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Biomedical subjects

S Sabanathan

Publications and source records attributed to S Sabanathan.

At least 19 recordsLinked to original sources
PubMed2003

Bronchoscopic lung volume reduction.

AIM: Because traditional lung volume reduction involves major surgery in unfit patients, resource implications are formidable. Many patients are too ill for consideration and overall survival rates have lead to questions about its continuation. We report on a new method of lung volume reduction, through a bronchoscopic approach. Patients with severe dyspnoea with end stage emphysema were recruited. Target areas for collapse therapy were upper lobes or segments with severe destruction, occupying a large volume, with surrounding lung compression and little perfusion. These were delineated radiologically and with ventilation-perfusion scanning. Endobronchial bloc-kade was initially with detachable, silicone balloons and later with especially designed and hospital manufactured stainless steel wire stents containing bio-compatible sponge. METHODS: Five males and 3 females with preoperative breathlessness at rest and muscle wasting were treated. Operative time was a mean of 67.5 min. Rehabilitation began immediately and 7 patients left hospital the following day. RESULTS: Five patients had improvements in well-being, dyspnoea, exercise tolerance, lifestyles and medication requirements. One patient survived at least 2 years and 2 are still alive 4(1/2) years later. Endoscopic balloon replacement with wire and sponge devices was required in 5 patients. Complications were related to intraoperative oxygenation problems in 2 patients and late infections in 4. CONCLUSIONS: Bronchoscopic lung volume reduction for the treatment of end-stage emphysema subjectively improved the majority of patients. The use of stents was promising: balloons were disappointing.

Aged↗
PubMed1999

A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.

Both epidural and paravertebral blocks are effective in controlling post-thoracotomy pain, but comparison of preoperative and balanced techniques, measuring pulmonary function and stress responses, has not been undertaken previously. We studied 100 adult patients, premedicated with morphine and diclofenac, allocated randomly to receive thoracic epidural bupivacaine or thoracic paravertebral bupivacaine as preoperative bolus doses followed by continuous infusions. All patients also received diclofenac and patient-controlled morphine. Significantly lower visual analogue pain scores at rest and on coughing were found in the paravertebral group and patient-controlled morphine requirements were less. Pulmonary function was significantly better preserved in the paravertebral group who had higher oxygen saturations and less postoperative respiratory morbidity. There was a significant increase in plasma concentrations of cortisol from baseline in both the epidural and paravertebral groups and in plasma glucose concentrations in the epidural group, but no significant change from baseline in plasma glucose in the paravertebral group. Areas under the plasma concentration vs time curves for cortisol and glucose were significantly lower in the paravertebral groups. Side effects, especially nausea, vomiting and hypotension, were troublesome only in the epidural group. We conclude that with these regimens, paravertebral block was superior to epidural bupivacaine.

Adolescent↗
PubMed1999

Oesophagogastrectomy in the elderly high risk patients: role of effective regional analgesia and early mobilisation.

BACKGROUND: Oesophagogastrectomy is the best available treatment for patients with carcinoma of the oesophagus or cardia. However, surgical resection may lead to increased mortality, morbidity and longer hospital stays in elderly (aged over 70 years) high risk patients. METHODS: To assess the impact of balanced pre-emptive and postoperative analgesia combined with early mobilisation in elderly patients undergoing oesophagogastrectomy we consecutively studied 52 patients (30 male, 22 female) of 75+/-4.2 years of age (mean+/-SD). Pre-emptive analgesia was by pre-incisional percutaneous paravertebral block combined with an opiate and a nonsteroidal anti-inflammatory drug (NSAID) premedication. Postoperative maintenance analgesia was by NSAID and continuous extrapleural intercostal nerve block. Following surgery all but three patients were returned to the ward. RESULTS: The hospital mortality rate was 7.6%. Morbidity caused by cardiovascular (27%), respiratory (23%) and cerebrovascular (19%) complications occurred in 19 patients, with two patients requiring ventilatory support. The mean hospital stay for the survivors was 10 days (range 8 to 30 days). All the survivors had their swallowing restored to normal and returned to their accustomed environment. CONCLUSIONS: These data suggests that surgical treatment can be achieved in the elderly high risk patients with acceptable mortality and morbidity. This is achieved by early mobilisation enabled by balanced pre-emptive and postoperative analgesia.

