Radiographic imaging features of thoracic complications after pneumonectomy in oncologic patients.

PURPOSE: The morbidity and mortality for pneumonectomy in patients has been reported to be as high as 24%. To determine if a subset of patients undergoing pneumonectomy for a malignancy would have similar complication rates and appearances, we performed a review of the radiographic findings of patients at our institution. METHOD: A retrospective review of a thoracic surgery database was performed at our institution for patients who underwent pneumonectomy between January 2001 and April 2004. All images were reviewed on the institutional patient archive communication system, by two experienced, fellowship trained, thoracic radiologists. RESULTS: There were 144 patients (112 men and 32 women) with a mean age of 52 years (range 21-83 years). Of the 144 patients, thoracic complications were present in 52 (36%) patients consisting of pneumonia in 19 (13%), empyema/pleural space infection in 9 (6%), adult respiratory distress syndrome (ARDS) in 8 (6%), bronchopleural fistula in 7 (5%), gortex graft failure/organ herniation in 4 (3%), chylothorax/chyle leak in 2 (1%), pulmonary embolus in 2 (1%), pulmonary hemorrhage in 1 (<1%). CONCLUSION: In oncologic patients, post-pneumonectomy complications occur in over a third of patients and can be life threatening. The presentations are similar to other pneumonectomy patients and are often radiographically detectable. Therefore it is important for radiologist to be aware of the radiographic manifestations of these complications so that appropriate immediate treatment is instituted.

Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients.

BACKGROUND: It is known that cardiac surgical patients with diabetes have greater peri-operative mortality and morbidity when compared with nondiabetic patients; the rate of adverse events in other surgery subspecialties has been only investigated minimally. The aim of this study was to test the magnitude of association between overt diabetes mellitus and postoperative complications across a spectrum of noncardiac surgical patients. METHODS: Prospective outcome data registries describing 1,343 data sets from a spectrum of surgical subspecialties were examined to establish the prevalence of diagnosed diabetes, the incidence of intra- and postoperative complications, and the difference in proportion of morbidity between diabetic versus nondiabetic patients. RESULTS: There was a significant difference in overall morbidity between diabetic and nondiabetic patients with a 2.0 and 1.6 times increased morbidity risk in known diabetic patients with and without malignancy, respectively. Known diabetes was related to the number of postoperative complications in noncardiovascular patients. CONCLUSION: This study quantified the association between known diabetes and the occurrence of complications during recovery after a spectrum of noncardiac surgery. Because of a high prevalence of prediabetic and undiagnosed conditions, the strength of associations between glucose dysregulation and operative outcomes may be even greater than we report.

Thoracoabdominal calcifications predict cardiovascular disease mortality in type 2 diabetic and nondiabetic subjects: 18-year follow-up study.

OBJECTIVE To evaluate cardiovascular disease (CVD) and total mortality associated with thoracoabdominal calcifications. RESEARCH DESIGN AND METHODS Thoracoabdominal calcifications of native radiograms were evaluated in 833 subjects with type 2 diabetes and 1,292 subjects without diabetes, aged 45-64 years, without prior evidence of CVD. The type 2 diabetic and nondiabetic study cohorts were followed up for 18 years. RESULTS After adjustment for conventional risk factors, marked thoracoabdominal calcifications predicted CVD/total mortality with hazard ratio (HR) (95% CI) of 1.5 (0.8-3.0)/1.8 (1.1-2.9) in type 2 diabetic men, 3.0 (1.6-5.7)/3.1 (1.9-5.0) in type 2 diabetic women, 5.0 (2.2-12)/4.0 (2.2-7.4) in nondiabetic men, and 7.8 (1.8-34)/3.0 (1.3-7.0) in nondiabetic women and in the presence of C-reactive protein below/over 3 mg/l with HR of 2.4 (1.3-4.4)/3.0 (1.4-6.1) in type 2 diabetic subjects and 4.0 (1.5-10.8)/6.6 (2.7-16.0) in nondiabetic subjects. CONCLUSIONS Thoracoabdominal calcifications in native radiograms are significant predictors of CVD and total mortality, especially in type 2 diabetic and nondiabetic women with elevated high-sensitivity C-reactive protein level.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome.

OBJECTIVE: First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS: Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS: Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION: This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

Outcomes Associated With Delirium in Older Patients in Surgical ICUs.

BACKGROUND: We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients. METHODS: Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patients >or= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument). RESULTS: Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p < 0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82). CONCLUSIONS: Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home.

