In vivo quantification of human pulmonary beta-adrenoceptor density using PET: comparison with in vitro radioligand binding.

UNLABELLED: A new method has recently been developed to quantify pulmonary beta-adrenergic receptors in vivo using PET. This study used in vitro radioligand binding assay (RLBA) as the gold standard to validate in vivo PET measurements. METHODS: Five male patients with lung cancer aged 57 yr (range 42-67 yr) were studied. PET scanning was performed the day before thoracotomy to determine regional pulmonary beta-receptor density. RLBA was carried out on cell membranes prepared from specimens of lung tissue obtained at the thoracotomy to measure beta-receptor density in vitro. In both cases, the hydrophilic nonselective beta-antagonist radioligand (S)-CGP-12177 was used. For PET studies, this was labeled with 11C and for RLBA with 3H. RESULTS: In the PET study, beta-receptor density (Bmax) was 9.43 +/- 1.32 pmole g-1 tissue. In the RLBA study, Bmax was 99.0 +/- 15.5 fmole mg-1 protein, equivalent to 9.90 +/- 1.55 pmole mg-1 tissue. These values are in good agreement with previously reported in vitro measurements on human lung membranes using 125I-iodocyanopindolol. A correlation was found between beta-adrenergic density obtained using PET and beta-adrenergic density obtained using RLBA (r = 0.92; p < 0.05). CONCLUSION: The results support the use of PET as a new method for imaging and the way for studies of physiological and pharmacological regulation of beta-adrenergic receptors through noninvasive serial measurements.

Acquired segmental emphysema: the enlarging spectrum of Swyer-James/Macleod's syndrome.

Three cases of Macleod's syndrome are described, all of which required surgical resections for distressing symptoms. This provided a rare opportunity to examine the pathologic features of a condition that is usually diagnosed on its radiologic features, and the etiology of which remains unestablished. Three patients (2 women and 1 man), aged 20, 23, and 24 years, were referred from respiratory physicians because of unilateral hyperlucent lungs and associated symptoms. All 3 patients had unilateral hyperlucent lungs, but only 1 patient had demonstrable mediastinal shift on expiratory and inspiratory chest computed tomographic scan. Segmentectomies were performed (n = 4) in all the patients without perioperative morbidity or mortality. Patients have been followed up between 6 and 18 months, and remain asymptomatic with a return to normal lifestyle. Histologic examination of the specimens found inflammation of the bronchus in all 3 patients, but only two specimens had evidence of bronchiolar inflammation. In only 1 patient was there a reduction in bronchiole number. All 3 patients showed presence of emphysema. These cases are notable for the segmental distribution of the disease. Pathologic examination lends support to the theory that previous respiratory tract infection may play a role in the pathogenesis of this condition.

Elective pneumonectomy: factors associated with morbidity and operative mortality.

We have retrospectively reviewed hospital records of 197 consecutive patients undergoing pneumonectomy for neoplastic disease between 1985 and 1990 to identify predictors of outcome. Seventeen of the 197 patients died during their hospital stay (8.6%; 95% confidence intervals, 6.7% to 11.2%). The most significant predictors of in-hospital mortality were presence of coexisting medical conditions (p less than 0.001), respiratory function tests showing an obstructive picture with a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.55 (p less than 0.001), 24-hour fluid replacement of more than 3 L (p less than 0.05), postoperative pulmonary edema (p less than 0.001), respiratory tract infection with positive sputum culture (p less than 0.01), postoperative renal failure (p less than 0.001), and cardiac arrhythmias (p less than 0.001). There were 232 postoperative management, problems occurring in 197 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation (p less than 0.05), perioperative blood loss or more than 2 L (p less than 0.05), and infusion of more than 3 L of fluid in the first 24 hours (p less than 0.05). Although retrospective analyses must be interpreted with caution, this study has identified preoperative and perioperative factors associated with in-hospital morbidity and mortality after pneumonectomy.

Method of endoscopic esophageal intubation using a rigid esophagoscope.

