Dov Weissberg

Hernia of the lung

BACKGROUND Lung hernia is uncommon and methods of management vary. During the past 17 years, we have seen 8 patients with this condition. METHODS Between 1984 and 2000, 8 patients with lung hernias were seen on our service. Three hernias were caused by a thoracic operation, one was due to chronic cough, and in four, the hernia was congenital, with delayed presentation. RESULTS Three patients had minimal symptoms and were not operated on. Closure of chest wall in the other patients was accomplished by suture approximation of ribs in 4 patients and by polypropylene mesh in 1 patient. There were no recurrences, and these patients remain asymptomatic. CONCLUSIONS Intercostal hernias are usually symptomatic and should be treated by operative closure. In supraclavicular hernias, the symptoms are usually minimal and complications are unlikely. These hernias can be left untreated, but the patients should be followed.

Suture closure versus stapling of bronchial stump in 304 lung cancer operations.

Suture closure of the bronchial stump was compared with staple closure after 304 operations for bronchogenic carcinoma over an 8-year period. In 154 cases (112 lobectomies and 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester, and in 150 cases (120 lobectomies and 30 pneumonectomies) an autosuture stapler was used. The time for suture closure ranged from 5-15 minutes, whereas stapling was accomplished uniformly in c. 90 seconds. Bronchopleural fistula developed after suture closure in seven cases (4.5%), but in none after stapling closure. Stapling of the bronchial stump after lobectomy or pneumonectomy for lung cancer is safer and quicker than suture closure, and is recommended as the method of choice.

Surgical Management of Tracheal Tumors

BACKGROUND Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor. METHODS In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved. RESULTS One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor. CONCLUSIONS Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Pleuroscopy in Patients with Pleural Effusion and Pleural Masses

We performed diagnostic pleuroscopy in 66 patients with pleural effusion and in 14 with pleural masses. The findings were diagnostic in 76 patients (95%). Pleural metastases were found in 63 patients, primary pleural or lung tumor in 5, and less common findings in the remainder. Only 1 minor complication occurred, and there were no deaths. Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 31 of 35 patients. Talc also was used with equal success and without complications in management of recurrent pneumothorax. We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure. It is simple and well tolerated, has a diagnostic yield of 95%, and is virtually free from complications. It provides the best way of insufflating talc for pleurodesis.

The use of talc for pleurodesis in the treatment of resistant empyema.

The use of talc in the infected pleural space has not been reported previously. Five patients who had empyema of the pleura in the fibrinopurulent stage and did not respond to treatment with tube drainage and antibiotics were treated by talc insufflation to stimulate pleural adhesions. Pleurodesis was achieved in all 5 patients, with complete recovery from empyema. No untoward effects were observed. These results suggest that talc pleurodesis may be an acceptable solution to the problem of empyema resistant to other methods of treatment.

Less than lobar resections for bronchogenic carcinoma.

We performed less than lobar resections for peripheral clinical Stage I primary lung cancers on 170 patients treated between 1973 and 1987 at two university centers, one in Hawaii and one in Israel. Most patients were poor risks and several had FEV1 < 1 liter. There were 6 (3.5%) hospital deaths. There were 58 segmental resections, 97 wedge resections and 15 less than lobar resections not otherwise specified. Seventy-three patients (43%) are living free of cancer from 5 to 11 years postoperatively and 20 additional patients died of causes unrelated to lung cancer after 5 years; thus disease free five year survival was 54.7%. Patients with adenocarcinoma had poorer prognosis than other cell types. Twenty-three patients (13.5%) had synchronous or metachronous second primary lung cancers. Nine of these patients are long term survivors. Twenty-four patients (14.1%) developed local recurrences with or without distant metastases. This promising long term cancer-free survival and the frequency of second primary lung cancers justifies less than lobar resection for peripheral, Stage I bronchogenic carcinoma, especially in the poor risk patient.

Pleuroscopy: Therapeutic Applications

Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.

Symptomatic Diaphragmatic Hernia: Surgical Treatment

Seventy-eight cases of symptomatic diaphragmatic hernia are reported--55 hiatal (42 sliding, 9 rolling, 4 intrathoracic stomach), 19 diaphragmatic hernias proper (12 Bochdalek, 7 Morgagni) and four diaphragmatic eventrations. Pulmonary function was compromised by massive herniation in ten cases. Four hernias were incarcerated. Surgery was performed in 76 cases, as emergency in ten. Two patients were rejected because of poor pulmonary function. One patient died and three hernias recurred. The results were satisfactory in 72 cases. In sliding hiatus hernia, gastro-oesphageal reflux is the main problem and investigations should include oesophagoscopy, fluoroscopy and manometry, with treatment directed at prevention of reflux. Surgical treatment, if indicated, is usually fundoplication and dilatation of strictures. In rolling hiatus hernia and all types of diaphragmatic hernia proper, the hernia per se is the main problem, with risk of incarceration. Surgery is always indicated and should comprise reduction of hernia contents, excision of the sac and closure of diaphragmatic rift.

Foreign Body Retrieval

Foreign body retrieval is the removal of objects or substances that have been introduced into the body. Objects may be inhaled into the airway, swallowed or lodged in the throat or stomach, or embedded in the soft tissues. About 80 percent of foreign body ingestions occur among children. Most foreign bodies pass through the gastrointestinal tract without complication, and endoscopic or surgical intervention is required only 10 to 20 percent of the time.