An unusual presentation of lipomatosis?
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Diagnosis, Differential↗
Biomedical subjects
B C McCaughan
Publications and source records attributed to B C McCaughan.
Devolved clinical management and casemix.
Devolved clinical management aims at greater medical and nursing involvement in the management of health resources and focuses on achieving measurable improvements in patient care through better use of resources. It permits the major drivers of the health care system (doctors), in collaboration with the major direct care providers (nurses), to be not only effective at allocating resources but also effective resource users. Casemix is a classification of patient care episodes based principally on resource use and can assist in the process of managing health services. We discuss the relationship between devolved clinical management and casemix systems. Health care organisations must move towards devolved clinical management, with a greater focus on the patient and a greater emphasis on accountability among all clinical disciplines.
Australia↗
Video-assisted thoracoscopy.
Recent advances in video-imaging and minimally invasive surgical instrumentation have expanded the role of thoracoscopy in the diagnosis and treatment of intrathoracic conditions. This prospective study describes the use of video-assisted thoracoscopy (VAT) in 100 consecutive patients. There were 70 males and 30 females with a mean age of 54.6. They underwent 103 VAT procedures with 41 thoracoscopic biopsies of lung, pleural, chest wall and mediastinal abnormalities, 32 for treatment of recurrent or persistent pneumothorax, 18 for thoracoscopic assessment of pulmonary and pleural tumours and 12 for thoracoscopic resection of peripheral lung lesions, chest wall, mediastinal and pleural tumours. Eighty-one patients had VAT procedures alone while the remaining 19 had VAT proceeding to thoracotomy. The mean operating time for VAT alone was 51 min (range 30-135 min). There were no operative deaths. There were 8 significant complications from which patients recovered fully. Patients who underwent VAT alone were shown to have earlier postoperative mobilization, reduction in parenteral analgesic requirement and reduced length of hospital stay compared to patients undergoing additional thoracotomy. A telephone survey of patients on returning home showed that patients undergoing VAT alone returned to full activity earlier than those who had thoracotomy (mean 9.0 vs mean 19.4 days). This study confirms that VAT is a safe and effective procedure in the management of pulmonary, mediastinal and pleural disease and the treatment of persistent and recurrent pneumothorax. Its role in the resection of pulmonary malignancy remains to be defined.
Activities of Daily Living↗
Primary lung cancer invading the chest wall.
Chest wall invasion per se does not preclude resection nor indicate incurability in patients with non-small cell lung cancer. Preoperative assessment identifies patients without evidence of distant metastases, spinal invasion, or regional lymph node metastases. At thoracotomy, these selected patients usually undergo complete resection of tumor with an expected 5-year survival, in the absence of lymph node involvement, in excess of 50% when en bloc resection of the lung and involved chest wall is performed. Neither radiotherapy nor chemotherapy appear to impact on this survival.
Adult↗
Perforation of the esophagus by a fish bone leading to cardiac tamponade.
A 32-year-old woman swallowed a fish bone and presented to the hospital 3 days later with chest pain and fever. While in the hospital, she became hypotensive. A computed tomographic scan showed a fish bone penetrating from the esophagus into the pericardium. The fish bone was removed at urgent thoracotomy with immediate relief of her circulatory compromise. At the time of the operation, the fish bone was noted to be abrading the surface of the left atrium. We report this case of cardiac tamponade secondary to a perforated esophagus after foreign body ingestion.
Adult↗
Combination chemotherapy with cisplatin, vindesine and mitomycin-C for advanced, inoperable non-small-cell lung cancer.
