Unusual retained foreign body in the lung: a tree branch.
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Adult↗
Biomedical subjects
Alan D L Sihoe
Publications and source records attributed to Alan D L Sihoe.
Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomized controlled trial.
OBJECTIVE: Studies in other surgical specialties have suggested that pre-emptive wound infiltration using a local anesthetic may reduce post-operative pain. We report the first randomized trial to assess the use of pre-emptive local anesthesia in video-assisted thoracic surgery (VATS). METHOD: Thirty-one consecutive patients undergoing bilateral needlescopic VATS sympathectomy for palmar hyperhidrosis were studied prospectively. Each patient acted as their own control. For each patient, one side was randomized to receive 10ml 0.5% bupivicaine injected to the port sites before incision, and the contralateral control side to receive 10ml saline. Pain severity on a visual analog scale (VAS) was recorded for each chest side at 4h, 1 day and 7 days following surgery. All patients were blinded to the results of randomization throughout the study. RESULTS: Follow up was complete for all patients. At 7 days after surgery, wound pain was significantly reduced by pre-emptive local anesthesia, with 10 (62.5%) of the 16 patients having residual pain reporting less pain on the pre-treated side (p=0.039). There was a trend for reduced pain on the pre-treated side at the other time points. Pain reduction by pre-emptive local anesthesia was not correlated with any demographic or clinical variable. Chest wall paresthesia distinct from localized wound pain was noted by six patients (19.4%), but was not reduced by pre-emptive local anesthesia. Overall, the post-operative discomforts felt by the patients after needlescopic VATS were mild, and did not cause significant functional disturbances. CONCLUSION: Pre-emptive wound infiltration with a local anesthetic may reduce post-operative wound pain in needlescopic VATS procedures.
Adolescent↗
The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients.
OBJECTIVE: The pain following thoracic surgery and trauma is often refractory to conventional analgesic strategies. However, it shares key characteristics with neuropathic pain which gabapentin, an anticonvulsant, has been proven to effectively treat. To our knowledge, this is the first prospective study assessing the use of gabapentin in cardiothoracic surgery patients. METHODS: Gabapentin was prescribed to 60 consecutive out-patients with refractory pain persisting at four weeks or more after thoracic surgery or trauma. Follow-up of 45 patients (75%) was performed for a median of 21 months (range: 12-28), and clinical data collected prospectively. The mean age of these patients was 51.6 years (range 22-83). Of these 45 patients, 22 had received video-assisted thoracic surgery (VATS), 8 had received thoracotomy, 3 had received median sternotomy, and 12 were treated for blunt chest trauma. RESULTS: The mean duration of pre-treatment refractory pain was 5.76 months (range 1-62). The mean duration of gabapentin use was 21.9 weeks (range 1-68). No deaths or major complications were encountered. Minor side effects-mostly somnolence and dizziness-occurred in 18 patients (40.0%), causing 3 patients (6.7%) to discontinue gabapentin. Overall, 33 patients (73.3%) noted reduction of pain. Chest wall paresthesia distinguishable from wound pain was relieved in 24 (75.0%) of 32 affected patients. Severe initial pain was significantly correlated with pain relief using gabapentin (p=0.009). No other demographical or clinical variable correlated with benefit or side effects. Satisfaction with gabapentin use was expressed by 40 patients (88.9%). Side effects were not a source of dissatisfaction in any patient. CONCLUSIONS: Gabapentin appears safe and well tolerated when used for persistent post-operative and post-traumatic pain in thoracic surgery patients, although minor side effects do occur. Gabapentin may relieve refractory chest wall pain in some of these patients, particularly those with more severe pain. Further studies are warranted to define the role of gabapentin in cardiothoracic surgical practice.
Adult↗
Analgesic effect of electroacupuncture in postthoracotomy pain: a prospective randomized trial.
