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Biomedical subjects

A N Graham

Publications and source records attributed to A N Graham.

At least 19 recordsLinked to original sources
PubMed2003

Treatment and outcomes of oesophageal perforation in a tertiary referral centre.

OBJECTIVE: The diagnosis and management of oesophageal perforation continues to challenge clinicians. We present our experience of perforated oesophagus in a Tertiary Referral Centre for Thoracic and Oesophageal Surgery. METHODS: Between 1985 and 2000, 75 patients (40 male) with oesophageal perforation were treated in out unit; age range 24-89, median 63. Retrospective review of these cases has been performed. RESULTS: There were 12 deaths (16%). With increases in time from perforation to diagnosis, there was a stepwise increase in the mortality rate. Immediate diagnosis 5%; early diagnosis (1-24h) 14%; late diagnosis (>24h) 44% (P>or=0.002). Site of perforation, aetiology, and treatment strategy had no influence on mortality. The only independent predictor of mortality identified was time to diagnosis from perforation (beta 0.429, P=0.001). Time to definitive management in those undergoing an operative procedure had no influence on outcome with multivariate analysis. CONCLUSIONS: Prompt recognition of the diagnosis of oesophageal perforation and rapid institution of supportive measures, followed by an appropriate, patient specific treatment option optimises the chance of a successful outcome. The wide range of presentation of oesophageal perforation necessitates individualisation of treatment.

Adult↗
PubMed1999

An unusual iatrogenic cause of right coronary air embolism.

A 62-year-old woman undergoing redo mitral valve replacement was noted to have persistent intracardiac air following standard deairing procedures. Transesophageal echocardiography (TEE) identified air bubbles entering the left atrium from the right superior pulmonary vein. Exploration of the pleural cavity revealed a fistula between the pulmonary parenchyma and the right superior pulmonary vein caused by the atriotomy closure suture transfixing the edge of the lung, which was repaired with immediate disappearance of the air emboli. This demonstrates that transesophageal echocardiography is an invaluable aid to ensuring complete deairing after open heart procedures.

Anastomosis, Surgical↗
PubMed1999

Systematic nodal dissection in the intrathoracic staging of patients with non-small cell lung cancer.

OBJECTIVE: Although systematic nodal dissection is accepted as an important component of the intrathoracic staging of disease in patients undergoing thoracotomy for lung cancer, many surgeons still do not routinely perform it. We reviewed our practice to assess the information provided by its routine application even when lymph node metastases are considered unlikely. METHODS: The records of 240 patients undergoing thoracotomy for clinically staged cT1-3 N0-1 non-small cell lung cancer were reviewed. In 5 cases (2%) mediastinal dissection was not performed because of specific contraindications and in 8 cases (3%) exploratory thoracotomy was performed. The pathologic findings in the 227 patients who underwent pulmonary resection with systematic nodal dissection were analyzed. RESULTS: The median number of nodal stations, including N1 and N2, examined and submitted separately for histologic assessment was 7 per patient (range 3-13). N2 disease was disclosed in 46 patients overall (20%), including 41 of the 227 patients undergoing pulmonary resection (18%) and 5 of those undergoing exploratory thoracotomy (62.5%). No subgroup had a 0% incidence of N2 metastases. Multivariate analysis showed that younger age, increasing tumor size, left lower lobe origin, and bronchial origin were significant independent variables for prediction of lymph node metastases at the N1 level, the N2 level, or both. CONCLUSIONS: Because no clinical or pathologic subset of patients with a negligible incidence of N2 disease could be discriminated, systematic nodal dissection must be routinely employed for accurate intrathoracic staging of non-small cell lung cancer.

Adenocarcinoma↗
PubMed1998

Prospective study on factors delaying surgery in ruptured abdominal aortic aneurysms.

Delays between rupture, eventual diagnosis and the repair of abdominal aortic aneurysms (AAAs) can significantly affect outcome, but the reasons for such delays in management are not always clear. A prospective study was, therefore, performed on 30 patients with ruptured AAAs. Twenty-three male and seven female patients, mean age 71.3 years, were studied. The general practitioner had made the correct diagnosis in only 38% of cases and the most common misdiagnosis was renal colic (24%). Non-vascular hospital doctors made the correct diagnosis in 55% of cases, but patients with back pain were the most frequently misdiagnosed by both types of doctor. The performance of an ultrasound scan significantly delayed referral to the vascular unit from a median of 0.75 to 2.50 hours and was of little benefit in aiding the diagnosis. In conclusion, the most striking delay factors in the management of ruptured AAAs are the high incidence of misdiagnosis and the lack of benefit of ultrasound scanning.

Aged↗
PubMed1997

Does the use of immunohistochemistry to identify micrometastases provide useful information in the staging of node-negative non-small cell lung carcinomas?

Immunohistochemical studies using epithelial markers have recently been published which identified micrometastases in lymph nodes that had not been found on routine pathological assessment, therefore increasing the accuracy of staging of non-small cell lung cancers. The presence of these micrometastases was associated with reduced survival. We have therefore performed a retrospective immunohistochemical study on all the lymphoid tissue from five lymph node stations (2 hilar, 3 mediastinal) from 49 patients with T1-2, N0 disease. Before immunohistochemistry was undertaken, all slides were reviewed, with the lymph nodes confirmed as negative. In total, 1447 lymph node slices (average 30 per case, 5.9 per lymph node station) were examined, these figures reflecting sectioning of lymph nodes at approximately 3 mm intervals before processing. MNF116, a broad spectrum anti-keratin antibody was then used to look for occult metastases, with adjacent serial sections being examined to ensure that any positively staining cells were detected solely by immunohistochemistry and not through deeper sectioning. In five cases, lymph nodes contained positively staining cells. Two cases proved to be false positives, further immunohistochemistry identifying the cells as benign mesothelial inclusions. In the remaining three cases, positive staining correlated with tumour cells in the adjacent serial sections. Follow-up on 46 of 49 patients revealed recurrence in 27% (actual survival 68%); however all three cases containing tumour cells on immunohistochemistry were free from recurrence. These results suggest that the use of immunohistochemistry adds little useful information above that of thorough routine examination of lymph nodes. They also document that benign mesothelial inclusions within lymph nodes are more frequent than previously reported.