Endoscopic intubation of malignant esophageal strictures carries a substantial risk of esophageal perforation. We have developed a method of endoscopic intubation that reduces to a minimum the elements of the procedure that have to be performed "blind." The use of this method has been associated with a reduction in perforation rates when compared with other series.

Thoracoscopic debridement of empyema thoracis.

BACKGROUND: The primary treatment of empyema thoracis remains intercostal tube drainage together with antibiotics. Failure of primary treatment has until recently been an indication for thoracotomy and decortication. Video-assisted thoracoscopic debridement (VATD) has increased the available treatment options but requires validation. METHODS: A retrospective analysis was undertaken of 44 consecutive patients who presented for surgical treatment of empyema thoracis over a 3-year period. RESULTS: Two patients were unsuitable for VATD and were treated with open decortication (OD). Thirty patients were successfully treated by VATD. Two patients were converted to OD at the first operation, and 10 patients required OD as a second procedure. The mean duration of preoperative symptoms before referral was 37.6 +/- 11.8 days (VATD) and 40.1 +/- 11.6 days (OD) (p = not significant). The mean duration of hospitalization before transfer was 13.7 +/- 2.4 days (VATD) and 11.5 +/- 3.4 days (OD) (p = not significant). Intercostal drainage was required for 4.0 +/- 0.3 days (VATD) and 8.5 +/- 2.0 days (OD) (p = 0.004). The postoperative hospital stay was 5.3 +/- 0.4 days (VATD) and 10.3 +/- 2.1 days (OD) (p = 0.001). CONCLUSIONS: Primary surgical therapy with VATD should be considered for all patients with pleural empyema, irrespective of the duration of symptoms. This approach does not preclude OD as a secondary procedure or conversion to OD after initial thoracoscopic assessment. The major advantages of VATD over OD are a shorter duration of postoperative intercostal drainage and reduced postoperative hospitalization.

Early and late outcome after diagnostic thoracoscopy and talc pleurodesis.

Although thoracoscopy is now recognized to be of both diagnostic and therapeutic value, the risks of this procedure have not been fully addressed. We retrospectively reviewed our experience with 100 patients who underwent 110 thoracoscopies during the period January 1989 to February 1991. Sixty-five men and 35 women (ratio of 1.9:1) underwent thoracoscopy using general anesthesia and intubation with a double-lumen endotracheal tube. The mean age was 64.2 +/- 11.6 years (range, 13 to 85 years). The diagnosis was established in 48 (85.7%) of the 56 patients with undiagnosed pleural effusions. Forty-four patients were referred for therapeutic thoracoscopic talc pleurodesis. Pleurodesis was successful in 42 patients (95.5%). Four patients (4%) had five postoperative complications (two bronchopleural fistulas, two chest infections, and one arrhythmia). Five patients (5%) died after thoracoscopy; mean age was 67.8 +/- 8.1 years (range, 55 to 77 years). The causes of death were cardiac arrest in 2, respiratory failure in 1, and malignant cachexia in 2. The findings of this study confirm that thoracoscopy can achieve high rates of diagnostic and therapeutic success but is not without attendant mortality in a high-risk patient population.

Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave's syndrome.

Ten patients seen at our unit over a 24-month period with either iatrogenic (n = 5) or spontaneous thoracic esophageal perforations (n = 5) were retrospectively reviewed. Five patients were seen within 24 hours of onset of symptoms, and 5 were seen after 24 hours or later. There was no significant difference in the presentation or subsequent clinical course in patients seen less or more than 24 hours after the onset of symptoms. Nine patients underwent primary repair together with drainage of the mediastinum, and in 1 of these a Heller's myotomy was also performed for achalasia. One patient had a two-stage esophagogastrectomy for a benign esophageal stricture. One patient (10%) with a spontaneous perforation died 48 hours after operation and was found at postmortem examination to have an in situ carcinoma at the site of the perforation. Four patients (40%) had nonfatal complications. Fistulas developed in 3 patients (30%); in 1 of these patients a second thoracotomy and a further rib resection was required for drainage of a mediastinal abscess. An esophago-cutaneous fistula and a persistent mediastinal abscess developed in 1 patient (10%) and necessitated two further thoracotomies for effective drainage. The mean hospital stay was 38.4 +/- 25.4 days (range, 16 to 76 days). The findings of this study suggest that primary repair combined with a drainage procedure is the treatment of choice for patients with a perforated intrathoracic esophagus, including those seen more than 24 hours after the onset of symptoms.

