David F. Weeden

The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma.

BACKGROUND There is evidence that perioperative blood transfusion may lead to immunosuppression. Our aim was to determine whether blood transfusion influenced survival after esophagectomy for carcinoma. METHODS The study group comprised 234 consecutive patients (175 men and 59 women) with a mean age of 66 years who underwent esophagectomy for carcinoma by one surgeon between 1988 and 1998. The impact of 41 variables on survival was determined by means of univariate and multivariate analysis. Follow-up was complete (mean follow-up, 19.2 months; standard deviation, 16 months; range, 0 to 129 months). RESULTS The operative mortality rate was 5.6% (13 deaths). Median operative blood loss was 700 mL (range, 150 to 7,000 mL). One hundred sixty-one patients (68.8%) received a blood transfusion postoperatively (mean transfusion, 2.6 units; range, 0 to 12 units). Overall actuarial 1-year, 3-year, and 5-year survival rates inclusive of operative mortality were 58.1%, 28.5%, and 16.1%, respectively. On univariate analysis, positive lymph nodes, pathological TNM stage, transfusion of more than 3 units of blood, incomplete resection, poor tumor cell differentiation, longer tumor, greater weight loss, male sex, and adenocarcinoma were significant (p < 0.05) negative factors for survival. On Cox proportional hazards regression analysis, after excluding operative mortality, lymph node involvement (p = 0.001), incomplete resection (p = 0.0001), poor tumor cell differentiation (p = 0.04), and transfusion of more than 3 units of blood (p = 0.04) were independent adverse predictors of late survival. CONCLUSIONS In addition to reaffirming the importance of completeness of resection and nodal involvement, this study demonstrates that blood transfusion (more than 3 units) may have a significant adverse effect on late survival after esophageal resection for carcinoma. Every effort should be made to limit the amount of transfused blood to the absolutely essential requirements.

Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.

Does surgery for primary non-small cell lung cancer and cerebral metastasis have any impact on survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy+/-adjuvant treatment) ranged from 19 to 27 months (mean 23.12+/-3.3 months) and at 1, 2 and 5 years from 56% to 69% (mean=63.9+/-5.6%), 28% to 54% (mean=38.7+/-11%) and 11% to 24% (mean=18+/-5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (mean=10.3+/-2.9 months) and 33-39.7% (mean=35.3+/-3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.

Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit

INTRODUCTION We reviewed our experience of the in-hospital management and early follow-up of patients admitted with a traumatic sternal fracture to a Thoracic Surgical Unit. PATIENTS AND METHODS Over a 7-year period, 73 consecutive patients (51 males) with a median age of 51 (range 17-84) years were admitted through the Emergency Department with an acute traumatic sternal fracture. The patients were hospitalised for cardiorespiratory monitoring, pain control and physiotherapy. Outpatient follow-up occurred 6 weeks after discharge. RESULTS The median hospital stay was 2 days (range 1-15 days). Sixty-four patients (88%) did not require parenteral analgesia or any other procedure that would necessitate admission to hospital. Three patients (4%) with severely displaced fractures and complex co-morbidities required surgical correction. Follow-up revealed no significant complications. CONCLUSIONS Admission to hospital is not necessary for every patient sustaining a sternal fracture and should be reserved for those with high-impact trauma, severely displaced fractures, significant associated injuries, complex analgesic requirements, important co-morbidities or inadequate domestic support.

Barotrauma-associated posterior tension pneumomediastinum, a rare cause of cardiac tamponade in a ventilated neonate: a case report and review of the literature

Ventilation‐associated neonatal barotrauma comprises a spectrum of conditions including pneumothorax, pulmonary interstitial emphysema, pneumopericardium and pneumomediastinum. Whilst pneumothorax is common, mediastinal and particularly posterior mediastinal air collections are rare. We report the case of a neonate, presenting with life threatening pericardial tamponade secondary to posterior tension pneumomediastinum. The infant was successfully resuscitated with an emergency left lateral thoracotomy and chest drain insertion. We believe this to be the first such case reported in the literature. We discuss aspects of pathophysiology, diagnosis and management relating to posterior pneumomediastinum.

Thoracic intrathymic thyroid and cervical goiter : Single-stage resection

Ectopic thyroid tissue in the chest is rare. We report a case of a euthyroid patient with benign ectopic thyroid tissue presenting as a thymic mass in association with a multinodular goiter. Both disorders were managed successfully by surgical intervention.

Pneumopericardium after lobectomy

A 34-year-old man with diagnosed malignant testicular teratoma was treated for pulmonary metastases. After orchidectomy and chemotherapy, he was referred for resection of a residual chest mass. That was achieved by middle lobectomy. Postoperative recovery was uneventful. Histologic examination found mature teratoma and a bronchial resection clearance margin of 12 mm. A week later the patient presented with a dry cough and marked dyspnea. A chest roentgenogram showed gross pneumopericardium (Fig 1, arrows) and a computed tomographic scan revealed a communication between the pneumopericardium and a loculated pneumothorax (Fig 2). Under fluoroscopy a percutaneous drain was inserted into the pneumothorax, resulting in rapid resolution of symptoms. At bronchoscopy no obvious bronchopleural fistula was seen but there was sloughing of the middle lobe bronchial stump. The stump was cauterized with a silver nitrate applicator. The pneumothorax, pneumopericardium, and a modest air leak resolved within 3 days. At 4-month follow-up the patient remains asymptomatic with normal radiography results. Address reprint requests to Dr Stuklis, 18 Alexander Parade, Roseville NSW, 2069 Australia; e-mail: rstuklis@yahoo.com. Fig 1.

Surgical treatment for an unusual cause of localized bronchiectasis

A 17-year-old girl presented with recurrent episodes of pneumonia related to localized bronchiectasis in the lingula. On computed tomography and magnetic resonance imaging, the cause of this was found to be an inwardly projecting exostosis arising from the left fifth rib. The patient underwent thoracotomy and excision of the exostosis with the affected area of lung. We report here the unusual case of a rib exostosis presenting with localized bronchiectasis.

An unusual bronchial obstruction in a fit young man

We describe the case of a previously well young man who presented acutely to hospital with a history of progressive chest symptoms and systemic upset. At admission, clinical evidence of left upper lobe collapse on respiratory examination and chest x-ray gave rise to significant clinical concern. Initial assessment by CT suggested a possible aspirated foreign body in the left upper lobe bronchus with distal left upper lobe collapse. Subsequent rigid bronchoscopy identified a solid abnormality totally occluding the left upper lobe bronchus, which did not appear to be a foreign body. The patient became progressively more unwell with clinical signs of chest sepsis and failed to settle with medical therapy. A decision was made to undertake a lobectomy to remove the collapsed lobe and obstructing endobronchial lesion. Histology confirmed that the cause of bronchial obstruction was a mesenchymoma (pulmonary hamartoma).