OBJECTIVES: To assess the activity of chemotherapy with cisplatin, vindesine and mitomycin-C (PVM) in advanced non-small-cell lung cancer (NSCLC) and to test the feasibility of preemptive therapy with PVM. DESIGN AND SETTING: A phase II clinical trial of PVM in patients with NSCLC treated at the Royal Prince Alfred Hospital between June 1987 and July 1990. PATIENTS: Forty-one patients with advanced, inoperable or recurrent NSCLC--22 women, 19 men, with a median age of 51 years. Thirteen patients had been treated previously with radiotherapy and/or surgery; 18 had extrathoracic metastases. Four patients previously deemed inoperable were treated preemptively with PVM before proceeding to radical surgery. INTERVENTIONS: Cisplatin 100 mg/m2, vindesine 5 mg and mitomycin-C 8 mg/m2, all given intravenously on Day 1, with vigorous hydration and antiemetic therapy. Cycles were repeated every four weeks. MAIN OUTCOME MEASURES: Objective tumour response to treatment, patient survival time, time to treatment failure, and treatment toxicity. RESULTS: There was one complete tumour response to PVM and 15 partial responses; 14 patients had stable disease and nine had progressive disease--yielding an objective response rate (complete plus partial responses) of 39% (16/41; 95% confidence interval [CI], 24%-56%). Responses were documented in all histological subgroups, in both locally advanced and disseminated disease, and in recurrent disease. Median survival of the group was six months (95% CI, 5-10 months; range, 0.5-19+ months), and is unchanged by exclusion of the four patients treated before surgery. Seven of the 41 patients (17%) survived 12 months or longer. Median time to treatment failure in patients who had an objective response was six months (95% CI, 5-10 months). Grade 3 or 4 nausea and vomiting occurred in 21 patients (51%). Haematological, renal and neurological toxicity were not major problems; there were no deaths from treatment toxicity. CONCLUSION: PVM is an active regimen in advanced NSCLC and can produce durable remissions. The potential palliative effects of PVM in incurable disease must be weighed against the risk of subjective toxicity.
Adult↗
Intrapleural bupivacaine in the control of postthoracotomy pain.
A randomized, double-blind trial was conducted to determine the effectiveness of intrapleural bupivacaine hydrochloride in the management of pain after thoracotomy. Thirty-three men and 7 women with a mean age of 62 years (range, 21 to 76 years) undergoing elective posterolateral thoracotomy were randomly allocated preoperatively to either a study group receiving 20 mL of 0.25% bupivacaine or a control group receiving 20 mL of 0.9% saline solution through a pleural catheter every 4 hours. Patients received supplementary doses of intramuscular papaveretum as required. Assessment of pain, somnolence, and breathing capacity was performed after the intrapleural injections at 4, 24, 48, and 72 hours postoperatively. Pain assessment, as measured by a linear analog scale, was lower in the bupivacaine group at all times, reaching significance at 4, 24, and 72 hours (p less than 0.05). The forced vital capacity and forced expiratory volume in 1 second at 6 weeks postoperatively remained significantly lower than preoperatively (p less than 0.05). The fall in forced vital capacity from this postoperative level was significantly less in the bupivacaine group at 4, 24, and 48 hours, and the fall in forced expiratory volume in 1 second was significantly less at 4 and 48 hours in the treated group. When used in conjunction with doses of parenteral narcotic, intrapleural bupivacaine gives better pain control with less respiratory depression than intermittent doses of narcotic alone.
Adult↗
Malignancy in a massive localized fibrous tumour of pleura.
Localized fibrous tumour of pleura is a rare condition. Most follow a benign course and are an incidental finding during routine chest X-ray. A small proportion of these tumours are malignant and have characteristic clinical and histopathological features. This case report is of a 65 year old woman who presented with respiratory symptoms and polyarthropathy, and had a subsequent resection of a massive pleural tumour with features suggestive of malignancy.
Aged↗
Pleurectomy for mesothelioma.
OBJECTIVE: To assess the effectiveness and safety of parietal pleurectomy in establishing a tissue diagnosis and controlling pleural fluid accumulation in patients with pleural mesothelioma, and to assess the success of this procedure in effecting palliation. DESIGN AND SETTING: Fifty consecutive patients with pleural mesothelioma who underwent thoracotomy at the cardiothoracic units at Concord and Royal Prince Alfred Hospital were reviewed retrospectively. The male:female ratio was 4:1 and the mean age was 63 years. In only 11 of the 50 patients was a tissue diagnosis of mesothelioma made before surgery. INTERVENTIONS: At thoracotomy, subtotal parietal pleurectomy was performed in 45 of the 50 patients. In two patients biopsy alone was performed and three patients were treated by a chemical pleurodesis only, as pleurectomy was not technically possible. Pulmonary decortication was required in 28 patients to allow full expansion of the underlying lung for effective pleurodesis. RESULTS: There was one postoperative death. The morbidity rate was 16%. Excluding the patient who died in the postoperative period, the median survival was 16 months, and ranged from three to 54 months, with 21% of patients surviving for more than two years. Only one patient developed a reaccumulation of pleural fluid. CONCLUSIONS: Pleurectomy, with decortication when required, provides both a tissue diagnosis and effective control of pleural fluid accumulation and therefore excellent palliation in patients with pleural mesothelioma. We advocate early thoracotomy in these patients.
