Joseph I. Miller

Chest wall resections and reconstruction: a 25-year experience

BACKGROUND Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions. METHODS A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed. RESULTS Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 +/- 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was 14 +/- 14 days. Mean intensive care unit stay was 5 +/- 9 days. In-hospital and 30-day survival was 93%. CONCLUSIONS Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.

Esophageal perforation: Emphasis on management

BACKGROUND Perforation of the esophagus is a deadly injury that requires expert management for survival. METHODS We performed a retrospective clinical review of 66 patients treated at Emory University affiliated hospitals for esophageal perforation between 1973 and 1993. RESULTS Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower-third injuries occurred in 43 cases (65%), middle third in 14 (21%), and upper third in 9 (14%). Early contained perforations were managed successfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural contamination recognized early were managed by primary closure and drainage in 28 patients. Reinforcement of the primary closure using stomach fundus, pleural, diaphragmatic, or pericardial flap was performed in 16 patients. Those perforations that escaped early recognition required thoughtful management, using generous debridement and drainage and sometimes esophageal resection. The esophageal T tube provided control of leaks in 3 of these patients and was a useful adjunct. Using these management principles, we achieved a 76% survival rate for all patients. Six patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate. CONCLUSIONS Esophageal perforation remains an important thoracic emergency. Aggressive operative therapy remains the mainstay for treatment; however, conservative management may be preferred for contained perforations and the esophageal T tube may be used for late perforations.

Limited Resection of Bronchogenic Carcinoma in the Patient with Marked Impairment of Pulmonary Function

Surgical resection is the treatment of choice for non-small cell bronchogenic carcinoma, and it is the only method providing prolonged arrest and chance for cure. From 1974 through 1984, 32 patients with marked impairment of pulmonary function had a limited resection for carcinoma of the lung. Marked impairment is defined as a maximum breathing capacity less than 35 to 40% of predicted, forced expiratory volume in one second less than or equal to 1 liter, and forced expiratory flow (FEV25-75) of less than or equal to 0.6 liter. Limited resection is defined as an operation that is less than a lobectomy, generally a wide wedge or segmental resection. The pathological stage of disease was Stage I in 31 patients and Stage II in 1 patient. Ten patients were treated by segmental resection and 22 by wide wedge resection. Two-year and three-year survival is 84 and 78%, respectively, and 10 patients (31%) have survived for five years. Recurrent disease developed in 8 patients, 5 of whom died. Recurrence was highest when the lesion crossed an intersegmental plane. In 1978, postoperative radiation therapy was added to the treatment of all patients whose lesion crossed an intersegmental plane. Since then, 18 patients have undergone wedge resection and postoperative irradiation with only 2 local recurrences at two years.

Long-term follow-up of coronary artery disease presenting in young adults.

OBJECTIVES This study evaluated long-term survival and predictors of elevated risk for young adults diagnosed with coronary artery disease (CAD). BACKGROUND Coronary artery disease is rarely seen in young adults. Traditional cardiac risk factors have been studied in small series; however, many questions exist. METHODS We identified 843 patients under age 40 with CAD diagnosed by coronary angiography from 1975 to 1985. Death, hypertension, gender, family history, prior myocardial infarction (MI), diabetes, heart failure, angina class, number of diseased vessels, ejection fraction (EF), Q-wave infarction, in-hospital death, and initial therapy were studied. Patients were followed for 15 years. RESULTS The mean age was 35 for women (n = 94) and 36 for men (n = 729). The average EF was 55%. Fifty-eight percent of the subjects had single-vessel disease, and 10% were diabetic. The strongest predictors of long-term mortality were a prior MI (hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.00 to 1.73), New York Heart Association class II heart failure (HR 1.75, 95% CI 1.03 to 2.97), and active tobacco use (HR 1.59, 95% CI 1.14 to 2.21). Revascularization, rather than medical therapy, was associated with lower mortality (coronary angioplasty: HR 0.51, 95% CI 0.32 to 0.81; coronary artery bypass graft: HR 0.68, 95% CI 0.50 to 0.94). Overall mortality was 30% at 15 years. Patients with diabetes had 15-year mortality of 65%. Those with prior MI had 15-year mortality of 45%, and patients with an EF <30% a mortality of 83% at 15 years. CONCLUSIONS Coronary disease in young adults can carry a poor long-term prognosis. A prior MI, diabetes, active tobacco abuse, and lower EF predict a significantly higher mortality.

Lung volume reduction surgery: Lessons learned

BACKGROUND The concept of lung volume reduction for generalized emphysema was proposed by Brantigan and associates in 1958 and reintroduced by Cooper and colleagues in 1994. The present study presents lessons learned from an 18-month experience. METHODS From August 1, 1994, to August 1, 1995, 53 patients underwent lung volume reduction at Emory University for generalized emphysema. There were 17 women and 36 men ranging in age from 55 to 75 years. The length of stay ranged from 10 to 59 days. At the time of presentation, 47 patients were receiving oxygen and 35 were receiving steroids. Forty-six patients were operated on using a median sternotomy and 7 through a unilateral thoracotomy. All patients underwent preoperative and postoperative pulmonary rehabilitation. RESULTS There was one early death and four late deaths. Lessons learned from this group of patients are presented. CONCLUSIONS Lung volume reduction surgery remains a sea of relatively uncharted waters, with the future direction yet to be determined.

