Long-term outcome after pneumonectomy at Siriraj Hospital.

Objective: The purpose of this study is to identify predictors of long term survival following pneumonectomy and compare New York Heart Association (NYHA) functional classification and ECOG performance status before and after surgery at Siriraj Hospital. Methods: All fifty three patients having a pneumonectomy between 1998 and 2009 were retrospectively studied. We compared each patient’s status before and after surgery. The parameters of survival were tested by univariate analysis, the Kaplan-Meier method, and differences in survival were determined by log-rank analysis. Results: There were 35 males (66%) and 18 females (34%) with a mean age (standard deviation) of 51±17 years (range 0.7-82 years). The majority of patients were lung cancer (77%) and destroyed lungs from infectious (12%) diseases. The mean follow-up time was 33 months, median 22 months, standard deviation 24 months, ranging between 0 and 131 months. Post-operative complication occurred in 11% of patients (bronchopleural fistula, bleeding, cardiac herniation and recurrent laryngeal nerve injury). Hospital mortality occurred in 7.5% (4 deaths). Late death occurred in 52.8% (28 deaths) including metastasis 30% (16 patients), pneumonia 19% (10 patients), and miscellaneous causes 3.7% (2 patients). Using univariate analysis, non lung cancer (P = 0.035) and the slow growing lung cancer (P = 0.007) were independent predictors of long term survival. The decrease in NYHA functional classification and ECOG performance status after surgery was not significant. Conclusion: Long-term survival after pneumonectomy for lung cancer occurred in 20% and non lung cancer in 60% of patients. Non lung cancer and the slow growing lung cancer were independent predictors of long term survival. Decreases in NYHA functional classification and ECOG performance status after pneumonectomy were not significant.

Comparison of intensity of platelet aggregation between patients receiving low and high aspirin dosage in post CABG patients.

Background: Aspirin used after coronary artery bypass graft surgery (CABG) improved patient survival and reduced graft thrombosis. However, individual variations in the antiplatelet effect of aspirin have been reported among CABG patients. Objective: To compare the intensity of platelet aggregation between patients receiving low and high aspirin dosage in post CABG patients. Methods: We prospectively studied the effect of aspirin dosage on platelet aggregation in 100 CABG patients. Oral aspirin was discontinued prior to CABG and re-started within 12 hours after CABG. Blood samples were collected and transferred to a laboratory prior to surgery then again on postoperative days two and eight for platelet aggregation test and platelet count within three hours after venipuncture. Results: One hundred patients (sixty five male and thirty five female patients) post coronary artery bypass graft (CABG) were evaluated for eligibility to enter the trial. The percentage of platelet aggregation was compared between low dose (<100 mg/day), and high dose (>100 mg/day) aspirin, at postoperative CABG days 2 and 8, which showed no significant difference for the platelet aggregation (p = 0.161 post CABG day 2 and p = 0.098 post CABG day 8). Conclusion: Low dosage aspirin should be used in post CABG patients because the intensity of platelet aggregation between patients post CABG receiving low and high aspirin dosage were not different, while the prophylactic effect of the low aspirin dosage in reducing the risk of cardiovascular events proved equally as effective as the high aspirin dosage.

Pulmonary sparing for resection of adenoidcystic carcinoma involving the tracheal carina and the right main bronchus: A case report.

A 40 year old female underwent successful pulmonary sparing resection of an adenoidcystic carcinoma (ACC) of the tracheal carina involving the right main bronchus with a size of 3 cm. The operative technique: A right thoracotomy was performed. The trachea and main bronchi were dissected. The left main bronchus was transected about 1 cm from the carina. The airway management was intermittent conventional ventilation via the operative field. The right bronchus was transected at the upper lobe and the intermediated bronchus 1.0 cm from the tumor margin. Finally the trachea was transected 1 cm above the tumor margin. The proximal end of the trachea was anastomosed end to end to the distal left main bronchus. The intermediate bronchus was incised vertically and 2/3 of the circumferential distal end of the upper lobe bronchus was anastomosed end to side to the incisional line of the intermediate bronchus. Then the neo-bronchial orifice of the right bronchus was anastomosed end to side to the lateral wall of the trachea 1 cm above the previous tracheal anastomosis. The patient recovered well from the operation and was discharged within 2 weeks after the operation. Early postoperative fiberoptic bronchoscopy revealed adequated anastomotic bronchial lumens and minimal granulation tissue at the left bronchial anastomosis.

Slide tracheoplasty with pericardial patch augmentation for reconstruction of severe congenital tracheal stenosis involving carina : A case report.

