Biomedical subjects
Publications and source records attributed to E W Cameron.
Injuries to the major pulmonary vessels are uncommon and are extremely difficult to manage. We report a case of an isolated pulmonary vein injury following a road traffic accident that was repaired successfully.
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A 66-year-old woman with a 3-month history of progressive dysphagia underwent transoral excision of a pedunculated cyst arising in the proximal esophagus. Histologic examination confirmed a pedunculated intraluminal foregut reduplication cyst. She remains well 1 year after excision with no recurrence of dysphagia.
BACKGROUND: There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious. METHODS: The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period. RESULTS: The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged. CONCLUSIONS: Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.
Pulmonary capillary hemangiomatosis is a rare disorder that is characterized pathologically by formation of capillaries along alveolar walls that may ultimately invade the pulmonary parenchyma and pulmonary arteries. The clinic presentation overlaps that of primary pulmonary hypertension, but the natural history of pulmonary capillary hemangiomatosis is one of rapid deterioration. The typical radiographic appearance is a diffuse bilateral reticulonodular pattern associated with enlarged central pulmonary arteries.
Amyloid deposition is an important cause of morbidity in long-term hemodialysis patients, but it has rarely been reported in the sternoclavicular joint, where the clinical picture may be consistent with an infection. The imaging features of one case are discussed. Biopsy with specific staining for the beta-2 microglobulin component of amyloid should be considered in the work up of a lesion of this joint in this clinical setting.
Chest drain placement is essential to the management of patients with abnormal thoracic collections of air or fluid. Frequently, in these critically ill patients, drain position can only be assessed by portable frontal radiographs. However, evaluation by axial chest CT in some cases reveals unexpected malplacement that may prompt repositioning to reduce morbidity and improve drain function.
The prediction of requirement for, and short- and long-term outcome of, prolonged mechanical ventilation after cardiac surgery is ill-defined. The aims of this study were to isolate any predictive indices which might identify those groups of patients who may require prolonged ventilation postoperatively and to determine which factors significantly affect outcome in the prolonged-ventilation group. Following case note review of 139 consecutive cardiac surgical patients ventilated for > or = 7 days following surgery, 43 factors were recorded on each patient, including smoking, pulmonary function, chest infection, and chronic obstructive airways disease. Of 139 patients, 89 were discharged from hospital (64% survival); of these, 52 were alive at long-term follow-up (58% long-term survival). Statistical analysis identified urban residence, chronic obstructive airways disease, prolonged operation, and bypass time as significant predictors of requirement for prolonged ventilation postoperatively. On multivariate analysis five factors were predictive of increased intensive care mortality, including urban residence, inotrope days, sepsis, perioperative cerebrovascular accident and coagulopathy requiring fresh frozen plasma transfusion postoperatively. Following discharge from hospital, four factors were found to be significant predictors of increased mortality: these are impaired preoperative ejection fraction, increasing age, impaired preoperative pulmonary function, and abscence of preoperative aspirin medication. These factors should be considered in intensive care planning, long-term follow-up and importantly on clinical decision making in the individual patient.
A casenote review identified 18 patients with carcinoma of the oesophagus and gastric cardia who underwent transthoracic oesophagectomy after instrumental perforation. Oesophagectomy was performed within 48 h in ten patients (early surgery group) and after a median delay of 22 (range 5-48) days in eight patients (delayed surgery group). All patients underwent resection via left thoracolaparotomy with immediate intrathoracic anastomosis using the stomach in 17 of 18 patients. There were no anastomotic leaks. Significant postoperative complications occurred in five of ten of the early group with two in-hospital deaths and a mean survival of 551 days. Six of eight patients in the delayed group developed postoperative complications with two in-hospital deaths and a mean survival of 297 days. Transthoracic resection with immediate intrathoracic anastomosis can be performed without anastomotic leakage but there is high associated respiratory morbidity. The timing of oesophagectomy has little effect on hospital morbidity or mortality rates but early surgery is associated with better long-term survival.
