Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Management of tuberculous empyema.

OBJECTIVE: In an attempt to establish a treatment protocol for tuberculous empyema, we retrospectively reviewed our experience over a 3-year period. METHODS: Between January 1996 and December 1998, 26 patients (23 male and three female) with an average age of 33.8 years (range 18-61 years) presented with tuberculous empyema. The empyema was right-sided in 13, left-sided in 12 and bilateral in one patient. Patients presented with respiratory symptoms for a mean duration of 4.43 months (range 1-48 months). All patients had a computerized scan of the chest and managed according to the stage of empyema. RESULTS: In patients with exudative empyema (n=4) the fluid was aspirated, but one patient required intercostal tube (ICT) drainage for 6 days. There were four patients with fibrinopurulent empyema treated with thoracoscopic drainage with a mean post-operative stay of 8 days (range 4-12 days). In the organizing stage (n=18), initial drainage with large ICT was performed. The pleura was less than 2 cm in thickness in eight patients, for which repeated installation of streptokinase was performed (three to seven times). Satisfactory results were achieved in six patients (75%) and the remaining two required decortication. Of the ten patients with thick cortex, one required a window and nine had decortication, two of which had additional lobectomy and two had pneumonectomy. All patients fully recovered with no mortality and with a mean duration of drainage of 18 days (range 3-61 days). CONCLUSION: Its stage and the state of the underlying lung should guide surgical treatment for tuberculous empyema. This protocol aims to achieve cure utilizing the least invasive approach and acceptable hospital stay.

Early experience with single lung transplantation for emphysema with simultaneous volume reduction of the contralateral lung.

OBJECTIVE: Single lung transplantation (SLT) for emphysema has given satisfactory long term results in most patients. The mediastinal shift caused by the native emphysematous lung may require further surgical intervention in selected cases. METHODS: We report a technique of simultaneous SLT and volume reduction of the contralateral lung in 4 patients with end stage respiratory failure secondary to emphysema. There were two right and two left SLT, performed in two male and two female patients. Their mean age was 52.2 (S.D. 4) years (range between 41 and 57 years) and the ischaemia time averaged 255.6 (S.D. 16) min (range between 225 and 255 min). The volume of the contralateral lung was reduced using staples. The stapled lines were buttressed by the donors pericardium. RESULTS: Their were no operative related complications apart from air leak which settled spontaneously within 5 days postoperatively. Teh pre-operative FEVI showed a mean value of 0.57 (S.D. 0.1) L (17.2% (S.D. 2) of the predicted) which improved to 1.79 (S.D. 0.4) L (58.2% (S.D. 8) of the predicted) at last follow up (P < 0.005). Radiological examinations at 1 year showed central mediastinum with satisfactory respiratory function. CONCLUSION: We conclude that this technique can be performed for patients with emphysema without increase in the operative morbidity and with good early respiratory function. Further follow up is required to assess the long term results of this procedure.

Medium term results of direct bronchial arterial revascularisation using IMA for single lung transplantation (SLT with direct revascularisation).

OBJECTIVE: To describe a technique of direct revascularisation of the bronchial artery using the left IMA and assess its medium term results in patients undergoing left single lung transplant (SLT). METHODS: Between March 1991 and September 1993, 22 patients who underwent direct bronchial revascularisation at the time of left SLT (20 pedicled IMA, one free IMA, and one direct anastomosis to the aorta) have been followed up for a minimum period of 1 year (mean 30 +/- 12 months). Their mean age was 47.8 +/- 9.6 and the original disease was emphysema in 19, lymphangioleiomyomatosis in two, and pulmonary fibrosis in one. The mean ischaemia time was 269.7 +/- 23.4 min. RESULTS: There was one early death (4.5%) and 3 patients were re-explored for bleeding. The actuarial survival at 1 and 3 years was 91 +/- 0.4% and 82.6 +/- 1%, respectively. Bronchial healing was excellent in all patients and angiographic studies showed patent vascular anastomosis in all 22 patients, with good run off in 20 and poor in two. One patient developed clinical obliterative bronchiolitis at 22 months (4.5%) during a period of follow up varying from 12 to 43 months (mean 30 S.D. 12). At last follow up the mean FEV1 was 1.4 +/- 0.4 and the mean FVC was 2.2 +/- 0.6. On average, each patient developed 1.5 +/- 0.6 infection episodes and 1 +/- 0.2 acute lung rejection. CONCLUSION: It is concluded that the medium term results of direct bronchial revascularisation are good. However the influence of this procedure on long term results needs further investigation.

Spontaneous pneumothorax: determinants of surgical intervention.