Palliative intubation for dysphagia in patients with carcinoma of the esophagus.

One hundred seven consecutive patients seen over a 6-year period with dysphagia secondary to advanced primary carcinoma of the esophagus underwent intubation. One hundred five patients underwent pulsion intubation. In 2 patients pulsion intubation was not possible, and laparotomy and traction intubation was performed. For the intubated group there were 65 men and 40 women (ratio, 1.6:1), with a mean age of 71.3 +/- 10.5 years (range, 36 to 92 years). Of the 105 patients who had pulsion intubation, a perforation developed in 11 (10.5%), which was responsible for the death of 4 patients (3.8%). A further 3 patients died of malignant cachexia, which resulted in an overall mortality of 6.7%. Late complications included tube displacement (4 patients; 3.8%) and tube obstruction (32 patients; 30.5%). Tube obstruction was due to advancement of malignant disease in 26 patients (81.2%) and food bolus impaction in the remaining 6 patients (18.8%). Pulsion intubation for advanced carcinoma of the esophagus can be performed with a low morbidity and early mortality. However, there is a substantial long-term morbidity of tube obstruction in almost a third of survivors.

Primary esophageal repair for Boerhaave's syndrome.

BACKGROUND: Boerhaave's syndrome is the most sinister cause of esophageal perforation. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. METHODS: We present a series of 21 patients seen in our unit in the 10 years 1987 to 1996. Esophageal repair was performed in 17 (81%) of them. After the resuscitation of the patient in the intensive care unit, our strategy is primary esophageal repair with a single layer of interrupted absorbable sutures combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy. The majority of patients (12/21) were referred more than 24 hours after perforation. RESULTS: The mean age of the patients was 60+/-17 years. The mean stay in the intensive care unit was 1.6+/-1.8 days and the median hospital stay, 14 days. There were three deaths, an overall mortality rate of 14.3%. CONCLUSIONS: When combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy, primary esophageal repair for Boerhaave's syndrome gives an acceptable mortality and should not be reserved for patients seen within 24 hours after spontaneous rupture.

Use of endotracheal silicone stents for relief of tracheobronchial obstruction.

In this article we describe our initial experience with bifurcated and longitudinal silicone stents that can be inserted entirely endoscopically. A total of 10 patients were stented; half had upper airways obstruction resulting from malignant disease and half had anastomotic obstruction after single-lung (3 patients), double-lung (1 patient), or heart-lung transplantation (1 patient). All patients derived immediate relief of life-threatening stridor. Stents were in place for between 5 days and 2 1/2 years (mean, 232.9 days). In the patients with malignant disease, the stents have provided effective relief from stridor for the remainder of their lives. In the transplant recipients, the medium-term results are encouraging, with the stents providing effective relief from stridor, although the longitudinal stents have been associated with distal migration, requiring that the stents be replaced on up to five occasions. The stents have not been associated with infection in the nonimmunosuppressed patients, and during the relatively short follow-up period there has been no tissue reaction to the material.

Thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax.

Initial experience of thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax is reported. Thirty-three out of 49 patients admitted with spontaneous pneumothorax were suitable for treatment with this minimally invasive method. This series demonstrates that this surgical management offers early discharge and return to normal activities with excellent medium-term results, despite the three early failures. It is felt that with increased experience in thoracoscopy and improved selection of patients, thoracoscopic bullectomy and pleurodesis will become the treatment of choice for primary spontaneous pneumothorax.