Adult↗
Giant pericardial cyst.
We report the excision of the largest pericardial cyst yet described. Despite causing collapse of the left lower lobe, and bronchitis, an excellent symptomatic result was obtained.
Adult↗
Tricuspid valve endocarditis cured by excision of a single vegetation.
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Adolescent↗
Carcinomatous involvement of the hilum and mediastinum: computed tomographic and magnetic resonance evaluation.
Magnetic resonance (MR) imaging and computed tomography (CT) were compared in 20 patients who had primary lung tumors, and the results were correlated with findings at surgery and pathologic evaluation. Both studies demonstrated a similar ability to detect hilar and mediastinal tumor. MR imaging detected more enlarged nodes in the mediastinum, but in several patients these enlarged nodes did not contain tumor. Consequently, MR imaging has a slightly higher false-positive rate in the evaluation of the mediastinum. Both modalities were highly sensitive, with specificity limited by the presence of enlarged benign lymph nodes in this series of patients.
Adenocarcinoma↗
Bronchial carcinoids. Review of 124 cases.
A total of 124 patients with bronchial carcinoid were seen at Memorial Sloan-Kettering Cancer Center between 1949 and 1983. Of these, 68 were female and 56 were male. The age range was 12 to 82 years (median 55 years). Eleven of the tumors were incidental pathological findings at autopsy or operation and were excluded from survival data determinations. At the time of diagnosis, 82 patients had disease confined to the lung or bronchus, 19 had regional lymph node metastases, and 12 had distant metastases. Patients with distant metastases were more commonly male and smokers, and their tumors were mainly atypical carcinoids histologically, compared with those of patients with localized disease. Patients with distant disease were treated with external radiation and/or chemotherapy, and their median survival was 8 months. Of the 101 patients with disease localized to one hemithorax, endobronchial resection was performed in six and pulmonary resection in 95 (pneumonectomy 14, bilobectomy nine, lobectomy 52, sleeve resection five, segmentectomy 15). Recurrence following endobronchial resection was observed in four of six patients. Disease-free actuarial survival (calculated by the Kaplan-Meier method) following pulmonary resection was 92% at 5 years and 77% at 10 years. Factors predisposing to recurrence were tumor size greater than 3 cm (p less than 0.004), an atypical carcinoid on histologic study (p less than 0.001), and regional lymph node metastases (p = 0.01). Disease-free survival at 5 and 10 years in 19 patients who had regional lymphatic metastases was 74% and 53%, compared with 96% and 84% in those without lymphatic metastases. We conclude that (1) carcinoid tumors are malignant and 10% of patients present with metastases and (2) for patients with clinically localized tumors, the prognosis is determined by the size and histologic features of the tumor and the status of the regional lymph nodes, which must be assessed at thoracotomy.
Adolescent↗
Chest wall invasion in carcinoma of the lung. Therapeutic and prognostic implications.
From 1974 through 1983, 125 patients underwent operation at Memorial Sloan-Kettering Cancer Center for non-small cell carcinoma of the lung invading the chest wall. (Excluded are those with superior sulcus tumors or distant metastases at presentation.) Eighty patients were male and 45 were female. Ages ranged from 33 to 88 years (median 60 years). Histologically, the tumors were epidermoid carcinoma in 46%, adenocarcinoma in 46%, and large cell carcinoma in 8%. All patients underwent thoracotomy (pneumonectomy 19, bilobectomy seven, lobectomy 75, wedge resection 10, and no pulmonary resection 14), with an operative mortality of 4%. At thoracotomy, mediastinal lymph node dissection was routinely performed, and the postsurgical stage was T3 N0 M0 in 53%, T3 N1 M0 in 13%, and T3 N2 M0 in 34%. Extrapleural resection was performed in 66 patients. En bloc resection of chest wall and lung was performed in 45 patients with an operative mortality of 2%. Complete resection of tumor was possible in 77 patients (62%). Extension of tumor beyond the parietal pleura significantly decreased resectability. The median survival of 48 patients having incomplete resection was 9 months, despite perioperative interstitial and external radiation. The actuarial 5 year survival rate (Kaplan-Meier) of 77 patients having complete resection was 40%. This percentage was not significantly influenced by the patient's age or sex or by tumor size or histologic type. Lymphatic metastases significantly reduced survival, with a 5 year actuarial survival rate of 56% for patients with T3 N0 M0 disease and 21% for those with T3 N1 M0 or T3 N2 M0 disease (p = 0.005). The extent of tumor invasion of the chest wall appeared to influence survival, but in the absence of lymphatic metastases the difference at 5 years was not significant. Complete resection offers a significant chance for long-term survival in lung cancer directly extending into parietal pleura and chest wall. Extrapleural resection or en bloc chest wall resection can be performed with a low operative mortality and an expected 5 year survival in excess of 50% in the absence of lymphatic metastases.