Predictors of general complications after video-assisted thoracoscopic surgical procedures.

BACKGROUND: The video-assisted thoracoscopic approach has become the preferred method for many procedures due to the reduced trauma, complication rate and morbidity. The aim of this study was a risk evaluation of patients undergoing video-assisted thoracoscopic surgery (VATS) procedures. METHODS: Between 1991 and 2004, 1,008 patients were included in this single-center retrospective analysis. Risk assessment was performed using univariate and multivariate analysis. RESULTS: Multivariate analysis revealed that patient age (p = 0.003), the duration of the VATS procedure (p = 0.008), redo-VATS (p < 0.001) and conversion to open thoracotomy (p < 0.001) correlated significantly with the incidence of complications. Patients with immune deficiency following organ transplantation had the highest complication rate at 31.7%, which was significantly higher than for patients with either benign disease (p = 0.010) or malignant disease (p = 0.019). CONCLUSIONS: VATS is a safe procedure, but extra caution is recommended for patients with a higher risk profile (age, redo-VATS, immune deficiency).

Nutritional depletion and its relationship to respiratory impairment in patients with chronic respiratory failure due to COPD or restrictive thoracic diseases.

OBJECTIVE: While malnutrition, especially fat-free mass index (FFMI), is a predictor for mortality in chronic obstructive pulmonary disease (COPD), less information on prevalence and mechanisms is available in patients with chronic respiratory failure (CRF) due to restrictive thoracic diseases (RTD). DESIGN AND SETTING: Cross-sectional study of patients consecutively admitted to an in-patient primary pulmonary centre. SUBJECTS: One hundred and thirty-two patients (30% RTD; 70% COPD) with CRF and intermittent non-invasive positive pressure ventilation. INTERVENTIONS: Malnutrition was quantified by bioelectrical impedance analysis or body mass index (BMI), and its relationship to laboratory, lung function, inspiratory muscle and blood gas parameters and 6-min walking distance (6-MWD) was assessed. RESULTS: Malnutrition in terms of BMI<20 kg/m(2) occurred in 16.1% of patients with COPD but none of those with RTD. FFMI<17.4 (<15.0 in female patients) kg/m(2) was found in 35.4 and 30.7%, respectively. FFMI was correlated with airway obstruction (sR(aw), r = -0.50; FEV(1)/VC, r = -0.28; P< or = 0.01 each) and lung hyperinflation (intrathoracic gas volume, r = -0.41; total lung capacity (TLC), r = -0.50; P< or = 0.001 each) in COPD, and with lung restriction in RTD (TLC, r=0.40; P=0.011). Furthermore, malnourished patients showed a higher inspiratory load (P (0.1)) and reduced 6-MWD in both groups. In COPD, only hyperinflation and P (0.1) were independently related to FFMI. CONCLUSIONS: Malnutrition as indicated by low FFMI was similarly prevalent in patients with CRF and COPD or RTD, but inadequately represented by BMI. The correlations between lung function impairments specific for the disease and FFMI emphasized the link between malnutrition and respiratory mechanical load irrespective of its aetiology.

A decade of cardiothoracic surgery at a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: The medical records at Aga Khan University were reviewed to analyze the trends, mortality and patients characteristics of cardiothoracic surgeries in the last decade. METHOD: The medical records of all adult cardiac, thoracic and combined cardiothoracic operations performed during January 1995 to December 2004 at the Aga Khan University Hospital were reviewed. Data were retrieved and analyzed for trends, patient characteristics, and procedure mortality. RESULTS: From January 1995 - December 2004, 4553 cases were eligible for the study, of which 73% were males and 9.4% were children. Male to female ratio changed from 1.3:1 to 3:1 from childhood to adulthood. Number of patients requiring cardiothoracic intervention increased continuously throughout the period, cardiac operations outnumbering thoracic or combined procedures. Ten-year average annual mortality remained 4.8% with slight variation per annum. Age distribution of cardiac surgery patients remained the same, however, constantly increasing number of over-70-year olds was observed. Mortality for isolated CABG, isolated valve and CABG with valve remained 1.9%, 4.3% and 18.3% respectively. CONCLUSION: Trends of cardiothoracic procedures appear similar to those in the developed countries, so are the mortality figures.

Low value of routine chest radiographs in a mixed medical-surgical ICU.

