Long-term survival after bilateral adrenalectomy for metastatic lung cancer: a case report.

Selected patients with solitary metastases from non-small cell lung cancer can benefit from an aggressive treatment approach that includes resection of the metastases. This approach has been used for solitary adrenal metastases, but successful long-term treatment of bilateral adrenal metastases has not been previously reported. This is the report of a patient with bilateral adrenal metastases from lung cancer who is disease-free 9 years after bilateral adrenalectomy and chemotherapy. From this evidence, one may hypothesize that adrenal metastases are occasionally lymphatic in origin and that metastases with this route of spread are more amenable to aggressive curative treatment than adrenal metastases of hematogenous origin.

Plasma cell granuloma of the lung.

Plasma cell granuloma is an uncommon, nonneoplastic pulmonary lesion. An 11-year retrospective review of resected pulmonary tumors yielded six patients with plasma cell granulomas. Fine needle aspiration biopsy results were falsely positive for carcinoma in one patient. Adherence or invasion of the mediastinum was present in three patients. Granuloma in one patient, who underwent two operative procedures, was deemed unresectable at the initial thoracotomy. For both diagnostic and therapeutic reasons, early surgical excision is recommended for plasma cell granulomas of the lung.

Metastasis-induced acute pancreatitis as the initial manifestation of bronchogenic carcinoma.

Metastasis-induced pancreatitis (MIAP) is a very rare initial manifestation of lung cancer. A review of one institution's experience and the English language medical literature was conducted to define the incidence, natural history, and optimal treatment of this unusual clinical problem. One of 802 (0.12 percent) lung cancer patients presented with MIAP. Seven additional cases were found in the literature. Small-cell carcinoma was present in six of eight patients. Prognosis is poor. Four patients died within two weeks of hospital admission. In patients with small-cell carcinoma and mild pancreatitis, chemotherapy may favorably influence recovery from pancreatitis. Those with severe pancreatitis tolerate chemotherapy poorly and initial supportive management is advisable. Patients with small-cell histologic features who recover from pancreatitis should receive chemotherapy. Survival beyond six months is possible.

Prognostic implications of pulmonary satellite nodules: are the 1997 staging revisions appropriate?

In the 1992 AJCC and 1993 UICC staging systems, primary lobe satellite nodules increased the T designation of the primary by one level and ipsilateral non-primary lobe satellite nodules raised the T designation to T4. The recent 1997 UICC and AJCC staging revisions assign a T4 (IIIb) designation to satellite nodules in a primary lobe, and a M1 (IV) designation to satellites in ipsilateral non-primary lobes. There is abundant evidence showing that satellite nodules are negative prognostic factors, but their inclusion in stage IIIb and IV may not be appropriate. The English-language medical literature was searched for papers reporting survival after surgical resection of lung cancer with satellite nodules (primary and non-primary ipsilateral lobe locations). Eleven articles were retrieved and their data pooled for analysis. Of 568 resected patients with satellite nodules, actuarial 5-year survival was 20%. Five articles gave separate survival data for satellite nodules in primary versus ipsilateral non-primary lobes. All five articles showed better survival for satellite nodules in a primary lobe. Satellite nodules in a primary lobe have a better prognosis than those in ipsilateral non-primary lobes. Survival for resected lung cancer with satellite nodules in a primary lobe is better than that usually observed for T4 (IIIB) disease. The 1997 staging revisions may unduly upstage patients with satellite nodules in a primary cancer lobe. However, satellite nodules in ipsilateral non-primary lobes share metastatic mechanisms and have survival results consistent with M1 stage disease. Their 1997 MI designation may be appropriate.

Gastroesophageal leaks after antireflux operations.

