Pleural-based giant solitary fibrous tumour with associated hypoglycaemia: unusual presentation with pulmonary hypertension in a patient with Doege-Potter syndrome.

Refractory hypoglycaemia in a patient with a solitary fibrous tumour (SFT) is very rare and was first reported in 1930 independently by Doege and Potter, leading to it being named 'Doege-Potter syndrome'. Here, we report the unusual case of a 77-year-old woman with a giant solitary fibrous pleural tumour who presented with complicating pulmonary hypertension and associated heart failure with hypoglycaemia, and subsequently underwent curative resection of the pleural mass with clinical improvement.

Delayed chylothorax in the absence of radiological evidence of rib or vertebral body fractures following blunt trauma.

Our case report illustrates effective implementation of conservative measures without the need for more invasive procedures, which can be required in refractory cases. Our patient was a 42-year-old female who fell from a horse and presented with a 1-week history of dyspnoea. Investigations revealed her to have a large right chylothorax, which was treated conservatively with chest drainage and octreotide. The patient remained in hospital for a total of 3 days prior to being discharged home without further complications. Blunt traumatic chylothorax should be considered as part of the differential diagnosis in patients who present with ongoing dyspnoea or chest discomfort within a 2-week preceding history of blunt trauma. Radiological imaging should be mandatory and the absence of posterior thoracic fractures does not exclude the diagnosis. Conservative management with pleural drainage, medium-chain triglyceride diet and octreotide yielded excellent results in our case.

Pulmonary lymphangioleiomyomatosis masquerading as unilateral heterogeneous emphysema.

Pulmonary lymphangioleiomyomatosis (LAM) is a rare, well-described pathology and usually is exclusive to females of a reproductive age. We present a 45 year-old lady who presented to the surgeons 1 year after an admission with acute dyspnoea following influenza infection. Initial computed tomography imaging findings demonstrated severe, heterogenous right-sided bullous emphysematous changes, but histopathological analysis of the post-operative specimen favoured a diagnosis of LAM. This case demonstrates the importance of considering LAM as a differential diagnosis for findings of unilateral emphysema or lobar emphysema, in which alpha 1-antitrypsin deficiency has been excluded and in those without a significant smoking history.

Excision of metastatic breast cancer from sternum and reconstruction in two patients with solitary metastatic spread.

Metastatic breast carcinoma is a relatively common clinical entity. However, the prognosis of oligometastatic and polygometastatic disease differs considerably pertaining to five-year survival. Metastatic breast carcinoma to the sternum has been described as early as 1988. We describe two cases in our institution who presented with solitary sternal metastases with a previous history of treated breast cancer. In both cases, there had been a history of previous left breast cancer treated aggressively with surgical resection and adjuvant oncological therapy and maintenance hormonal therapy. Partial sternectomy or total sternectomy for solitary metastatic sternal deposits is well established with relatively low morbidity and mortality and improvement in quality of life and possible improvement in long-term survival. Furthermore, reconstructive options are inherently dependent on extent of resection performed. These techniques can incorporate the use of sternal plates in order to approximate defects and reinforce the sternum in the setting of partial sternectomy.

The value of a preoperative ventilation-perfusion scan in patient selection for pneumonectomy.

Guidelines regarding operability of patients with lung cancer are well established. The measured and predicted pulmonary function provides a practical guide to the safety of lobectomy or pneumonectomy. We describe a patient who had an unexplained precipitous fall in preoperative FEV(1) that would have precluded a required pneumonectomy but for an urgent ventilation-perfusion (V/Q) scan. This case highlights the fact that clinical acumen rather than a strict adherence to established guidelines is vital in the assessment of lung cancer patients awaiting potentially curative surgery.

Should all patients with non-small cell lung cancer who are surgical candidates have cervical mediastinoscopy preoperatively?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed is whether all potential surgical candidates with non-small cell lung cancer should have cervical mediastinoscopy pre-operatively. Two hundred and forty-one papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that patients with resectable non-small cell lung cancer who have had a negative mediastinal CT scan should all undergo mediastinoscopy. The number needed to treat with mediastinoscopy to prevent an unnecessary thoracotomy is around 5-15 patients. Exceptions to this may be patients with a T1 tumour, patients with a small peripheral tumour or patients who have had a negative PET scan.

Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery.

BACKGROUND: The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit. METHODS: Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality. RESULTS: Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality. CONCLUSIONS: Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.

The effectiveness of high dependency unit in the management of high risk thoracic surgical cases.

OBJECTIVE: To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. INTRODUCTION: There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. METHOD: Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. RESULT: One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. DISCUSSION: The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk cases with favourable outcome. It provides excellent pain control facilities, detects complications early and avoids unnecessary ITU admissions. It also provides an excellent training opportunity for both medical and nursing staff.