Aged↗
PubMed1999

Post-thoracotomy spirometric lung function: the effect of analgesia. A review.

BACKGROUND: The effects of postthoracotomy pain management on pulmonary function has been assessed. METHODS: All English language publications involving prospective, randomised, controlled studies of patients undergoing postero-lateral thoracotomy incisions where perioperative spirometry had been studied were included. The mean postoperative percentage preservation of preoperative lung function was recorded or determined for each analgesic regimen. RESULTS: 55 studies were reviewed with a total of 1762 patients. The most effective analgesic method in terms of preservation of spirometric function was paravertebral analgesia, patients having approximately 75% of their preoperative values in the first 48 hours after surgery. Most other techniques e.g. intercostal nerve blocks, epidural local anaesthetics or local anaesthetic-opiate combinations produced approximately a 55% preservation by 48 hours. Interpleural analgesia was the least effective, with a mean of 35% preservation by 48 hours, less even than TENS or cryoanalgesia. CONCLUSIONS: A thoracotomy potentially produces a marked reduction in postoperative pulmonary function and the choice of pain management has major implications. Attenuation of postthoracotomy pulmonary dysfunction by effective analgesia should be provided for all patients undergoing chest surgery. Simply providing effective analgesia on its own without regard to pulmonary function is inadequate. Spirometric monitoring should be standard in all thoracic units and is essential for objective comparisons of the efficacy of different methods of pain management.

Analgesia↗
PubMed1998

Pleural bupivacaine placement for optimal postthoracotomy pulmonary function: a prospective, randomized study.

OBJECTIVE: To determine dependent chest tube losses of bupivacaine with paravertebral versus interpleural administration, thereby helping to explain the significant differences in pulmonary function that exist between these two techniques. DESIGN: A prospective, randomized study. SETTING: A single hospital. PARTICIPANTS: Twelve adult patients undergoing posterolateral thoracotomies. INTERVENTIONS: Paravertebral or interpleural administration of bupivacaine. MEASUREMENTS AND MAIN RESULTS: Analgesia, as assessed by visual analog pain scores and patient-controlled morphine requirements, was similar in both groups. Postoperative spirometric values were significantly better at most times with the paravertebral route of administration. Dependent chest tube bupivacaine losses were approximately four times higher in the interpleural group. CONCLUSION: Local anesthetic on the diaphragm might actively impair respiratory function through diaphragmatic and abdominal muscle weakness, while failing to contribute to pain relief.

Aged↗
PubMed1998

Lung volume reduction surgery for emphysema. A review.

Lung volume reduction surgery is emerging as a promising treatment option for selected patients with severe, debilitating end-stage emphysema refractory to medical management. Lung volume reduction surgery involves the removal of space occupying severely diseased, slowly ventilating and hyperexpanded lung, thus allowing the better conserved adjoining lung parenchyma to expand into the vacated space and function effectively. The operation can be accomplished by unilateral or bilateral thoracoscopy, thoracotomy or median sternotomy. The most emphysematous areas are excised using stapling or laser techniques or both. This review summarises the results of lung volume reduction surgery performed by various operative techniques. Results indicate that in the majority of patients improvement occurs in subjective dyspnoea and objective pulmonary function while oxygen and steroid dependence are reduced or eliminated at the cost of acceptable mortality and morbidity. Even though bilateral procedures produced much greater improvement, it is emphasized that it is the lung resection and not the operative approach that is critical to the success of the operation. Regardless of the technique used, the surgical treatment of emphysema is palliative in nature.

Endoscopy↗
PubMed1997

Surgical treatment of primary malignant chest wall tumours.