OBJECTIVE: To assess the long term efficacy of intercostal tube drainage for spontaneous pneumothorax and determine the clinical parameters associated with surgery. EXPERIMENTAL DESIGN: Retrospective analysis with a mean follow-up of 62.3+/-19.3 months (range 23 to 94 months). SETTING: Riyadh Medical Complex, Riyadh (Saudi Arabia), the biggest referral centres for Ministry of Health providing specialized hospital care. PATIENTS: Over a period of six year, 123 patients had 182 episodes of spontaneous pneumothorax. Male to female ratio was 29.75:1 (p=0.00001). Average age was 26.35+/-8.33 years for men and 37.25+/-14.6 years for women (p=0.01). Seventy eight per cent of patients were aged 11 to 30 years (p=0.00001). Majority were nonsmokers (100/123, p=0.00001). It was first episode of spontaneous pneumothorax for 86 patients. Other 37 patients had 57 episodes previously (mean 1.54+/-0.73; range 1 to 4). INTERVENTIONS: Intercostal tube drainage for all patient with spontaneous pneumothorax. Limited axillary thoracotomy with bullectomy and pleuroabrasion for 32 patients not responding to intercostal tube drainage. RESULTS: Intercostal tube drainage alone had success rate of 90.7% in first, 52.4% in second, 15.4% in third and 0% for more than 3 episodes of spontaneous pneumothorax. Among the 32 patients who underwent surgery, only one had early recurrence that did not require drainage. We found that patients with history of recurrence, respiratory distress and those requiring tube thoracostomy for more than 4 days and negative suction to expand the lung were more liable to undergo surgical intervention (p=0.00001 for all variables). CONCLUSIONS: We recommend early surgery to hasten recovery and shorten the hospital stay in patients with history of recurrent spontaneous pneumothorax, respiratory distress and those requiring tube thoracostomy for more than 4 days and negative suction to expand the lung.

Incidence of carcinoma in multinodular goitre in Saudi Arabia.

Over a period of 3 years, 614 patients were admitted to the General Surgery Department at the Riyadh Central Hospital with thyroid enlargements. Based on the clinical examination and non-invasive investigations, the thyroid swellings were classified into solitary nodule (45%), multinodular (44%) and diffuse goitre (11%). Subsequent classification of the goitres on the basis of intraoperative findings and histopathological examination revealed increase in the number of multinodular goitres to 70% while the solitary nodule and diffuse goitres dropped to 24% and 6%, respectively. Malignant changes were seen in 10% of the multinodular goitres after pathological examination. 75% of the carcinomas seen in multinodular goitres were of the papillary type. In almost none of the cases, it was possible to discover the malignancy preoperatively. The study recommends surgical intervention in all nodules goitres irrespective of being solitary or multinodular.

The non-functioning pleuro-peritoneal shunt: revise or replace?

Pleural malignancy commonly leads to troublesome and recurrent effusion. Cure is not possible and effective palliation is important for the 2-3 months median survival following diagnosis. We have previously emphasised the role of pleuro-peritoneal shunts (PPS) in this situation. A number of shunts (11%) malfunction and we have revised our policy as to how best to deal with this problem. We studied our 70 patients who required the insertion of 71 PPS over seven years: there were 8 cases (11%) of non-functioning shunts necessitating re-exploration. In two cases the shunt was blocked due to infection which may have been present prior to insertion of the shunt. In these cases the shunt was removed and drainage was performed. In one shunt non-function was due to obstruction of the pleural limb and it was re-positioned successfully. The remaining five shunts were found to be blocked by fibrinous tissue. Replacement of two of these led to a functioning shunt until the death of the patients, while the three shunts which were revised failed to function. One shunt became infected and was removed and the other two became blocked again. Following subsequent replacement the function was restored until the death of the two patients. We conclude that non-functioning pleuro-peritoneal shunts should be replaced rather than revised to avoid subsequent complications.

Surgery for unilateral bronchiectasis: results and prognostic factors.

SETTING: King Khalid University Hospital referral centre for thoracic surgery, Riyadh, Saudi Arabia. OBJECTIVE: To assess the results of surgery and factors influencing its outcome in patients with unilateral bronchiectasis. DESIGN: A retrospective analysis of 40 patients with unilateral bronchiectasis who were operated upon consecutively at King Khalid Hospital, between July 1987 and May 1993. RESULTS: Left-sided disease was seen in 60% (n = 24) and right-sided in 40% (n = 16) of the patients. The entire lung was involved in 30% of cases (n = 12). Of these, the left lung was totally involved in 22.5% (n = 9) and the right in 7.5% (n = 3). A lobectomy was performed on 21 patients, basal segmentectomy with preservation of apical segment on 7, and pneumonectomy on 12. There was no operative mortality in this series. Six patients (15%) developed postoperative complications, bleeding (n = 4) and prolonged air leak (n = 2). During an average follow-up period of 30.7 months (+/- 15.4 months), 29 patients (72.5%) were cured and the remaining 11 (27.5%) improved. No patients with Pseudomonas aeruginosa infection (n = 3) or obstructive airway disease (n = 5) were cured (P = 0.02 and P = 0.002 respectively). CONCLUSION: Curative resection for selected patients with unilateral bronchiectasis can be performed safely with good results and low morbidity. Pseudomonas aeruginosa infection and obstructive airway disease have an adverse effect on postoperative cure.