Joel D. Cooper

An improved technique to facilitate transcervical thymectomy for myasthenia gravis

We have used the transcervical method of thymectomy in patients with myasthenia gravis and believe that complete thymectomy is accomplished with minimum morbidity. For the past eight years we have used an improved technique for the transcervical approach, employing a specially designed sternal retractor that permits improved visualization of the anterior mediastinum. We have reviewed 65 patients operated on between 1977 and 1986. Patients were assessed using a modified Osserman classification (0 = asymptomatic; 1 = ocular signs and symptoms; 2 = mild generalized weakness; 3 = moderate generalized weakness; 4 = severe generalized weakness, respiratory dysfunction, or both). The mean grade for all patients at the time of thymectomy was 2.7. At most recent follow-up, the mean clinical grade was 0.5. In addition, 85% of patients were free of generalized weakness, 95% had improved by at least one grade, and 86% had improved by two or more grades. Comparing these results with those reported following thymectomy through a sternotomy reveals that the transcervical approach gives equivalent results.

Extended Indications for Median Sternotomy in Patients Requiring Pulmonary Resection

We have employed median sternotomy in 9 patients for resection of both benign and malignant lung lesions. The most frequent use of this approach was for bilateral wedge resection, though unilateral resection was done in 2 patients. Our experience supports the previously documented usefulness of median sternotomy for minor bilateral resections and suggests that more complex pulmonary resections are possible when an appropriate indication exists. We compared the effects of median sternotomy with those of lateral thoracotomy on postoperative vital capacity and peak airway flow. Both incisions results in a marked loss of measured lung function, but recovery occurs notably sooner after median sternotomy than ater lateral thoracotomy.

The Value of Adjuvant Radiotherapy in Pulmonary and Chest Wall Resection for Bronchogenic Carcinoma

Thirty-five patients, 29 men and 6 women, underwent pulmonary and chest wall resection for treatment of bronchogenic cancer which had extended into the chest wall. Anterior chest wall resection was performed in 6 patients, lateral resection in 2, and posterior resection in 27. Marlex mesh was employed as a prosthetic material in 13 patients. Radiotherapy was given as part of the planned therapeutic regimen in 13 patients. Three patients (8.5%) died in the postoperative period. There was 21 late deaths. Eleven patients are alive 7 months to 12 years after resection. The overall actuarial survival, including operative mortality, is 38% at 5 years. Actuarial survival of the 13 irradiated patients is 56% at 2 and 5 years. We believe that bronchogenic carcinoma with chest wall involvement is not hopeless, and that resection of the lung and chest wall can be performed with an acceptable mortality rate.

Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula

Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml. Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation. High-output thoracic duct fistulas may be handled by supradiphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.

Bronchial omentopexy in canine lung allotransplantation.

Impaired bronchial healing has been a major source of morbidity and mortality following clinical lung transplantation. Bronchial ischemia secondary to division of the systemic bronchial blood supply may be an important cause of these complications. Bronchial omentopexy was performed in conjunction with lung allotransplantation in 6 dogs. Revascularization of the distal bronchial circulation through the omental pedicle was demonstrated in all instances by postmortem injection studies done through the celiac artery. Bronchostenosis occurred in 1 dog. No other complications were encountered. In view of the frequency of bronchial anastomotic complications following human lung transplantation, the technique of bronchial omentopexy warrants serious consideration.

Trachea–Innominate Artery Fistula: Successful Management or 3 Consecutive Patients

Trachea-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Three successive patients who developed this complication while receiving ventilatory assistance through a tracheostomy tube were successfully managed, with long-term survival. Bleeding was controlled by direct digital pressure on the innominate artery or by hyperinflation of the balloon cuff of the tracheostomy tube. In 2 patients, replacement of the tracheostomy tube with an orotracheal tube improved direct access to the innominate artery for digital compression. Late follow-up examination of the right carotid circulation revealed complete reversal of flow in the right internal and common carotid arteries in the 2 patients studied.

