Biomedical subjects
Publications and source records attributed to F M Shamji.
Angiosarcoma is a rare and highly malignant tumor of vascular origin. The causative factors include trauma, radiation, foreign bodies, thorium dioxide, and viral infections. We report a case of angiosarcoma occurring in a thoracotomy incision 17 years after operation for stage I lung cancer.
AIM: Achalasia is a disease of the oesophagus characterized by increased lower oesophageal sphincter (LOS) tone, absence of LOS relaxation with swallowing and aperistalsis of the body of the oesophagus. The aetiology and pathogenesis of idiopathic achalasia is still controversial. METHODS AND RESULTS: We examined 16 oesophageal biopsies and one low oesophagectomy specimen from patients with achalasia. The control group was composed of five autopsy cases with no history of oesophageal disorders, three cases of diffuse oesophageal spasm, one of gastro-oesophageal reflux disease and one patient with oesophageal carcinoma. Sections were immunostained for neurofilaments NF70 and NF200, S100 protein and neurone-specific enolase. Biopsies with inflammatory infiltrates, were in addition immunostained with antibodies against leucocyte common antigen as well as for CD20, CD43, CD68 and CD45RO. All biopsies were examined after plastic embedding, and electron microscopy (EM) was performed on samples containing autonomic plexus. An inflammatory infiltrate of varying intensity was present along the nerve fascicles and around ganglion cells in 90% of the cases of achalasia. T-lymphocytes predominated in all these cases. The autonomic nerves showed loss of fibres and degenerative changes which were discernible only by EM. Although there was no convincing neuronal loss or signs of active neuronal degeneration in biopsied cases, the oesophagectomy specimen revealed total absence of neurones and significant loss of nerve fibres. The control group showed normal plexuses and no inflammation. CONCLUSION: Degeneration and significant loss of nerve fibres associated with predominant T-cell lymphocytic inflammatory infiltrate around the myenteric plexus support the concept for the inflammatory, probably autoimmune, aetiology of autonomic nervous system injury in primary achalasia.
STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.
OBJECTIVE: The authors set out to determine whether immediate enteral feeding minimizes early postoperative decreases in handgrip and respiratory muscle strength. SUMMARY BACKGROUND DATA: Muscle strength decreases considerably after major surgical procedures. Enteral feeding has been shown to restore strength rapidly in other clinical settings. METHODS: A randomized, controlled, nonblinded clinical trial was conducted in patients undergoing esophagectomy or pancreatoduodenectomy who received immediate postoperative enteral feeding via jejunostomy (fed, n = 13), or no enteral feeding during the first 6 postoperative days (unfed, n = 15). Handgrip strength, vital capacity, forced expiratory volume in one second (FEV1), and maximal inspiratory pressure (MIP) were measured before surgery and on postoperative days 2, 4, and 6. Fatigue and vigor were evaluated before surgery and on postoperative day 6. Mobility was assessed daily after surgery using a standardized descriptive scale. Postoperative urine biochemistry was evaluated in daily 24-hour collections. RESULTS: Postoperative vital capacity (p < 0.05) and FEV1 (p = 0.07) were consistently lower (18%-29%) in the fed group than in the unfed group, whereas grip strength and maximal inspiratory pressure were not significantly different. Postoperative mobility also was lower in the fed patients (p < 0.05) and tended to recover less rapidly (p = 0.07). Fatigue increased and vigor decreased after surgery (both p < or = 0.001), but changes were similar in the fed and unfed groups. Intensive care unit and postoperative hospital stay did not differ between groups. CONCLUSIONS: Immediate postoperative jejunal feeding was associated with impaired respiratory mechanics and postoperative mobility and did not influence the loss of muscle strength or the increase in fatigue, which occurred after major surgery. Immediate postoperative enteral feeding should not be routine in well-nourished patients at low risk of nutrition-related complications.
BACKGROUND: Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum. METHODS: The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added. RESULTS: Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05). CONCLUSIONS: Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.
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To avoid the laborious task of investigating the cerebrovascular circulation in the midst of a trachea-innominate artery fistula, we strongly recommend preoperative cerebrovascular investigations in all patients about to undergo mediastinal tracheostomy. Paramount to this dictum remains the possibility of asymptomatic cerebrovascular disease. Inadequate preoperative cerebrovascular assessment may result in, as described in this report, the possibility of significant postoperative neurologic morbidity or mortality. Angiography should assist the surgeon in deciding which method of cerebral arterial reconstruction is best suited to the individual circumstance. We recommend the avoidance of innominate artery reconstruction even with the interposition of autologous tissues, as the operative field remains grossly infected.
BACKGROUND: Previous reports have described bronchial obstruction after left pneumonectomy (so-called post-pneumonectomy syndrome) in the presence of a right aortic arch with the bronchus being compressed between the ascending aorta and thoracic spine. This study reports on 4 patients with left postpneumonectomy syndrome in the presence of a normally located left aortic arch and ascending thoracic aorta. METHODS: The case histories of 4 patients with this syndrome were reviewed and several features common to all 4 were noted. In each case, the obstruction was thought to be due to a clockwise rotation of the mediastinum with bronchial compression occurring between the right main pulmonary artery and thoracic spine. RESULTS: Three patients were treated by repositioning of the mediastinum, and all 3 obtained relief of their dyspnea. In these cases, permanent repositioning was ensured by the insertion of a prosthesis filled with saline solution. The fourth patient was successfully treated by resection of a portion of the adjacent thoracic vertebra. CONCLUSIONS: Postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms.