BACKGROUND: The role of electroacupuncture in postthoracotomy pain control is uncertain. We conducted a pilot study to evaluate the role of electroacupuncture in the management of early postthoracotomy wound pain. METHODS: A total of 27 patients with operable non-small cell lung carcinoma who received thoracotomy were recruited and randomized to receive either electroacupuncture or sham acupuncture in addition to routine oral analgesics and patient-controlled intravenous analgesia for postoperative pain control. All patients received acupuncture twice daily with visual analog pain score recorded for the first 7 postoperative days. Specific chest acupoints (LI 4, GB 34, GB 36, and TE 8) were targeted. Patient-controlled analgesia was used for the first 3 postoperative days in all patients, and the cumulative dosage used was recorded. RESULTS: Two patients were excluded after randomization because of complications unrelated to acupuncture. Interventions and data collection were completed for the remaining 25 patients (13 in the electroacupuncture group; 12 in the sham acupuncture group). There was a trend for lower visual analog scale pain scores in the electro-acupuncture group between postoperative days 2 and 6, although this did not reach statistical significance. The cumulative dose of patient-controlled analgesia morphine used on postoperative day 2 was significantly lower in the electroacupuncture group (7.5 +/- 5 mg versus 15.6 +/- 12 mg; p < 0.05). Such delay of onset of pain control may be related to the frequency of electroacupuncture used. CONCLUSIONS: Electroacupuncture may reduce narcotic analgesic usage in the early postoperative period. A prospective randomized controlled trial using different electroacupuncture frequency is warranted to verify this benefit.
Acetaminophen↗
Video-assisted thoracic surgery pulmonary resection for lung cancer in patients with poor lung function.
BACKGROUND: The aim of this study is to evaluate the early outcome of patients with poor lung function who underwent video-assisted thoracic surgery (VATS) pulmonary resection for primary non-small cell lung carcinoma. METHODS: We reviewed retrospectively the records of patients with lung cancer undergoing VATS lung resection over a period of 5 years. Twenty-five patients with preoperative poor lung function defined as forced expiratory volume in 1 second less than 0.8 L or the percentage predicted value for forced expiratory volume in 1 second less than 50% were identified. Thirteen patients underwent VATS lobectomies and 12 VATS wedge resections. Data were analyzed with respect to demographics, risk factors, and early postoperative outcome and survival. RESULTS: There were 8 cases of morbidities (29%) and no surgical mortality. Five of these 8 patients had respiratory-related complications after surgery. A deterioration in pulmonary performance as indicated by the Eastern Cooperative Oncology Group (ECOG) score was seen in 7 patients (28%), with only 1 patient having an ECOG score greater than 2. No patient required home oxygen supplementation beyond the third month postoperatively. After a median follow-up period of 15.1 months (range, 1 to 24), 5 patients died. Only 1 patient (4%) died of a respiratory complication (pneumonia 6 weeks after surgery). The other 4 deaths were due to recurrent or metastatic disease. The actuarial survival rates at 1 and 2 years were 80% and 69%, respectively. CONCLUSIONS: Video-assisted thoracic surgery pulmonary resection for cancer in patients with poor lung function can achieve acceptable functional and oncologic outcome.
Aged↗
Double aortic arch causing tracheo-esophageal obstruction.
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Airway Obstruction↗
Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis.
OBJECTIVE: Chest wall paresthesia is a reported sequela of thoracotomy and Video-Assisted Thoracic Surgery (VATS) which is distinct from wound pain. Although needlescopic VATS confers less post-operative pain and better cosmesis, the incidence of paresthesia after needlescopic VATS has not been quantified. METHODS: For homogeneity of the patient cohort, we studied 50 patients who received bilateral needlescopic VATS sympathectomy (T2-T4 excision) for palmar hyperhidrosis using 2 or 3 mm instruments during a 36-month period at a single institute. A standard questionnaire was administered by telephone interview, with 34 patents responding (68.0%). The median post-operative observation time was 16.5 months (range: 10-40 months). Collected data were compared with a historical group who received conventional VATS using 10 mm ports. RESULTS: Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of 'bloating' (41.2%), 'pins and needles' (35.3%), or 'numbness' (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS. CONCLUSIONS: Chest wall paresthesia affects a significant but previously overlooked proportion of patients following needlescopic VATS, but has minimal impact on post-operative satisfaction. Needlescopic VATS offers no apparent advantage over conventional VATS with regard to paresthesia.
Adolescent↗
Alveolar capillary dysplasia with congenital misalignment of pulmonary vessels.
Alveolar capillary dysplasia with misalignment of pulmonary vessels is an uncommon congenital cause of persistent pulmonary hypertension of the newborn. It is universally fatal, and diagnosis is entirely dependent upon surgical lung biopsy. We present a case of alveolar capillary dysplasia with misalignment of pulmonary vessels occurring in a full-term neonate, emphasizing that early involvement of the thoracic surgeon for a histological diagnosis allows expensive and ineffective treatments to be avoided.
