Mediastinal lymph node metastases in lung cancer: is size a valid criterion?
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Humans↗
Biomedical subjects
D K Kaplan
Publications and source records attributed to D K Kaplan.
Oesophageal obstruction during nasogastric feeding.
Although complications of enteral feeding are usually minor, we report an unusual and serious case of oesophageal obstruction after feeding with osmolite, a commonly used polymeric enteral feeding preparation. The patient described underwent rigid oesophagoscopy to remove the feed which had solidified and blocked the entire oesophageal lumen. The procedure resulted in oesophageal perforation which needed surgical repair by thoracolaparotomy and was followed by a difficult postoperative course. In vitro tests showed that all commonly used feeds containing casein (osmolite, ensure, ensure plus, paediasure, fortison, and pulmocare) solidified at a pH of less than 5. Clinifeed (containing dried skim milk) and peptamen (containing peptides) remained liquid at a pH of less than 1. Solidified feed could be liquefied by the addition of pepsin or pancrex V (a pancreatic enzyme formulation). We conclude that solidification could occur in all feeds containing casein and that alternative feeds should be considered in patients with increased gastric acidity. In addition, pepsin or pancrex V could be used to liquefy solidified feed.
Caseins↗
Use of the Denver pleuroperitoneal shunt in the treatment of chylothorax secondary to filariasis.
A 57 year old woman developed a chylothorax as a result of having had filariasis as a child. This failed to respond to conservative measures but was successfully managed by means of a Denver pleuroperitoneal shunt.
Anastomosis, Surgical↗
Esophagogastrectomy via left thoracophrenotomy.
Esophagogastrectomy is generally considered to be the treatment of choice for resectable tumors of the esophagus. Although many approaches and techniques have been advocated, since April 1983 we have used a left thoracophrenotomy approach for most lesions of the lower two thirds of the esophagus and gastric cardia. Stapling instruments have been used for mobilization of the stomach and fashioning of the esophagogastric anastomosis. One-hundred fifteen patients undergoing resection of malignant tumors with this technique were retrospectively reviewed. Perioperative mortality was 8.7% (10/115). The rate of anastomotic leakage was 1.7% (2/115), and benign narrowing of the anastomosis requiring dilation developed in 16 patients. The rate of recurrent anastomotic tumor was 4.3%. Eighteen patients had complications, and the mean postoperative hospital stay was 13 days. Survival at 3 years was 22.1%. During the period of study, 22 patients underwent esophageal resection by some other approach; the reasons for this are described. The advantages of the left thoracophrenotomy approach are discussed.
Adult↗
Case conference 3--1990. Two patients develop some signs and symptoms of malignant hyperthermia during cardiac surgery with cardiopulmonary bypass--is it the real thing.
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Aged↗
Recent surgical experience for pulmonary tuberculosis.
Lung resection for pulmonary tuberculosis is unusual today. Over a 10-year-period 31 patients with pulmonary tuberculosis underwent thoracotomy at this Regional Centre. Five of these were for complications of known tuberculosis; two subsequently proved to be complications of pulmonary tuberculosis, and the remainder were for suspected malignancy. The clinical features, radiology, microbiology, and pathology are reviewed and the contemporary role of the surgeon in the management of pulmonary tuberculosis is examined.
Adult↗
Oesophagogastrectomy in patients over 70.
Although the results of oesophageal resection for benign and malignant disease are well documented, the risk of operative death and long term survival in patients over the age of 70 is not well defined. The outcome has been reviewed for 46 patients (23 male, 23 female) aged 70 years or more (mean 74 years) undergoing oesophageal resection during a period of seven years; 16 patients were 75 years or over. All resections were performed with the EEA stapler, except for one cervical anastomosis that was stitched by hand. In 42 patients resection was for malignancy. Six patients died within 30 days of operation or during the initial hospital stay, giving an operative mortality of 13%. Only one of the 16 patients aged 75 years or more died. Cardiopulmonary complications accounted for most of the operative deaths. Patients were scored retrospectively by a multifactual risk factor. Patients who left hospital had a mean preoperative score of 3.66, compared with 15.2 for those who died. Use of such a score may help to improve selection for surgery in this age group. It is concluded that oesophagogastrectomy may be performed in selected patients over the age of 70 years with acceptable mortality, morbidity, and length of hospital stay.
Adenocarcinoma↗
Cervical thymectomy in the treatment of myasthenia gravis.
Treatment modalities in myasthenia gravis consist of surgery, chemotherapy and plasmapheresis. Thymectomy can be accomplished either through a median sternotomy or through a small, transverse cervical incision. Forty patients who underwent cervical thymectomy for non-thymomatous myasthenia gravis were studied retrospectively. Twenty-six patients (65%) showed a favourable response to thymectomy and there were statistically significant improvements in myasthenic symptoms and reductions in medication requirements. Age, sex, duration of symptoms and thymic histology were not predictive of response to thymectomy. Operative mortality was zero and operative morbidity was minimal. During the last 6 years, only two of 22 patients required admission to the intensive care unit postoperatively. The postoperative hospital stay ranged from 2 to 23 days. Cervical thymectomy does not preclude later sternotomy in those patients who fail to respond favourably. We therefore recommend cervical thymectomy as the initial surgical procedure in the treatment of non-thymomatous myasthenia gravis.