Ischemia of the gastric tube during use as an esophageal substitute may have serious consequences. We describe a method to correct substernal gastric tube ischemia using the left internal thoracic artery as a source of arterial inflow to a short gastric artery. This permitted successful reconstruction of the upper alimentary tract in this patient.
Cystic and bullous diseases of the lung are of special interest, referring to a wide variety of pathologic conditions. A thorough knowledge of these conditions and associated pathophysiology is necessary in planning the best type of treatment.
Contrary to the issues of perioperative morbidity and survival following surgery for lung cancer, little attention has been given to quality-of-life. To address this, quality-of-life was assessed preoperatively and 1, 3, 6 and 9 months postoperatively in a cohort of 117 consecutive subjects who underwent thoracotomy with a certain or presumptive diagnosis of lung cancer. Those with cancer (n = 91) confirmed at thoracotomy were contrasted to those without (n = 26). Moderate to severe dyspnea, reported in 14% preoperatively, increased to 34% at 1 and 3 months (p < 0.005) but returned to approximately 10% at 6 and 9 months. Similarly, activities of daily living were impaired in 11% preoperatively; this disability increased to 21% at 1 month (p < 0.005), and returned to baseline at 6 and 9 months. Those with cancer compared to those without a postoperative diagnosis of cancer had similar quality-of-life preoperatively but deteriorated more in the postoperative period. This study demonstrates that important deterioration in quality-of-life occurs during the first 3 months postoperatively in those with a final diagnosis of cancer but improvement back to baseline can be expected thereafter.
Systemic arterial supply to the lung without sequestration is an unusual vascular anomaly in which a portion of normal lung tissue is supplied by an artery arising from the aorta. This entity shares some features with bronchopulmonary sequestration and hypogenetic lung (scimitar syndrome) but has unique imaging features that allow preoperative diagnosis. The authors describe such a case in a 21-year-old man who presented with hemoptysis.
We report a malignant hyperthermia-susceptible patient who required investigation for a large, symptomatic anterior mediastinal mass. Multiple attempts at tissue diagnosis under local anaesthesia were unsuccessful. Following awake fibreoptic tracheal intubation, general anaesthesia was administered using ketamine, midazolam, and nitrous oxide, maintaining spontaneous ventilation. Prophylactic dantrolene was not used, to avoid potential muscle weakness and respiratory compromise. Diagnostic mediastinotomy was performed without incident. We conclude that ketamine anaesthesia is appropriate for patients with anterior mediastinal masses, and is considered safe in malignant hyperthermia-susceptible patients.
Chylothorax complicating pulmonary resections is exceptional and management of this complication remains controversial. We report a case of chylothorax after a right pneumonectomy and radical subcarinal nodal dissection. Successful nonoperative management consisted of controlled tube drainage, fasting, and total parenteral nutritional support for a period of 2 weeks. A review of the literature reveals 27 other cases of this complication after intrapleural pneumonectomy: 12 were treated by conservative measures alone and 15 required surgical intervention. Factors that will determine the management and the ultimate success of conservative management include (1) a relative delay in initial occurrence, (2) a decrease in or complete cessation of leakage while receiving total parenteral nutrition, and (3) favorable lymphangiographic findings.
A 72-year-old acyanotic woman had development of acute right heart failure with systemic hypotension 2 hours after a curative right intrapericardial pneumonectomy for primary lung cancer. A postoperative pulmonary angiogram revealed a major left to right shunt through previously unsuspected partial anomalous venous drainage of the left upper lobe of the lung.
Of special concern in the management of neurogenic tumours arising in the thorax is spinal-cord compression resulting from either intraspinal lesions or vertebral-body destruction and collapse. A review of 16 cases disclosed three dumbbell tumours, six intrathoracic tumours, one case of neurofibromatosis with multiple intraspinal neurogenic tumours, two malignant neurogenic tumours with vertebral-body destruction causing spinal-cord compression and four foraminal lesions with central intraspinal (extradural) extension. There were 3 men and 13 women, ranging in age at the time of operation from 37 to 79 years. Three patients, of the six with intrathoracic tumours, were asymptomatic; the remaining 13 had preoperative symptoms ranging in duration from 3 weeks to 12 months (average, 9 months). Back pain with intercostal neuralgia was present in eight patients and neurologic signs were present in six patients. A routine chest radiograph was abnormal in 10 patients, and x-rays of the thoracic spine were abnormal in 4 of the other 6 patients. The tumour was excised surgically in all patients. Complications developed postoperatively in two patients: one had Horner's syndrome, transient paraparesis and bleeding; the other had a small subarachnoid-cutaneous fistula. The authors conclude that dumbbell neurogenic tumours and those causing vertebral-body destruction and collapse demand a multidisciplinary one-stage surgical approach. If the lesion is malignant and resection is not complete, radiotherapy or chemotherapy is necessary.
Percutaneous embolization of the bronchial arteries to control massive or recurrent hemoptysis has become an accepted procedure, especially in treating patients with chronic pulmonary disease who are poor candidates for lung resection. Nonbronchial systemic collateral arteries and pulmonary arteries may contribute significantly to pulmonary hemorrhage, but embolization of these vessels has not been stressed in recent literature. When embolization of the bronchial artery fails to control hemoptysis, nonbronchial systemic collateral arteries should be embolized. If no systemic collaterals are present, then embolization of segmental pulmonary arteries may prove helpful.
Cystic disease of the lung should be considered in the differential diagnosis of any patient presenting with respiratory symptoms. The most important aids available to the thoracic surgeon for the evaluation of cystic disease are history, physical examination, and chest radiograph. Confirmation of diagnosis often requires computed tomography, pulmonary and thoracic aortic angiography, and upper gastrointestinal barium series.