Pulmonary inflammatory pseudotumor causing lung collapse responding to corticosteroid therapy.

Pulmonary inflammatory pseudotumor (PIP) is a rare benign tumor that represents less than one percent of all tumors found in the lungs. Despite the benign etiology, PIP can cause significant clinical problems due to its growth rate and potential to compromise adjacent pulmonary and thoracic structures. Complete surgical resection is the preferred therapy for PIP to prevent recurrence, however, this is not possible in some patients due to the size or location of the tumor. We present the case of an 18 year-old male presenting with PIP in the proximal left mainstem bronchus causing complete left lung collapse. Surgical resection was not possible due to tumor location, and therefore the patient was treated with corticosteroids with marked response. Corticosteroid use has for PIP has been described in few other situations, and this case demonstrates the potential for this therapeutic option in patients with PIP who have a contraindication to surgical resection.

Successful Removal of a Chronic Aspirated Foreign Body after Twelve Years.

Chronic retention of aspirated foreign bodies is rare but can result in indolent systemic and respiratory symptoms. Bronchoscopy may show features of tissue reaction to the foreign body, including granulation tissue, endobronchial stenosis, strictures, edema, and airway distortion. The diagnosis of foreign body aspiration is often difficult to establish since some patients may not give a clear history of aspiration or may present late. In addition, patients may be misdiagnosed with chronic pneumonia, bronchitis, asthma, or malignancy. We present the case of a 42-year-old male who had a chronically retained piece of an aluminum beverage container in the left mainstem bronchus for 12 years. Careful history, radiographic evaluation, and bronchoscopic examination revealed the foreign body, which was successfully extracted by rigid bronchoscopy.

Minimally invasive transhiatal esophagectomy after thoracotomy.

Patients with end-stage achalasia may not be candidates for a transhiatal minimally invasive esophageal resection because of anatomic challenges and adhesions from previous interventions, namely, thoracotomy. Given the tactile feedback provided through a GelPort laparoscopic system (Applied Medical, Rancho Margarita, CA) we proposed that a minimally invasive transhiatal esophagectomy would be feasible in this patient cohort. The procedure was successful in 4 patients; seven complications occurred in 3 of the patients. At follow-up all patients demonstrated that they were meeting their nutritional needs with an oral diet.

Use of reprogrammed cells to identify therapy for respiratory papillomatosis.

A patient with a 20-year history of recurrent respiratory papillomatosis had progressive, bilateral tumor invasion of the lung parenchyma. We used conditional reprogramming to generate cell cultures from the patient's normal and tumorous lung tissue. Analysis revealed that the laryngeal tumor cells contained a wild-type 7.9-kb human papillomavirus virus type 11 (HPV-11) genome, whereas the pulmonary tumor cells contained a 10.4-kb genome. The increased size of the latter viral genome was due to duplication of the promoter and oncogene regions. Chemosensitivity testing identified vorinostat as a potential therapeutic agent. At 3 months after treatment initiation, tumor sizes had stabilized, with durable effects at 15 months.

Modified Tikhoff-Linberg procedure for posterior chest wall sarcoma.

The Tikhoff-Linberg procedure was originally described more than 80 years ago as a limb-sparing surgical option for malignancies involving the shoulder girdle. However, involvement of the chest wall was a contraindication, consigning patients to either amputation or shoulder disarticulation. With the addition of prosthetic and autologous tissue reconstruction of the chest wall, this procedure is a viable option for an extended group of patients. The modified procedure offers an excellent functional result, leaving the patient with a fully functional arm and hand.

Thoracic surgery skill proficiency with chest wall tumor simulator.

OBJECTIVES: Inclusion of specialized simulation into surgery training may enhance the educational experience of residents. We set out to develop a simulated chest wall tumor model to teach the specifics skills needed for chest wall tumor resection with prosthetic reconstruction. METHODS: The model was constructed from porcine rib blocs and additional materials (Fig. 1A and B). Thirteen general surgery residents were asked to perform en bloc tumor resection with "mesh sandwich" reconstruction of the chest wall defect (Fig. 2A and B). Evaluation consisted of knowledge-based examination, operative time, and skill assessment with an objective checklist and subjective global rating scale. A thoracic surgeon proctored and evaluated the practice sessions. RESULTS: Scores on the knowledge-based examination suggested no association with resident training year. More time was needed by junior level residents to complete the simulated operative task, even though the average time improved with repetitive practice. Average task-specific scores were comparable amongst the resident groups. The mid-level residents demonstrated the greatest improvement in skill proficiency; however, scores were consistently highest amongst the PGY-5s CONCLUSIONS: Our data suggest simulation is an effective teaching tool and training module for skill development needed for rarely performed procedures. The incorporation of this and similar simulation trainers is likely to improve surgical education and patient safety.