Antibodies↗
PubMed1997

Total thoracic esophagectomy for esophageal cancer.

BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.

Adenocarcinoma↗
PubMed1996

Assessment of outcome after thoracoscopic sympathectomy for hyperhidrosis in a specialized unit.

Transthoracic endoscopic electrocautery of the sympathetic chain is increasingly being used as a technique for producing the effects of upper thoracic sympathectomy. In November 1990 we introduced this operation as a regional service in Northern Ireland and have assessed the results in patients with idiopathic hyperhidrosis of the palms and axillae. There were 92 sympathectomics carried out for hyperhidrosis on 47 patients between 26 November 1990 and 6 September 1993. Full follow-up was possible in 45 patients (96%) at a median of 13 months (range 3-36) after the operation. Symptoms were improved in 43 patients (96%) at review. In three patients surgery failed to control symptoms on one side, and in two there was bilateral recurrence at 4 and 8 months after initial good results. Compensatory hyperhidrosis occurred in 35 patients (56%) and was severe in 4 (9%). Nine of 34 patients (34%) with plantar symptoms reported improvement in these post-operatively. This paper, with its high level of full follow-up, confirms thoracoscopic sympathectomy to be effective treatment for both palmar and axillary hyperhidrosis. Patient selection, however, is important and the risk of compensatory hyperhidrosis must be fully explained.

Adult↗
PubMed1994

Intraperitoneal rupture of ectopic varices--a rare complication of portal hypertension.

A 50 year old man presented with sudden abdominal pain, abdominal distension and shock. At emergency laparotomy a large amount of blood was found in the peritoneal cavity. There was micronodular cirrhosis of the liver and the spleen was enlarged. The bleeding was traced to distended veins in the right paracolic gutter which were oversewn and the abdomen closed. A coagulopathy was diagnosed and treatment including high dose aprotinin commenced. However, he continued to bleed and at a second laparotomy the area of previous haemorrhage was packed. Further deterioration continued until death 12 hours later. Intraperitoneal haemorrhage from ectopic varices is a rare occurrence. There is a high mortality rate usually due to an advanced coagulopathy. This is the first report of aprotinin being used in an attempt to treat this. On the basis of this report aprotinin would not seem to be of benefit for this condition.

Hemorrhage↗
PubMed1993

Aortoesophageal fistula secondary to thoracic aortic aneurysm repair.

The development of a fistula between the aorta and the oesophagus after graft replacement of the thoracic aorta is extremely rare. We report a case which occurred 3 years and 7 months after repair of an aneurysm of the descending thoracic aorta and review the previous reports of this uniformly fatal condition.

Aged↗
PubMed1992

Risk of rupture of postangiographic femoral false aneurysm.

The surgical management of 50 false aneurysms caused by transfemoral arterial catheterization was reviewed to document the incidence and effects of rupture before repair. Twelve false aneurysms ruptured, leading to shock in six patients, distal ischaemia in three and stroke in one. The mean(s.d.) time from catheterization to rupture was 2.8(1.7) (range 1-6) days. Postoperative complications occurred in seven patients with ruptured and eight with non-ruptured aneurysms (P < 0.04). The mean(s.d.) age of patients with ruptured aneurysms was 67.2(6.3) (95 per cent confidence interval 63.5-70.8) years and those without 58.5(9.1) (95 per cent confidence interval 55.3-61.7) years (P < 0.008). On multiple regression analysis, age, peripheral vascular disease and raised plasma liver enzyme levels on admission were found to be significant independent predictive variables for rupture (all P < 0.05). It is recommended that patients with these risk factors undergo urgent operative correction of femoral false aneurysm.

Aneurysm, False↗
PubMed1992

Delayed presentation of bilateral popliteal artery injury.

We describe a patient who developed serious vascular complications following gunshot wounds to both popliteal fossae. There was minimal evidence of vascular injury on presentation to hospital, in particular ankle systolic pressures were normal. Five days following the initial injuries he was found to have a false aneurysm of the popliteal artery in his right leg and an arteriovenous fistula affecting the popliteal vessels of his left leg. The roles of arteriography and Doppler pressure studies in assessment of possible peripheral vascular injury following penetrating trauma are discussed. It is emphasised that a high index of suspicion and careful clinical review is essential if vascular injuries and their complications are not to be missed.

Adult↗
PubMed1992

Randomised clinical trial of chest drainage systems.

BACKGROUND: Problems in the management of thoracic trauma have stimulated the search for an alternative to underwater seals for drainage of the pleural cavity. A chest drainage bag incorporating a one way flutter valve has been compared with underwater seal drains in a randomised clinical trial. METHODS: During June-December 1989 119 patients undergoing elective thoracotomy were randomised to receive postoperative chest drainage by drainage bags (56 patients, 87 drains) or by underwater seal drains (63 patients, 98 drains). Daily drainage volumes, the requirement for pleural suction, mobility, and complications were recorded prospectively. RESULTS: There was no significant difference between the two groups in the mean volume drained, the requirements for pleural suction, or the occurrence of complications. Patients with drainage bags were fully mobile 23 hours (95% confidence interval 0-47 hours) earlier than the others. CONCLUSIONS: When used after elective thoracotomy drainage bags are safe and effective and permit earlier mobility than underwater seal drains.

Adolescent↗