OBJECTIVE: To determine the diagnostic efficacy (DE) and therapeutic efficacy (TE) of daily routine chest radiographs (CXRs), and to establish the impact of abandoning this CXR from daily practice on total CXR volume, ICU length of stay (LOS), readmission rate, and ICU mortality. DESIGN: Prospective controlled study in two parts. The first part comprised a 1-year period during which attending physicians were blinded for findings on daily routine CXRs and were only informed if something deemed important was seen by the radiologist (predefined major abnormalities) who reviewed all CXRs as usual. The second part comprised a half-year period during which daily routine CXRs were replaced by clinically indicated CXR. SETTING: Mixed medical-surgical ICU of a teaching hospital. RESULTS: Data on 1,780 daily routine CXRs in 559 hospital admissions were collected. DE of daily routine CXRs was 4.4%. The most frequent unexpected major abnormalities were new or progressive infiltrates (1.8%) and oropharyngeal tube malposition (0.7%). TE of daily routine CXRs was 1.9%. The most frequent intervention was oropharyngeal tube adjustment (0.6%). No relation was found for DE or TE and hospital admission type or intubation and mechanical ventilation. In the second study part, 433 CXRs were obtained in 274 admissions. Abandoning daily routine CXRs did not affect clinically indicated CXRs orders, or ICU LOS, readmission rate, and mortality. A total CXR volume reduction of 35% (which equaled 9,900 per bed per year [US dollars]) was observed after abandoning daily routine CXRs. CONCLUSION: Diagnostic and therapeutic value of the daily routine CXR is low. Daily routine CXRs can be safely abandoned in the ICU.

Noninvasive ventilation for chest wall and neuromuscular disorders.

Neuromuscular and chest wall disorders are individually uncommon but together form an important group of conditions that can lead to chronic ventilatory failure. This is best recognised in scoliosis, kyphosis, following a thoracoplasty, in muscular dystrophies, such as Duchenne muscular dystrophy (DMD), and myotonic dystrophy, after poliomyelitis and with motor neurone disease (amyotrophic lateral sclerosis). If bulbar function is impaired, tracheostomy ventilation may be required, but in other situations, noninvasive ventilation is preferable. Positive pressure techniques using nasal and face masks are usually the first choice, but negative pressure ventilation is an alternative. There are no randomised-controlled trials regarding the indications for initiating noninvasive ventilation, but this is usually provided if there are symptoms due to nocturnal hypoventilation or right heart failure in the presence of a raised carbon dioxide tension in arterial blood (Pa,CO2) either at night or, more usually, in the daytime as well. There is no evidence that "prophylactic" ventilatory support is of benefit if this is provided before ventilatory failure has appeared. Careful selection of patients is required, especially in the presence of progressive neuromuscular disorders such as DMD and motor neurone disease. There are no randomised-controlled trials concerning the outcome of noninvasive ventilation in these conditions, but studies have shown an improved quality of life, physical activity and haemodynamics, normalisation of blood gases and slight improvement in other physiological measures, such as the vital capacity and maximal mouth pressures. Survival in chest wall disorders is approximately 90% at 1 yr and 80% at 5 yrs, and similar figures have been obtained in nonprogressive neuromuscular conditions. If, however, the underlying disorder is deteriorating, particularly if it involves the bulbar muscles, it may limit survival despite the provision of adequate noninvasive ventilatory support.

Necrotizing soft tissue infection of the chest wall.

Necrotizing soft tissue infection (NSTI) of the chest wall is a relatively rare but highly lethal surgical infection which has received little attention in the medical and surgical literature. The data reported are based on a literature review, including a Medline database search, and search of existing bibliographies. Twenty well-documented cases of primary chest wall involvement by NSTI were found. Thirteen patients were male. Patients' ages ranged from 10 weeks to 78 years. Thirteen patients were postoperative (65%). The diagnosis was initially considered in only 3 of the postoperative cases, a cause of significant delays in surgical treatment. Among those who lived long enough for their wounds to close, 2 had secondary healing, 5 experienced delayed skin grafting over the granulating wound, and 1 had skin grafting combined with muscle transfer. Mortality was 60%. Chest wall NSTI is a rapidly spreading, highly lethal infection. A high index of suspicion, early diagnosis, and aggressive approach are essential to its successful treatment.

Morbidity and validity of the hemiclamshell approach for thoracic surgery.