A retrospective review of gastroesophageal leaks complicating antireflux operations was conducted to determine the incidence, predisposing factors, optimal treatment, and outcome in such patients. Twelve postoperative gastroesophageal leaks occurred in a series of 1,005 antireflux procedures (1.2%). Four of the 12 patients had undergone a previous hiatal operation, and this was a significant risk factor for postoperative leak (p < 0.001). Ten of the 12 patients had undergone "incomplete" wraps that involved suturing of the gastric fundus to the esophagus, and this was a significant risk factor for postoperative leak (p < 0.04). Five patients had peritoneal contamination and 7 had mediastinal or pleural soilage. Patients with peritoneal perforations were less likely to require intensive care unit admission than were patients with thoracic perforations (p < 0.05). Six of the 12 perforations were either well contained or well drained at the time of the diagnostic contrast study. All 6 of these patients responded to conservative treatment. The remaining 6 perforations were not contained at the time of diagnosis. Two of the affected patients initially received conservative treatment (1 death and 1 late empyema) and 4 were treated by operation (1 death). The mortality associated with gastroesophageal perforation was 17%. Contained perforations can be treated conservatively but noncontained perforations require early and aggressive surgical intervention.

Mediastinal amyloidosis.

Systemic amyloidosis is an unusual cause of mediastinal lymphadenopathy. Thoracic surgeons are often called upon to establish a diagnosis in patients with mediastinal lymphadenopathy, so familiarity with mediastinal amyloidosis is valuable. We report our experience with 2 patients, and discuss the diagnostic role of mediastinoscopy and other less invasive biopsy techniques. General anesthesia may pose significant risks in this disease; nonoperative biopsy techniques should be considered if the diagnosis of amyloidosis is suspected.

Mediastinoscopic treatment of mediastinal cysts.

Selected patients with mediastinal cysts can be managed safely and effectively by mediastinoscopic techniques. Small cysts in favorable locations can be excised partially or nearly completely. Cysts that are intimately associated with vital structures are better suited to mediastinoscopic cystotomy and chemical sclerosis. Three cases are presented and technical aspects are discussed.

Catheter-induced pulmonary artery rupture in the setting of cardiopulmonary bypass.

Pulmonary artery rupture is an infrequent complication of flow-directed catheters. Because cardiopulmonary bypass offers an opportunity for control of gas exchange and hemorrhage, pulmonary artery rupture in this setting is different from that occurring in the intensive care unit and catheterization laboratory. A collective review of 30 published cases was conducted. Sixty-nine percent of patients were female and 50% had valvular heart disease. The right pulmonary artery was injured in 93% of cases. Arterial rupture presented with airway hemorrhage in 29 of 30 patients. Six patients presented with a herald airway bleed after catheter insertion but before operation. Three of 4 patients died when operation was performed in the face of a herald bleed. Airway hemorrhage most commonly developed during bypass weaning (19 cases). Recurrent hemorrhage occurred in 45% of patients (9/20) treated conservatively compared with 0% (0/7) in those having surgical control of bleeding (p = 0.07). Three patients died in the operating room. Overall mortality was 41%. Uncontrolled hemorrhage was the leading cause of death. Conservative management strategies are associated with a high incidence of secondary, often fatal, hemorrhage. Although pulmonary resection controls bleeding, mortality from other causes is a problem. A treatment protocol is proposed that considers these management dilemmas.

Necrotizing soft tissue infections of the chest wall.

BACKGROUND: Necrotizing soft tissue infections of the chest wall are uncommon, and they have received little discussion in the medical literature. METHODS: We performed a collective review of the literature to summarize information on etiology, prevention, treatment, complications, and outcome of chest wall necrotizing soft tissue infections. Manual, Medline, and Current Contents searches of the English-language medical literature were done. RESULTS: There were 9 reported cases of necrotizing soft tissue infection of the chest wall. Eight were complications of invasive procedures and operations. Tube thoracostomy for empyema (4 patients) was the most common antecedent procedure. Excessive soft tissue dissection during chest tube insertion was implicated in the genesis of these infections. Necrotizing infections complicated esophageal operations in 2 patients. Overall mortality was 89%. Only 3 of the 9 patients underwent early and adequate debridement. Chest wall stability and wound reconstruction were problematic in patients who survived the initial septic illness. CONCLUSIONS: Necrotizing soft tissue infections of the chest wall are highly lethal infections that require urgent and aggressive debridement. Diagnostic delay and inadequate debridement are common reasons for treatment failure. Repetitive surgical debridement is often needed to control sepsis. Wound closure is challenging in patients who survive the initial septic phase of their illness.

Reoperation for complications of the Angelchik antireflux prosthesis.