The Management of Nonmalignant Intrathoracic Esophageal Perforations

Eight patients with nonmalignant intrathoracic esophageal perforations recognized more than 48 hours (48 hours to 14 days) after rupture were treated at Toronto General Hospital between 1973 and 1978. Perforation was due to postemetic rupture in 7 patients and to instrumentation in 1. The patients were seen with pain (8), vomiting (7), fever (7), shock (4), respiratory insufficiency (5), pleural effusion (7), pulmonary infiltrates (7), and leukocytosis (6). All patients were managed with thoracotomy. Direct suture closure of the perforation was carried out in 4 patients with midesophageal perforations. Postoperative localized leaks developed in 2 of these patients but healed with conservative management. Cervical esophagostomy and esophageal diversion were used in 1 patient in whom a severe empyema developed in the postoperative period. Direct suture closure, reinforced with a gastric patch, was used to close three lower esophageal perforations. None of these patients had a postoperative leak but all developed subsequent reflux esophagitis. All 8 patients survived. In patients with delayed recognition of a nonmalignant intrathoracic esophageal perforation, elimination of continued chemical and bacterial contamination can be achieved by a clear definition and closure of the esophageal mucosal margins. The obliteration of potential pleural spaces by good tube drainage, lung decortication, and the elective use of mechanical ventilation with positive end-expiratory pressure decreases the incidence of uncontrolled intrapleural sepsis.

Aspiration Needle Biopsy of Thoracic Lesions

We reviewed our experience with 2,114 percutaneous aspiration needle biopsies of intrathoracic lesions. Aspiration was performed for cytological diagnosis employing biplane fluoroscopy and a 20 gauge needle, 0.9 mm in outside diameter. A satisfactory specimen was obtained in 88% of biopsies, and the chance of obtaining a correct diagnosis of a malignant lesion was 81.5%. The false positive rate was 2.3%, and the cytologists could always distinguish between primary and secondary neoplasms. A false negative rare of 13.6% (36 patients) resulted in only three delayed thoracotomies and two instances of interval metastases discovered at mediastinoscopy. Cellular specificity in primary tumors was not sufficiently accurate to affect therapy. Pneumothoraces occurred frequently (31.9% of patients) but wee generally small; 10.4% of patients required chest drainage. There were no recorded instances of tumor implantation in needle tracts. We conclude that a rapid and accurate diagnosis of intrathoracic pathology can be obtained by this technique. It is associated with an acceptable morbidity and may greatly expedite both patient care and investigation.

Status of Lung Transplantation

Selected patients with terminal lung disease have been managed effectively by lung transplantation. Strict selection criteria for donors and recipients, attention to technical detail, and avoidance of perioperative corticosteroids increase the likelihood of success. The underlying pulmonary disease determines the appropriate procedure. Single-lung transplantation is most appropriate for patients with pulmonary fibrosis. Patients with emphysema or septic pulmonary disease who have adequate or recoverable cardiac function can be well served by double-lung transplantation. However, such patients are still treated in some centers by combined heart-lung transplantation. Patients with right-heart failure secondary to vascular or parenchymal pulmonary disease are best managed by combined heart-lung transplantation. Donor availability, airway healing, and diagnosis of rejection remain significant problems and are the focus of experimental and clinical investigation in many centers.

Peptic Ulcer in Acquired Columnar-Lined Esophagus: Results of Surgical Treatment

Ulcerative peptic esophagitis may lead to the progressive replacement of squamous by columnar epithelium in the distal esophagus. A typical peptic ulcer (Barretts ulcer) may develop in the columnar-lined segment, although this is a rare occurrence. Between 1975 and 1985 at Toronto General Hospital we treated 11 patients with penetrating peptic ulcer and acquired, columnar-lined esophagus. Presenting symptoms related to the ulcer were precordial and lower dorsal back pain in 4 patients, dysphagia in 6, and massive hemorrhage of the upper gastrointestinal tract in 4. None of the ulcers healed following a trial of medical therapy, and ultimately all 11 patients underwent antireflux procedures (gastroplasty and partial fundoplication). There was one operative death. Complete healing of the ulcer was observed in the 8 patients who underwent follow-up endoscopy between two and five months after operation. There has been no recurrence of symptoms resulting from ulcer in subsequent follow-up, which extends from 1 to 11 years (mean, 5 years). Adenocarcinoma developed in the columnar-lined segment in 2 of the 11 patients, which was diagnosed at 32 and 91 months following operation, respectively.