Adenocarcinoma↗
Tetralogy of Fallot with absent pulmonary valve. Early and late results of surgical treatment.
From 1957 through September, 1983, 35 patients with tetralogy of Fallot and absent pulmonary valve underwent operation. Two subgroups of patients were recognized: minimally symptomatic (Group A, n = 21) and markedly symptomatic (Group B, n = 14). Group B patients were symptomatic at an earlier age and were younger at operation. Ages ranged from 1 day to 42 years (mean = 7.8 +/- 7.4 SD). Repair consisted of closure of the ventricular septal defect and relief of the right ventricle-pulmonary artery pressure gradient (nine patients received a tissue valve). In five patients, partial resection and/or plication of the aneurysmal pulmonary arteries also was performed. Operative mortality was 4.8% in Group A and 35.7% in Group B. In up to 25 years of follow-up, there was one late death in Group A (an early case with complete heart block); the remaining 19 patients are asymptomatic. In Group B, there were four late deaths, three related to cardiopulmonary insufficiency. These results indicate pulmonary valve insufficiency is tolerated well in minimally symptomatic patients. For markedly symptomatic patients, results may be improved if repair includes establishment of pulmonary valvular competence and reduction of size and length of aneurysmal pulmonary arteries.
Adolescent↗
Early and late results of pericardiectomy for constrictive pericarditis.
Records of 231 patients (171 males, 60 females; aged 10 months to 83 years [median 45 years]) who underwent operation for constrictive pericarditis at the Mayo Clinic from 1936 through 1982 were reviewed. All had had hemodynamically significant pericardial constriction preoperatively, and pericardial disease was confirmed at operation. Preoperatively, 69% were in New York Heart Association Class III or IV and 81% had peripheral edema or ascites. Pericardiectomy was performed through a left anterolateral thoracotomy (34%), a median sternotomy (27%), a U incision (Harrington) (21%), or a bilateral anterior thoracotomy (18%). Postoperatively, 28% of patients had evidence of low cardiac output; 70% of the 32 deaths within 30 days of operation were due to low cardiac output. Operative risk was significantly (p less than 0.001) related to preoperative disability (1% for Class I or II; 10% for class III; 46% for Class IV). Median postoperative follow-up was 9 years (longest was 43 years). Probability of survival for patients dismissed alive from the hospital was 84% at 5 years, 71% at 15 years, and 52% at 30 years. Long-term survival (excluding operative mortality) was not significantly influenced by the disability class preoperatively, the operative approach, or the development of low cardiac output in the immediate postoperative period. At the end of the follow-up interval, there were 141 patients in whom functional capacity could be assessed; 140 were in Class I or II. We conclude that a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. We recommend early pericardiectomy when pericardial constriction is diagnosed, and we continue to use a left anterolateral thoracotomy as the preferred approach for most patients.
Adolescent↗
Appendicectomy audit.
Of 200 consecutive appendicectomies performed at Royal Prince Alfred Hospital the indications for operation were suspected acute appendicitis (65%), chronic or recurrent appendicitis (11.5%), interval appendicectomy (3%) and appendicectomies incidental to other operations (20.5%). Of those operated upon for suspected acute appendicitis, the appendix revealed acute inflammation pathologically in 64% of patients. Pathological changes occurred with the same frequency in both the incidental appendicectomy group and the chronic appendicitis group. Within the group with a provisional diagnosis of acute appendicitis there were marked variations in the documentation of peroperative symptoms, signs and investigations. On average 11.5 hours passed between the time these patients presented and when appendicectomy was performed. The patients spent an average of 6.4 days in hospital and only 33% had any documentation follow-up in the hospital records. Auditing systems can only be instituted in Australia if the structure of medical services is borne in mind. Adoption of overseas systems based on different patterns of medical care will add little to patient care.
Appendectomy↗