The surgical treatment of pulmonary metastases.

The surgical management of pulmonary metastases remains controversial, as no randomized trials have compared surgical excision with nonoperative treatment (to our knowledge). A Medline-generated review of the literature was undertaken to determine the factors influencing survival following metastasectomy in published trials. In the absence of randomized comparative trials, data must remain inferential and circumstantial. However, the literature does support the anecdotal observation that patients with metastatic disease can achieve long-term survival following surgical excision, irrespective of the source of the primary neoplasm, if there is no demonstrable extrathoracic disease and complete excision of the pulmonary disease is possible. Other factors noted as influencing survival appear to be anecdotal and variable from report to report. Pulmonary metastasectomy should be considered in patients with sufficient pulmonary reserve when the lung is the only site of metastatic disease and the lesions can be totally excised. An algorithm is proposed for a logical approach to the problem.

Pulmonary metastectomy. Current indications for removing lung metastases.

Despite a great deal of literature on pulmonary metastectomy, the treatment of pulmonary metastases remains somewhat controversial. However, review of the literature does allow the development of certain algorithms to approach this problem, and these are discussed.

Prospective, randomized, double-blind study using prophylactic cephalothin for major, elective, general thoracic operations.

A total of 211 patients were entered into a randomized, double-blind study of postoperative infection in which an antibiotic (cephalothin) and a placebo were used. The antibiotic was effective in reducing sleep wound infections (p less than 0.05) and superficial wound infections (p less than 0.01). The incidence of pulmonary infections was decreased, but the change was not statistically significant, and the incidence of empyema was unaffected.

Use of the silicone tracheal T-tube for the management of complex tracheal injuries.

This paper reports on the use of the silicone Montgomery T-tube for the management of 18 patients with complex tracheal injuries. Our use of the tube was as follows: prior to definitive resection, as a better alternative to tracheostomy tube, while we were awaiting the most appropriate time for resection; at the time of resection, as an adjunct to segmental subglottic resection, used to stent residual abnormal laryngeal mucosa: following tracheal resection for uncertain or unsatisfactory healing: as sole treatment, when resection was deemed unsuitable or inappropriate. When stenting the high region, the upper limb of the T-tube can be brought through the vocal cords with preservation of a functional voice and without injury to the vocal cords even with prolonged use. In contrast to a tracheostomy tube, the T-tube provides respiration through the the nasopharynx, so that humidification and phonation are maintained. It is generally trouble free, requires little if any maintenance, and can remain in place for a year or more when necessary.

The timing of tracheotomy: a systematic review.

STUDY OBJECTIVE: To examine the impact of the timing of tracheotomy on the duration of mechanical ventilation, the secondary changes to the trachea, and the clinical course of critically ill patients in the ICU. DESIGN: A systematic review of the literature. METHODS: Two independent reviewers conducted a MEDLINE search for relevant literature in the form of randomized or observational controlled clinical studies. Studies were selected for review by criteria determined a priori; and the methodologic quality of selected studies was evaluated by duplicate independent review, also using criteria determined a priori. RESULTS: Five studies were identified, of which three were quasirandomized and none were blinded. Agreement between reviewers of methodologic quality was high (kappa=0.87). CONCLUSIONS: There is insufficient evidence to support that the timing of tracheotomy alters the duration of mechanical ventilation or extent of airway injury in critically ill patients.

Experience with primary neoplasms of the trachea and carina.