Adolescent↗
Anastomotic narrowing after esophagogastrectomy with the EEA stapling device.
We studied a series of 176 patients undergoing esophageal resection with the aid of the EEA surgical stapling device (Auto Suture U.K. Limited, Great Britain) during a period of 7 1/2 years. A total of 160 patients (91%) were operated on for malignant disease. Operative death occurred in 15 patients (8.5%), and there were three anastomotic leaks (1.7%). The prevalence of dysphagia caused by both benign and malignant strictures after esophageal resection in which the EEA stapler was used was 17.4%. The rate of benign anastomotic narrowing in discharged patients was 12.5%. Anastomotic stricture resulting from recurrent tumor caused dysphagia in 6.2% of the patients undergoing resection for malignant disease. The highest rate of benign anastomotic narrowing occurred in patients who had undergone esophageal resection for benign, nondilatable strictures. In these patients, the prevalence of benign anastomotic narrowing was 37.5%, compared with 9.6% in the patients undergoing resection for malignant disease (p less than 0.001). An additional trend was noted: The smaller the stapling head used to construct the anastomosis, the higher the prevalence of benign anastomotic narrowing; however, a statistically significant difference could not be documented. Ninety-five percent of patients with benign anastomotic narrowings complained of dysphagia within the first 6 months after the operation; 79% of these patients required two or fewer dilatations to relieve the dysphagia. Dysphagia after esophageal resection with the aid of EEA stapler occurred in just over one of six patients. The usual cause of the dysphagia was benign anastomotic narrowing, which responds well to dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)
Anastomosis, Surgical↗
Carcinoma of the bronchus with unsuspected microscopic resection-line involvement.
In a series of 560 pulmonary resections for bronchial carcinoma, unsuspected microscopic tumor was present at the bronchial resection margin in 26 patients (4.5%). Adjuvant chemotherapy or radiotherapy was given in two patients. In follow-up times ranging from 1 to 72 months (mean, 22 months), 58% of patients were alive and free of recurrent disease. Twelve patients underwent periodic surveillance bronchoscopy in an attempt to identify early local recurrence. Eighty-three percent of these patients were alive and disease-free in follow-up times from 4 to 72 months (mean, 29.7 months). Only one choscopies. It was concluded that microscopic residual resection-line tumor does not preclude prolonged survival and that no benefit from surveillance bronchoscopy could be demonstrated in this small patient sample.
Bronchi↗
Oesophagogastrectomy using stapling instruments.
Oesophagogastrectomy is generally considered to be the treatment of choice for resectable tumours of the oesophagus. We have, since January 1980, used stapling instruments whenever possible for the resection and anastomosis. We have also, since June 1983, employed a left thoracotomy approach for lesions of the gastric cardia and mid- or lower oesophagus. One hundred and sixty four patients underwent oesophagogastrectomy during a seven year period, 75 via left thoracotomy. The overall peri-operative mortality was 7.9%. Complications occurred in 17% of patients with anastomotic leakage in 1.8% and anastomotic strictures in 9.7%. Mean hospital stay was 14 days. In the left thoracotomy sub-group mortality was 5%, the complication rate 23%, leak rate 3%, stricture rate 12% and mean hospital stay 13 days.
Adult↗
Use of an omental pedicle graft to repair a large oesophageal defect.
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Adult↗
What a load of bullae!
Appropriate and timely insertion of chest drains can be lifesaving. The radiological absence of lung markings is not exclusively diagnostic of pneumothorax. The insertion of an intrapleural drain should effect an immediate clinical and radiological improvement. Failure to achieve the expected result should prompt a full clinical reassessment.
Adult↗
Pulmonary resection using automatic stapling devices.
Between January 1980 and December 1986, 674 patients underwent pulmonary surgery at this institution under the supervision of one surgeon (RJD). Automatic stapling devices were used to close the bronchus in all but 12 patients. Malignant disease was the reason for 85% of resections. The operative mortality was 4.9% (3.2% in patients undergoing lobectomy and 8.3% in those undergoing pneumonectomy). The complication rate was 17.3%. Bronchopleural fistula (BPF) occurred in 11 patients, an incidence of 1.7%. The post-pneumonectomy incidence of BPF was 2.7% within 3 months of surgery and 4.5% overall. Stapled closure of one or more hilar vessels was employed in 153 patients. The role of staplers in pulmonary surgery with particular reference to the incidence of bronchopleural fistula is examined.
Adolescent↗
Staphylococcal infection of a left ventricular aneurysm.
Left ventricular aneurysm formation is a common complication of myocardial infarction. Depending on the definition used, the incidence in survivors of acute myocardial infarction is between 4% and 40%, with mural thrombi present in about half of all aneurysms. Infection of these thrombi at times of bacteraemia might be expected to occur quite commonly but has been described only occasionally. We present such a case and review previously reported cases.
Heart Aneurysm↗