Charles L. Roper

The current role of mediastinoscopy in the evaluation of thoracic disease

OBJECTIVE Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease. METHODS We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998. RESULTS We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease. CONCLUSIONS Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.

Percutaneous Transthoracic Aspiration Needle Biopsy

An experience based on 1,211 patients has shown aspiration needle biopsy to be a valuable technique for diagnosing bronchogenic carcinoma and other localized intrathoracic lesions that are beyond the reach of the fiberoptic bronchoscope. In 896 patients with malignant intrathoracic neoplasm, the aspirate demonstrated malignant cells in 96%. A false cytological diagnosis of carcinoma occured in 2 patients, for a true positive rate of 99%. However, the true negative rate was only 87%. In 77% of 31 immunosuppressed patients, the causative agent of a focal infectious process was diagnosed. Pneumothorax was the only notable complication, occuring in 24% of patients, with 14% requiring chest tube drainage. The procedure is relatively simple and rapid, generally causes little patient discomfort, and can be performed in virtually any hospital.

Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies

BACKGROUND Sleeve lobectomy and bronchoplasty are established alternatives to pneumonectomy for bronchial malignancies involving a main bronchus. However, potential bronchial anastomotic complications have deterred the general application of these types of resection. Some reports have contained a mixture of non-small cell lung cancer (NSCLC) and tumors of low-grade malignancy, making it difficult to assess the long-term results of these procedures as an alternative to pneumonectomy for lung cancer. METHODS We retrospectively reviewed our experience with sleeve lobectomy and bronchoplasty for bronchial malignancies from January 1988 to September 1998 separating NSCLC (n = 58) from tumors of low-grade malignancy (n = 19). We compared the overall results between sleeve lobectomy and pneumonectomy (n = 142) performed for NSCLC over the same time interval. RESULTS For NSCLC, after sleeve lobectomy, the operative mortality was 5.2% (3 of 58 patients) and the overall 5-year actuarial survival was 37.5%. After pneumonectomy, the operative mortality was 4.9% (7 of 142 patients) and the overall 5-year actuarial survival was 35.8%. For tumors with low-grade malignancy, there was no operative mortality after sleeve lobectomy or bronchoplasty and the 5-year actuarial survival was 100%. Major bronchial anastomotic complications occurred in 3 patients among the 77 patients who underwent sleeve resection. CONCLUSIONS Sleeve resection can be performed with a low risk of bronchial anastomotic complication. The long-term survival after sleeve resection for NSCLC is similar to pneumonectomy. Excellent results are obtained after sleeve resection for low-grade malignancies.

Esophageal Replacement with Colon in Children: Functional Results and Long-term Growth

Twenty-three children consecutively undergoing colon interposition for esophageal replacement were evaluated with barium swallows, clinical interviews, and questionnaires. Fourteen patients underwent colon interposition because of caustic burns of the esophagus only or of the hypopharynx and esophagus. Nine children had long-segment esophageal atresia or esophageal atresia with tracheoesophageal fistula and are included in our operative group. The mean follow-up was 12.8 years for all patients. Strictures, leaks, and colon ischemia at the proximal anastomosis represent the major morbidity for the operative procedure. Analysis of growth charts reveals that patients who ingest lye tend to remain in the 50th percentile after colon transplant, while patients with esophageal atresia or tracheoesophageal fistula who had been in the 12th percentile preoperatively improved to the 33rd percentile after successful transplantation. Radiographic examinations, functional results, and growth curves demonstrated excellent results in 20 patients. Although the choice of a conduit for esophageal replacement is controversial, the surgeon can expect good long-term function and growth with the use of colon in children.

Surgical Intervention in Histoplasmosis

Histoplasmosis is a ubiquitous disease in endemic areas that has a generally subclinical course. Excessive inflammatory response may bring some patients to the attention of a thoracic surgeon to exclude malignancy of a noncalcified pulmonary or mediastinal mass or to relieve compression of specific structures. Mediastinal granuloma or fibrosing mediastinitis may involve the superior vena cava, pulmonary vessels, heart and pericardium, tracheobronchial tree, or esophagus. The cases of 94 recently treated patients are presented as well as a review of the American surgical literature. The current use of computed tomography, the time and extent of operative intervention, and the role of antifungal therapy are important to an overall understanding of the surgical treatment of the manifestations of histoplasmosis.