From 1963 to 1983, 44 patients presented with a primary tracheal neoplasm that was amenable to surgical treatment. Forty-two of the 44 tumors were malignant. Thirty-three patients were managed by resection and primary anastomosis. The following resections were done: trachea only, 12; trachea plus carina, 13; trachea plus cricoid cartilage, four; and trachea plus larynx, four. There were two operative deaths in these 33 patients. Prosthetic reconstruction with heavy-duty Marlex mesh was done in six patients. Three of the six died of erosion of the innominate artery during the postoperative period. In three patients with nonresectable tumors, a silicone-coated Montgomery T-tube provided transient but worthwhile palliation. In two patients with nonobstructive adenoid cystic carcinoma involving the subglottis, irradiation was chosen as the initial treatment, since resection would necessitate laryngectomy. Resection, including laryngectomy, may be required in the future. The following points are emphasized: (1) A majority of operable neoplasms can be resected through a cervical collar incision and median sternotomy. Median sternotomy is the optimal operative exposure in most neoplasms necessitating resection of the carina. (2) Partial resection of the cricoid with sparing of the recurrent laryngeal nerves and larynx is possible in some patients with primary malignant tumors involving the proximal trachea and subglottic region. (3) In patients with adenoid cystic carcinoma, resection may afford excellent, long-term palliation even when the resection is incomplete. Pulmonary metastases are common in patients with adenoid cystic tumors. However, they usually progress slowly, may remain asymptomatic for many years, and are not necessarily a contraindication to resection of the primary tumor even when they are synchronous. Our experience suggests that adjunctive radiotherapy is beneficial in patients with adenoid cystic carcinoma.

Massive hiatus hernia: evaluation and surgical management.

OBJECTIVE: Paraesophageal hernias represent advanced degrees of sliding hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resulting in acquired short esophagus, which should influence the type of repair selected. METHODS: Between 1960 and 1996, 94 patients with massive, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included postprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemia in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscopy by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sliding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was hypotensive in 21 patients (51%), and the amplitude of peristalsis in the distal esophagus was diminished in 24 patients (59%). These abnormalities are both features of significant gastroesophageal reflux disease. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measured during manometry. The average distance was 15.4 +/- 2.33 cm (11 to 20 cm), which is consistent with acquired short esophagus. The normal distance is 20.4 cm +/- 1.9 (p < 0.0001). RESULTS: All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplication. A gastroplasty was added in 75 cases (80%) because of clearly defined or presumed short esophagus. There were two operative deaths, and two patients were never followed up. Among the 90 available patients, the mean follow-up was 94 months; median follow-up was 72 months. Seventy-two patients (80%) are free of symptoms (excellent result); 13 (13%) have inconsequential symptoms requiring no therapy (good result); and three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor results because of recurrent hernia and severe reflux. Both were successfully treated by reoperation with the addition of gastroplasty because of acquired shortening, which was not recognized at the first operation. CONCLUSIONS: Most of these 94 patients had symptoms or endoscopic, manometric, and operative findings that were consistent with a sliding hiatus hernia. There was a high incidence of endoscopic reflux esophagitis and of acquired short esophagus. True paraesophageal hernia, with the esophagogastric junction in a normal abdominal location, appears rare. Our observations were supported by measurements obtained at preoperative endoscopy and manometry, and by findings at the time of surgical repair. These observations support the choice of a transthoracic approach for repair in most patients.

Results of surgical treatment for thymoma.

Ten years' experience with surgical treatment of thymoma in 52 patients is reported, 25 patients with myasthenia gravis and 27 without. Twenty-five patients had noninvasive tumors (Stage I) and 27 had invasive tumors (Stages II and III). Of the 52 patients, 29 had surgical resection as the only treatment and the remaining 23 had surgical resection with adjunctive preoperative or postoperative radiotherapy. Currently, 39 patients are alive (20 with myasthenia and 19 without), 10 are dead (none dying of myasthenia or tumor), and three patients have been lost to follow-up. The mean follow-up time for all patients was 5.6 years. There were no operative deaths in this series. The 5 year cumulative survival rate for the entire group of 52 patients is 81%; for patients with myasthenia it is 92%; and for those without myasthenia, 71%. This series suggests that the prognosis following resection of thymoma relates primarily to the stage of the tumor and is not significantly influenced by the presence or absence of coexisting myasthenia gravis. The improved survival rate, in contrast to a 1973 report, is a reflection of improved long-term medical management of myasthenia gravis and better postoperative supportive care.

Bronchial carcinoid tumors: twenty years' experience.