The Angelchik antireflux prosthesis is associated with complications that require reoperation in 5% to 15% of patients. To determine the morbidity and success of reoperation for these complications, we conducted a retrospective study of 15 patients. Time to reoperation ranged from 3 weeks to 113 months with a mean of 31 months. Indications for reoperation included dysphagia (8 patients), recurrent reflux (6 patients), and prosthesis migration (1 patient). Ten patients underwent prosthesis removal and fundoplication, 4 had prosthesis removal without fundoplication, and 1 patient had the prosthesis repositioned. Iatrogenic splenic injury occurred in 2 patients (13%); one splenectomy and one splenic repair were done. Four patients (27%) required intraoperative blood transfusion. There were no operative deaths. Removal of the prosthesis without fundoplication resulted in a significantly higher incidence of recurrent reflux (75%) than prosthesis removal and fundoplication (10%) (p < 0.04). Although reoperation for complications of the Angelchik antireflux prosthesis can be technically difficult, morbidity and mortality are acceptable. An antireflux procedure should be done at the time of prosthesis removal.

Is general thoracic surgical practice evidence based?

BACKGROUND: In evidence-based medicine clinical decisions are based on experimental evidence of treatment efficacy. There are no data on the extent to which general thoracic surgical practice is evidence based. METHODS: A list of 50 thoracic surgical treatments was derived from the operating room log of one surgeon practicing at both a tertiary care cancer center and an affiliated community general hospital. Minor diagnostic procedures and procedures performed as part of experimental protocols were excluded. For each treatment a Medline search was done to obtain the best published evidence supporting the treatment's efficacy. The evidence was then placed in one of three categories developed by the Oxford Centre for Evidence-Based Medicine: (1) evidence from randomized controlled trials (RCTs); (2) convincing non-experimental evidence; and (3) interventions without substantial evidence. RESULTS: Category 1 evidence supported 7 of 50 thoracic surgical treatments. Category 2 evidence supported 32 treatments, and 11 treatments were without substantial supportive evidence. CONCLUSIONS: The majority of commonly performed general thoracic surgical procedures are supported by nonexperimental evidence. Although there are many obstacles to the performance of surgical randomized controlled trials, the limitations of nonrandomized studies are such that continued emphasis on randomized controlled trials in general thoracic surgery is warranted. This study could serve as a baseline reference for future assessments of evidence-based medicine in general thoracic surgical practice.

Self-inflicted pneumothoraces.

Self-inflicted pneumothoraces are rare manifestations of psychiatric illness. Two patients with self-inflicted pneumothoraces are reported, and the typical clinical features of factitious disorders are described. If thoracic surgeons are aware of these conditions, inappropriate surgery- and poor outcomes-can be avoided.

Pulmonary resection for lung trauma.

BACKGROUND: Pulmonary resection is rarely required for trauma, and its mortality is reportedly high. METHODS: A 10-year retrospective review of pulmonary resections for trauma was done. RESULTS: Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001). CONCLUSIONS: Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.

Cardiopulmonary bypass resuscitation for accidental hypothermia.

Many victims of accidental hypothermia have been successfully resuscitated with cardiopulmonary bypass, but questions remain regarding treatment indications and efficacy. To assess the role of cardiopulmonary bypass in resuscitation from hypothermia, a collective literature review was performed. Data on 68 hypothermic patients resuscitated with cardiopulmonary bypass were analyzed. Impairment from alcohol, drug abuse, or mental illness was the most common predisposing factor for accidental hypothermia. Mean initial core temperature was 21 degrees C. Sixty-one patients (90%) were in cardiac arrest. Femoral-femoral bypass was used in 72% of patients. Overall survival was 60%. Eighty percent of survivors returned to their previous level of function. Sixty-seven percent of nonsurvivors died because of inability to establish a cardiac rhythm or wean from bypass. Patient age, type of cardiopulmonary bypass (femoral-femoral or atrial-aortic), and initial core temperature were not significant prognostic indicators. There were no survivors among the 6 patients with a core temperature less than 15 degrees C. Patients in cardiac arrest had a higher mortality than patients who were not (p = 0.02). Climbing and avalanche victims had a higher mortality than other hypothermic patients (p = 0.003). The possibility of publication bias must be considered before firm conclusions can be drawn from this collective literature review. Controlled studies comparing the efficacy of cardiopulmonary bypass and alternative warming techniques have not been done. Nevertheless, cardiopulmonary bypass has several advantages over other warming methods for profoundly hypothermic patients. Tissue perfusion and oxygenation are maintained while rapid warming occurs. Cardiopulmonary bypass resuscitation is recommended for hypothermic patients in arrest and for patients with core temperatures lower than 25 degrees C, irrespective of rhythm. Patients in stable condition with temperatures between 25 degrees and 28 degrees C can be treated with cardiopulmonary bypass or conventional warming methods.

