Recurrent spontaneous esophageal rupture.

Spontaneous esophageal rupture is an uncommon and poorly understood condition. Recurrent rupture is extremely rare, with only one previously reported case in the literature. Here, we present a case series of two patients who had recurrent ruptures, and discuss the principles underlying the management of such cases.

The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma.

BACKGROUND: There is evidence that perioperative blood transfusion may lead to immunosuppression. Our aim was to determine whether blood transfusion influenced survival after esophagectomy for carcinoma. METHODS: The study group comprised 234 consecutive patients (175 men and 59 women) with a mean age of 66 years who underwent esophagectomy for carcinoma by one surgeon between 1988 and 1998. The impact of 41 variables on survival was determined by means of univariate and multivariate analysis. Follow-up was complete (mean follow-up, 19.2 months; standard deviation, 16 months; range, 0 to 129 months). RESULTS: The operative mortality rate was 5.6% (13 deaths). Median operative blood loss was 700 mL (range, 150 to 7,000 mL). One hundred sixty-one patients (68.8%) received a blood transfusion postoperatively (mean transfusion, 2.6 units; range, 0 to 12 units). Overall actuarial 1-year, 3-year, and 5-year survival rates inclusive of operative mortality were 58.1%, 28.5%, and 16.1%, respectively. On univariate analysis, positive lymph nodes, pathological TNM stage, transfusion of more than 3 units of blood, incomplete resection, poor tumor cell differentiation, longer tumor, greater weight loss, male sex, and adenocarcinoma were significant (p < 0.05) negative factors for survival. On Cox proportional hazards regression analysis, after excluding operative mortality, lymph node involvement (p = 0.001), incomplete resection (p = 0.0001), poor tumor cell differentiation (p = 0.04), and transfusion of more than 3 units of blood (p = 0.04) were independent adverse predictors of late survival. CONCLUSIONS: In addition to reaffirming the importance of completeness of resection and nodal involvement, this study demonstrates that blood transfusion (more than 3 units) may have a significant adverse effect on late survival after esophageal resection for carcinoma. Every effort should be made to limit the amount of transfused blood to the absolutely essential requirements.

Thoracic intrathymic thyroid and cervical goiter: single-stage resection.

Ectopic thyroid tissue in the chest is rare. We report a case of a euthyroid patient with benign ectopic thyroid tissue presenting as a thymic mass in association with a multinodular goiter. Both disorders were managed successfully by surgical intervention.

An evidence-based approach to drainage of the pleural cavity: evaluation of best practice.

Recent surveys have uncovered major variations in key aspects of intercostal drain management, suggesting that decisions are being made on individual preferences without resorting to sound evidence. We provide an up-to-date review of the best practice with evidence-based recommendations and expert consensus views. The following aspects of chest drain management have been addressed: indications for drainage, insertion technique, complications, management of an indwelling chest drain, indications and technique for removal. The emphasis in this review is that safe intercostal drain practice relies upon adherence to a few important principles. Furthermore, when in doubt, particularly with a complex thoracic problem, one should seek prompt specialist advice.

Giant thoracoabdominal ganglioneuroblastoma in a 17-year-old patient.

The most common malignant neurogenic tumors in children are neuroblastic tumors, classified as ganglioneuroblastoma or neuroblastoma. Ganglioneuroblastomas usually occur at the sympathetic ganglia in the mediastinum, whereas neuroblastomas occur in the abdominal cavity. We describe a case of large posterior mediastinal ganglioneuroblastoma extending from the aortic arch to the left renal hilum in a 17-year-old boy. Despite chemotherapy, post-treatment computed tomography showed disease progression. The patient underwent a thoracolaparotomy incision and excision of the tumor. These malignant mediastinal tumors can potentially grow to a very large size. If alternative treatment has failed, resection can be accomplished with relative safety.

An unusual complication from hemostatic packing to control bleeding during cervical mediastinoscopy and an off-pump approach for the later exploration of the superior vena caval injury.

Cervical mediastinoscopy has been widely used and is considered a safe method for the histologic diagnosis and staging of many conditions. Hemorrhage still remains one of the main possible complications, and hemostasis is usually achieved without any further surgical intervention. We present a previously unreported complication of absorbable hemostatic gauze packing, which led to superior vena caval injury and multiple pulmonary emboli, necessitating further surgical repair with the use of a veno-venous shunt.

Does surgery for primary non-small cell lung cancer and cerebral metastasis have any impact on survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy+/-adjuvant treatment) ranged from 19 to 27 months (mean 23.12+/-3.3 months) and at 1, 2 and 5 years from 56% to 69% (mean=63.9+/-5.6%), 28% to 54% (mean=38.7+/-11%) and 11% to 24% (mean=18+/-5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (mean=10.3+/-2.9 months) and 33-39.7% (mean=35.3+/-3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.

Use of extracorporeal membrane oxygenation in the management of septic shock with severe cardiac dysfunction after Ravitch procedure.

We report the case of an 18-year-old patient who underwent Ravitch procedure for pectus carinatum and subsequently had septic shock develop with severe cardiac dysfunction requiring treatment with extracorporeal membrane oxygenation. We advocate the use of extracorporeal membrane oxygenation in adult patients with intractable cardiorespiratory failure due to sepsis post-thoracic surgery unresponsive to conventional therapy.

Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the 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 VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.

Benign mesenchymoma of the mediastinum: a report and review of the literature.

Benign mesenchymoma is a rare type of germ cell tumour. An extensive literature search revealed only one described case of mediastinal mesenchymoma in Europe and three cases in Asia. We describe our recent experience of a mediastinal mesenchymoma and present the fascinating imaging and operative findings. The preoperative diagnosis of these lesions remains difficult and therefore surgical resection is recommended.