Capillaries↗
Should cervical ultrasonography be a routine staging investigation for lung cancer patients with impalpable cervical lymph nodes?
OBJECTIVES: Detection of cervical N3 lymph nodes is currently not a routine preoperative investigation for lung cancer patients. We designed a study to assess if the frequency and accuracy of detection of metastatic cervical lymph nodes using cervical ultrasonography (US) and fine needle aspiration (FNA) justify their routine use in all lung cancer patients with impalpable cervical lymph nodes. METHODS: Fifty patients with suspected and potentially operable non-small cell lung cancer were enrolled. Patients with palpable cervical lymph nodes were excluded. In addition to routine preoperative investigations, all patients received cervical US to determine the presence of cervical lymph nodes. Nodes suspicious of harboring malignancy according to a specific set of sonographic criteria (which include shape, echogenicity, nodal architecture, and vascular patterns) were subjected to biopsy by ultrasound-guided FNA. RESULTS: Normal cervical lymph nodes were detected by cervical US in 30 patients (60%). Cervical lymph nodes suspicious of harboring malignancy were detected in 10 patients (20%). FNA confirmed cervical nodal metastasis in four of these patients (8%). The TNM staging of two patients (4%) was revised up to stage IIIb as a result, excluding them from further surgery. Cost analysis suggests this technique to be cost-effective when used as a routine preoperative investigation to exclude patients from unnecessary surgical intervention. No mortality or complications were encountered in all patients. CONCLUSIONS: Cervical US and FNA is a safe and cost-effective method of evaluating the status of impalpable cervical lymph nodes in lung cancer patients. Further study is warranted to establish the role of cervical US and FNA in lung cancer staging algorithms.
Adult↗
Incidence of chest wall paresthesia after video-assisted thoracic surgery for primary spontaneous pneumothorax.
OBJECTIVE: Video-assisted thoracic surgery (VATS) is an established treatment for recurrent or complicated primary spontaneous pneumothorax (PSP). However, a proportion of patients still complains of chronic pain or discomfort after VATS pleurodesis. We aimed to investigate if paresthesia is a distinct component of the post-operative discomfort in patients receiving VATS for PSP. METHODS: Telephone interviews were conducted with 52 patients who had received VATS pleurodesis for PSP in our institute during a defined 24 month period. A standardized questionnaire was used to identify paresthetic discomforts which the patients themselves could distinguish from their wound pain. Responses were obtained from 51 patients (42 male, 9 female) with a mean age of 24.1 years (range 14-63 years), giving a response rate of 98.0%. RESULTS: With a median observation time of 19 months (range 2-24 months), 27 patients (52.9%) reported experiencing paresthesia as a post-operative complication distinct from their wound pain. The most commonly described characteristics of the paresthesia were 'pins and needles' (37.0%), 'numbness' (25.9%) or a sensation of abnormal 'swelling' in the chest wall (11.1%). Although only two of the affected patients (7.4%) described the paresthesia as 'severe', consequent functional disturbances in daily life were noted by seven patients (25.9%), and 11 patients (40.7%) actively sought medical or alternative, holistic therapies to relieve the paresthesia. Eight (21.0%) of the 38 patients followed-up for over 12 months after surgery still experienced the paresthesia. CONCLUSIONS: Although it should not detract from the proven advantages of VATS, paresthesia in the chest wall represents a distinct but previously overlooked post-VATS complication. It is a potential source of significant post-operative morbidity, and may run a chronic course in some patients. Further study is warranted to elucidate its mechanisms and optimum management.
Adolescent↗
Video-assisted thoracic surgery for primary spontaneous hemopneumothorax.