The use of the TDMAC-heparin shunt in replacement of the descending thoracic aorta.

The use of a flexible polyvinyl tube bonded with tridodecylmethylammonium-heparin (Gott) as a temporary shunt during the resection of lesions of the descending thoracic aorta has proven a safe and simple means of providing adequate circulation to the abdominal viscera and spinal cord. This technique avoids the metabolic consequences of ischemia to the lower body, diminishes left ventricular afterload during aortic clamping, and obviates the requirement for systemic anticoagulation associated with pump bypass. Between September 1970 and October 1974, 24 patients have been operated using the TDMAC shunt. There were two deaths (9%) among the 22 patients undergoing elective resections. Two patients with acutely dissecting and ruptured aneurysms expired. Followup data has been obtained on all patients from one to 46 months postoperative. The ease with which the shunt is inserted and its adaptability to varied clinical and anatomic situations is stressed. We feel that TDMAC-Heparin shunt provides the best method of circulatory support for elective operative procedures on the descending thoracic aorta.

Malignant fibrous histiocytoma of the lung

Malignant fibrous histiocytoma (MFH) is among the most common soft tissue sarcomas of adult life, but rarely occurs elsewhere. We report an example of primary MFH of the lung and review 15 previously reported acceptable cases with current follow‐up information. Histologically, the tumor in our case was pleomorphic with storiform and fascicular areas. Tumor cells showed positive immunostaining for alpha1‐antitrypsin, alpha1‐antichymotrypsin, and vimentin. Stains for desmin, cytokeratin, myoglobin, epithelial membrane antigen, S‐100 protein, and lysozyme were negative. Electron microscopic study showed histiocyte‐like, fibroblast‐like, intermediate, and undifferentiated tumor cells. A variety of methods were used to treat these patients. Two patients survived for 5 or more years, two were alive and well at 8 and 12 months, respectively, two were alive with metastatic tumor at 3 and 18 months, respectively, and ten patients died of tumor, with an average survival of 1 year.

Esophagogastrostomy with the EEA stapler.

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeons error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.

Transbronchial catheterization of pulmonary abscesses

A major indication for bronchoscopy in patients with pulmonary abscess is the need to establish adequate drainage. Often, associated bronchial swelling precludes direct entry into the cavity with standard suctioning devices. Satisfactory drainage may require numerous bronchoscopic procedures, prolonging hospitalization and subjecting the patient to the complications of pyogenic pulmonary abscess. We have recently adopted the technique of passing angiography catheters through the rigid bronchoscope into the abscess cavity, thereby facilitating the bacteriological diagnosis and drainage of the cavity.

Immunostains for blood group antigens lack prognostic significance in T1 lung carcinoma.

Recent reports have suggested that the retention of blood group antigen expression on tumor cells may be an important prognostic factor for survival. From 1986 to 1991, 136 patients underwent operative resection for their T1 N0 non-small cell lung carcinoma. One hundred twenty tissue blocks were available for antigen testing, and the histologic types were as follows: adenocarcinoma (73 patients), squamous cell (39 patients), large cell/undifferentiated (7 patients), and mucoepidermoid (1 patient). Follow-up is complete for all patients (mean, 41 months). This distribution of patients among the blood groups was as follows: A, 56 (47%); O, 53 (44%); B, 9 (7.5%), and AB, 2 (1.7%). Immunostaining was performed for A, B, and H blood group antigens. The 5-year actuarial survival in the blood group A patients (53%) did not differ significantly from that in the blood group O patients (59%). Similarly, when tumors were examined for their respective antigens, no significant differences were found in the 5-year survival of either blood group A or O patients between the tumors that retain and those that lose blood group antigen expression. Retention or loss of blood groups A or O antigen expression does not predict survival in patients with early-stage lung carcinomas.