BACKGROUND: Esophageal carcinoma is predominantly a disease of the elderly, a group often only considered for palliative therapies. METHODS: A case note review identified 31 octogenarians undergoing resection for carcinoma of the esophagus or gastric cardia over a 12-year period ending December 1994. RESULTS: Nineteen patients made either an uncomplicated postoperative recovery (n = 12) or suffered minor complications (n = 7). Of the 12 patients who suffered moderate or severe complications, 5 died (in-hospital mortality, 16%). The deaths included 2 of 3 patients who underwent emergency operation for esophageal perforation and 3 of 28 patients who underwent elective esophagectomy (elective mortality rate, 10.7%). Nineteen of the 26 survivors (73%) experienced no further dysphagia. The 5-year survival rate was 17%. CONCLUSIONS: Elective esophageal resection can be performed safety in selected octogenarians who have no or few coexisting medical problems and present with a localized carcinoma that is technically easy to resect. Patients undergoing emergency operations or in whom moderate or severe postoperative complications develop often have poor physiologic reserve and are therefore at risk of early postoperative death.
A 48-year-old man with B-cell lymphoma of the stomach was seen with recurrent pneumonia, weight loss, and anorexia. A barium study revealed a large malignant gastric ulcer with a gastrobronchial fistula. A computed tomography (CT) scan of the abdomen showed a gastric neoplasm invading the left lower lobe of the lung and the spleen.
Gestational trophoblastic tumour (GTT) of the uterus can cause severe and even life threatening haemorrhage in patients who may be contemplating future pregnancy. Three cases of successful pregnancy after uterine artery embolization to control severe haemorrhage from uterine GTT are reported. Both uterine arteries had been selectively catheterized and embolized in these patients. The areas of pathological circulation measured on the pre- and post-embolization films had been reduced by over 80%. Embolization failed to control haemorrhage in another four patients in whom the uterine arteries had not been selectively catheterized and embolized and where the embolization procedures had reduced the areas of pathological circulation by less than 65%. The conclusions are that control of severe haemorrhage from uterine GTT is likely if both uterine arteries are selectively catheterized and embolized. Patients thus treated can become pregnant.
One hundred patients with carcinoma of the distal oesophagus or gastric cardia undergoing oesophagogastrectomy were randomized to receive either a stapled or handsewn oesophagogastric anastomosis. Five patients died in the early post-operative period at a mean of 16 days (in-hospital mortality 5%) allowing detailed follow up on the remaining 95 patients who were followed up to death or for a minimum of 36 months. A stapled anastomosis was quicker to perform (P < 0.001), resulting in a shorter operative time (P < 0.005) and was associated with decreased blood loss (P < 0.05). The number of anastomotic leaks, length of in-patient stay, stricture formation and survival in the two groups was not statistically different. A stapled oesophagogastric anastomosis fulfills all of the requirements for routine use in thoracic surgical practice when performing oesophageal resection for carcinoma of the distal oesophagus or gastric cardia. It is quick to perform allowing a shorter operating time and lower blood loss and does not appear to be associated with a previously noted increased incidence of benign anastomotic stricture formation when compared with handsewn anastomoses.
Oesophagogastrectomy for carcinoma of the oesophagus or gastric cardia has been reported as being associated with a poorer outcome in young adults than in older patients in an Oriental population. A retrospective analysis of 597 patients who underwent oesophagogastrectomy for carcinoma was undertaken to ascertain if resection in younger Scottish patients was associated with the same poorer outcome. Forty-seven patients aged less than 50 years were compared with 323 patients aged 50-69 years and 227 patients aged 70 years and older. Young patients had a higher incidence of distal third oesophageal tumours than older patients, who tended to have carcinomas of the gastric cardia. There were no differences with regard to tumour pathology, stage, extent of resection, hospital mortality or survival. In Scotland, carcinoma of the oesophagus or gastric cardia in young adults behaves similarly to that in older patients, and survival following resection is independent of age.