OBJECTIVE: Video-assisted thoracic surgery (VATS) has changed the way we manage a number of thoracic conditions. This study presents near over a decade of experience from our institution on management of spontaneous hemopneumothorax (SHP), with particular reference to the use of VATS. METHODS: Retrospective review between March 1988 and December 2002 with 793 patients treated for spontaneous pneumothorax, 30 (3.8%) patients had SHP. The clinical features, indications for surgery and outcomes are discussed. RESULTS: All 30 SHP patients were male with mean age of 25 years. Signs of significant hypovolemia occurred in 4 patients, 3 required blood transfusion. Mean initial blood drainage from tube thoracostomy was 594 ml. All SHP patients received surgery (5 thoracotomies, 25 VATS). Active bleeding was identified in 16 patients; 12 from torn apical vascular adhesion band and 4 from vascular bleb. Postoperative complications after thoracotomy include 2 chest infections and 1 air leak, while VATS had 1 chest infection and 1 air leak (P=0.022). Mean postoperative hospital stay following VATS was 3.9 days and thoracotomy 7.5 days (P=0.0021). There is no recurrence of pneumothorax or SHP during mean follow-up of 21 months. CONCLUSION: SHP can be life threatening and is a cause for patients presenting with unexplained signs of significant hypovolemia. Surgery in the form of VATS should be considered early in the management of SHP, with potentially less postoperative complications and shorter postoperative hospital stay compared with open thoracotomy.
Adolescent↗
Lung cancer staging.
The staging of lung cancer is a continuously progressing field, with advances in technology not only improving prognostic accuracy, but fundamentally changing pre-operative investigation algorithms. Noninvasive staging is currently undergoing revolutionary developments with the advent of Positron Emission Tomography, whereas Video-Assisted Thoracic Surgery has already been established as an essential, minimally invasive diagnostic tool for invasive histological staging. Molecular staging may transform future lung cancer staging, promising extremely accurate substaging, and potentially prompting a revision of our anatomically based conceptualization of lung cancer spread. This review presents an appraisal of current lung cancer staging modalities, and presents an overview of recent developments in molecular staging.
Biomarkers↗
Early results of endoscopic lung volume reduction for emphysema.
BACKGROUND: We determined the feasibility, safety, and short-term efficacy of bronchoscopic placement of a one-way endobronchial valve in selected bronchopulmonary segments as an alternative to surgical lung volume reduction. METHODS: A total of 21 patients with incapacitating emphysema who underwent this procedure were studied. All patients had placement of the endobronchial valves into the most emphysematous lung segments. We recorded any major complications or deaths attributed to the procedure and analyzed (1) improvements in the spirometric and functional parameters and quality of life and (2) the radiologic changes compared with the baseline data at 30 and 90 days. RESULTS: A total of 20 patients had complete follow-up data. There was no mortality in the group studied. The forced expiratory volume at 1 second, forced expiratory volume at 1 second (percentage of predicted), forced vital capacity, and forced vital capacity (percentage of predicted) all improved significantly at 90 days (0.73 +/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P =.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs 73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m; P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and the St George Respiratory Questionnaire showed significant improvements at 90 days. The Medical Research Council dyspnea grade also improved significantly at 30 and at 90 days (P =.006 and P =.003, respectively). CONCLUSIONS: Endobronchial valve placement is a safe procedure, with significant short-term improvements in functional status, quality of life, and relief of dyspnea in selected patients with emphysema. A larger study with long-term follow-up is therefore warranted.
Adult↗
Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study.
OBJECTIVE: On-pump beating heart coronary artery surgery provides the opportunity to examine the isolated effect of cardiopulmonary bypass. This prospective randomized study compares the early clinical outcomes and inflammatory response of patients undergoing elective on-pump and off-pump beating heart coronary artery bypass grafting. METHOD AND PATIENTS: Thirty-seven consecutive patients undergoing elective coronary artery bypass grafting were recruited from a pool of 73 patients, with 19 patients randomized to on-pump beating heart surgery and 18 patients to off-pump coronary bypass surgery. Intraoperative events and postoperative outcomes were recorded. Plasma levels of interleukin-6, interleukin-8, and interleukin-10, tumor necrosis factor-alpha, and vascular cell adhesion molecule-1 were measured before the operation, intraoperatively, after the operation, and 4, 24, and 48 hours thereafter. RESULTS: There was no significant difference in clinical outcomes between the 2 groups. The operating time was longer and consumption of platelets was greater for the on-pump beating heart group. There was no postoperative mortality or major complication in either group. There was significant elevation in the levels of interleukin-6, interleukin-8, and interleukin-10 and tumor necrosis factor-alpha during and immediately after the operations in the on-pump beating heart group when compared with the off-pump group. Levels of interleukin-8 (P =.01) and tumor necrosis factor-alpha (P =.0004) remained significantly elevated 4 hours after the operation in the on-pump beating heart group. The level of vascular adhesion molecule dropped significantly during the operation but was elevated 4 hours (P =.026) after the operation in the on-pump beating heart group. CONCLUSION: The use of cardiopulmonary bypass alone without global myocardial ischemia secondary to aortic crossclamping and cardioplegic cardiac arrest can trigger intense inflammatory responses.