We reviewed 69 patients with documented carcinoid tumors, 67 of whom had resectable disease. Operations included nine pneumonectomies, 31 lobectomies, 12 bilobectomies, five segmental resections, and 10 sleeve resections. Follow-up on 65 patients reveals 40 surviving beyond 5 years and 13 beyond 20 years since resection. There were no operative deaths and only one recurrence (local) that was subsequently successfully resected. Twenty patients had had recurrent unifocal pneumonitis or hemoptysis for up to 5 years prior to diagnosis. Two patients had the carcinoid syndrome. Biopsy was performed on 23 tumors and resulted in "moderate-to-severe" hemorrhage in six cases. Lymphatic spread was present in seven cases. All seven are alive and free of disease, six of whom have been followed from 5 to 24 years. Diseased resection margins were present in two cases, with both surviving 20 years after resection. All 10 sleeve resections were performed more than 5 years ago. We conclude that carcinoid tumors carry a favorable prognosis upon resection, even when intrathoracic lymphatic metastases are present and are resected. Lung-sparing resections including sleeve resections should be utilized. Recurrent pneumonia or hemoptysis or both requires diligent investigation. Biopsy of the tumors may be performed with care.

Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung.

Between 1979 and 1984, mediastinoscopy was performed on 1,000 of the 1,500 patients admitted to the Thoracic Surgical Service of the Toronto General Hospital with the diagnosis of carcinoma of the lung. In 144 cases, concomitant anterior mediastinoscopy was also performed. Abnormal mediastinal nodes were found in 296 (29.6%). The overall complication rate was 2.3%, with no deaths. Mediastinoscopy revealed diseased nodes in 24% of patients with squamous cell carcinoma, 29% with adenocarcinoma, 54% with small cell undifferentiated carcinoma, 31% with large cell undifferentiated carcinoma, and 12% with bronchoalveolar carcinoma. Abnormal mediastinal nodes were found with equal frequency in right- and left-sided tumors and occurred in 31% of tumors in the main bronchus, 25% of upper lobe tumors, and 17% of lower lobe tumors. Of the 704 patients having negative results of mediastinoscopy, 590 were subjected to thoracotomy. Ninety-three percent underwent resection (85% curative, 7% palliative) and 7% had unresectable tumors. Of the resections, 20% were pneumonectomies. At thoracotomy, 52 of the 590 patients with negative mediastinoscopic results were found to have abnormal mediastinal nodes. Sixty-two of the 296 patients with positive results of mediastinoscopy were selected for thoracotomy. Eighty-six percent had resectable lesions (67% curative, 18% palliative) and 14% unresectable. The pneumonectomy rate in this group was 35%. These current data support our previous opinion that routine mediastinoscopy can be done with negligible morbidity and provides essential information for the classification and management of cancer of the lung.

One-stage reconstruction for pharyngolaryngectomy. Esophagectomy and pharyngogastrostomy without thoracotomy.

From 1969 to 1981, a total of 22 patients underwent laryngopharyngectomy and nonthoracotomy esophagectomy, with immediate pharyngogastrostomy, for hypopharyngeal or postcricoid carcinoma. Thirteen initially had been treated by high-dose radiotherapy, but the tumor had either persisted or recurred. Four patients underwent planned preoperative irradiation on the morning of the operation. Two patients had had previous high-dose local irradiation to the neck for other disease, and three patients had no irradiation. There was one operative death. Anastomotic leaks developed in four patients, but only one of the leaks was considered a serious problem. Three patients had transient dysphagia, but only one required dilatation. Transient delayed gastric emptying was a problem in three other patients. The average postoperative stay was 31 days, with 38% of patients being discharged by 21 days. All patients were discharged eating a normal diet. Fifty percent survived longer than 12 months, with an actuarial survival rate of 30% at 5 years. The patient surviving longest is disease free at 12 years. Palliation was considered excellent in all 21 operative survivors. Immediate pharyngogastrostomy via nonthoracotomy esophagectomy is a safe and excellent means of palliation in this group of patients, for whom palliation is often the only option.

Transhiatal esophagectomy with gastric transposition for pharyngolaryngeal malignant disease.

