphagia, hemoptysis, and bronchitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Evolution of treatment strategies for adenocarcinoma of the esophagus and gastroesophageal junction

Between 1980 and 1988, 91 patients with adenocarcinoma of the esophagus were treated by surgical resection and selective postoperative therapy. Operative mortality was 2%. Pathologic stage was I in 4, II in 26, and III in 61. Actuarial 2- and 5-year survival was 24% and 8%. From 1987 to 1989, 16 patients with adenocarcinoma of the esophagus were treated with two cycles of 5-fluorouracil and cisplatin followed by surgical resection. There was 1 complete response (6%), 5 partial responses (31%), and 10 with no response (63%). Twelve patients had resection. Pathologic stage was I in 1, II in 4, and III in 8. There was one chemotherapy-related death and one surgical death. Actuarial 4-year survival is 42%. From 1990 to 1993, 22 patients with adenocarcinoma of the esophagus were treated with two cycles of etoposide, doxorubicin, and cisplatin followed by surgical resection. There was 1 complete response (5%), 11 partial responses (50%), and 10 with no response (45%). Eighteen patients had resection. Pathologic stage was 0 in 1, II in 8, and III in 9. There were no treatment-related deaths. The actuarial 2-year survival is 58%. Conclusions are necessarily limited because the patients were not treated in a randomized fashion. These preliminary results with preoperative chemotherapy appear improved (p = 0.04 and p = 0.004, respectively) as compared with results from 1980 to 1988 without preoperative chemotherapy.

Slide tracheoplasty for long-segment congenital tracheal stenosis

Resection and reconstruction of long congenital tracheal stenosis often is impossible or results in excessive anastomotic tension. Anterior tracheoplasty using a patch of pericardium or cartilage may result in granulation tissue needing repeated bronchoscopies, tracheostomy, and stents and may produce recurrent stenosis. Tracheoplasty may be performed by dividing the stenosis at midpoint, incising the proximal and distal narrowed segments vertically on opposite anterior and posterior surfaces and sliding these together. The stenotic segment is shortened by half, the circumference doubled, and the lumenal cross-section quadrupled. Approach is cervical or with partial sternotomy. Cardiopulmonary bypass is not necessary. Four patients (ages: 3 months, 3 1/2 years, 19 years, and 19 years) were so treated for stenosis of 36% to 83% of tracheal length. Blood supply was not impaired. Healing was excellent and complications were minimal.

Temporary and permanent restoration of airway continuity with the tracheal T-tube

The advantages of the tracheal T-tube compared with a regular tracheostomy tube are a physiologic direction of air flow, preservation of laryngeal phonation, and superior patient acceptance. Between 1968 and 1991, 140 patients aged 7 months to 95 years underwent placement of T-, TY- (n = 7), or a modified extended T-tube (n = 4). Primary diagnosis was postintubation stenosis in 86 patients, burn injury in 13 patients, malignant airway tumors in 12 patients, and various disorders in 29 patients. Stenting with a silicone rubber tube was temporary in 31 patients and 14 underwent later operative reconstruction. Definitive permanent insertion was performed in 49 patients. A modified tube was used in 4 patients with left main bronchial stenosis with effective long-term palliation in 3. Postoperative airway obstruction prompted placement in 32 patients. Positioning of the T-tube above the vocal cords in 12 patients for subglottic stenosis was effective in 10. The T-tube was not tolerated in 28 patients (20%) because of obstruction of the upper limb or aspiration. Five of 10 patients under the age of 10 years had airway obstruction necessitating tube removal. Long-term intubation in 112 patients exceeded 1 year in 49 patients and 5 years in 12 patients. Only 5 patients required tube removal for obstructive problems more than 2 months after placement. The tracheal T-tube restores airway patency reliably with excellent long-term results and represents the preferred management of chronic airway obstruction not amenable to surgical reconstruction.

