Darroch W.O. Moores

Subxiphoid pericardial drainage for pericardial tamponade

As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.

Treatment of esophageal obstruction with covered, self-expanding esophageal wallstents

BACKGROUND Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition. METHODS From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control. RESULTS Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods. CONCLUSIONS Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

Treatment of Stage I Lung Cancer (T1N0M0, T2N0M0)

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.

Pathology of Primary Tracheobronchial Malignancies Other than Adenoid Cystic Carcinomas

Most primary tracheal tumors are malignant. Malignancy of larynx and bronchi are much more likely than trachea. Tracheal tumors are most likely due to direct extension for surrounding tumors. Squamous cell carcinoma and adenoid cystic carcinoma make up about two-thirds of adult primary tracheal tumors. Because of their predominantly local growth pattern, malignant salivary gland-type tumors show a better outcome than other histologic types.

Thoracic esophagostomy: A novel surgical approach for preservation of esophageal length for use in subsequent reconstruction

them. Successive increase in the right ventricular preload coupled with a delayed and staged increase in the minute volume ventilation maintains the pulmonary veins free from air until the patient is completely weaned from CPB. In conclusion, the deairing technique reported here is simple, reproducible, controlled, safe, and effective. Moreover, it is cost-effective because the deairing time is short, and no extra expenses are involved. References 1. Komukai K, Hirooka K, Taneike M, Yasuoka Y, Yamamoto H, Hashimoto K, et al. ST elevation during open heart surgery—floating air bubble in saphenous vein graft. Images in cardiovascular medicine. Circulation. 2005;111:e374. 2. Abu-Omar Y, Cifelli A, Matthews PM, Taggart DP. The role of microembolisation in cerebral injury as defined by functional magnetic resonance imaging. Eur J Cardiothorac Surg. 2004;26:586-91. 3. Tingleff J, Joyce FS, Pettersson G. Intraoperative echocardiographic study of air embolism during cardiac operations. Ann Thorac Surg. 1995;60:673-7. 4. Svenarud P, Persson M, van der Linden J. Effect of CO2 insufflation on the number and behavior of air microemboli in open-heart surgery: a randomized clinical trial. Circulation. 2004;109:1127-32. TABLE 1. Residual air emboli 10 minutes after termination of CPB (n 1⁄4 20) Study group (n 1⁄4 10) Control group (n 1⁄4 10)