Between 1981 and 1988, 41 patients underwent pharyngolaryngoesophagectomy with transhiatal gastric transposition and primary pharyngogastrostomy for hypopharyngeal, laryngeal, and cervical esophageal carcinoma. All patients had squamous cell carcinoma. Twenty-one patients had been treated initially by high-dose radiotherapy, but the tumor had either persisted or recurred. Four patients had previously received high-dose local radiotherapy to the neck for unrelated diseases, and in 16 patients no preoperative radiotherapy was given. There was one operative death. Anastomotic leaks developed in nine previously irradiated patients and three required flap reconstructions. Thirty patients had satisfactory swallowing postoperatively and three swallowed poorly. Delayed gastric emptying was a serious problem in two patients, necessitating pyloric bag dilatation in one and pyloroplasty in another. The average postoperative stay was 31 days. Thirty-seven percent survived longer than 12 months and 15% longer than 24 months. The probability of survival after 2 years is 35%. All deaths from recurrent disease occurred within 412 days postoperatively. At present, pharyngolaryngoesophagectomy with gastric transposition and primary pharyngogastric anastomosis offers the best chance for cure or palliation with acceptable morbidity and function for selected patients with advanced hypopharyngeal and laryngeal tumors.

Ten-year experience with extracorporeal membrane oxygenation for severe respiratory failure.

In the last ten years, 17 patients with respiratory failure refractory to standard ventilator therapy have been treated with extracorporeal membrane oxygenation (ECMO) at the Toronto General Hospital. One patient was treated with ECMO twice. Four perfusions were veno-arterial, the remainder veno-venous. Perfusions ranged from 1 1/2 to 19 days, with a mean of six days. Ten patients died during treatment or soon after it was discontinued. Eight patients improved enough to allow resumption of standard ventilation, and four patients recovered sufficiently to have normal arterial blood gas levels on room air. Three are long-term survivors. Multiple surgical procedures have been performed successfully during use of ECMO including lung lavage, open lung biopsy and three lung transplants. Major complications include hemorrhagic diatheses and sepsis. The technique involves a substantial commitment of time and personnel but remains a tenable option for presumed reversible life-threatening respiratory failure.

Technique of successful lung transplantation in humans.

We have performed five single lung transplantations for end-stage pulmonary fibrosis, with four long-term survivors. Two patients underwent right lung transplantation and two underwent left lung transplantation. The procedure is performed with one lung anesthesia, although cardiopulmonary bypass is available on standby if required. Donor and recipient procedures are performed in adjacent operating rooms. On the basis of laboratory studies, a pedicle of omentum is wrapped around the bronchial anastomosis after its completion to restore bronchial artery circulation and protect the anastomosis. The four patients were discharge from the hospital within 4 to 6 weeks and three returned to normal employment at 3 months. Success in these cases is attributed to careful patient selection, use of cyclosporine, and use of an omental pedicle to protect and improve healing of the bronchial anastomosis.

Esophagectomy for complex benign esophageal disease.

We evaluated the use of total thoracic esophagectomy and replacement with stomach in a group of 21 patients between 1976 and 1986 who had undergone multiple unsuccessful esophageal operations. All patients had between one and four unsuccessful operations for benign esophageal disorders. Sixteen patients had primary motor disorders: achalasia in nine and esophageal spasm in seven. Of these patients, 11 also had recurrent gastroesophageal reflux and peptic esophagitis. Complicated reflux disease characterized by severe esophagitis, stricture, and impaired peristalsis without primary motor disorder occurred in five patients. In one patient a functionally impaired long-segment colon interposition was removed and replaced with stomach. Total thoracic esophagectomy and cervical esophagogastric reconstruction was done in all patients. The transhiatal approach was chosen for resection in 16 patients and thoracotomy was used in the other five. There was one perioperative death (5%), from massive aspiration 4 days after transhiatal esophagectomy. Other complications included transient anastomotic leak (three patients), tracheoesophageal fistula (one), recurrent nerve palsy (one), and transient hoarseness (two). Follow-up is complete between 1 and 10 years and reveals the following functional results: 12 patients good to excellent, seven fair, one poor. In this patient group in which multiple prior procedures have failed to improve severe incapacitating symptoms, we believe further attempts at hiatal reconstruction are unlikely to succeed. For this circumstance, we recommend total thoracic esophagectomy with the use of stomach as the replacement organ of choice.

