Percutaneous endoscopic gastrostomy risks rendering the gastric conduit unusable for esophagectomy.

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

Effectiveness of screening aqueous contrast swallow in detecting clinically significant anastomotic leaks after esophagectomy.

BACKGROUND: Aqueous contrast swallow study is recommended as a screening procedure for the evaluation of esophageal anastomotic integrity following esophagectomy. The aim of this study was to assess the accuracy of water-soluble contrast swallow screening as a predictor of clinically significant anastomotic leak in patients with esophagectomy. PATIENTS AND METHODS: The records of 505 consecutive patients undergoing esophagectomy in Mayo Clinic from January 1991 through December 1995 were retrospectively reviewed. 464 (92%) patients had water-soluble contrast swallows performed in the early postoperative period (median postoperative day 7, range 4-11 days). RESULTS: A total of 39 radiological leaks were obtained but only 17 of these had clinical signs of anastomotic leakage. Furthermore, 25 patients who had normal swallow study developed a clinical anastomotic leak. There were therefore 22 (4.7%) false positive and 25 (5.4%) false negative results giving values for the specificity, sensitivity and false negative error rate of the radiological examination of 94.7, 40.4, and 59.5% respectively. Aspiration of the contrast agent was noted on fluoroscopy in 30 (6.5%) patients. Only 2 (0.4%) patients developed aqueous contrast agent-caused aspiration pneumonia. There was no procedure-related mortality. CONCLUSION: While radiological assessment of esophageal anastomoses in the early postoperative period using aqueous contrast agents appears to be a relatively safe procedure, the poor sensitivity and high false negative error rate of this technique, when performed on postoperative day 7 and in a series with clinical anastomotic leak rate of 9%, is insufficient for it to be worthwhile as a screening procedure.

Lobar torsion after pulmonary resection: presentation and outcome.

OBJECTIVE: We reviewed our experience on postoperative lobar torsion. METHODS: Between January 1972 and January 1998, 7887 patients underwent pulmonary resection at our institution. Seven (0.089%; 4 women and 3 men; median age, 68 years) patients required surgical reintervention for lobar torsion. RESULTS: The indications for pulmonary resection were non-small cell carcinoma in 5 patients, lymphoma in 1 patient, and metastatic prostate carcinoma in 1 patient. The right upper lobe was resected in 3 patients, the left lower lobe in 2 patients, and the right middle and right lower lobe in 1 patient each. Postoperative radiographs demonstrated pulmonary infiltrates and volume loss in 5 patients and complete opacification in 2 patients. The median white blood cell count was 10.6 x 10(9) cells/L (range, 9.3-14.9 x 10(9) cells/L), and the median peak temperature was 38.4 degrees C (range, 37.8 degrees C-40.2 degrees C) during the first 48 hours postoperatively. The diagnosis of lobar torsion was made a median of 10 days (range, 2-14 days) after the initial operation; 4 patients underwent completion pneumonectomy, and 3 had lobectomy. Median hospitalization was 24 days and ranged from 10 to 56 days. There were no postoperative deaths. Complications after reoperation included respiratory failure in 2 patients, atrial arrhythmia in 2 patients, and empyema, urinary tract infection, and a transient ischemic attack in 1 patient each. CONCLUSIONS: Lobar torsion represents a difficult diagnostic dilemma in the early postoperative period after pulmonary resection. A high index of suspicion is necessary to avoid a delay in treatment. Late diagnosis results in further pulmonary resection and prolonged hospitalization in the majority of cases.

Laparoscopic repair of large paraesophageal hiatal hernia.

BACKGROUND: The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. METHODS: Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. RESULTS: Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). CONCLUSIONS: Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.

Surgical treatment of primary lung cancer with synchronous brain metastases.

OBJECTIVES: The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial. METHODS: From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer. RESULTS: The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001). CONCLUSION: Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.

Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence.

BACKGROUND: Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed. METHODS: All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis. RESULTS: Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis. CONCLUSIONS: Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.

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

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

Ivor Lewis esophagogastrectomy for esophageal cancer.

BACKGROUND: To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience. METHODS: We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995. RESULTS: There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV. CONCLUSIONS: Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.

Pneumonectomy for malignant disease: factors affecting early morbidity and mortality.