Objective: Slide tracheoplasty seems to be the most efficient surgical procedure for correcting long-segment funnel-shaped congenital tracheal stenosis. However, in cases of extremely long-segment or those involve carina, slide tracheoplasty when operated alone has certain degree of limitations which often need additional operative procedure. The authors report a technique of slide tracheoplasty in combination with pericardial patch augmentation in a child with congenital tracheal stenosis involving the carina. Methods: A 3-month-old girl, previously diagnosed with Tetralogy of Fallot and congenital tracheal stenosis, presented with severe cyanosis and serious major airway obstruction after a few days of upper respiratory tract infection (URI). Because of the failure to maintain her ventilation with a high positive pressure ventilator, an emergency slide tracheoplasty with a modified right Blalock’s Taussig shunt was performed under a cardiopulmonary bypass. The intraoperative finding revealed a complete tracheal ring stenosis involving the lower half of the trachea and carina. It was transected at the middle and a vertical incision was made at the posterior wall of the upper trachea and anterior wall of the lower and extended into orifices of the main bronchus. The upper and lower tracheal flaps were slid together and sutured with interrupted Proline 5-0. Consequently, she still had significant obstruction of the main bronchi postoperatively and needed a re-operation two days later. Under cardiopulmonary bypass support, the lower anastomotic sutures were removed and an additional bronchial incision was made into the main bronchus. The anterior upper tracheal flap was separated into two, and each equal flap was pulled down and sutured to the main bronchus. Then an autologous pericardial patch was used to cover all the airway defects. Intraoperative fiberoptic bronchoscopy demonstrated adequate tracheo-bronchial lumen. Results: The child had postoperative hyperactive airway reaction and needed prolonged ventilator support and tracheostomy for tracheal toileting. Repeated postoperative bronchoscopy found moderated granulation tissue which was easily removed by catheter suction. Unfortunately, the patient expired six months after the surgery due to uncontrolled sepsis. However, a bronchoscopic finding before the patient’s death revealed adequate major airway patency. Conclusion: Combined slide tracheoplasty with pericardial patch augmentation made reconstruction of the complex congenital tracheal stenosis involving carina or tracheal bronchus possible and minimized the result of unflavoric excessive granulation tissue forming caused by pericardial tracheoplasty alone.

An unexpected complication of traditional Thai massage.

Traditional massage is one of the art of the Thai people, but its application in an inappropriate situation or with incorrect technique may contribute to severe complications. we report a 46-year-old man who was massaged by his nephew in oreder to relieve an aching right leg. Unfortunately, he developed a deep venous thrombosis with subsequent acute pulmonary embolism. Emergency embolectomy was performed because the thrombus engaged into the left heart through the foramen ovale.

The Sternal Turn Over Procedure with Preservation of the Internal Mammary Vessel and Rectus Abdominis Muscle Pedicles for the Repair of Severe Pectus Excavatum.

Pectus excavatum or funnel chest is one of the most common congenital chest wall deformities. Surgical correction should be considered for all patients with moderate to severe deformities because of the significant cosmetic and psychological improvement, subjective increase in exercise tolerance, documented changes in the cardiac and respiratory status, and prevention of the development of scoliosis after surgical intervention in these patients. The sternal turn over procedure with preserved internal mammary vessels and rectus abdominis muscle pedicles for the corrective repair of severe pectus excavatum, involves resection of the deformed thoracic wall, sternum and ribs, preserving an attachment of the rectus abdominis muscle,and a vascular pedicle of the internal mammary vessel. A short segment resection above the ipsilateralcostal cartilage is mandatory to allow reposition of the vascular pedicle onto the presternal surface after turn over of the sternum. Multiple corrective osteotomy and costoplasty must be completed before refixing the sternum and ribs. The modified sternal turn over procedure restores the sternal blood supply and should be applied to the severe form of pectus excavatum which needs extensive and multiple bony resection. The procedure has been applied to a boy and a girl aged 5 years. At a three year follow up, the results obtained are excellent.

Recurrent hemoptysis caused by left subclavian artery aneurysm: A case report.

A 41 year old man with a left subclavian artery aneurysm was presented to the hospital with clinical symptom of recurrent hemoptysis. CT scan and angiography confirmed the diagnosis. Surgical treatment consisted of femoro-femoral cardiopulmonary bypass and left thoracotomy, aneurysm resection and descending aortico-subclavian vein bypass grafting. The incidental two small saccular aneurysms of the lower descending thoracic aorta were excised and directly repaired. The pathologic study revealed typical atherosclerotic changes. The patient had postoperative persistent chyle leakage and required rethoracotomy and supradiaphragmatic ligation of the thoracic duct. The patient was able to resume his usaul activity after two months of surgery.

Thymolipoma simulating cardiomegaly: A case report.

A routine chest radiograph of a 27-year-old woman who presented with chronic cough for four weeks disclosed an anterior mediastinal mass simulating cardiomegaly. The computed tomography revealed a mass with diffuse fat density intermingled with soft tissue density. At thoracotomy a thymolipoma weighing 750 g was completely resected and typical histological findings were demonstrated. She made a good recovery and remained in good health at her most recent follow-up visit.