Erik Gyllstedt

Bilateral thoracoscopic splanchnicectomy: effects on pancreatic pain and function.

OBJECTIVE To evaluate prospectively the effect of bilateral thoracoscopic splanchnicectomy on pancreatic pain and function. SUMMARY BACKGROUND DATA Severe pain is often the dominant symptom in pancreatic disease, despite a wide variety of methods used for symptom relief. Refinement of thoracoscopic technique has led to the introduction of thoracoscopic splanchnicectomy in the treatment of pancreatic pain. METHODS Forty-four patients, 23 with pancreatic cancer and 21 with chronic pancreatitis, were included in the study and underwent bilateral thoracoscopic splanchnicectomy. Effects on pain (visual analogue scale) and pancreatic function (standard secretin test, basal serum glucose, plasma insulin, and C-peptide) were measured. RESULTS Four patients (9%) required thoracotomy because of bleeding. There were no procedure-related deaths. The mean duration of follow-up was 3 months for cancer and 43 months for pancreatitis. Pain relief was evident in the first postoperative week and was sustained during follow-up, the average pain score being reduced by 50%. All patients showed a decrease in consumption of analgesics. Neither endocrine nor exocrine function was adversely affected by the procedure. CONCLUSIONS Bilateral thoracoscopic splanchnicectomy is beneficial in the treatment of pancreatic pain and is not associated with deterioration of pancreatic function.

Early Surgical Results After Pneumonectomy for Non-Small Cell Lung Cancer are not Affected by Preoperative Radiotherapy and Chemotherapy

BACKGROUND Higher operative risks after pneumonectomy for non-small cell lung cancer (NSCLC) have been reported after neoadjuvant chemotherapy or radiotherapy, or both. Patients who underwent pneumonectomy for NSCLC were evaluated for effect of neoadjuvant treatment on mortality and morbidity, especially bronchopleural fistula. METHODS Between 1996 and 2003, 130 consecutive patients underwent pneumonectomy: 35 received preoperative radiotherapy and chemotherapy (the neoadjuvant group), and 95 patients did not (the first-surgery group). Operative mortality and postoperative complications were compared between the groups. RESULTS Minor postoperative complications were comparable in both groups (p > 0.10). Five patients in the neoadjuvant group and 10 in the first-surgery group had serious complications (p = 0.55). Eight had bronchopleural fistulas (7 right and 1 left, p < 0.01); 3 were in the neoadjuvant group (p = 0.49). Three fistulas required reoperation. One patient in the first-surgery group died within 30 days postoperatively. Duration of symptoms (hazard ratio, 6.6; p = 0.01) and right-sided pneumonectomy (hazard ratio, 2.4; p = 0.05) were associated with an increased risk of bronchopleural fistula. Induction treatment, postoperative radiotherapy, or coverage of the bronchial stump did not increase the risk of bronchopleural fistulation. Survival at 1 and 5 years was comparable for the neoadjuvant and first-surgery groups: 74% and 46% vs 72% and 34%, respectively (p > 0.2). CONCLUSIONS Pneumonectomy is a safe procedure with low operative mortality. Postoperative morbidity is significant, especially bronchopleural fistulas after right-sided pneumonectomy (11%). However, neither operative mortality nor morbidity appears to be directly associated with preoperative radiotherapy or chemotherapy.

A novel treatment approach for paediatric Gorham-Stout syndrome with chylothorax.

Aim:  To expand the treatment options in paediatric Gorham–Stout syndrome (GSS) when conventional therapy is ineffective.

Hydrolysis of big endothelin-1 by a serine protease in the membrane fraction of human lung

The hydrolysis of human big endothelin 1-38 (bigET-1) was investigated in the membrane fractions from three human lung specimens. The hydrolysis products were identified by HPLC or by amino acid analysis, peptide sequencing and mass spectrometry, and the contractile effects of synthetic bigET-1, synthetic ET-1 and the major metabolite were tested on isolated rabbit pulmonary arteries. The dominating hydrolysis product was identified as bigET1-31, formed by a chymostatin-sensitive enzyme. Soybean trypsin inhibitor also suppressed bigET1-31 formation, while two other serine protease inhibitors, 3,4-dichloroisocoumarin and aprotinin, had no (or a limited) inhibitory effect. Through a partly phosphoramidon-sensitive enzymatic activity, endothelin-1 (ET-1) was formed independently of bigET1-31. On isolated pulmonary arteries, bigET1-31 had a contractile effect similar to that of synthetic bigET-1, with pEC50% values of 7.3 +/- 0.1 (n = 6) and 7.1 +/- 0.1 (n = 8), respectively. The pEC50% value of ET-1 was 9.2 +/- 0.3 (n = 6). These results indicate that human pulmonary membranes, besides hydrolysing bigET-1 to ET-1, also express serine protease activity that is responsible for the formation of the biologically active product, bigET1-31.

