Retroperitoneal lymph node dissection as adjuvant therapy in the treatment of non-seminomatous testicular cancer.

OBJECTIVE: To assess the results of retroperitoneal lymph node dissection (RPLND) of residual masses in patients with disseminated non-seminomatous germ cell tumour treated with cisplatin-based chemotherapy, both in terms of extension of surgery, morbidity and survival. PATIENTS AND METHODS: Retrospectively, all patients treated for non-seminomatous germ cell tumour at the University Hospital of Antwerp were studied from January 1987 till December 1997. In patients with non-seminomatous testicular cancer more than stage I, the 'wait and see' strategy changed and patients were treated with chemotherapy. Patients were assessed at the end of chemotherapy and if a residual masses persisted, a RPLND was performed. If possible, a nerve-sparing lymphadenectomy was performed. Extension of surgery, morbidity and survival were analysed. RESULTS: Sixty patients had a non-seminomatous germ cell tumor of the testis and were analysed. The median follow-up was 78 months (range: 13-144 months). Thirteen patients with stage I disease were treated with orchiectomy only and none of these patients had recurrent disease. Forty-seven patients were treated with cisplatin-based chemotherapy. A complete response was observed in sixteen patients (34%), while 31 patients (66%) achieved a partial response and were treated with a RPLND. Fifteen patients underwent RPLND above the level of the renal trunk. In two patients malignant cells or fibrotic tissue were found above the renal trunk and bilateral. In five patients viable tumour cells were found in the region below the renal trunk. Sixteen patients underwent RPLND below the level of the renal trunk, of which nine had a unilateral resection, containing viable tumour in two patients. Operative mortality was 0%. One patient died six months after RPLND due to metastatic disease. In two patients, an important retroperitoneal bleeding occurred. Resection of adherent organs was performed in two patients. Long term sexual problems were reported by thirteen patients (65%) with bilateral lymphadenectomy versus two patients (18%) in the unilateral group. The survival of the patients treated with a RPLND was 97% and in the whole group of patients with a non-seminomatous testicular cancer 98%. CONCLUSION: RPLND has a place in the treatment of patients with non-seminomatous testicular cancer after chemotherapy in case of residual masses. Although mortality is low, morbidity is acceptable. In a limited number of patients there was a need of resection of adherent organs when a resection above the renal trunk was performed.

Chronic osteomyelitis after sternotomy.

Two patients with chronic sternal osteomyelitis after an initially uncomplicated coronary artery bypass grafting (CABG) operation are described. Chronic osteomyelitis, caused in both cases by Pseudomonas aeruginosa, occurred six and four months after CABG respectively. Because chronic infection failed to respond to local wound care and medical therapy, more radical treatment was needed. Steel wires were removed and surgical debridement was performed. In one patient, an additional omental transposition was performed. In both cases radical debridement in combination with antibiotics successfully eradicated the infection.

Coronary artery bypass grafting on the beating heart using the Octopus method.

STUDY OBJECTIVE: To study the usefulness and effectiveness of off-pump coronary bypass grafting with the Octopus heart stabilizing device. METHOD: The files of thirty-one patients undergoing coronary artery bypass with the aid of the Octopus heart stabilizing device between April 1996 and October 1998 were studied retrospectively. Patients were divided into group A (n = 23), patients with single or double vessel disease and technically suitable coronary lesions for off-pump procedure and group B (n = 8), patients with multiple vessel disease considered to be with excessive risk for cardiopulmonary bypass due to poor general condition combined with renal failure and/or chronic obstructive pulmonary disease. Standard median sternotomy (n = 27), lateral thoracotomy (n = 1) or minithoracotomy (n = 3) were performed for access and for harvesting the left internal mammary artery (LIMA). MEASUREMENTS AND RESULTS: The mean number of bypasses was 1.2 and 1.1 in groups A and B, respectively. Thirty patients received a LIMA graft to the left anterior descending artery (LAD). Homologous blood transfusions were needed in five patients (21%) in group A and four (50%) in group B. There were no wound infections or neurologic complications. All patients in group A survived and are asymptomatic. One patient in group B died of septic shock, two have residual angina pectoris or dyspnea, and five are asymptomatic. CONCLUSION: Coronary artery bypass using the Octopus heart stabilizing device proved to be a safe and effective technique resulting in complete revascularization in group A patients with no mortality. Incomplete revascularization may offer a substantial benefit to patients who cannot tolerate cardiopulmonary bypass due to poor general condition. We prefer median sternotomy, allowing precise harvesting of the internal mammary artery and more precise anastomoses without increased morbidity.

Left middle lobe resection for bronchiectasis in Kartagener's syndrome.

We report the case of a young girl with Kartagener's syndrome who suffered from severe bronchiectasis confined to the left middle lobe. Due to chronic abscedation which failed to respond to medical therapy, resection of the left middle lobe was performed. Although there was an initial clinical benefit, afterwards she had to be treated again for recurrent infectious exacerbations.