James C. Harvey

Early thoracic duct ligation for postoperative chylothorax

Four cases of postoperative chylothorax occurring at this institution over the past 5 years, as well as an extensive review of the world literature, are presented. Of the four cases, three occurred after resection of carcinoma of the lung and one after resection of recurrent chondrosarcoma of the chest wall. These patients were treated nonoperatively for varying periods of time ranging from 2 days to nearly 3 weeks. Subsequently, all patients underwent ligation of the thoracic duct. Early reoperation for ligation of the thoracic duct resulted in no morbidity or mortality. In one case of delayed thoracic duct ligation, after an attempt at ligation of minor lymphatic vessels, the single mortality occurred. In view of the experience with these patients and that reported in the literature, we propose that not only is thoracic duct ligation superior to nonoperative management, but that it should be undertaken without delay.

DIAPHRAGMATIC HERNIA FOLLOWING TRANSHIATAL ESOPHAGECTOMY Case report

Transitional esophagectomy (THE) has been advocated as an alternative to the classic transthoracic approach. A variety of complications have been previously described with THE however, these can be avoided with meticulous detail to its technique. We report a patient who developed a complete small bowel obstruction secondary to a diaphragmatic hernia following transhiatal esophagectomy. Techniques to prevent such a rare complication is described.

Chemoradiation in advanced nonsmall cell lung cancer

PURPOSE Resectability, local control, and survival were evaluated in advanced stage nonsmall cell lung cancer treated with simultaneous chemoradiation therapy delivered in an accelerated, interrupted twice-a-day schedule. METHODS AND MATERIALS Forty-seven consecutive patients with Stage IIIA or IIIB nonsmall cell lung cancer, consenting to participation in the study, received cisplatin, 30 mg/m2 for 3 days, etoposid, 80 mg/m2 for 3 days, and 5-fluorouracil, 900 mg/m2 for 4 days. Radiation therapy consisted of 2 Gy given twice a day for 5 days. Two weeks rest was planned between cycles. Patients were evaluated for resectability after the second cycle. Any patient with unresectable tumor received a third cycle of treatment. RESULTS Forty-seven patients were evaluable for acute toxicity: eighteen (38%) required an extended rest period for esophagitis or low blood count; 3 (6%) had sepsis, of whom 1 (2%) expired. Three patients (6%) had multiple blood transfusions for low hemoglobin. Median follow-up is 23.6 months, with a range of 10-49 months. Nine patients (19%) failed locally; 15 (32%) had local and distant failure; 7 (15%) failed only at distant sites. Twelve patients (25.5%) are alive with no evidence of disease; 4 patients were lost to follow-up with disease. The 2-year actuarial survival is 49%, and the 4-year is 28.2%. CONCLUSION Simultaneous chemoradiation is well tolerated with acceptable toxicity. The overall 2- and 4-year actuarial survival is somewhat better than that reported in the literature. Resectability in Stage IIIB patients was not increased with this regimen nor was any surgical specimen free of cancer. The 47% distant failure rate is not different from those reported by others.

Aortoesophageal fistula after reconstruction of the thoracic spine

Aortoesophageal fistula is a rare complication after neurosurgical repair of the thoracic spine. We report an instance of a lethal aortoesophageal fistula caused by a pseudoaneurysm that developed after long contact between the prosthetic material from a spinal reconstruction procedure and the thoracic aorta. Pathologic examination showed that the mesh formed the roof of the pseudoaneurysm and was the most probable cause of the lesion.

Absorbable mesh in placement of temporary implants

PURPOSE To evaluate absorbable mesh for the suturing of afterloading catheters in patients with tumors involving the chest wall. METHODS AND MATERIALS Patients underwent thoracotomy and resection of tumor; a layer of absorbable mesh was then sutured to the tumor bed. Nylon flexiguide afterloading catheters were sutured into the mesh at about 1.5 cm distance from each other. A second layer of mesh was then sutured on top of the catheters. The chest wall was closed. Orthogonal radiographs and CT scans of the area of implants were done to verify catheter position in each patient on day 1 and on the last day of implant. Computer dosimetry by digitization of dummy sources was performed on each set of radiographs. The same seed for both sets of films was chosen as the origin of digitization. All seed coordinates were compared directly to offset for any rotation of the patient during the two sets of films. The distances were calculated from all seed positions to the origin, then tabulated and compared. RESULTS The distances agreed within a few millimeters (7-8 mm). The differences may be attributed to the patients breathing and to the localization uncertainty. The resulting dose alteration was negligible. CONCLUSION This technique appears to provide adequate anchorage of catheters with resulting constant seed position and dose distribution in areas of scant tissues or in surgical beds of considerable size.