Tracheobronchial sleeve resection in children and adolescents

Bronchoplastic techniques preserving lung parenchyma allow resection and reconstruction of the major bronchi and carina and are widely used in adults. The smaller and more delicate airways of children make such operations more demanding, but successful outcome can still be achieved with particular attention to technique. The authors treated 12 patients age 8 to 19 years (mean, 13.8 years) over a 12-year period. Ten patients had tumors of the airway: carcinoid (4), mucoepidermoid (2), malignant fibrous histiocytoma (1), adenocarcinoma (1), granular cell (1), and invasive fibrous tumor (1); and 2 had nonneoplastic strictures. Previous operative treatment included incomplete local excision in 2 and laser ablation in 1. Carinal resection and reconstruction was performed in 6 patients, main-stem bronchial resection in 3, and sleeve lobectomy in 3. There was one death after a complex airway reconstruction for extensive mediastinal fibrosis involving the airway. Postoperative morbidity consisted of prolonged atelectasis in 3 patients. Residual malacia in 1 patient with postpneumonectomy syndrome required further tracheobronchial resection. Follow-up is complete (mean, 64 months; range, 7 to 130). There has been no anastomotic stenosis or tumor recurrence. Preservation of lung function is expected in all patients. In 7 patients, bronchoscopy 4 months to 11 years postoperatively confirmed anastomotic patency and growth. The understanding of bronchoplastic techniques and precise attention to technical detail should allow these procedures to be successfully performed in pediatric patients.

Short-segment intestinal interposition of the distal esophagus

Esophageal replacement remains a challenge. Colon and jejunum provide alternative conduits to replace the lower esophagus when stomach is not suitable. Between 1971 and 1991, 41 patients underwent short-segment interposition of the esophagus with jejunum or colon. Indications were failed antireflux procedures (n = 21), nondilatable stricture (n = 9), achalasia (n = 2), moniliasis (n = 2), Barrett's esophagus with carcinoma in situ (n = 2), hemorrhagic esophagitis after esophagogastrectomy (n = 1), motility disorder (n = 1), instrumental perforation (n = 1), carcinoma (n = 1), and leiomyosarcoma (n = 1). Thirty-one patients (75.6%) had prior surgical procedures. Interposition with colon was performed in 22 patients and with jejunum in 19. Major complications occurred in 45% after colon interposition (10/22) and hospital mortality was 4.5% (1/22). Major complications after jejunal interposition occurred in 31% (6/19) and hospital mortality was 10.5% (2/19). A contained anastomotic leak occurred in 1 patient, perforation of a colon segment in 1, and jejunal graft necrosis in a third. Late functional results in 34 patients with a mean follow-up of 87 months were excellent or good in 26, fair in 5, and poor in 1. Colon interposition failed to improve symptoms in 2 patients with gastrointestinal motility disorders. Six patients underwent manometry and barium food provocation study. Two colon segments and 3 jejunal interpositions were hypoperistaltic or aperistaltic according to manometry. There was 1 case of aperistaltic jejunum with a distended afferent loop. When stomach is not available, successful palliation of swallowing can be accomplished with either jejunum or colon. Surgeons involved in the management of esophageal disease should be familiar with the technical details of both procedures.

Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management

OBJECTIVE

Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment.

SUMMARY BACKGROUND DATA

The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea.

METHODS

Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis.

RESULTS

There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction.

CONCLUSIONS

Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.

Idiopathic laryngotracheal stenosis: radiologic findings

OBJECTIVE

Acquired nonneoplastic laryngotracheal stenosis can be either focal or diffuse. Diffuse tracheal stenosis is caused by sarcoidosis, tuberculosis, histoplasmosis, relapsing polychondritis, tracheopathia osteoplastica, and Wegener's granulomatosis. Focal tracheal stenosis, on the other hand, usually results from placement of an endotracheal or tracheostomy tube or from previous neck trauma. At our institution, since 1971, we have seen 49 cases of focal laryngotracheal stenosis that could not be attributed clinically or histologically to any one of the aforementioned causes. The purpose of this study was to study the radiologic features of these idiopathic laryngotracheal stenoses.

MATERIALS AND METHODS

A retrospective review of records showed that radiologic studies were still available in only 15 of the 49 patients with idiopathic laryngotracheal stenoses. All 15 patients had radiographs and plain tomograms, and one patient had a CT scan of the neck. Three radiologists reviewed all the images.

RESULTS

The radiologic appearance was variable: the stenoses were from 2 to 4 cm long with a lumen between 3 and 5 mm in diameter at the narrowest portion. The narrowing was concentric and shaped like an hourglass in eight patients (53%) and was eccentric in the other seven (47%). The margins of the stenosis were smooth in nine patients (60%) and irregular and lobulated in six patients (40%). A dominant mass measuring approximately 1 cm in diameter was present in two patients (13%). No evidence of calcification or ossification was seen.

CONCLUSION

Idiopathic laryngotracheal stenosis produces focal stenosis of the cervical part of the trachea, 2 to 4 cm long. The lumen is severely compromised, measuring no more than 5 mm in diameter at its narrowest portion. The stenosis can be concentric or eccentric and can have either smooth or lobulated margins. Special attention should be paid to the airways when chest radiographs of patients with a history of prolonged dyspnea and wheezing are reviewed. The prevalence of focal stenosis of the larynx and the upper part of the trachea due to tracheal intubation has declined since the introduction of low-pressure, high-volume retention cuffs. Therefore, idiopathic laryngotracheal stenosis should be considered in the differential diagnosis in patients with focal narrowing of the airway.