Thoracoscopic Splanchnicectomy for Chronic, Severe Pancreatic Pain

Fourteen patients with pancreatic cancer, 2 with cancer of the papilla of Vater, and 14 with chronic pancreatitis were operated on with bilateral thoracoscopic splanchnicectomy caused by severe chronic pain. The median follow-up time was 13 months. Twenty patients were followed up for 3 months and 14 for at least 6 months. The surgical results were evaluated prospectively, both with visual analogue scale (VAS) and with documentation of the consumption of analgesics at elective follow-up after 1 week and 1, 3, 6, and 12 months postoperatively. All 30 patients stated that the characteristics of their pain had changed at recovery from anaesthesia, but only 6 of them reported immediate complete pain relief. All but 1 of the 14 patients with chronic pancreatitis had clearly reduced pain as evaluated by VAS 1 month after the operation, and this beneficial effect remained for the whole study period. Furthermore, the need for analgesics decreased. Also, in the 16 patients with cancer, there was on average a marked relief of pain from 1 week and onwards. The 6 cancer patients with survival more than 3 months had reduced pain for the remaining period of their lives. It seems that the final pain relief is persistent as is the reduced consumption of analgesics. There was no correlation between the number of cut nerves and pain relief as evaluated by VAS. Three patients were reoperated on for intrathoracic bleeding the evening after the operation, and one had transient pain located to one of the port sites. Otherwise, there were no postoperative complications. The operation time was short and the length of hospital stay in most patients was 24 hours or less. It was concluded that thoracoscopic splanchnicectomy appears to be a promising and relatively simple treatment for severe chronic pancreatic pain. Further studies are needed to establish its role in the management of intractable pancreatic pain.

Pulmonary sequestration--a review of 8 cases treated with lobectomy.

Background and Aims: Pulmonary sequestration (PS) is a rare congenital malformation where non-functioning lung tissue is separated from the bronchial tree and vascularised with an aberrant artery from the systemic circulation. The aim of this report was to study all patients who were treated for PS at Lund University Hospital between 1994 and 2004, with emphasis on clinical presentation of the disease and evaluate the results of surgical treatment. Material and Methods: 8 cases were identified, 7 females and one male, with a mean age of 7.3 years (range 25 days — 17 years) at the time of diagnosis. Results: Out of 8 patients, seven presented with respiratory symptoms and two with congestive heart failure. Five patients had other congenitial malformations; including scimitar syndrome and congenital heart disease. All the patients underwent a successful lobectomy. There were no major postoperative complications. At a medium follow-up of 77 months all of the fully treated children were doing well. Conclusion: Respiratory and cardiovascular symptoms are the most common symptoms related to PS. The wide range of clinical symptoms may cause diagnostic problems, especially in children and young adults with concomitant congenital heart disease. Therefore PS should be considered as a differential diagnosis in children with unexplained respiratory symptoms or with signs of congestive heart failure. In patients with PS, lobectomy seems to be a good therapeutic option.

Conversion of angiotensin I to angiotensin II by chymase activity in human pulmonary membranes.

An aprotinin-insensitive, angiotensin II (Ang II)-forming chymase has recently been identified in human heart tissue. We studied the hydrolysis of Ang I in human lung membranes. The hydrolysis products Ang II, Ang III, Ang-(1-9), Ang-(2-9), Ang-(1-7) and Ang-(8-10) appeared in membrane preparations from four patients. Two metabolic pathways for the formation of Ang II were identified; one depending on ACE activity (1.4 nmol Ang II/min/mg membrane protein) and the other on serine protease activity (2.1 nmol/min/mg). The serine protease activity was inhibitable to only 30 +/- 8% (mean +/- SEM) by aprotinin, suggesting chymase activity to play a role in the Ang I-conversion of human lung.

Chest wall sarcoma: outcome in 22 patients after resection requiring thoracic cage reconstruction

Purpose. To evaluate the outcome after resection of malignant chest wall sarcoma, requiring reconstruction of the chest wall. Subjects. Twenty-two patients, 15 with primary tumours, were operated on in our institution between 1983 and 1996. Four patients underwent surgery after a previous intralesional or marginal excision and three patients because of a local recurrence. Methods. The tumour was resected ‘en bloc’, including skin, muscle and thoracic skeleton. When necessary, adjacent organs invaded by the tumour, such as lung, pericardium and diaphragm, were also removed to obtain a wide margin. Reconstruction of the chest wall was performed with Marlex mesh (n=9), methylmethacrylate cement (n=2) or a Marlex methylmethacrylate ‘sandwich’ (n=11). Results. The median tumour size was 9.5 (2–20) cm. The most common type of tumour was chondrosarcoma (12 cases). No patient died in hospital. Five patients required reoperation because of complications, two patients because of loosening of the acrylate prosthesis, two because of necrosis of soft tissue coverage and one was reoperated because of bleeding. Four patients died of generalized tumour disease between 5 and 77 months after surgery and one patient died of a local recurrence 32 months after the primary operation. Seventeen patients are alive, with a median follow-up of 36 (4–162) months. Microscopic radicality (negative margin) was achieved in 17 patients but 5 of these had local recurrences. Two of five patients with positive margins had a local recurrence of the tumour. Of the seven patients with local recurrences, two also developed metastases. Discussion. Large chest wall sarcomas can be successfully resected and the chest wall reconstructed with low morbidity and mortality.