OBJECTIVE: This is a prospective study to evaluate the indications and outcome of the hemiclamshell incision (longitudinal partial sternotomy combined with an antero-lateral thoracotomy) as used for a consecutive series of patients requiring surgery for various thoracic pathologies not ideally approached by postero-lateral thoracotomy, sternotomy or thoracoscopy. METHODS: All patients with a hemiclamshell incision performed between 1994 and 1998 were prospectively analyzed regarding indications, postoperative morbidity and outcome (clinical examination and pulmonary function testing) in order to validate this incision for thoracic surgery. RESULTS: 25 patients (15 men, 10 women) with an age ranging from 16 to 73 years (mean 43 years) underwent a hemiclamshell incision. The indications for the hemiclamshell approach were (1) chest trauma with massive hemorrhage requiring urgent access to the mediastinum and the ipsilateral pleural space (40%), (2) tumors of the anterior cervico-thoracic junction with suspicion of vascular involvement (28%) and (3) lesions involving both one chest cavity and the mediastinum (32%). The 30-day mortality was 8%. One patient suffered a sternal wound infection, mediastinitis and pleural empyema after a gun shot wound, whereas wound healing was uneventful in all other patients. Analgesic requirements for postoperative pain relief were not increased as compared to those following a standard thoracotomy. At 3 months normal sensitivity of the entire chest wall and intact shoulder girdle function was noted in 90% of the patients. Pulmonary function testing showed no restriction due to the hemiclamshell incision. CONCLUSIONS: The hemiclamshell incision is a useful approach in selected patients and does not cause more morbidity or long-term sequelae than a standard thoracotomy.

Noncardiac thoracic surgery in children. A retrospective study.

A retrospective study of noncardiac thoracic surgery in children (age < 16 years) comprised 126 patients consecutively operated on over a 10-year period. The surgical procedures included chest-tube insertion for neonatal pneumothorax in 33 children, 12 of whom died within 5 days after birth. Primary intrathoracic disorders were treated in 55 cases, mainly congenital pulmonary malformations in the youngest and traumatic conditions in the oldest. There were no early postoperative deaths in this group, but seven children were dead at the time of follow-up. In 38 children surgery was performed for involvement of intrathoracic organs secondary to other, often malignant diseases. Eleven of these children were dead at follow-up. Noncardiac thoracic surgery is thus required for a number of reasons in children and is well tolerated, although serious primary disease can increase mortality.

COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit: a retrospective 20-year survival study.

OBJECTIVES: To evaluate the long-term prognosis of ventilator-dependent patients. DESIGN: Retrospective study. SETTING: A prolonged respiratory care unit (PRCU). The PRCU provides comprehensive medical, nursing, and respiratory care to tracheostomized, ventilator-dependent adult patients who had failed all attempts at weaning. Because of their medical complexity, these patients could not be discharged to a lower level of care. PATIENTS: Of the 293 patients admitted to the PRCU over a 20-year period beginning January 1, 1977, 145 had respiratory failure from COPD, 22 from spinal cord disease or trauma, 34 from primary CNS disease, 50 from primary neuromuscular disease, and 16 from chest wall disease. Twenty-six patients were not classifiable into the above categories. MEASUREMENTS: Demographics, diagnoses, and survival data were reviewed. The survival of patients with COPD was compared with the other diagnosis categories using the Cox proportional hazards model. RESULTS: The median survival for the entire group was 9 months; younger age and female gender were both predictive of longer survival (both, p < 0.001). The median survival of those with COPD (5 months) was significantly shorter than that of patients with spinal cord disease (47 months), neuromuscular disease (17 months), and chest wall disease (27 months) (all, p < 0.01). These differences in survival were present even with inclusion of gender and age in the model as covariates. The survival of patients with CNS disease was not significantly different from survival of patients with COPD. CONCLUSION: Chronically ventilated patients with respiratory failure from COPD have a significantly worse prognosis than patients with respiratory failure from other causes.

Comparison of two preoperative indices to predict perioperative mortality in non-cardiac thoracic surgery.

OBJECTIVE: The preoperative classifications: physical status of the American Society of Anesthesiologists (ASA-PS) and/or cardiac risk index (CRI) of Goldman are widely used to estimate the perioperative risk in patients undergoing noncardiac throacic surgery. We tried to determine the validity of both methods in predicting the perioperative mortality in 845 consecutive patients scheduled for major elective noncardiac thoracic surgery. METHODS: Preoperatively, each patient was assigned 2 independent estimations of risk according to the ASA-score (ASA grade, I-IV) and CRI score (CRI grade, I-IV), respectively. RESULTS: Twenty-five patients died within 4 weeks after the operation, the others survived the perioperative period. The grading according to ASA as well as to the CRI score showed a direct correlation with the outcome: The higher the preoperative score, the higher was the mortality rate. When various combinations of ASA and CRI were tested, the lowest mortality rate was found in presence of ASA < or = III and CRI = I. Multivariate regression analysis showed that the ASA score had an independent correlation with perioperative mortality, whereas such a relationship was absent for CRI. CONCLUSIONS: The subjective assessment by an experienced anesthesiologist as expressed by the ASA-score is a valid method in the determination of the perioperative risk. CRI does not contribute additional information for the general perioperative risk.

