Thoracic complications of radiofrequency ablation of recurrent hepatoma.

INTRODUCTION: Radiofrequency ablation (RFA) for unresectable primary or secondary hepatic malignancies have gained widespread availability and acceptance over the past 5 years. Complication rates have been reported to range from 0% to 27%. CLINICAL PICTURE: We report a patient with symptomatic right pleural effusion due to a diaphragmatic fistula and another with biliptysis post-RFA, for recurrent hepatoma. TREATMENT: Percutaneous drainage of both the pleural effusion and biloma was performed. However, surgical repair of the diaphragmatic fistula was only required for the former for persistent drainage. OUTCOME: Both patients were successfully treated with minimal morbidity. CONCLUSION: High index of suspicion is required for the early diagnosis and treatment of diaphragmatic fistulas. Simple catheter drainage can potentially obviate the need for surgery.

Postoperative portable chest radiographs: optimum use in thoracic surgery.

PURPOSE: Daily portable chest radiographs are routinely ordered in many institutions after thoracic surgery. Our purpose was to assess the efficacy and cost of this practice and to determine the optimum use of postoperative x-ray studies. METHODS: A prospective review of all portable chest x-ray films after 100 consecutive elective thoracotomies (DRG 75) was conducted. Each x-ray study initiated a three-part survey. First, the surgeon listed whether the x-ray study was routine and the anticipated management had it not been available. The radiologist then interpreted and scored the x-ray study as follows: negative, expected findings; A, minor findings necessitating no intervention; B, minor findings necessitating intervention; or C, major findings necessitating intervention. Finally, the x-ray film and the interpretation were returned to the surgeon. Any interventions necessitated by the x-ray study were recorded. RESULTS: In 6 months, 99 patients underwent 82 pulmonary resections and 18 other major procedures. In the postoperative period, 769 portable chest x-ray studies were ordered, median five per patient (range 2 to 49). Of these, 731 (95%) were routine and 38 (5%), nonroutine. Severity scores were as follows: negative in 106 (13.8%), A in 558 (72.5%), B in 59 (7.7%), and C in 46 (6.0%). X-ray findings altered management in 43 of 769 studies (5.6%): in 33 routine (4.5%), in 10 nonroutine (26.3%), in 13 A (2.3%), in 22 B (37.3%), and in 8 C (17.4%). CONCLUSIONS: These results demonstrate that routine daily portable chest x-ray studies have a minimal impact on management. It is, in fact, nonroutine x-ray studies that more often alter management. Had routine portable chest x-ray studies, which cost $114 each in our institution, been limited to one immediately after the operation, only 133 such studies (100 routine and 33 nonroutine) would have been needed in the care of these patients. Elimination of 636 (82.7%) x-ray studies reduces the cost of care by $725 per patient ($286,000 annually). For major thoracic procedures, it is safe, efficacious, and cost effective to eliminate routine postoperative portable chest x-ray studies and order nonroutine portable studies only when clinically indicated.

Primary intrathoracic malignant effusion: a descriptive study.

BACKGROUND: Patients who present with malignant pleural/malignant effusion without a definite primary site are not well described in the medical literature. In the course of our clinical practice, we have observed certain traits that are peculiar to patients with such a presentation. We have applied the term primary intrathoracic malignant effusion (PIME) to describe this condition. STUDY OBJECTIVES: Patients must fulfill the following criteria before a diagnosis of PIME can be made: clinical presentation dominated by pleural/pericardial effusion; histologic proof of malignancy obtained from the pleura and/or pericardium; no definite primary site in the lungs or elsewhere from CT scan of the chest, chest radiograph, or physical and endoscopic examination; no history of malignancy; and no history of asbestos exposure. Exposure to environmental tobacco smoke (ETS) among the nonsmokers was examined in a case-control setting. METHODS: We conducted a retrospective search of our database of patients who were referred to the Department of Medical Oncology with a diagnosis of pleural/pericardial effusion from January 1993 to January 2000. RESULTS: Seventy-one of 200 patients from our database met the criteria. A significant majority of the patients were women (65%) and nonsmokers (72%). All patients had adenocarcinoma shown on biopsy. The majority of patients (63%) had disease localized to the intrathoracic serosal surfaces; the rest had distant metastases involving the lung (50%), bone (27%), liver (19%), brain (8%), and skin (4%). Six patients had two or more sites of distant metastases. There was a significant association with ETS exposure when compared to a control group comprised of patients with colonic cancer, matched for sex and age. The median survival was 10 months for patients with disease localized to the pleura/pericardium and 7 months for those with distant metastases. Thirty-eight patients (54%) received chemotherapy. All had platinum-based chemotherapy, except for three patients. The median survival for patients treated or not treated with chemotherapy was 12 months and 5 months, respectively. This difference in survival was statistically significant (p = 0.003). CONCLUSIONS: PIME should be viewed as a distinct entity. Its etiology remains largely unknown, although exposure to environmental tobacco smoke may play a part. Platinum-based chemotherapy may have a positive biological effect on this disease. More studies are required to elucidate the epidemiology, possible etiologic factors, and treatment options for this group of patients.

Acquired platelet dysfunction with eosinophilia: review of seven adult cases.