Disease recurrence after resection for stage I lung cancer.

OBJECTIVE: To asses the incidence of local recurrence and distant metastases after complete resection for stage I lung cancer in order to predict the predominant prognostic factors. METHODS: We retrospectively reviewed 123 patients with stage I lung cancer who underwent curative resection over a 2-year period between January 1987 and December 1988. There were 83 male and 40 female patients with a mean age of 64.8 +/- 12 years (range between 39 and 82 years). Multivariate analysis of prognostic factors for long term survival was undertaken. RESULTS: T1N0 lesions were found in 34 patients and T2N0 in 89. The histological diagnosis was Squamous carcinoma in 75, Adenocarcinoma in 38, large cell carcinoma in 6 and small cell carcinoma in 4 patients. Pneumonectomy was performed in 27 patients (5 T1 and 22 T2) while 96 required lobectomy (29 T1 and 67 T2). At 5 years 50 patients died. This was due to local recurrence in 12, distant metastasis in 24, second primary in 1, unrelated disease in 3, while the cause was unknown in 10 patients. At 5 years, 10 patients were alive with evidence of recurrence. The mean interval for local recurrence was 19.8 months and for distant metastasis was 18 months. The overall 5 year survival was 67% +/- 4 for T1 and 56% +/- 5 for T2 lesions (NS). The rate of recurrence was significantly less for T1 lesions (P = 0.02). Survival was significantly less for patients requiring pneumonectomy rather than lobectomy (P = 0.01) whether for T1 or T2. CONCLUSION: In stage I lung cancer T2 lesions requiring pneumonectomy for complete resection had a worse prognosis and higher incidence of local recurrence.

Oesophageal resection after instrumental perforation.

Between 1981 and 1987, 11 patients underwent oesophageal resection following endoscopic perforation of the oesophagus. They had a median age of 67 years with a range of 36 to 88 years. They all were managed either by one- or two-stage oesophageal resections. Six patients were perforated at other hospitals, 5 on site. Seven had carcinoma of the middle or lower third of the oesophagus, 2 of these were perforated at attempted palliative intubation. Four had benign peptic strictures perforated during dilatation. Seven were resected within the first 24 hours and 4 between 2 and 10 days after perforation. All 4 patients with benign disease survived but 4 of the 7 patients with cancer died giving an operative mortality of 36.3%. Respiratory complications were the most common postoperative problem: all deaths were attributed to respiratory failure. Perforation of the thoracic oesophagus carries a high mortality. Resection after perforation in benign strictures may be life saving in a potentially lethal condition but resection after perforation, even in operable cancer, still carries a high mortality.

Surgery for bullous disease of the lung.

Between July 1986 and December 1990, 22 patients underwent 23 operative procedures for bullous disease at Harefield Hospital. Their ages ranged from 21 to 71 years (mean 49.8 years). There were 18 males and 4 females. All patients were operated upon for symptoms of exertional dyspnoea. Four patients belonged to functional class IV, 11 to class III and 3 to class II. In 80% of patients, computed tomography was performed as part of the preoperative assessment. The bullae were dealt with in 13 patients on the right side, in 7 on the left and in 2 bilaterally. Six patients were treated by a modified Monaldi procedure and 17 by bullectomy. There was no operative mortality. Mean hospital stay was 14.8 days. Two patients required a second operative procedure during their hospital stay for persistent air leak and pneumothorax. One of these had a Monaldi procedure in the first instance but underwent bullectomy later. All patients improved symptomatically, 10 patients moving up two grades and 12, one grade. Mean FEV1, FVC and MVV were significantly improved postoperatively, but there were no significant changes in RV or TLC. A graduated exercise test was performed in 4 patients. Improvements were seen in ventilation and oxygen consumption at anaerobic threshold and maximum exercise. Surgery for bullous disease improves symptoms by reducing airway obstruction and increasing ventilatory capacity on exercise.

Factors influencing mortality and morbidity following oesophageal resection.