Perioperative management in thoracic surgery.

The quality of perioperative treatment for patients undergoing thoracic surgery is of the utmost importance for postoperative morbidity and mortality. Hence, it was the purpose of this study to examine various aspects of our own procedure. The clinical course following 812 successive thoracotomies in 792 patients over a period of 3 years was documented and analysed. The overall complication rate was found to be 19.7%, with a mortality of 3.8% over a 30-day period. Secretostasis, atelectasis and pneumonia were the most common complications. Owing to the predeposition of autologous blood, the percentage of patients requiring allogeneic blood transfusion was reduced from 27% to 9%. There was no evidence suggesting an increase in the complication rate or a longer stay in hospital. Perioperative antibiotic prophylaxis has reduced postoperative wound infection significantly. Similar reductions in the FEV1 are recorded following thoracic surgery, irrespective of the amount of lung tissue resected. This observation indicates that the remaining lung tissue is severely compromised throughout the postoperative period and that the surgical trauma alone is a major factor influencing postoperative pulmonary function for at least 2 weeks.

[Minimally invasive thoracic surgery]. / Minimal invasive Thoraxchirurgie.

Surgery of the intrathoracic organs may be performed without compromise of respiratory mechanics considering minimally invasive principles. An analysis of our experience of 373 thoracoscopic interventions reveals that the diverse procedures performed on the pleura (pleurectomy, pleurodesis), on the lung (wedge resection, fistula closure, ligature of parenchymatous leaks) and on other definec anatomical structures such as the sympathetic nerve or the thoracic duct, are effective in the therapy of intrathoracic disease. The most important pathological conditions which may be treated by thoracoscopy are listed. The range of complications (7%) and their causes are discussed. Current developments and innovations are summarized by a short review of the literature.

Video-assisted thoracic surgery: the approach of choice for selected diagnosis and therapy.

Unconvinced of the benefits of video-assisted thoracic surgery (VATS) over conventional posterolateral thoracotomy (PLT) we undertook an evaluation of the VATS approach for various diagnostic and therapeutic intrathoracic procedures. For the 18 months ending December 31, 1992, 55 consecutive patients (28 males, 27 females, age 48 +/- 17 years) were eligible to undergo VATS for diagnosis and/or treatment of a variety of conditions. Thirty-eight were chosen for VATS and 17 for PLT. Three VATS patients were converted to PLT (7.9%). Thus 35 VATS patients formed our first experience with the minimally invasive approach. We observed operating time (OT), length of stay (LOS), days of postoperative narcotic use (DNA), achievement of diagnostic and/or therapeutic objectives and morbidity and mortality. For analysis of LOS and DNA due to the procedure alone patients were outliers if LOS was prolonged for reasons other than the procedure, pain or related complications. For estimation of anticipated LOS and DNA due to VATS, 9 of the 35 VATS patients were outliers. For the remaining 26, LOS was 4.9 +/- 2.5 days and DNA was 2.6 +/- 1.7 days after surgery. For the 35 VATS patients OT was 87 +/- 30 minutes. Complications after VATS were few and similar to those experienced after PLT. A diagnostic and/or therapeutic objective was achieved in all patients without mortality. We found that definitive procedures carried out with VATS require fewer hospital days and less postoperative analgesia than expected after similar procedures performed through standard PLT. Diagnostic and therapeutic objectives are easily attainable and complications are few. (ABSTRACT TRUNCATED AT 250 WORDS)

A survey of non-cardiac fetal intrathoracic malformations diagnosed by ultrasound.

Between November 1986 and April 1993, 22 cases of intrathoracic abnormality were detected prenatally by ultrasound, and examined postnatally. There were 11 cases of diaphragmatic hernia, 5 cases of cystic adenomatoid malformation of lung, one case of chylothorax, two cases of lung sequestration, and three cases of bronchogenic cyst. The total number of deliveries during that period was 48,281 and the total number of major anomalies at that time was 669 (1.38%). Cases of hydrothorax of various etiology, as well as thoracic cage anomalies were excluded. Prenatal diagnosis allows planned delivery and the assembly of neonatologists and pediatric surgeons.