OBJECTIVE: The purpose of this report is to analyze factors affecting morbidity and mortality after pneumonectomy for malignant disease. METHODS: We retrospectively reviewed the cases of all patients who underwent pneumonectomy for malignancy at the Mayo Clinic. Between January 1, 1985, and September 30, 1998, 639 patients (469 men and 170 women) were identified. Median age was 64 years (range 20 to 86 years). Indication for pneumonectomy was primary lung cancer in 607 (95.0%) patients and metastatic disease in 32 (5.0%). Factors affecting morbidity and mortality were analyzed by univariate and multivariate analysis. RESULTS: Cardiopulmonary complications occurred in 245 patients (38.3%; 95% confidence interval 34.6%-42.2%). Factors adversely affecting morbidity with univariate analysis included age (P <.0001), male sex (P =.04), associated respiratory (P =.02) or cardiovascular disease (P <.0001), cigarette smoking (P =.02), decreased vital capacity (P =.01), forced expiratory volume in 1 second (P <.0001), forced vital capacity (P =.002), diffusion capacity of the lung to carbon monoxide (P =.005), oxygen saturation (P <.05), arterial PO (2) (P =.007), preoperative radiation (P =.02), bronchial stump reinforcement (P =.007), crystalloid infusion (P =.01), and blood transfusion (P =.02). Factors adversely affecting morbidity with multivariate analysis included age (P =.0001), associated cardiovascular disease (P =.001), and bronchial stump reinforcement (P =.0005). There were 45 deaths (7.0%; 95% confidence intervals 5.2%-9.3%). Factors adversely affecting mortality with univariate analysis included associated cardiovascular (P <.0001) or hematologic disease (P <.005), lower preoperative serum hemoglobin level (P =.004), preoperative chemotherapy (P =.01), decreased diffusion capacity of lung to carbon monoxide (P =.002), right pneumonectomy (P =.0006), extended resection (P =.04), bronchial stump reinforcement (P =.007), and crystalloid infusion (P =.01). Factors affecting mortality with multivariate analysis included hematologic disease (P =.01), lower preoperative serum hemoglobin (P =.003), and completion pneumonectomy (P =.01). CONCLUSION: Multiple factors adversely affected morbidity and mortality after pneumonectomy for malignant disease. Appropriate selection and meticulous perioperative care are paramount to minimize risks in those patients who require pneumonectomy.

Management of postpneumonectomy empyema and bronchopleural fistula.

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

Surgical treatment of hepatic and pulmonary metastases from colon cancer.

BACKGROUND: Surgical resection of isolated hepatic or pulmonary metastases secondary to colorectal cancer has been shown to yield acceptable long-term survival. However, results are inconclusive for surgical resection of both hepatic and pulmonary metastases. METHODS: We reviewed the records of all patients who underwent surgical resection of both hepatic and pulmonary metastases from colorectal cancer between 1980 and 1998. RESULTS: A total of 58 patients underwent resection of both hepatic and pulmonary metastases secondary to colorectal cancer. All patients had local control of their primary cancer before metastasectomy. There were no operative deaths. Morbidity occurred in 12% of patients. Follow-up was complete in all patients, with a median duration of 62 months (range, 6 to 201 months). The 5- and 10-year survivals were 30% and 16%, respectively. A premetastasectomy carcinoembryonic antigen level greater than 5 ng/mL increased the risk of early death (p = 0.029). Neither the number of pulmonary lesions nor the time interval between the primary surgery and the metastasectomy had a significant impact on survival (p = 0.67). At 5 years, 55% of patients were free of disease. Four patients had lymph node involvement at the time of pulmonary resection and all 4 patients died within 22 months of their pulmonary metastasectomy. CONCLUSIONS: Resection of both hepatic and pulmonary metastases secondary to colorectal cancer in highly selected patients is safe and results in long-term survival. Thoracic lymph node involvement and elevated carcinoembryonic antigen levels before pulmonary metastasectomy are associated with reduced survival.

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

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

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

BACKGROUND: Esophagectomy for benign disease is performed infrequently. We reviewed the Mayo Clinic's experience with patients who required esophageal reconstruction for benign esophageal disease. METHODS: From March 1956 to October 1997, all patients who required resection and reconstruction for a benign condition of the esophagus were reviewed. RESULTS: There were 255 patients (141 male, 114 female). Median age was 55 years (range, 2 to 100). The original diagnosis was an esophageal stricture in 108 patients (42%), primary motility disorder in 84 (33%), perforation in 36 (14%), hiatal hernia in 18 (7%), and other in 9 (4.0%). Reconstruction was with stomach in 168 patients (66%), colon in 70 (27%), and small bowel in 17 (7%). The anastomosis was intrathoracic in 144 patients (57%) and cervical in 111 (43%). There were 13 postoperative deaths (mortality 5%); 142 patients (56%) had at least one complication. Median hospitalization was 14 days (range, 6-95 days). Follow-up was complete in 226 patients (88.6%) for a median of 52 months (range, 1 month to 29 years). A total of 175 patients (77.4%) were improved. Functional results were classified as excellent in 72 patients (31.8%), good in 23 (10.2%), fair in 80 (35.4%), and poor in 51 (22.6%). CONCLUSIONS: Esophageal reconstruction for benign disease resulted in functional improvement in a majority of patients. It can be done with low mortality and acceptable morbidity. Early morbidity is adversely affected by the diagnosis of perforation and the route through which the conduit is placed. Late functional outcome is adversely affected by the diagnosis of paraesophageal hernia and a cervical anastomosis.