Radiotherapy alone for patients with operable carcinoma of the lung.

Between 1966 and 1980, 72 patients with operable carcinoma of the lung were treated primarily with radiotherapy because coexisting, nontumor related medical problem, or patient refusal prevented thoracotomy. We compared results obtained in this group with results obtained by thoracotomy in 123 consecutive patients over the age of 70, who were assessed in a similar fashion, but who underwent thoracotomy. All patients in both groups had proven, nonsmall cell carcinoma of the lung without clinical, laboratory, or radiologic evidence of tumor spread. All patients in both groups had a negative staging mediastinoscopy, and bronchoscopic findings consistent with operability. Many of the patients treated with radiotherapy had less than a curative dose as their general medical condition prevented a course of radical radiotherapy. It is apparent, however, that the results of radiotherapy for patients with operable carcinoma of the lung may be disappointing and that for patients who are marginal in terms of operative risk, the benefits of surgical resection may warrant the risks involved.

Sleeve lobectomy for carcinoma of the lung.

Sleeve lobectomy for non-oat cell carcinoma involving a major bronchus preserves functioning lung tissue and, in carefully selected patients, provides long-term survival comparable to pneumonectomy. Seventy patients underwent sleeve lobectomy between 1967 and 1978. Twenty-seven patients were considered compromised (Group I) because they had severe respiratory impairment which contraindicated pneumonectomy. Forty-three patients were considered uncompromised (Group 2) and underwent elective sleeve lobectomy. Seventy patients with a similar non-oat cell carcinoma involving the proximal bronchi underwent pneumonectomy (Group 3) during this period. Perioperative complications occurred more frequently in Group 1 (59%) than in Group 2 (21%) or Group 3 (23%). Both periopeative mortality rate and the incidence of bronchial disruption (bronchovascular and bronchopleural fistulas) were higher in Group I (19% and 22%) than in Group 2 (9% and 5%) or Group 3 (3% and 7%). Survival depended primarily on the surgeon's ability to perform a complete resection of the tumor. An incomplete resection resulted when tumor was found in the highest lymph node or in the last bronchial resection margin when paraffin sections were reviewed. The 5 year survival rate was 18% for compromised patients (Group 1) who underwent complete resection, and there were no survivors among patients undergoing incomplete resections. Uncompromised patients ( Group 2) had a 5 year survival rate of36% with complete and 12% with incomplete resections. Pneumonectomy patients (Group 3) had a 64% 5 year survival rate with a complete resection and 16% with an incomplete resection. The stage of the disease at the time of operation had a profound effect on the survivail. There was no difference inthe 5 and 8 year survival rates between uncompromised patients undergoing sleeve resection ( Group 2) and patients undergoing peneumonectomy (Group 3) for comparable stage of their disease. A careful pre- and postoperative functional assessment revealed that pulmonary performance was improved in 44% of Group 1, 63% of Group 2, and only 14% of Group 3 patients. Patients wiht impaired pulmonary reserve underwent sleeve lobectomy with an adequate disease-free interval when complete tumor excision was possible. Uncompromised patients whose extensive disease required incomplete resection had palliation by sleeve lobectomy equivalent to that by pneumonectomy. When complete t-mor resection was possible, patients with uncompromised pulmonary reserve had a perioperative complication rate and long-term survival equivalent to that of pneumonectomy while preserving pulmonary parenchyma, which permitted an improvement in postoperative pulmonary performance.

Adenoid cystic carcinoma of the airway: thirty-two-year experience.