Esophageal perforation in recessive dystrophic epidermolysis bullosa.

Recessive dystrophic epidermolysis bullosa is an inherited mechanobullous disease characterized by skin blistering and esophageal bullae. In response to minor trauma, a split in the dermis or esophageal subepithelium occurs. Esophageal perforation is a rare complication. Because the esophagus is diseased in these patients, we believe that esophagectomy rather than repair is the treatment of choice for esophageal perforations. We report a patient for whom early primary repair failed and esophagectomy was required.

Cerebrovascular accident complicating extended cervical mediastinoscopy.

The safety and efficacy of staging cervical mediastinoscopy is well established. Extended cervical mediastinoscopy has been proposed as a safe and effective method of staging left upper lobe lung cancers. We report a case of cerebrovascular accident complicating extended cervical mediastinoscopy.

Open lung biopsy as an outpatient procedure.

BACKGROUND: Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice. METHODS: We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day. RESULTS: Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3%+/-7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred. CONCLUSIONS: Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.

Operation and photodynamic therapy for pleural mesothelioma: 6-year follow-up.

BACKGROUND: Conventional therapy for pleural mesothelioma has met with disappointing results. METHODS: From 1991 to 1996, 40 patients with malignant pleural mesothelioma were treated with surgical resection followed by immediate intracavitary photodynamic therapy. RESULTS: The series included 9 women and 31 men with a mean age of 60 years. Morbidity and treatment-related mortality rates for the entire series, pleurectomy, and extrapleural pneumonectomy were 45% and 7.5%, 39% and 3.6%, and 71% and 28.6%, respectively. Median survival and the estimated 2-year survival rate for the entire series, stages I and II patients (n = 13), and stages III and IV patients (n = 24) were 15 months and 23%, 36 months and 61%, and 10 months and 0%, respectively. Multivariate analysis identified stage, length of hospital stay, photodynamic therapy dose, and nodal status as independent prognostic indicators for survival. CONCLUSIONS: Surgical intervention and photodynamic therapy offer good survival results in patients with stage I or II pleural mesothelioma. For patients in stage III or IV, better treatment modalities need to be developed. Improvements in early detection and preoperative staging are necessary for proper patient selection for treatment.

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease.

BACKGROUND: Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done. METHODS: Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected. RESULTS: A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients. CONCLUSIONS: There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

Duration of knowledge in general thoracic surgery.

BACKGROUND: Medical knowledge changes rapidly, so current medical education approaches emphasize the development of life-long learning skills ("teaching the learner to learn") as opposed to the simple acquisition of contemporary medical knowledge. Because there are no data on the rapidity of change of general thoracic surgical knowledge, we do not know whether this trend in medical education is appropriate for thoracic surgical trainees. We undertook a study to assess the duration of knowledge in general thoracic surgery. METHODS: The first general thoracic surgery article from each issue of The Annals of Thoracic Surgery between 1965 and 1997 was abstracted into a summary statement. A form, made up of 360 summary statements in random order, was assessed by 6 general thoracic surgeons. They assessed statement validity on a 5-point scale (1 = statement false; 5 = statement true). Average statement validity scores for 30 time intervals were calculated. The relationship between time of publication and statement validity was analyzed. RESULTS: Average validity scores ranged from 2.24 (represents 1965 to 1966) to 4.32 (represents 1969 to 1970). Validity scores increased with time (y = 3.46 + 0.017x, where y is validity score and x is time), and this was significant (r = 0.40; p = 0.027). However, the absolute change in average validity scores over the 33-year study period was only 0.52 or 13.1% of the "modern" era scores. CONCLUSIONS: The assumption that medical knowledge changes quickly may not be true in general thoracic surgery. Although life-long learning skills are important, general thoracic surgery training programs should continue to emphasize fundamental knowledge in the specialty.