Multipurpose simulator for technical skill development in thoracic surgery.

BACKGROUND: Our appreciation for the increased role of simulation in surgical education has led us to develop a simulator for effective training of fundamental invasive thoracic skills. MATERIALS AND METHODS: Study subjects were fourth year medical students (MS-4, n = 6) rotating on a surgery clerkship, and surgical interns (PGY-1, n = 6). All subjects completed demographic surveys and rated their comfort level performing the thoracic skills. A computerized instructional module was given to all participants. Additionally, interns attended a boot camp with didactics, live demonstrations, and supervised practice sessions. Subjects were asked to perform a thoracentesis and insert a chest tube on the models, repetitively, during three sessions, and their skills were rated. Participants were asked to rate their comfort levels performing the procedure before and after the sessions. RESULTS: Interns reported a greater exposure to surgery (9.7 ± 3.2 wk versus 6 ± 1.8 wk; P = 0.03). Although interns were initially faster, operative times were comparable by the third session. Initially, technical skill ratings for thoracentesis were significantly lower in the MS-4 group (P < 0.03). The scores significantly increased by the final simulation (P ≤ 0.04), and were similar to the PGY-1 skill ratings. Significant improvement with chest tube placement each week (P ≤ 0.05), resulted in scores comparable to the intern group as well. Both groups reported higher comfort levels after the simulation sessions. CONCLUSIONS: Our simulation trainers were effective educational tools for fundamental thoracic procedures. Our study demonstrates improved technical skill and higher comfort levels with the simulated procedures.

Modified French window as an alternative to thoracotomy for complex intrathoracic pathology.

Video-assisted thoracic surgery is associated with less pain and shorter recovery than open procedures. Due to limited exposure, video-assisted thoracic surgery is not suitable for the management of all intrathoracic pathology. Muscle-sparing thoracotomies are smaller, but they are not associated with less pain or faster recovery. A modified French window is a useful approach to complex intrathoracic pathology and may result in less postoperative pain and shorter recovery than standard and muscle-sparring thoracotomies. This technique is suitable for the management of complex intrathoracic disease.

Open lobectomy simulator is an effective tool for teaching thoracic surgical skills.

BACKGROUND: Simulation has long been appreciated and used in professional industry training. The effectiveness of high-fidelity, low-cost simulators in such settings has led to its integration into surgical education for skill development. Simulation may possibly have a role in surgical specialty training. METHODS: Replicas of a human torso with a posterolateral thoracotomy incision were constructed from poultry netting and casting fiberglass, and used to house a previously prepared bovine lung. After reviewing computerized instructional material, student volunteers were asked to perform a lobectomy with the assistance of a thoracic surgeon, who also evaluated the subjects. Objective data were collected from knowledge-based examinations and technical skills evaluation scales. Statistical analysis was performed with the Student's t test. RESULTS: The initial success rate was 88.9% (16 of 18). Significant improvements were appreciated in both subjective and objective measures by the third week with weekly repetition. The average operative time was reduced to 34.8 +/- 5 minutes from 48.5 +/- 4.9 minutes (p = 0.01). The average task-specific score was 7.8 +/- 0.8 (versus 5.6 +/- 2.1; p = 0.05), and students achieved an average global performance score of 28.6 +/- 3.8 (p = 0.01). Scores on knowledge-based examinations also significantly improved. CONCLUSIONS: This open lobectomy simulation can be used to effectively teach thoracic surgery techniques. Our results prove the effectiveness of simulation training in thoracic surgery. Additional studies will determine whether simulation is effective for different training levels in thoracic surgery.

Intraoperative radiation therapy in the multimodality approach to upper aerodigestive tract cancer.

