Francis H. Cole

Video-assisted thoracic surgery: Primary therapy for spontaneous pneumothorax?

BACKGROUND This study assessed the role of video-assisted thoracic surgery (VATS) in current therapy for spontaneous pneumothorax. METHODS We compared a retrospective series of 89 patients treated conventionally with a consecutive group of 30 patients undergoing VATS pleural abrasion. The 89 earlier patients were predominantly male (81%). Treatment groups included observation/aspiration (7 or 17%), tube thoracostomy (32 or 36%), multiple tubes (7 or 9%), and thoracotomy (43 or 48%). Of the 30 patients treated with VATS, 18 (66%) were male. Primary indications for operation were recurrent pneumothorax (17) and persistent air leak (9). RESULTS Hospital lengths of stay (LOS) for the earlier group were 5 days for simple tube and 7 days for primary thoracotomy; LOS for initial intervention followed by thoractomy exceeded 15 days in all subgroups. The average LOS in the VATS group was 13 days; 6 patients treated with primary VATS (no chest tube) had a mean LOS of 6.5 days. Complications included 3 (10%) prolonged air leaks (more than 7 days) and 2 (7%) early recurrences. CONCLUSIONS We do not recommend VATS as primary therapy for spontaneous pneumothorax; tube thoracostomy remains the treatment of choice. However, we strongly support surgical intervention early (3 days) in patients with a persistent air leak, and as primary therapy in a nonurgent situation if standard indications exist. This study shows no advantage of VATS over conventional thoracotomy in hospital stay or complication rate.

Management of Broncholithiasis: Is Thoracotomy Necessary?

Endoscopic treatment of broncholithiasis is controversial. From 1953 through 1984, 66 operations were performed on 40 patients with broncholithiasis in an endemic area for histoplasmosis. They are reviewed here retrospectively. All patients had cough; wheeze, hemoptysis, and lithoptysis were present in 60%, 45%, and 26%, respectively. Bronchoscopic stone removal was successful in 19%, whereas 21% of patients required no treatment. The 25 patients who were affected more severely required thoracotomy and operations varying from simple lung wedge resection to repair of a bronchoesophageal fistula. Optimum preservation of lung function was a major treatment guideline. All survived, and most have returned to normal preoperative activity. For selected patients, bronchoscopy and stone removal may be all that is required for broncholithiasis.

Dysphagia Resulting from Esophageal Ring

ince the original work of Ingelfinger and Kramer [ Z ] and Schatzki and Gary [7] on the production of dysphagia by esophageal rings S was published in 1953, a substantial number of reports on the subject have appeared. Some of these reports comprise a sizable series of patients, such as the account of Postlethwait and Sealy of 59 cases [61, while others cite a solitary case [l]. Uniformity of opinion is lacking on the etiology, pathophysiology, and preferred surgical management of the disorder. In reporting the following 7 patients with esophageal ring occurring at various levels of the esophagus we hope to clarify certain aspects of this fascinating anomaly.

Modified Blalock shunts utilizing pericardial tube grafts

In the last decade, 14 patients underwent an aorticpulmonary shunt for cyanotic heart disease, at which time the subclavian artery was either deemed too small or too short to function satisfactorily as a Blalock shunt. In each case a rectangular piece of pericardium was excised, rolled into a tube, and sutured down one edge to create a tube graft. One end of the graft was sutured to the stump of the subclavian artery near its takeoff and the other end was sutured end-to-side to the corresponding pulmonary artery. During the same period, 5 children had azygos vein grafts and 2 had Teflon grafts inserted to create a modified Blalock shunt. This article will discuss the indications, techniques, and long term results of aorticpulmonary shunts of all types, and more specifically the complications and long term results in patients where these grafts were used.

Thoracic Surgery in the Patient with Sickle-Cell Hemoglobin

ypoxia may precipitate major symptoms in patients with sicklecell hemoglobin or “sickle trait.” This factor is especially H important to the patient having thoracotomy with resultant disturbances of oxygenation. This report is an analysis of the course of 20 patients who had 23 pulmonary operations in the face of sickle-cell hemoglobin compared to a group of 1,053 control Negro patients with normal hemoglobin who also had pulmonary operations.