Carcinoma of the superior pulmonary sulcus.

From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoasts syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.

Predictors of outcome in thymectomy for myasthenia gravis

BACKGROUND Factors determining predictability of response to thymectomy for myasthenia gravis (MG) vary in the literature. METHODS A 25-year retrospective review (1974 to 1999) of all thymectomies performed at a single institution was undertaken. RESULTS In 113 consecutive thymectomies for MG, women comprised 79% (89 of 113 patients), and mean age was 40+/-15 years. Complications occurred in 14% of patients (16 of 113). In-hospital mortality was 0, but 90-day hospital mortality was 0.88% (1 of 113 patients). Follow-up was obtained in 81% (92 of 113 patients) at a mean of 51+/-59 months postoperatively. Complete remission was achieved in 21% of patients (19 of 92), and marked improvement of MG in 54% (50 of 92), for a total benefit rate of 75%. Fourteen percent (13 of 92) were unchanged, and 11% (10 of 92) were worse. Using univariate analysis, sex, age, and pathology correlated significantly with outcome (p < 0.05): 80% of women (57 of 70) benefited from the procedure, versus 57% of men (12 of 21). Eighty percent (57 of 70) of patients less than 51 years of age were improved or in remission, versus 57% (12 of 22) older than 50. Twenty-three percent (5 of 22) of patients with thymoma deteriorated, versus 7.1% (5 of 70) without thymoma. Sex did not significantly correlate in the multivariate model. CONCLUSIONS Sex, age, and thymic pathology are potential predictors of outcome in thymectomy for MG, and may shape treatment decisions and target higher-risk patients.

A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections

BACKGROUND Prolonged air leak is the major limiting factor in early hospital discharge following pulmonary resection. The purpose of this study was to determine whether the use of bovine pericardial strips as a buttress along the lung staple line would decrease air leaks and hospital stay after lobectomy and segmentectomy. METHODS This was a multicenter trial consisting of 80 patients undergoing pulmonary resection, randomly assigned to the control group (40 patients) or treatment group (40 patients). The treatment group had reinforcement with bovine pericardium. RESULTS No statistical differences were noted in the mean intensive care unit length of stay (p = 0.9), number of days with a chest tube (p = 0.6), or total length of stay (p = 0.24). Increased air leak duration was associated with assignment to the control group (r = 0.27, p = 0.02). The mean duration of air leak was 2 days and the mean time to chest tube removal was 5.9 days in patients with a buttressed staple line compared to 3 days and 6.3 days, respectively, for patients with nonbuttressed staple lines. CONCLUSIONS Within the data of this study, no statistical differences were noted between buttressed and nonbuttressed patients. However, the trend toward shortened air leak time and tube removal time was apparent in the buttressed group. With greater number of patients studied, it is likely that the cost of bovine pericardium would be justified by shorter air leak duration and hospitalization.

Angiogenesis As A Predictor Of Survival After Surgical Resection For Stage I Non-Small-Cell Lung Cancer

OBJECTIVES Some patients with surgically resected stage I non-small-cell lung cancer eventually have metastatic disease. A histologic marker of metastatic potential and diminished survival for stage I non-small-cell lung cancer may distinguish this patient population. This study evaluates the degree of angiogenesis as a predictor of cancer-related death after operation for stage I non-small-cell lung cancer. METHODS Demographic, surgical, and histopathologic data, including presence of vascular invasion, were reviewed for 106 patients with stage I non-small-cell lung cancer from 1985 through 1990. Visual quantitation of microvessels immunostained with factor VIII-related antigen and CD31 in 5 microm sections from the paraffin blocks of tissue defined rumor angiogenesis. RESULTS Follow-up was 95.1% complete, mean 5.2 +/- 3.0 years. Lung cancer-related mortality rate was 24.4% at 5 years. Mean microvessel counts were 20.7 +/- 11.2 for FVIII and 29.6 +/- 18.1 for CD31. Univariate analysis revealed an FVIII count of at least 20 (p = 0.025) and blood vessel invasion (p = 0.017) to be significant predictors of disease-related death. After adjustment for other patient and tumor characteristics, multivariate Cox regression analysis found an FVIII count of at least 20 (hazard ratio 2.9) and blood vessel invasion (hazard ratio 3.7) to be significant independent correlates of lung cancer death (p = 0.018 and p = 0.011, respectively). CD31 quantitation did not predict survival on univariate or multivariate analyses and did not correlate strongly with FVIII quantitation (Spearmans rank correlation r = 0.19). CONCLUSIONS This analysis reveals a significant association between tumor neovascularization and cancer-related mortality rate among patients with stage I non-small-cell lung cancer. Microvessel quantitation of FVIII, as an indicator of tumor angiogenesis and metastatic potential, may define a subset of patients with stage I non-small-cell lung cancer who could benefit from adjuvant therapy after surgical resection.

Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery

Desmoplastic reactions secondary to adjuvant chemotherapy and radiation in stage IIIA lung cancer, plus advances in complex tracheobronchial surgery, have rejuvenated an interest for augmenting bronchial stump coverage and suture line reinforcement. We present the techniques and applications of harvesting pleural, azygos vein, pericardial flaps, and fat pad grafts, and intrathoracic transposition of chest wall muscle flaps.