Bronchobiliary fistula: principles of management.

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

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

BACKGROUND: Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperfusion, we reviewed our experience with direct fenestration of the aorta. METHODS: A retrospective analysis of all consecutive aortic fenestrations performed between January 1, 1979, and December 31, 1999, was performed. Fourteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three type A and 11 type B patients. In the acute dissection group (n = 7), indications for surgery were malperfusion in six patients (leg ischemia, 4; renal ischemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), thoracoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1. RESULTS: Emergency aortic fenestration was performed in seven patients (surgically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacement was performed in four patients, combined with ascending aortic replacement (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acute fenestration was performed for organ malperfusion after prior proximal aortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (descending thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and pararenal aorta, 1). Concomitant aortic replacement was performed in six patients (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was successful at restoring flow in all 10 patients with malperfusion. Operative mortality for emergency fenestration was 43% (3/7). The three deaths that occurred were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm formations at the fenestration site. CONCLUSION: Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality. Elective fenestration combined with aortic replacement can be performed safely in chronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits.

Role of surgical resection in broncholithiasis.

BACKGROUND: Broncholithiasis is an uncommon problem with life-threatening complications. The purpose of this study was to update our experience in patients with broncholithiasis managed by surgical intervention. METHODS: From January 1984 to January 1998, 118 patients were diagnosed with broncholithiasis at our institution. We reviewed the medical records of those patients who underwent surgical treatment. RESULTS: There were 47 patients (19 men and 28 women). Median age was 58 years (range, 18 to 90 years). Indications for operation were symptoms in 44 patients and abnormal roentgenograms in 3 patients. Operative procedures included lung resection in 30 patients, broncholithectomy with or without bronchoplasty in 16, and segmental bronchial resection in 1 patient. There were no operative deaths. Postoperative complications occurred in 16 patients (34%). Follow-up was complete in 46 patients (98%) and ranged from 11 to 165 months (median, 74 months). The 15-year actuarial survival did not differ significantly from that of a matched control group (p = 0.774). At follow-up, 28 patients (68.3%) were asymptomatic. Symptoms continued in 12 patients. Recurrent or persistent disease was documented in 6 patients (14.6%). The site of recurrence was in a new location in 3 patients, a previous site in 2, and unknown in 1 patient. Subsequent management included observation in 3 patients, bronchoscopic removal in 2, and bilobectomy in 1 patient. CONCLUSIONS: Surgical resection for broncholithiasis is an effective method of management for this disease and can be done with low mortality and morbidity. Progression of the disease may lead to recurrence and further surgical intervention.

Primary non-Hodgkin's lymphoma of the lung.

BACKGROUND: Primary non-Hodgkin's lymphoma of the lung is a rare entity. Although the prognosis is favorable, clinical features, prognostic factors, and patient management have not been clearly defined. METHODS: We reviewed retrospectively the records of 48 patients operated on for primary pulmonary non-Hodgkin's lymphoma. The study group consisted of 21 male (44%) and 27 female (56%) patients with a mean age of 61.8 years. Thirty-seven and a half percent of patients were asymptomatic, and 62.5% were seen with pulmonary symptoms, systemic symptoms, or both. A definitive diagnosis was obtained by thoracotomy in 90% of patients, thoracoscopy in 8%, and anterior mediastinotomy in 2%. RESULTS: Complete surgical resection was possible in 19 patients (40%). A mucosa-associated lymphoid tissue lymphoma (MALT) was found in 35 patients and lymphoma that was not of this type, in 13. The 1-year, 5-year, and 10-year survival rates were 91%, 68%, and 53%, respectively in the group with mucosa-associated lymphoid tissue lymphoma and 85%, 65%, and 64% in the group with lymphoma that was not of the mucosa-associated lymphoid tissue type. None of the prognostic factors studied (mode of presentation, smoking history, bilateral disease, postoperative stage, complete resection, adjuvant chemotherapy, histology) significantly influenced patient survival. CONCLUSIONS: Primary non-Hodgkin's lymphoma of the lung occurs with nonspecific clinical features. Although patient survival is good, prognostic factors could not be identified.