Pulmonary arteriovenous malformations: therapeutic options

We have treated 21 patients (13 female, 8 male) with pulmonary arteriovenous malformations (PAVMs). Mean age at diagnosis was 37.5 years (range, 15 to 72 years). Presenting symptoms included dyspnea on exertion (67%), hereditary hemorrhagic telangiectasia (57%), and major neurologic events (33%). In our early experience, 8 patients had no specific treatment; their case histories illustrate the major neurologic complications of untreated PAVMs. Nine patients (8 primarily, 1 after recurrence) underwent conservative surgical excision; 4 had lobectomy, and 5 had segmentectomy or subsegmental excision. One patient underwent staged bilateral thoracotomies for multiple bilateral lesions. The arterial oxygen tension was found to increase after excision of large or solitary PAVMs. All surgically treated patients were relieved of dyspnea, and none had postoperative recurrence of PAVMs or neurologic complications related to PAVMs. Five patients underwent balloon occlusion of PAVMs. Two patients chose to have solitary PAVMs occluded rather than undergo thoracotomy. One underwent surgical excision 5 years later, and the other required repeat balloon embolization 4 years later when recanalization of the PAVMs was documented. Three patients with numerous PAVMs received palliation with multiple balloon embolizations. The high incidence of associated major neurologic complications mandates aggressive treatment of PAVMs whenever feasible. Conservative surgical resection remains the treatment of choice. Balloon embolization offers an alternative therapy for patients who are poor surgical risks or those whose lesions are too numerous to resect.

Expiratory collapse of the trachea presenting as worsening asthma

A 50-year-old woman with lifelong asthma had nearly total expiratory collapse of her distal trachea. The signs and symptoms were similar to those of asthma except for a pronounced upper airway component to her wheezing and the immediate onset of dyspnea on exertion. Surgical repair led to significant improvement in symptoms and resolution of tracheal collapse on expiration. Ultrafast computed tomography was a valuable adjunct to bronchoscopy in diagnosis and management. Expiratory collapse of the trachea should be considered in the differential diagnosis of wheezing and intractable reactive airway disease.

Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection

We received the clinical and pathologic features of 22 cases of papillary carcinoma of the thyroid that invaded the trachea and were treated by thyroidectomy and airway resection with or without reconstructive surgery over an interval of 16 years. We studied the fine relationships between lamina propria and lymphatics in the region between the isthmus of the thyroid and the trachea. The manner of invasion of papillary carcinoma of the thyroid was by blunt dissection along blood vessels and collagen fibers oriented perpendicularly to the tracheal lumen between cartilaginous rings. Although lymph node metastases were found in 14 patients (64%), we observed lymphangitic tumor in the tracheal mucosa in only three patients (14%). We devised a staging system for papillary carcinoma of the thyroid based on the extent of invasion of the trachea. Of the 11 patients with stage I, II, or III disease, none of six (0%) followed for 5 years died of thyroid cancer in the 5-year observation period; one patient in this group died later of thyroid cancer. Of the 11 patients with stage IV disease, five of seven (71%) followed for 5 years died of thyroid cancer in the 5-year observation period; one additional patient in this group died later of thyroid cancer.

Idiopathic laryngotracheal stenosis and its management

We describe idiopathic laryngotracheal and upper tracheal stenosis in 49 patients with no other cause for their stenosis. Traumatic, iatrogenic, infectious, and specific inflammatory processes were excluded. Histopathologically dense fibrosis of keloidal type thickened the lamina propria and choked the ducts of mucous glands but did not destroy cartilage. Thirty-five patients were treated by single-stage resection and reconstruction: 29 by laryngotracheal resection with laryngotracheoplasty and 6 by cricotracheal segmental resection. Thirty-two patients achieved good or excellent results in respiration and voice, 2 needed annual dilations, and 1 required permanent tracheostomy.