Operative mortality and morbidity following oesophageal resection has fallen in recent years. We have attempted to identify the factors responsible for this improvement by reviewing the results of surgery at this hospital over the last 6 years. Two hundred and two oesophageal resections were performed between January 1981 and June 1987 for carcinoma. Of these, 21 patients (10.4%) died before leaving hospital. Fourteen patients died of multisystem failure, 1 died of pure respiratory failure and 2 died of renal failure. Two died of surgical causes (other than anastomotic leak), 1 died of pulmonary embolus and 1 from a cerebro-vascular accident. No patient died of purely cardiac causes. The most significant risk factors in those dying (Chi-square test) were: postoperative respiratory failure, defined as reventilation after initial successful extubation, (P less than or equal to 0.001), reoperation as an emergency in the early postoperative period (P less than or equal to 0.001), anastomotic leak (P less than or equal to 0.01) and age over 70 (P less than or equal to 0.005). Less significant risk factors were chyle leak and histologically undifferentiated tumour. Of the 181 survivors, 103 left hospital with no complications of any kind. The mean stay in hospital for survivors was 15 days. Respiratory infection occurred in 22% of patients, prolonged gastric stasis in 8%, wound infection in 5% and empyema in 1%. As long as high risk groups are accepted for radical surgery, operation will carry a significant mortality in those groups. In others, we believe that perioperative monitoring and early aggressive treatment of complications can further reduce mortality and morbidity.

Videothoracoscopy in the treatment of early empyema: an initial experience.

Seventeen consecutive patients were referred for management of empyema between April 1991 and March 1992. Fourteen patients defined as having an 'early' empyema were initially treated by videothoracoscopy. The other three patients, defined as having a 'late' empyema proceeded directly to thoracotomy. Videothoracoscopy was successful in 10 out of the 14 patients. The mean postoperative stay was 7.8 days. At a mean follow-up at 16.7 months, these patients were rendered apyrexial with full lung expansion and no residual pleural collection. The postoperative results were at least equivalent to other conventional forms of treatment without an undue level of complications. In this series, thoracoscopy was found to be successful when symptoms had been present up to 31 days before presentation at the first hospital, and the mean length of treatment before referral to Harefield was 47 days. It is now our policy to videothoracoscope all patients with empyema thoracis, regardless of the length of referral. It may circumvent the need for a thoracotomy, it does not add any increased risk of complications, and does not appreciably increase the length of hospital stay should thoracotomy ultimately be required.

Iatrogenic oesophageal perforations: a clinical review.

Thirty patients with iatrogenically induced perforation of the oesophagus were managed in our unit between January 1986 and December 1996. Thirteen (43%) of these injuries were referred after upper gastrointestinal endoscopy performed by physicians. Ten (33%) cases were referred by ENT surgeons and general surgeons referred 7 (23%) cases. Of these patients, 15 (50%) had no abnormality of the oesophagus found before perforation. Only 18 (60%) of patients were referred within 24 h of injury. The mean duration of care required in the intensive care unit was 1.5 days +/- 2.5 days and the mean inpatient hospital stay 26.5 days +/- 22.1 days. The mortality was 10% (three cases). Oesophageal perforation remains a serious life-threatening injury. The early diagnosis of this uncommon condition requires a high index of suspicion as the symptoms are often non-specific. Identification of the site of perforation is necessary as the management of cervical and thoracic perforations differs considerably. Early referral combined with appropriate therapy would appear to result in a better outcome than previously published data. It is therefore suggested that patients with this relatively rare condition should be referred as soon as possible to a centre with expertise in its management.

Suxamethonium and cardiac arrest.

We report a case of cardiac arrest due to hyperkalaemia following administration of suxamethonium during a procedure to facilitate a change of endotracheal tube in a septic patient. The cause of this rare but fatal complication is briefly described and discussed. In view of this, suxamethonium should be used with great caution in patients with burns and other forms of physical injury, in a number of nervous system disorders, and in critically ill patients requiring prolonged ITU care.