Lung carcinoid related Cushing's syndrome: report of three cases and review of the literature.

Three patients with lung carcinoid related Cushing's syndrome (LCRCS) treated at Frenchay Hospital, Bristol between 1984 and 1994 are described. The first patient presented with hyperpigmentation 13 years after bilateral adrenalectomy. The second patient had no recurrence or metastases 14 years after removal of a typical carcinoid tumour. The last patient survived nine years after diagnosis of liver metastasis. The possibility of LCRCS should be considered in every patient proved to have Cushing's disease and bilateral adrenal enlargement on abdominal computed tomography. Biochemical sets of investigation (for example, adrenocorticotrophic hormone (ACTH) stimulation, dexamethasone suppression, and metyrapone response) could be misleading and should not be relied upon solely. Search for an ectopic ACTH source should be called off only when ACTH has been demonstrated in the surgically removed specimen, and most importantly, when the serum ACTH concentration returns to normal after surgery. Lung carcinoid tumours are compatible with long survival, and liver metastasis could prove indolent and slowly growing.

Adult congenital lobar emphysema in pregnancy.

A young woman presented with left sided chest pain. Chest radiography revealed a hyperexpanded left upper lobe and the rare diagnosis of congenital lobar emphysema was made. She was then found to be pregnant. Thoracotomy and left upper lobectomy were performed during the pregnancy without adverse effects to the mother or fetus. The implications of pregnancy on the surgical management of this rare condition are discussed.

Strangulated iatrogenic diaphragmatic hernia: a late diagnosed complication.

Three cases of iatrogenic diaphragmatic herniation are reported following thoracic and high abdominal surgery. Each case presented at least 6 months after the original surgery with symptoms of acute upper gastrointestinal obstruction. Diaphragmatic herniation was not considered in the initial differential diagnosis which lead to a delay in their referral. We emphasise the importance of checking the diaphragm following upper abdominal surgery and care when closing a defect.

Spontaneous rupture of a congenital diaphragmatic eventration.

A 51-year-old man presented as an emergency with acute intestinal obstruction following herniation of abdominal contents into the left hemithorax through a spontaneous rupture of his eventrated left hemidiaphragm. He underwent a left thoracotomy with reduction of the herniated abdominal contents, repair of the diaphragmatic rupture and plication of the diaphragm. He made an uneventful recovery and remains asymptomatic. This is the first reported case of spontaneous rupture of an eventration of the diaphragm.

Thoracoscopy in the diagnosis and management of recurrent pleural effusions.

Between April 1984 and July 1988, 102 patients with persistent or recurrent pleural effusions investigated by conventional methods in whom a diagnosis had not been achieved were submitted to thoracoscopy under general anesthesia. A positive diagnosis was obtained in 80.3% of the patients. The procedure was well tolerated, and although some of these were seriously ill patients, there were no procedure-related deaths.

Leiomyomas of the lower respiratory tract.

Leiomyomas account for about 2% of benign tumours of the lower respiratory tract. From the relatively few cases reported in the literature, it appears that these tumours most commonly occur in the fourth decade, although one third of patients are under the age of 20 years. The distribution of leiomyomas favours the distal part of the tracheobronchial tree and the most common site for tracheal lesions is the membranous portion of the lower third. Over 90% of pulmonary parenchymal leiomyomas, which themselves are more common in women, are incidental findings on chest radiographs whereas bronchial lesions are important causes of irreversible lung damage. Tracheal lesions may present as bronchial asthma. Accurate early diagnosis rests on a high index of clinical suspicion and histological examination of bronchoscopic biopsy specimens or frozen section material obtained at exploratory thoracotomy. Treatment could be conservative surgery, but 65% of reported cases have been managed by lobectomy or pneumonectomy as a result of advanced irreversible lung disease or unawareness of the benign nature of the lesion.

Early decortication for the disorganized pleural space.

Early decortication is advocated for the disorganized pleural space. This series reviews 85 patients operated on for haemothorax and empyema as a result of penetrating chest trauma (61 cases), blunt chest trauma (2), post-pneumonic empyema (15), tuberculous empyema (4) and chronic pneumothorax (2). The aetiology, surgical technique and results are discussed. In 83% of cases there was complete clinical recovery and radiological re-expansion of the affected lung.

Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus: mechanical stapling versus hand suturing.

Four hundred fifty cases of pneumonectomy for carcinoma of the bronchus are reviewed. The incidence of bronchopleural fistula is compared in two separate groups differentiated according to whether the bronchus was closed with interrupted sutures or with the auto-suture stapling clamp. The incidence of fistula was 11.1% in the interrupted suture group and 2.6% with the auto-suture group. The diagnosis and the method of treatment in this unit are discussed and the etiologic factors responsible for the fistula are reviewed. The conclusions are that there is no single causative factor in the development of bronchopleural fistulas and that the incidence of fistula is considerably reduced by the use of the auto-suture clamp.