Surgical management and radiological characteristics of bronchogenic cysts

Forty-two patients with bronchogenic cysts were treated over a 30-year period (1962 to 1991). The location was mediastinal in 37 and intrapulmonary in 5. Cysts were symptomatic in 21 patients (50%) and complications occurred in 11 (26%). The complications included infection in 5 patients, hemorrhage into the cyst in 2 patients, dysphagia due to esophageal compression in 2, adenocarcinoma arising from a bronchogenic cyst in an 8 1/2-year-old girl, and an esophagobronchopleurocutaneous fistula as a result of previous incomplete resection in 1 patient. Magnetic resonance imaging has been found to provide specific diagnostic information about bronchogenic cysts. All but 2 patients were treated with complete excision. One patient was managed by observation and another had drainage of the cyst by mediastinoscopy. Complications of treatment occurred in only 2 patients. One had a minor wound infection and the other had Clostridium difficile enterocolitis. Only 4 patients were lost to follow-up. No late complication or recurrence developed in those patients having complete excision. We recommend complete excision in most instances to confirm the diagnosis, relieve symptoms, and prevent complications.

Long-term follow-up of neoadjuvant chemotherapy with 5-fluorouracil and cisplatin with surgical resection and possible postoperative radiotherapy and/or chemotherapy in squamous cell carcinoma of the esophagus

Seventy patients with local squamous cell carcinoma of the esophagus were treated between 1981 and 1990 with preoperative chemotherapy, surgical resection, and possible postoperative radiation therapy and/or chemotherapy. Chemotherapy included two cycles of 5-fluorouracil (1000 mg/m2) by continuous intravenous infusion on days 1-4 and cisplatin (100 mg/m2) on day 4. Complete clinical response (CCR) was achieved in 28 (41%) patients, partial clinical response (PCR) in 17 (25%), and no response in 23 (34%). Fifty-five (81%) patients were resected, 6 (9%) were explored, and 7 (10%) were unable to have surgery. Microscopic analysis of 55 resected patients showed 50 (91%) with active tumor, 1 (2%) with necrotic tumor, and 4 (7%) with a pathological complete response to chemotherapy. Twenty-six of the 55 resected patients (47%) had no gross evidence of disease at the time of surgical inspection. Median overall survival was 21.86 months (range 2-107 months) for all patients and 26.71 months (range 2-107 months) for resected patients. Actuarial 5-year survival rate was 31% for all patients and 39% for resected patients. Prolonged survival correlates with complete clinical response to chemotherapy, low pathological stage of disease, and successful resection of the lesion.

Clinical manifestation of mediastinal fibrosis and histoplasmosis

We treated 20 patients thought to have mediastinal fibrosis secondary to Histoplasma capsulatum. All but 1 were symptomatic. The most common symptoms were dyspnea (8), hemoptysis (6), postobstructive pneumonia (5), and superior vena caval obstruction (2). Nine patients had severe stenosis of the trachea, carina, or main bronchus. Special stains identified Histoplasma capsulatum in surgical specimens in 9 patients. Surgical procedures were done for 18 of 20 patients (resection of subcarinal mass, 6; right middle and lower lobectomy, 5; carinal pneumonectomy, 4; esophagoplasty, 4; sleeve resection, 3 (with right main bronchus in 1, right lower and middle lobectomy in 1, and carina in 1); right upper lobectomy, 1; middle lobectomy, 1; and bronchoplasty of left main bronchus, 1. There were 4 deaths, 3 after complications of carinal pneumonectomy and 1 in a patient with tracheobronchial obstruction that could not be dilated. Two patients were treated with amphotericin and 4 with ketoconazole. Sclerosing mediastinitis secondary to histoplasmosis presents tremendous surgical challenges because of the intense fibrosis encountered. Bronchoplastic procedures are possible in spite of the intense fibrosis. High mortality rates after carinal resection may be encountered. The exact role of antifungal therapy is as yet undefined.

Postpneumonectomy syndrome: diagnosis, management, and results

Airway obstruction may be caused by extreme mediastinal shift and rotation after right pneumonectomy or after left pneumonectomy in the presence of a right aortic arch. Eleven adults (aged 18 to 58 years) with severe symptoms were treated surgically between 5 months to 17 years after pneumonectomy (7 right, 4 left). An initial patient with only one functional lobe was treated unsuccessfully by aortic division and bypass graft. Ten underwent mediastinal repositioning. After two recurrences prostheses were used to maintain mediastinal position. Five patients who underwent such repositioning are doing well from 5 months to more than 5 years later. One died 1 month after operation probably of pulmonary embolism. One who showed residual airway collapse after operation has some recurrent obstruction. Three other patients who showed severe malacic obstruction of the airway after mediastinal repositioning variously underwent aortic division with bypass graft and tracheal and bronchial resection. One is well almost 6 years later. Two died postoperatively. Occurrence of the syndrome is unpredictable. Where malacic changes have not occurred, mediastinal repositioning may reasonably be expected to correct obstruction. Optimal treatment for concurrent severely malacic airways is unclear.