Seven adults with acquired platelet dysfunction with eosinophilia presented with histories of spontaneous bruising and three also had moderate thrombocytopenia. Six patients had platelet function tests performed and all showed variable storage pool defects. When assayed, IgE concentrations were raised. Although only two patients had parasites isolated in their stools, all seven responded to antihelminth treatment. It is speculated that the IgE response to parasites mediates mast cell degranulation, which leads to in vivo platelet activation.

Silicone thorax: a complication of tube thoracostomy in the presence of mammary implants.

Rupture of silicone breast implants is usually either iatrogenic or due to trauma. We present a case of blunt chest wall trauma in a patient with bilateral breast implants. Emergency chest tube thoracostomy resulted in rupture of one of the prostheses and caused subsequent migration of silicone into the chest cavity, where it led to empyema. The patient ultimately required a thoracotomy to evacuate the silicone and decorticate the lung. Review of the literature and methods to avoid this complication are described.

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.

An unusual manifestation of severe caustic injury.

Knowledge of the sequelae of caustic ingestion is of relevance to staff of the Emergency Room, Intensive Care Unit, surgical and gastroenterology services. It poses a considerable management problem and may result in life-threatening complications such as visceral perforation. This case report demonstrates an unusual and previously unreported manifestation of caustic injury.

Melioidosis splenic abscess--an unusual presentation as osteomyelitis of rib.

INTRODUCTION: We report an unusual case of splenic melioidosis abscess presenting as osteomyelitis. CLINICAL PICTURE: A 74-year-old nondiabetic gentleman presents with a non-healing left chest wall abscess from osteomyelitis. TREATMENT: He underwent rib resection and the infection was found to involve the underlying pleura, lung, adjacent stomach, liver and diaphragm with a splenic abscess. Splenectomy was performed. Histology showed suppurative granulomas and cultures grew Burkholderia pseudomallei. OUTCOME: The patient recovered well with antibiotics. CONCLUSION: Melioidosis should not be forgotten as a cause of chronic suppurative infections in our endemic population.

Anaesthetic considerations for lung volume reduction surgery--a case report.

INTRODUCTION: This case describes some of the unique problems faced by the thoracic anaesthesiologists during anaesthesia for lung volume reduction surgery. CLINICAL PICTURE: The usual pulmonary function requirements for lobectomy are normally not met in these patients with severe emphysema. TREATMENT: Maintenance of the functional residual capacity of the lung and normocapnia during anaesthesia are not as important. Instead problems due to barotrauma and dynamic hyperinflation from positive pressure ventilation are. OUTCOME: Modification of ventilation strategy and providing an anaesthetic tailored towards early extubation is the cornerstone of the anaesthetic plan. CONCLUSION: A good understanding of the respiratory physiology in patients with severe emphysema is essential.

Primitive neuroectodermal tumour of the chest wall--a report of two cases and review of literature.

INTRODUCTION: Primitive neuroectodermal tumours (PNETs) of the chest wall are rare entities and little is known regarding its biological activity and prognostic factors. Two cases are reported and the available literature reviewed to highlight the presentation and management of these tumours. CLINICAL FEATURES: We report 2 patients who were diagnosed with PNET of the chest wall in our centre. As there are no clinical features or basic diagnostic measures which are characteristic of these tumours, diagnosis is based on special tests. With the advent of newer immunohistochemical methods, it is now diagnosed more confidently. TREATMENT: Both patients received multidisciplinary modalities of treatment, comprising extensive surgical resection, chemotherapy and radiotherapy. OUTCOME: One patient succumbed to the disease one year after diagnosis and the other is currently disease-free, both clinically and radiologically at 24 months. CONCLUSION: Despite multidisciplinary modalities of treatment, the prognosis of PNET is still generally poor. Early diagnosis and treatment are important to improve the chances of survival.

Active management of a patient with endstage pulmonary emphysema using lung volume reduction surgery and intensive rehabilitation.

INTRODUCTION: Lung volume reduction surgery (LVRS) and pulmonary rehabilitation are newer options available in the treatment of advanced emphysema. We describe the progress of our first local patient to have undergone these 2 new treatment modalities. CLINICAL PICTURE: A 65-year-old man with advanced emphysema, limited by crippling dyspnoea despite maximal medical therapy with inhaled bronchodilator therapy, methylxanthines and supplementary oxygen. TREATMENT: Physical reconditioning with a 4-week inpatient pulmonary rehabilitation programme, followed by LVRS and a further 6-week outpatient pulmonary rehabilitation. OUTCOME: Dramatic improvements in spirometric indices, arterial blood gases, exercise capacity and overall functional status. Improvements maintained at one-year follow up period. CONCLUSIONS: LVRS with pulmonary rehabilitation is an exciting new treatment option in a select group of patients with advanced emphysema. Their role in improving overall performance status and quality of life should be considered in patients otherwise considered to have reached the limits of medical therapy.

Thoracoscopic thymectomy in a previous sternotomy.

A video assisted thoracoscopic surgery (VATS) thymectomy is a viable alternative to conventional open thymectomy in myasthenia gravis (MG). A previous operation in the same anatomical region is generally considered a relative contraindication to any minimally invasive approach in the same area. Few cases of VATS on previously operated chests have been reported. We report a case of a VATS thymectomy in a patient who had undergone two previous sternotomies for cardiac disease.