METHODS: We have reviewed our experience in 38 patients with adenoid cystic carcinoma of the upper airway seen between 1963 and 1995. The mean age was 44.8 years (15 to 80 years) with a male/female ratio of 1:1.1. Thirty-two of the 38 patients were treated by resection and reconstruction (primary anastomosis 28; Marlex mesh prosthesis 4). Twenty-six of the 32 patients undergoing resection received adjuvant radiotherapy. Six patients with unresectable tumors were treated primarily with radiotherapy only. RESULTS: Pathologic examination revealed local invasion beyond the wall of the trachea in all patients. In a majority, microscopic extension was found in submucosal and perineural lymphatics, well beyond the grossly visible or palpable limits of the tumor. Lymphatic metastases were relatively uncommon, occurring in only five of 32 (19%) patients undergoing resection. Metachronous hematogenous metastases occurred in 17 of 38 patients (44%). Thirteen of these 38 patients (33%) had pulmonary metastases. Sixteen of 32 resections were complete and potentially curative. There were two deaths within 30 days of operation. The mean survival in the 14 patients undergoing complete resection was 9.8 years (12 months to 29 years). Sixteen of 32 resections were incomplete (residual tumor at the airway margin on final pathologic examination), with one operative death occurring in this group. The mean survival in the 15 surviving patients was 7.5 years (4 months to 21 years). Six patients were treated with primary radiation only and had a mean survival of 6.2 years (2 months to 14.3 years). In the patients with pulmonary metastases, mean survival was 37 months (4 months to 7 years) from the time of diagnosis of the pulmonary metastasis until their death. CONCLUSION: Adenoid cystic carcinoma of the upper airway is a rare tumor, which is locally invasive and frequently amenable to resection. Although late local recurrence after resection is a feature of this tumor (up to 29 years), excellent long-term palliation is commonly achieved after both complete and incomplete resection. There was a small difference in survival between patients having complete and incomplete resection. Long periods of control can be obtained with radiotherapy alone. The best results, in this series of patients, were obtained by resection. Adjuvant radiotherapy is assumed to favorably influence survival.

Airway complications after double lung transplantation. Toronto Lung Transplant Group.

We have had success with en bloc double lung transplantation in the management of selected patients with end-stage parenchymal pulmonary disease. Airway complications have been more prevalent in our own experience with double lung transplantation than in reports of combined heart-lung transplantation from other centers. Between November 1986 and March 1989, 16 patients underwent double lung transplantation. Allografts were preserved by topical hypothermic immersion in 12 patients and by pulmonary artery flush with cold crystalloid solution in the most recent four patients. Thirteen patients underwent tracheal anastomosis and the most recent three patients underwent bilateral bronchial anastomoses. Fatal ischemic necrosis of the donor trachea and both main bronchi developed in three patients. Preterminal airway ischemia developed in a patient who had systemic sepsis. Partial anastomotic dehiscence, which went on to form fibrous strictures necessitating endoscopic placement of silicone rubber airway stents, developed in two additional patients. Two other patients had late strictures and required subsequent placement of bifurcation stents. There was no relationship between development of airway complications and gas exchange in the donor lungs, lung ischemic time, early postoperative gas exchange, early postoperative mean pulmonary artery pressure, or frequency of early postoperative rejection. Severe postoperative hypotension occurred in five of eight patients with airway complications and in three of eight patients without airway complications.

Single lung transplantation and closure of patent ductus arteriosus for Eisenmenger's syndrome. Toronto Lung Transplant Group.

A case report of the first single lung transplantation and closure of a patent ductus arteriosus for Eisenmenger's syndrome is presented. The operation was performed on Sept. 28, 1988. The patient was extubated on postoperative day 8, discharged from the intensive care unit on postoperative day 13, and discharged from the hospital on postoperative day 43, free of symptoms and without supplementary oxygen. Subsequent symptoms of dyspnea, presyncope, and fatigue recurred in association with subvalvular right ventricular outflow tract obstruction. Symptomatic improvement occurred gradually in association with reduction of the outflow tract obstruction. The patient is in New York Heart Association class I-II 12 months after the operation. The rationale, methods, and management of this patient are discussed, as well as the potential for application of this operation in similar settings.