The cure rate of operable lung cancer and locally advanced head and neck cancer remains suboptimal, with a limited rate of local control despite improvements in the surgical removal of primary tumors and in methods for mediastinal lymph node dissection, in particular. The efficacy of adjuvant therapy, such as EBRT, has improved, and the immediate efficacy of new chemotherapeutic drugs is increasingly significant, although local recurrences remain frequent. Locoregional failure is not uncommon in upper aerodigestive tract cancers. Factors limiting radiocurability for locally advanced (stage III) lung cancer include mediastinal intolerance of irradiation (high risk of mediastinal fibrosis, which increases exponentially when levels of much more than 50 Gy are administered to the whole mediastinum) and the very high radiosensitivity of the healthy lung, which can develop fibrosis with relatively small or moderate doses starting at 18 to 20 Gy, and even more frequently when larger volumes are irradiated. Head and neck neoplasms are less difficult sites in which to administer doses of up to 70 Gy of external beam radiotherapy initially, but, like locoregionally recurrent lung cancers, they are not easily reirradiated with tumoricidal doses of EBRT. For these reasons, IORT seems to be a good option for increasing local control, because areas of [figure: see text] residual microscopic disease may be irradiated using IOERT approaches without affecting critical organs to the same extent. In addition, careful patient selection is paramount. Combined modality treatment regimens incorporating IORT may benefit patients with locally advanced disease. The ability of IORT to sterilize microscopic residual disease can enhance the "completeness" of resection and thus, theoretically, improve local control. Although distant disease dissemination remains by far the overriding issue, as newer effective agents emerge, local failure will continue to be a problem. Preliminary studies have demonstrated that IORT can be administered to patients who have locally advanced NSCLC and head and neck cancer, in the context of aggressive combined modality therapy, and is generally well tolerated. Long-term efficacy and benefit can only be determined in the setting of carefully designed clinical trials. (See the article by Thomas and Merrick elsewhere in this issue for further discussion of this topic.) Several relatively small, single-institution pilot studies exploring the utility and benefit of IORT for locally advanced upper aerodigestive tract cancers have been conducted. Clear conclusions have been difficult to determine because of the mixing of disease stages, varying degrees and completeness of surgical resection, varying radiation doses, different schemas, and other factors. Yet, given the major morbidity and mortality associated with locally recurrent lung cancer, methods of improving local control need to be pursued and refined. Encouraging preliminary data suggest that IOERT can be safely administered and may benefit local control. Based on several centers' expertise in the combined modality treatment of locally advanced lung cancer and familiarity with IORT, the UCSF Thoracic Oncology Program has proposed a multicenter phase 2 study incorporating IORT in a combined multimodality treatment schema for patients who have completely resected locally advanced stage IIIA and IIIB NSCLC (nonpleural effusion, non-N3) (Fig. 1). It is hoped that this study will commence in the upcoming year.

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis.

BACKGROUND: Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS: A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS: One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS: Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.

Delayed surgical management of a traumatic aortic arch injury.

We report successful management of a blunt traumatic injury to the aortic arch with intentionally delayed surgical repair. The aorta was repaired after the stabilization of other, potentially fatal, traumatic injuries.

Deep venous thrombosis and ABO blood group are unrelated in trauma patients.

BACKGROUND: Although epidemiologic studies of the general population have demonstrated a deficit of blood group O among patients with deep venous thrombosis (DVT), few studies have evaluated the importance of blood group in high-risk patients. The purpose of this study was to evaluate the importance of ABO blood group as a thrombotic risk factor in injured patients. METHODS: Injured patients with a discharge diagnosis of DVT were identified from an institutional trauma registry and compared with control patients matched for age and Injury Severity Score. ABO blood types of patients and controls were obtained from the regional blood center database. RESULTS: Three hundred forty-three case-control pairs were identified from a total of 401 consecutive cases of DVT. Blunt injury was the predominant mechanism of injury, accounting for 90.4% of cases. Chest (p = 0.01) and extremity (p < 0.001) Abbreviated Injury Scale scores were independent predictors of DVT. However, there was no significant difference in blood group distribution or the A to O ratio between patients with and without DVT. For non-type O patients, the odds ratio for developing DVT was 1.1 (95% confidence interval, 0.8-1.5; p = 0.5) in comparison with type O patients. CONCLUSION: These data do not support a clinically relevant association between blood type and DVT in trauma patients. Injury-associated derangements of coagulation may be more important than any hypercoagulability related to blood type in this population.

Intracoronary E-/L-selectin blockade reduces neutrophil infiltration in heart transplantation.

BACKGROUND: This study examined the effect of local intracoronary delivery of a unique monoclonal antibody (mAb) to both E- and L-selectin (EL-246) on neutrophil infiltration after global ischemia during cardiac transplantation. METHODS: In 12 ovine heart transplants, allograft coronary arteries were locally perfused with EL-246 (n = 6), or isotype-matched control antibodies (n = 2) or saline (n = 4). At 24 hours posttransplant, myocardium was analyzed for neutrophil infiltration and myocardial water content. RESULTS: The mean number of intramyocardial neutrophils per area (PMN/hpf) was greatly reduced in the allografts perfused with EL-246 (3.45 +/- 0.4 PMN/hpf), compared with an average 6.5 +/- 0.97 PMN/hpf in control hearts (p = 0.004). Peripheral leukocyte counts were unaffected; myocardial water content was not significantly reduced. CONCLUSIONS: Local perfusion of cardiac allografts with blocking antibody EL-246 before reperfusion significantly reduced the neutrophilic infiltration that occurs early after transplantation. Prohibiting neutrophil-endothelial adhesion and transmigration may be useful in decreasing neutrophil-dependent post-reperfusion injury in transplantation and routine cardiac surgery.