Aged↗
Airway stenting for unresectable esophageal cancer.
Because of the close anatomical relationship between the upper esophagus and the tracheobronchial tree, many patients with advanced esophageal cancer will suffer from airway complications. These include airway stenosis or esophago-respiratory fistulation. Airway stenting is proven to offer effective palliation for patients with both these complications. When managing such patients, the thoracic surgeon faces different options in terms of pre-stenting investigation, choice of stents and stenting strategy. Although airway stenting is a safe and effective procedure in experienced hands, there are nonetheless complications which await the unwary. This review discusses the currently available options for airway stenting in these patients, and offers practical advice on avoiding the pitfalls.
Airway Obstruction↗
Selective lobar collapse for video-assisted thoracic surgery.
BACKGROUND: Video-assisted thoracic surgery (VATS) is conventionally performed under single-lung ventilation. A small proportion of patients are often excluded from undergoing VATS because of their inability to tolerate single-lung ventilation. We describe a simple technique of selective lobar lung collapse that may help to recruit additional, selected patients for VATS. METHODS: We use a standard suction catheter placed under bronchoscopic guidance to the target lobar bronchus through a single-lumen endotracheal tube. The catheter is left open to air, or suction can be applied to facilitate lobar collapse. The remaining lobe of the same lung can be ventilated throughout surgery. Surgery is performed using standard VATS techniques. RESULTS: Using this technique we have successfully performed VATS on 63 chest sides in 35 patients. The procedures performed included thoracodorsal sympathectomies (n = 28), mechanical pleurodesis procedures (n = 3), mediastinal and pleural biopsies (n = 2), and lung wedge resections (n = 2). We encountered no mortality or morbidity in all cases. CONCLUSIONS: This technique is simple and safe and requires no expensive disposable devices. Although not essential for most patients undergoing VATS, it deserves to be in the armamentarium of the thoracic surgeon. Further studies will be required to better define its application in clinical practice.
Adult↗
Actinomycosis: an often forgotten diagnosis.
We report a case of actinomycosis presenting as a chest wall mass in a 35 year-old man. Thoracic actinomycosis poses a diagnostic challenge to clinicians not only because it is uncommon and often forgotten, but also because culture of the causative microbes is technically difficult. The classic microscopic appearance of this Gram-positive bacteria associated with surrounding sulfur granules often forms the basis of diagnosis.
Actinomycosis↗
Severe acute respiratory syndrome complicated by spontaneous pneumothorax.
Severe acute respiratory syndrome (SARS) presents an unprecedented diagnostic and therapeutic challenge to clinicians. Despite recent progress in identifying and analyzing the coronavirus that is responsible for it, few reports have addressed the clinical complications of SARS. The present study was a two-center retrospective cohort study. All patients in the study had SARS, were managed in the two major Hong Kong hospitals (ie, Prince of Wales Hospital and United Christian Hospital), and had developed spontaneous pneumothorax during their hospitalization between March 10, 2003, and April 28, 2003. Spontaneous pneumothorax was reported in 6 of 356 SARS patients who were treated at the two hospitals during the period. This represents an incidence of 1.7%. None of the six patients had a history of smoking or pulmonary disease. The rate of admission to the ICU was 66.7% and the crude mortality rate was 33.3% in this group of patients. There was a trend for the mean neutrophil count in these patients to be higher than in previously reported cohorts of comparable SARS patients (14.5 x 10(9) vs 4.6 x 10(9) neutrophils per liter, respectively). Conservative measures like tube thoracostomy or observation alone offered satisfactory initial symptomatic management in five of six patients. Spontaneous pneumothorax is a specific and potentially life-threatening complication in SARS patients. Patients with extensive lung injury, as indicated by severe clinical courses, and in particular high neutrophil counts, appear to be most at risk. The benefits of surgical management must be balanced against the potential risks to health-care workers.
Adult↗