OBJECTIVE: Primary malignant tumours of the bony chest wall are uncommon and data concerning treatment and results are sparse. METHODS: To assess the results of surgical resection and chest wall reconstruction we reviewed our experience with primary malignant chest wall tumours treated since 1958. RESULTS: Of the 49 lesions, 42 were found in the ribs and the remaining 7 in the sternum. These included chondrosarcomas [22], solitary plasmacytoma [18], Ewing's tumours [7], Askin's tumour [1] and Desmoid tumour [1]. Skeletal reconstruction was performed in 36 of the 49 patients. Marlex mesh alone was used in 17 patients. Since 1972, a sandwich of two layers of Marlex mesh with a filler of methyl methacrylate was utilised [19] successfully, producing better functional and cosmetic results. Primary soft tissue closure was possible in all but 8 cases in whom latissimus dorsi myocutaneous flaps were used. Bilaterally, partially transposed pectoralis major muscle was used to cover upper sternal defects in 4 cases. All but 1 patient had an uneventful post-operative recovery none requiring ventilatory support. SURVIVAL: Overall survival at 5 and 10 years was 68%. The differential figures for 10-year survival were for chondrosarcoma 67%, Ewing's sarcoma 43%, and solitary plasmacytoma 59%. These were the results of radical en-bloc excisions. The patient with Desmoid tumour is alive at 5 years, following incomplete initial resection and the patient with Askin's tumour survived for 3 years. CONCLUSION: Radical en-bloc excision remains the treatment of choice in all primary malignant chest wall neoplasms except large solitary plasmacytomas where incisional biopsy followed by irradiation appears to be the method of preference. In Ewing's and Askin's tumours, additional chemotherapy and radiotherapy have to be used. The extent of surgical excision should only be limited by the amount of tissue necessary to remove for adequate malignant tissue clearance, since even large defects can be reconstructed with little functional disturbance.

Adult↗
PubMed1997

Carcinoid tumour of the lung.

A retrospective analysis of 29 patients with carcinoid tumour of the lung treated between 1980 to 1995 is presented. There were 15 females and 14 males with a mean age of 57 years (range 28-72). Fourteen of the 29 carcinoids were peripheral and the remaining 15 were central. Preoperative histology was available in 17. Surgical resection was carried out in 27 patients, one patient was unfit whilst the other patient had multiple liver metastases at presentation. Surgical treatment offered were lobectomy (n = 19), pneumonectomy (n = 3), sleeve lobectomy (n = 3) and segmentectomy (n = 2). Twenty three patients were stage 1 tumours, 3 were stage II and one was stage III and 1 was stage IV. Postoperative histology confirmed typical carcinoids in 24 patients and the remaining 5 were atypical. There was one perioperative death from massive pulmonary embolism and there was no morbidity. Overall five year survival rate for patients with carcinoid was 96.4%. Five year survival for typical carcinoid and that of atypical carcinoid was 100% and 77.8% respectively. Typical carcinoids carry an excellent prognosis and should be offered conservative lung resection, whilst atypical carcinoids which behave aggressively should be treated by radical lung resections.

Carcinoid Tumor↗
PubMed1997

Continuous paravertebral block for post thoracotomy analgesia in children.

The use of continuous paravertebral analgesia was studied in 15 children with a mean age of 9.8 years (2-16 years). Nine patients received pre-emptive and postoperative paravertebral analgesia while six children studied earlier in the series received only post operative paravertebral analgesia. Excellent pain relief was attained in all patients, as assessed by the graded pictures of facial expression or visual analogue pain scores and morphine requirements. There were no pulmonary complications and no complications related to the continuous paravertebral infusion of bupivacaine. We conclude that continuous paravertebral block is an effective and safe method for post thoracotomy pain relief in children.

Adolescent↗
PubMed1996

Stenting in malignant obstruction of superior vena cava.

The treatment of patients with malignant superior vena caval obstruction with minimal morbidity has been made possible by the recent introduction of expandable metal stents as the sole palliative treatment or as an adjunct to other treatment modalities. To alleviate the distressing symptoms of superior vena caval obstruction, self-expanding metal stents were used successfully in 12 (Wallstent device in 6 and Gianturco device in 6 patients) of 13 patients. The diagnoses were small cell carcinoma (n = 4), squamous cell carcinoma (n = 4), non-Hodgkin's lymphoma (n = 1), and mesothelioma (n = 1), and a diagnosis of malignancy was not confirmed (although strongly suspected) in the remaining three cases. Eleven patients had immediate relief of obstruction and there was no change in one patient. Mean follow-up was 3.7 months (range 1 to 10 months). Excellent palliation was obtained in all but one patient in whom recurrent superior vena caval obstruction developed 3 months after stenting. Mean survival was 4.8 months (range 1 to 10 months). The ease of insertion with the use of local anesthesia with radiologic control, the self-expanding nature of the stent, and the lack of major complications on follow-up of up to 10 months are particular advantages. The self-expanding superior vena caval stents are a useful addition to our armamentarium in the management of malignant superior vena caval obstruction.