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Primary small-cell cancer of the esophagus is a rare tumor that disseminates early with a uniformly poor prognosis if untreated. Sixteen patients with malignant dysphagia referred to the Thoracic Surgical Unit, City Hospital, Edinburgh, within a 10-year period had a diagnosis of primary small-cell cancer of the esophagus. Seven patients underwent subtotal esophagectomy or esophagogastrectomy, either alone or with adjuvant chemotherapy or radiotherapy, with a mean survival of 20 months (standard deviation 35.4 months, range 2 weeks to 96 months). The remaining nine patients had disseminated disease when they were first seen and were treated symptomatically by intubation alone (1 patient), intubation and palliative chemotherapy or radiotherapy (3 patients), palliative chemotherapy (2 patients), palliative radiotherapy (1 patient), or no therapy (2 patients), with a mean survival of 4.8 months (standard deviation 2.6 months, range 2 to 9 months). Patients seen with this aggressive tumor should be assessed urgently for evidence of metastatic spread and then offered resection in combination with chemotherapy if they are otherwise fit for operation. This treatment regimen has given us one long-term survivor (96 months) who, we believe, is the only patient to have been cured of this condition. Patients seen with disseminated disease should have symptomatic treatment of the dysphagia combined with palliative chemotherapy.
Predictors of outcome in long-stay patients following cardiac surgery have hitherto been ill defined. The aims of this study were to test the Parsonnet pre-operative scoring system and to define a scoring system for inhospital mortality applicable post-operatively to strengthen the clinical decision-making process. Following case note review of 262 consecutive patients who stayed 7 days or more in intensive care, a total of 110 pre-, intra- and post-operative factors were documented. In this long-stay group the Parsonnet score was confirmed to be predictive of 30 day mortality. Univariate analysis identified significant association between mortality in the Intensive Care Unit (ICU) and the following: inotrope days, (defined as number of inotropes times number of days) ventilation, units of platelets (P = < 0.00001), chest reopening, fresh frozen plasma units (P < 0.002), total parenteral nutrition, noradrenaline, Parsonnet score (P = 0.005), dopamine, bypass time, vasodilators, intra-aortic balloon counterpulsation, enteral nutrition and other major surgery (P < 0.05). Stepwise logistic regression on these significant factors was used to produce the Edinburgh Cardiac Surgery Score (ECS) applicable from Day 10 onwards in the intensive care unit: ECS Score = (Inotrope days) +2 (Ventilation) + (Platelets) + (Parsonnet) -3. The ECS score may be a useful predictor of ICU mortality probability for cardiac surgical patients requiring 10 days or more intensive care and is presently undergoing prospective evaluation in our centre.
We have reviewed 70 consecutive elderly patients (70 years or older) who underwent pneumonectomy for bronchogenic carcinoma, in order to evaluate morbidity, mortality, and long-term survival. The majority of the patients had stage II (n = 32) or III (n = 25) disease. Fifteen deaths occurred in the peri-operative period (21%). Pre-operative factors associated with peri-operative death included a history of ischaemic heart disease (P = 0.001) and right-sided tumour (peri-operative mortality for right pneumonectomy = 37%, left pneumonectomy = 6%, P = 0.001). Poor lung function (as assessed by pre-operative spirometry), peripheral vascular disease, cerebrovascular disease, diabetes mellitus, and hypertension were not significant risk factors for peri-operative death. Post-operatively, the requirement for ventilation, or the development of post-operative myocardial infarction, adult respiratory distress syndrome and respiratory failure were significantly associated with peri-operative death. Over 60% of the patients developed one or more complications. The absolute survival rates for operative survivors were 51% and 27% at 1 and 5 years, respectively (stage I, 60% and 40%; stage II, 63% and 33%; stage III 33% and 14%). The absolute overall survival rates were 40% and 21% at 1 and 5 years, respectively. We conclude that pneumonectomy is justified in elderly patients but right-sided lesions and ischaemic heart disease should be considered as relative contra-indications.