Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn.

BACKGROUND: Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine). METHODS: Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year. RESULTS: A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17). CONCLUSIONS: Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).

Pulmonary Mucormycosis Treated With Lobectomy.

A 57 year old man was referred from an outside facility for an unresolving pneumonia. Imaging of the chest demonstrated a right lung mass with a consolidation in the middle lobe, pleural effusion, and mediastinal lymphadenopathy. Cytologic examination of cultures from the bronchoscopy and thoracentesis did not yield a definitive diagnosis. Video-assisted thoracoscopic surgery (VATS) was performed because of a retained hemothorax and a suggestive lesion. Biopsy specimens obtained during VATS were consistent with mucormycosis. The patient underwent a middle lobectomy and pleurectomy without any adverse event. When bronchoscopy and thoracentesis cannot provide a diagnosis, thoracoscopic pleural biopsy can be the next step in the diagnosis of mucormycosis.

Treatment for sternoclavicular joint infections: a multi-institutional study.

BACKGROUND: Sternoclavicular joint (SCJ) infections are rare and difficult to manage. Surgery is necessary for treatment. METHODS: A retrospective chart review of the university hospital and Veterans Administration (VA) hospitals of all patients treated for SCJ infections since 2001 was conducted. Fifteen [15] patients were identified and evaluated for the types of infections, risk factors, treatments and survival. RESULTS: All 15 patients were symptomatic including: pain [13], erythema [9], purulent drainage [3], fever greater than 38.3 °C [2], and leukocytosis [9]. The associated medical problems included: diabetes mellitus (DM), hypertension (HTN) and renal failure. All patients underwent intraoperative joint resection. Sixty-seven percent (67%) of intraoperative wound cultures grew staphylococcus aureus. Fourteen patients were discharged on intravenous antibiotics. The follow-up ranged between 1 week-11 months. Thirteen patients are currently alive without infection. Two patients died: 1 of sepsis and 1 of unknown causes after discharge. CONCLUSIONS: Symptomatic SCJ infections require surgical intervention. The most common organism was staphylococcus aureus.

Biopsy first: Lessons learned from Cancer and Leukemia Group B (CALGB) 140503.

OBJECTIVE: Cancer and Leukemia Group B 140503 is an ongoing, multicenter randomized trial assessing whether sublobar resection is equivalent to lobectomy for the treatment of stage I A non-small cell lung cancer (NSCLC) ≤2 cm in diameter. The objective of this report is to determine the reasons precluding intraoperative randomization. METHODS: From June 15, 2007, to March 22, 2013, 637 patients were preregistered to the trial. Three hundred eighty-nine were randomized successfully (61%), and 248 patients were not randomized (39%). We analyzed the reasons for nonrandomization among a subset of the nonrandomized patients (208) for whom additional data were available. RESULTS: Of these 208 patients, undiagnosed benign nodules (n =104, 16% of all registered patients) and understaging of NSCLC (n =45, 7% of all registered patients) were the dominant reasons precluding randomization. Granulomas represent one-quarter of the benign nodules. The understaged patients had unsuspected nodal metastases (n =28) or other more advanced NSCLC. The rate of randomization was significantly greater in those patients who had a preoperative biopsy (P <.001). CONCLUSIONS: In a carefully monitored cohort of patients with suspected small NSCLC ≤2 cm, a substantial number are misdiagnosed (benign nodules) or understaged. These patients may not have benefited from a thoracic surgical procedure. Preoperative biopsy significantly increased the rate of correct diagnosis. Preoperative biopsy of small suspected NSCLC will reduce the number of nontherapeutic or unnecessary thoracic procedures. Accuracy in preoperative diagnosis is increasingly important as more such small nodules are discovered through lung cancer screening.

The use of thrombolytics in the management of complex pleural fluid collections.

BACKGROUND: To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. METHODS: We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). RESULTS: One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. CONCLUSIONS: Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.

Successful Treatment of Invasive Pulmonary Mucormycosis in an Immunocompromised Patient.

A 59-year-old man undergoing chemotherapy for acute myelogenous leukemia had a bilateral pneumonic process. The right lung subsequently developed several small cavitary lesions extending from the central hilum to the chest wall. Despite medical therapy, repeat imaging demonstrated coalescence into a single, large, central cavitary lesion. Thoracic surgery was consulted because of the central hilar involvement of all three lobes; a pneumonectomy would have been required to resect the lesion. However, he was not a candidate for pneumonectomy because of a low predicted postoperative forced expiratory volume in 1 second. We performed a rib resection, debridement, and marsupialization, in which the skin was sewn circumferentially to the parietal pleura. His wound was managed with wet-to-dry dressings. Postoperatively, he recovered well, with resolution of his cough. Three weeks after surgery, he was discharged from the hospital, and the cavity completely closed at 4 months.

Post traumatic pulmonary pseudoaneurysm requiring pneumonectomy: a case report.

A 57-year-old male presented with progressive exertional dyspnea, cough, and hemoptysis. He underwent a chest computed tomography (CT) that demonstrated a 27 cm × 20 cm right chest mass that was causing a local mass effect. Pertinent history revealed that the patient had suffered a severe chest trauma from a MVA in 1981. The patient underwent workup including: needle localized biopsy, bronchoscopy and endoscopic biopsy. There was considerable concern for a malignant process and a subsequent right pneumonectomy with en bloc resection of the chest wall and diaphragm was performed. The final pathology concluded the mass to be a large pseudoaneurysm. Pseudoaneurysms after traumas are extremely rare, especially blunt trauma, and should be considered once other etiologies have been excluded.