Aged↗
PubMed1996

Thoracic paravertebral space location. A new method using pressure measurement.

The major drawback of paravertebral space location using the traditional method of loss of resistance to air or saline is a failure rate of at least 10%. We investigated whether pressure measurement during needle advancement could improve reliability. Twenty-nine blocks in 14 awake adult patients undergoing treatment for chronically painful neuralgic conditions of the chest or abdominal wall were studied. In erector spinae, the mean inspiratory pressure (29.5 mmHg, SD 14.2), exceeded the expiratory pressure (19.4 mmHg, SD 9.7). However, upon traversing the superior costo-transverse ligament, there was a sudden lowering of pressures and the mean expiratory pressure (7.6 mmHg, SD 3.7) exceeded the inspiratory pressure (3.3 mmHg, SD 2.9). No negative pressures were recorded. Correct needle placement was confirmed by X ray screening and contrast injection. All blocks were successful and uncomplicated. Location of the paravertebral space by this objective method of 'pressure inversion' improves sensitivity and specificity and should lead to an improvement in the success rate of thoracic paravertebral analgesia.

Adult↗
PubMed1996

Results of surgical treatment of stage I and II lung cancer.

Pulmonary resection remains the most appropriate treatment for localised bronchogenic carcinoma, since prognosis and outcome are currently dependent on surgical resectability. A retrospective analysis of our experience with three hundred and thirteen stage I (n=250) and stage II (n=63) patients treated surgically form the basis of this report. The initial pulmonary resection was lobectomy in 173 patients, bilobectomy in 38, sleeve lobectomy in 12, pneumonectomy in 59, wedge excision or segmentectomy in 31. The overall operative mortality was 3.2%; 4.03% for lobectomy and 1.6% for pneumonectomy. Morbidity was observed in 21 (6.7%) patients. Four out of sixteen small cell carcinoma patients had postoperative adjuvant chemotherapy. Survival in patients with stage I tumours was 71% at 5 years and 61% at 10 years compared with 41% at 5 years and 35% at 10 years for patients with stage II disease. The five year survival after pneumonectomy was significantly (p<0.05) better for both stage I and stage II lung cancer than after lobectomy. Five year survival in stage I carcinoma was not influenced by histological type, while there was statistically significant difference (p<0.05) in survival between adenocarcinoma (0%) and squamous cell carcinoma (46%) in stage II disease. We conclude that an aggressive surgical approach can provide an excellent prognosis for recovery and long term cure in most patients with early stage lung cancer.

Carcinoma, Bronchogenic↗
PubMed1996

Results of surgical treatment of oesophageal cancer.

Oesophagogastrectomy is the best available treatment for patients with carcinoma of the oesophagus or cardia. A retrospective analysis of our experience with 485 patients who were treated surgically forms the basis of this report. Of the 317 patients who underwent resection (resectability rate of 65%) only 210 were considered to be potentially curative. Overall, the 5-year survival rate for oesophageal cancer was 3%, whilst curative resection had a 5-year survival rate of 22% and varied according to stages. Five-year survival rate was 67.7% for patients with Stage I disease compared with 27.6, 9.4 and 6.4% for Stages IIa, IIb and III disease respectively. There were no 5-year survivors with Stage IV disease or with those patients who underwent an incomplete resection. Curative resection carried a mortality rate of 3.8%, whereas incomplete resection or palliative procedure carried higher mortality rates of 14 and 20.7% respectively. Adequate post-operative analgesia was provided by continuous extrapleural intercostal nerve block. Morbidity, mainly caused by respiratory complications, occurred in 30 patients (6.2%), with three patients requiring ventilatory support. Outcome was influenced mostly by the extent of the disease and the completeness of surgical resection rather than by histological type. We conclude that surgical treatment provides better longevity than any other type of therapy and remains the standard against which combined modality treatment should be compared. Our experience suggests that surgical treatment can be achieved with minimal morbidity and mortality.

Aged↗