David Beggs

Predictors of operative death after oesophagectomy for carcinoma

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease.

Surgical management of primary empyema of the pleural cavity: outcome of 81 patients

Postpneumonic empyema is the most common form of empyema thoracis and is still recognised as a major cause of morbidity and prolonged hospital stay. We reviewed 106 patients retrospectively who underwent surgical management of pleural empyema over a period of three years from August 2005. We identified 81 patients (76%) (58 males, mean age 52 years) with primary empyema and 25 patients (24%) with secondary empyema. The first group of patients with primary empyema was analysed. Twenty-nine patients (36%) had stage II empyema and 52 patients (64%) had stage III. The majority of stage II empyema patients underwent thoracoscopic debridement (28 patients) and one patient had open thoracotomy and debridement. Stage III patients underwent thoracoscopic decortication (32 patients) of those six patients (19%) were converted to open decortication, open decortication (19 patients) and fenestration (one patient). Mortality rate was 0% for all procedures. Median length of hospital stay was six days for thoracoscopic debridement, five days for thoracoscopic decortication and eight days for open decortication. Patients treated with video-assisted thoracoscopic surgery (VATS) debridement or decortication spent less time in hospital and the conversion rate to open procedure for stage III empyema was only 19%, which encourages us to consider VATS debridement/decortication as a first choice treatment.

Long term results of surgery versus continuous hyperfractionated accelerated radiotherapy (CHART) in patients aged . 70 years with stage 1 non-small cell lung cancer

BACKGROUND Patients with T1N0 non-small cell lung cancer (NSCLC) are preferably treated by anatomic lobectomy. However, not all such patients are suitable for lobectomy due to their age or co-morbidity. Our aim was to determine the results obtained following lobectomy, wedge resection (WR) or continuous hyperfractionated accelerated radiotherapy (CHART) in patients aged >70 years. PATIENTS Two hundred and fifteen consecutive patients aged >70 years, with pathologic stage 1 NSCLC in our unit between 1991 and 2001 were studied. Of these patients, 149 had a lobectomy, 47 had a WR and 19 had CHART. Follow-up was 100% complete. RESULTS Analysis demonstrated the WR and CHART patients to have reduced pulmonary function (FEV(1) 59% and 52%, respectively, of predicted vs. 76%, P<0.001) when compared to the lobectomy group but there were no differences among the groups with regard to mean age and histologic tumour type. There were no operative mortality among patients after WR; however, a 2.7% 30-day operative mortality among patients undergoing lobectomy (P=0.29). Kaplan-Meier survival curves at 1 and 5 years for patients undergoing WR, lobectomy and CHART was 98% and 74% vs. 97% and 68% vs. 80% and 39%, respectively (P=0.0484). The frequency of local/regional recurrence in the WR group (19.1%) was not significantly higher than in the lobectomy group (18.4%, P=0.38) when compared to the CHART group (27%, P=0.07). CONCLUSION Loco-regional recurrence and survival after WR and lobectomy in elderly patients with stage I NSCLC are comparable. Although the numbers are small, these data suggest that CHART is a reasonable treatment option for those who are not suitable candidates for surgery.

Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV antireflux operations in relation to the severity of oesophagitis

OBJECTIVE Belsey Mark IV (BM IV) and total fundoplication gastroplasty (TFG) were the standard anti-reflux operations in two consecutive periods in Nottingham City Hospital Thoracic Surgery Unit. The aim of this study was to compare the long-term results obtained by these two procedures emphasizing their relation to the severity of the oesophageal mucosal damage. METHODS Ninety patients (50 females and 40 males with a mean age of 57 years) who had a BM IV operation between 1976 and 1983 and 86 patients (46 females and 40 males, with a mean age of 56.5 years) undergoing a TFG procedure between 1983 and 1986 were evaluated. All patients were assessed preoperatively by means of clinical history, barium meal and endoscopy. In addition, 72 of the patients having a TFG had prolonged pH monitoring and manometric studies. The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to the criteria published by Orringer et al. (Orringer MB, Skinner DB, Belsey RHR. Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-33). RESULTS In the BM IV group there was one post-operative death (1.1%). The median follow-up was 11 years (range 3-18 years). Overall good results were achieved in 64 patients (71.9%). In patients without oesophagitis (n = 24) the success rate was 91.7% while for grades I (n = 17), II-III (n = 36) and IV (n = 12) oesophagitis this was 76.5, 66.7 and 41.7%, respectively (P = 0.01). The actuarial success rate at 10 through to 18 years was 71.0%. In the TFG group there was no postoperative death. The median follow-up was 10 years (range 2-14 years). Overall good results were achieved in 78 patients (90.7%). In the absence of oesophagitis (n = 10) the success rate was 90.0% and for grades I (n = 12), II-III (n = 26) and IV (n = 38) oesophagitis this was 91.6, 92.3 and 89.4%, respectively. The actuarial success rate at 10 through to 14 years was 90.3%. The differences in the overall success rate (P = 0.002), the success rates forgrades II-III (P = 0.02) and IV (P = 0.001) oesophagitis and the long-term actuarial success rates (P = 0.001) were significant. CONCLUSION These data provide evidence on the superiority of the TFG against the BM IV in achieving long-term relief of reflux symptoms in the presence of severe oesophagitis. We believe that failure of BM IV in this setting is due to obvious or subtle oesophageal shortening.

Residual apical space following surgery for pneumothorax increases the risk of recurrence

OBJECTIVE Residual air spaces on chest radiographs after pneumothorax surgery are not uncommon. We aimed to study their incidence and impact on surgical outcomes. METHODS Four hundred and twenty-seven patients [283 men and 144 women with a median age of 31 (14-96) years] underwent surgery for pneumothorax from 1995 to 2005 in a single unit. Video-assisted thoracoscopy was used in 225 cases (53%). Outcomes were: duration of intercostal drainage and hospital stay, recurrence, re-operation and referral to chronic pain clinic. RESULTS Median duration of intercostal drainage and hospital stay were 5 and 6 days, respectively. We found a recurrence rate of 6.6% (n=28), re-operation rate of 2.8% (n=12) and need for referral to pain clinic of 7% (n=30). In 129 patients (30%) a small residual apical space (RAS) was reported on chest radiograph prior to discharge. Hospital stay and duration of drainage were longer in these cases (p=0.002 and 0.02, respectively). On multivariate analysis RAS on chest radiograph was associated with increased risk of recurrence [hazard ratio 3.1 (1.4-6.8 95% CI)] (p=0.005); but no need for re-operation or referral to pain clinic. Re-operation was associated with VATS surgery (p=0.001) and when no abnormalities were identified at operation (p=0.04). Referral to pain clinic was more common after open surgery (p=0.01). DISCUSSION The risk of recurrence after pneumothorax surgery is low. But the presence of a residual apical space on chest radiography after surgery increases it significantly. Recurrence may be due to the failure to achieve early pleural symphysis.

Dysphagia due to pancreatic pseudocyst with mediastinal extension

This case report describes a patient who presented with severe dysphagia, found to be due to a large pancreatic pseudocyst extending into the mediastinum. The patient was successfully treated by cystgastrostomy.