Douglas E. Wood

Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality

OBJECTIVESnDescending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis.nnnMETHODSnA retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999.nnnRESULTSnWe treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 +/- 4 computed tomographic imaging studies, 4 +/- 1 transcervical drainage procedures, and 2 +/- 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 +/- 1 computed tomographic imaging studies, 2 +/- 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment.nnnCONCLUSIONnDescending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis.

Improved prediction of lobar perfusion contribution using technetium-99m–labeled macroaggregate of albumin single photon emission computed tomography/computed tomography with attenuation correction

OBJECTIVEnLung cancer resection can require removal of an entire lobe and, at times, bilobectomy or pneumonectomy. Many patients will also have significantly compromised lung function that requires limiting the extent of surgery or could preclude surgery altogether. The preoperative assessment should include predicted postoperative forced expiratory volume in 1 second (ppoFEV1), because a ppoFEV1 of <40% predicts significantly increased perioperative morbidity. The ppoFEV1 can be estimated by multiplying the preoperative FEV1 by the residual perfused territory percentage, as predicted on planar perfusion scintigraphy (PPS). However, ppoFEV1 using PPS has shown variable correlation with spirometry-measured postoperative FEV1.nnnMETHODSnWe propose an improved method for assessing regional lung perfusion in preoperative lung surgery patients. Patients undergo single photon emission computed tomography/computed tomography (SPECT/CT) imaging with attenuation correction using the conventional perfusion agent, technetium-99m-labeled macroaggregate of albumin. The CT image provides information for manual segmentation of each lobe. These segmentations are applied to the SPECT images to determine lobar perfusion. This proposed method was compared with PPS.nnnRESULTSnThis technique was evaluated in 17 patients. As expected, the perfusion contributions of the right and left lungs, calculated from SPECT/CT, correlated closely with those obtained from PPS (Pearson r=0.995). However, the lobar perfusion contributions obtained by PPS and SPECT/CT were significantly different, by 2 methods of comparison (Hotellings P=1.7×10(-6) and P=1.7×10(-4)).nnnCONCLUSIONSnThis new SPECT/CT technique provides an anatomically more accurate assessment of lobar perfusion. This technique can refine which patients should be operative candidates and allow better prediction of postoperative function in contrast to the anatomically inaccurate planar scintigraphic predictions, which often underestimate the postoperative FEV1. This new technique is expected to have a significant effect on the resectability of patients with lung cancer.

Utilization of Cardiothoracic Surgeons for Operative Penetrating Thoracic Trauma and Its Impact on Clinical Outcomes

BACKGROUNDnLarge series reporting outcomes for penetrating thoracic trauma have identified injury pattern and injury severity scoring as predictors of poor outcome. However, the impact of surgical expertise on patient outcomes has not been previously investigated. We sought to determine how often board-certified cardiothoracic surgeons are utilized for operative thoracic trauma and whether this has an effect on patient outcomes.nnnMETHODSnA level I trauma center registry was queried between 2003 and 2011. Records of patients undergoing surgery as a result of penetrating thoracic trauma were retrospectively reviewed. Patient demographics, injuries, injury severity, utilization of a cardiothoracic surgical operative consult and outcomes were recorded. Patients operated on by cardiothoracic surgeons were compared with patients operated on by trauma surgeons using stepwise multivariate analyses to determine the factors associated with utilization of cardiothoracic surgeons for operative thoracic trauma and survival.nnnRESULTSnCardiothoracic surgeons were used in 73.0% of cases (162 of 222) over the study period. The use of cardiothoracic surgeons increased incrementally both overall (38.5% to 73.9%), and for emergent/urgent cases (31.8% to 73.3%). When comparing patients undergoing operation on an emergent/urgent basis by cardiothoracic versus trauma surgeons, there was no significant difference with regard to demographics, mechanism of injury, injury severity scoring, or surgical morbidity. Stepwise logistic regression showed the presence of a cardiothoracic surgeon to be independently associated with survival (odds ratio 4.70; p = 0.019).nnnCONCLUSIONSnUse of cardiothoracic surgeons for operative thoracic trauma increased over the study period. Outcomes for severely injured patients with elevated chest injury scores or decreased revised trauma scores may be improved with appropriate operative consultation with a board-certified cardiothoracic surgeon.