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

BACKGROUND: The Society of Thoracic Surgeons (STS) established the National Database (NDB) for Cardiac Surgery in 1989. Since then it has grown to be the largest database of its kind in medicine. The NDB has been one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery. METHODS AND RESULTS: This report explains the numerous changes in the NDB and its structure that have occurred over the past 2 years. It highlights the benefits of these changes, both to the individual member participants and to the STS overall. Additionally, the vision changes to the NDB and reporting structure are identified. The individuals who have participated in this effort since 1989 are acknowledged, and the STS owes an enormous debt of gratitude to each of them. CONCLUSIONS: Because of their collective efforts, the goal to establish the STS NDB as a "gold standard" worldwide for process and outcomes analysis related to cardiothoracic surgery is becoming a reality.

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

OBJECTIVE: Great vessel reconstruction for arterial occlusive disease has been shown to be a durable procedure. The purpose of this report is the examination of the influence of cause and risk factors on outcomes for the identification of patients who may be better treated with endovascular techniques or other surgical approaches. METHODS: Data for patients who underwent aortic-origin great vessel reconstruction between 1988 and 1998 were reviewed. The data were analyzed with Fisher exact test, life-table analysis, and log-rank test. RESULTS: Ninety-two vessels underwent revascularization in 58 patients (15 men, 43 women; mean age, 54 years; age range, 20 to 82 years). Etiology was atherosclerosis obliterans (n = 40; 69%), Takayasu's arteritis (n = 13; 22%), radiation arteritis (RA; n = 4; 7%), and mediastinal fibrosis (n = 1; 2%). The symptoms were cerebrovascular (n = 25), upper extremity (n = 8), or both (n = 23), and two patients were asymptomatic. The bypass grafting was performed with single-limb synthetic grafts (n = 23) or grafts plus side arms (n = 28). Seven patients underwent innominate endarterectomy. The mean follow-up period was 45 months (range, 0 to 126 months). The perioperative stroke (n = 4; 7%) and death (n = 2; 3%) rates were not related to the cause of disease. The patients with creatinine levels of 2 or more (n = 4) had a combined perioperative stroke/death rate of 50% (vs 7% for patients with healthy creatinine levels; P <.05). The patients with hypercoagulable states (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33% vs 4% for patients without hypercoagulable states; P <.05) and an increased late thrombosis rate. The primary and secondary graft patency rates at 5 years were 80% +/- 7% and 91% +/- 5%, respectively. Patients with RA had a greater risk of stroke or death at 3 years (33% free of stroke or death vs 79% for patients with atherosclerosis obliterans and 92% for patients with Takayasu's arteritis; P =.02) and an increased major late infection rate (50% vs 2% for all others; P =.01). CONCLUSION: Patients with thrombophilia and renal insufficiency have increased perioperative stroke and stroke/death rates, respectively. Patients with RA have an increased incidence rate of late major infection, which directly contributes to an increased rate of stroke or death. Patients with thrombophilia have an increased rate of late graft thrombosis. These patient conditions should be approached cautiously, and some patients may benefit from endovascular therapy.

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

BACKGROUND: Little information exists regarding functional outcome and quality of life after esophagectomy and subsequent esophageal reconstruction for benign disease as evaluated by the patients themselves. METHODS: Eighty-one patients completed a combined two-part questionnaire regarding esophageal function and quality of life (MOS SF-36) a median of 9.8 years (range, 10 months to 18.9 years) after esophageal reconstruction for benign disease. There were 43 men (53.1%) and 38 women (46.9%). Median age at time of esophageal reconstruction was 51 years (range, 6 to 78 years). Intestinal continuity was established with stomach in 58 patients (71.6%), colon in 16 patients (19.8%), and small bowel in 7 patients (8.6%). RESULTS: Dysphagia to solids was present in 48 patients (59.3%) and 27 patients (33.3%) required at least one postoperative dilatation. Heartburn was present in 50 patients (61.7%) which required medication for control in 37 patients (45.7%). The number of meals per day was three to four in 58 patients (71.6%), more than four in 15 patients (18.5%), less than three in 6 patients (7.4%), and unknown in 2 patients (2.5%). The size of each meal was smaller than preoperatively in 46 patients (56.8%), larger in 22 patients (27.2%), unchanged in 12 patients (14.8%), and unknown in 1 patient (1.2%). The number of bowel movements per day increased in 37 patients (45.7%), was unchanged in 36 patients (44.4%), and decreased in 8 patients (9.9%). Resection for perforation was associated with smaller postoperative meals compared with resection for stricture (p < 0.05). Age, sex, and type of esophageal reconstruction did not affect late functional outcome. Regarding quality of life, physical functioning, social functioning, and health perception were decreased (p < 0.05). No significant change was observed in role-physical, mental health, bodily pain, energy/fatigue, and role-emotional scores. CONCLUSIONS: Self-assessment of postoperative esophageal symptoms after esophagectomy and reconstruction for benign disease demonstrates that symptoms are frequently present at long-term follow-up and unaffected by the type of reconstruction.