Biomedical subjects

E R Townsend

Publications and source records attributed to E R Townsend.

At least 19 recordsLinked to original sources

PubMed1998

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.

Adult↗

PubMed1997

"Sneeze of a cancer from the lung": sternumentum carcinomae pulmonariae.

The protean manifestations of the clinical presentation of carcinoma of the lung are well known. In the following case report we describe an unusual presentation of such a carcinoma. We further describe this occurrence in Latin as befits what we believe to be a new presentation.

Bronchial Neoplasms↗

PubMed1997

Homograft as a conduit for superior vena cava syndrome.

This report outlines the management of a 30-year-old man with severe multiresistant mycobacterium tuberculosis of his right lung. Despite medical therapy he had open tuberculosis with positive sputum smears. A right pneumonectomy was undertaken, but due to distorted hilar anatomy, the superior vena cava was resected. Postoperatively, superior vena cava syndrome developed and failure of venous drainage was demonstrated by bilateral arum venography and computed tomographic scanning. The superior vena cava syndrome was successfully relieved using an aortic homograft as a superior vena cava replacement instead of a spiral vein graft or a prosthetic conduit.

Adult↗

PubMed1997

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.

Debridement↗

PubMed1997

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.

Adult↗

PubMed1996

Factors affecting long term survival following resection for lung cancer.

BACKGROUND: Survival following pulmonary resection for primary lung cancer is considered to be principally dependent on the clinical stage of the disease. A study was undertaken to verify this and to identify other contributing factors. METHODS: The case records of all patients who underwent surgery for lung cancer over a two year period between January 1987 and December 1988 were reviewed retrospectively. RESULTS: One hundred and forty-seven lobectomies and 60 pneumonectomies were performed with 2.8% and 5.3% operative mortality, respectively. Squamous carcinoma was the commonest pathology (60%) followed by adenocarcinoma (30%). The overall five year survival was 45.5% (95% CI 44.1% to 57.9%). There were 123 patients with stage I disease, 40 with stage II, and 37 in stage IIIa with five year survival of 59.4% (95% CI 50.8% to 68%), 30% (95% CI 15.9% to 44.1%), and 16.2% (95% CI 3.5% to 31%), respectively. There were no differences in survival with respect to sex, extent of resection, or cell type. In patients with stage II disease the five year survival of those with T1 lesions (50%, 95% CI 37.3% to 62.9%) was better than those with T2 (28.1%, 95% CI 16.9% to 39.3%). Of eight patients over the age of 70 with stage IIIa disease none survived more than 24 months. CONCLUSIONS: Stage at operation is the most accurate predictor of long term survival in early lung cancer and surgery remains an effective treatment, particularly in stage I and II disease. Further study is needed to assess the prognostic value of subdividing stage II disease into T1 and T2 lesions. Major resection for locally advanced disease in older patients may be relatively ineffective.

Adenocarcinoma↗

PubMed1996

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.

Adult↗

PubMed1995

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.

Adolescent↗

PubMed1994

Surgical management of spontaneous pneumothorax.

Despite the promising potential of video-assisted thoracoscopic pleurectomy in the treatment of pneumothoraces, conventional surgical intervention by a thoracotomy and pleurodesis with ligation/stapling of bullae remains the main form of treatment in many hospitals. It is with this in mind that we present our experience of 250 patients who have undergone surgical pleurodesis for treatment of a persistent or recurrent spontaneous pneumothorax. Of these patients, 74 had undergone parietal pleurectomy (PP), 93 pleural abrasion (PA), 60 transaxillary apical pleurectomy (TAP), and 23 had undergone apical pleurectomy via a posterolateral or submammary thoracotomy (APT). In general, there were few complications and we could show no discernible difference in the rate of complications between the groups. Despite there being no significant difference in the median period of postoperative intercostal tube drainage, there was a significant difference between the groups in the number of patients with a postoperative hospital stay equal to or greater than seven days and a postoperative serosanguinous volume loss greater than 500 ml. Those patients that had undergone parietal pleurectomy tended to remain in hospital for a longer period (> or = 7 days) and to have a heavier serosanguinous volume loss (> 500 ml). There have been no recurrent cases in the PP and APT groups. Their respective median follow up periods are 62 (range 15-83) and 32 (range 15-54) months. The median follow up period in the PA group was 42 (range 13-69) months, one recurrence occurred after 7 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1993

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.

Aged↗

PubMed1992

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.

Adenocarcinoma↗

PubMed1992

Cardiac torsion after lobectomy with partial pericardectomy.

Cardiac herniation and torsion after intrapericardial pneumonectomy without closure of the pericardium is widely recognized. However, such a complication occurring after lobectomy has been rarely discussed in the literature. We describe a case of cardiac torsion of late onset that developed in a woman who had undergone left upper lobectomy as part of a resection for a malignant thymoma.

Female↗

PubMed1992

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.

Aged↗

PubMed1992

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.

Adult↗

PubMed1992

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.

Adult↗

PubMed1992

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.

Adult↗

PubMed1992

Folded lung: a masquerader of malignancy.

Four cases of folded lung were observed over an 8-year period up to 1990. Because of suspected malignancy, three patients underwent exploratory thoracotomy, without subsequent morbidity or mortality, but the fourth patient declined surgery. Although folded lung may have characteristic computed tomographic features, these may be mimicked by carcinoma. If the patient is fit enough, exploratory thoracotomy is advisable in order to establish the diagnosis and permit resection of the lesion, if indicated, while avoiding the risks entailed by false negative CT scan and needle biopsy.

Aged↗

PubMed1990

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.

Equipment Design↗