Kamal A. Mansour

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.

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.

Single-Stage Complete Muscle Flap Closure of the Postpneumonectomy Empyema Space: A New Method and Possible Solution to a Disturbing Complication

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.

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.

Bowel Interposition for Esophageal Replacement: Twenty-Five–Year Experience

BACKGROUND From 1972 to 1996, bowel interposition reconstruction after esophagectomy for benign and malignant conditions was performed in 129 of 131 patients. The indication for operation was benign disease in 94 patients (72.9%) and malignant disease in 35 patients (27.1%). Benign stricture was the most common presentation in the benign group (41 patients), and adenocarcinoma was the most common indication in the malignant group (19 patients). METHODS One hundred thirty-three conduits were performed in the 129 patients. Four patients (3.1%) required reoperative reconstruction. Of the 97 conduits employed for reconstruction of benign disease, the right colon was used in 70 patients, the left colon in 9 patients, and the transverse colon in 4 patients. A jejunal interposition graft was employed in 11 patients and a free jejunal autograft in 3 patients. The right colon was used in 15 patients with malignant disease, the left colon in 9 patients, and the jejunum in 12 patients. RESULTS The mean age of the population was 54.5 years (range, 14 to 72 years) with a male-to-female ratio of 1.3:1. The average number of prior thoracic or abdominal procedures was 2.9 (range, 1 to 8) with 50.9% of patients undergoing reoperation. The mean length of stay was 21.7 days (range, 8 to 290 days). Complications occurred in 37.1% of patients with anastomotic leak occurring in 14.8% and ischemic colitis in 3.0% of conduits performed. The in-hospital mortality was 5.9%. CONCLUSIONS Bowel interposition reconstruction after esophagectomy for benign and malignant disease can be performed with an acceptable morbidity and mortality, despite prior operative procedures in the abdomen or chest. Colonic and jejunal conduits, employed alone or in combination, can effectively restore gastrointestinal continuity.

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.

Pericardiectomy: Current Indications, Concepts, and Results in a University Center

During a 7 1/2-year period, 102 patients underwent pericardiectomy in the Emory University Affiliated Hospitals for a wide variety of pericardial disease. Seventy-six patients had predominantly effusive pericardial disease, and 26 patients had constrictive pericarditis. Nineteen cases of constrictive pericarditis developed in patients who had undergone previous open-heart operations. Hospital mortality at six weeks was 8.8%. The surgical approach was a left anterior thoracotomy in 72 patients; median sternotomy in 26 patients; and a subxiphoid approach in 4 patients. Only 2 patients required cardiopulmonary bypass. A detailed discussion of each subgroup of patients with pericardial disease requiring pericardiectomy is given.

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.

Sternal resection and reconstruction

Twenty-one patients underwent sternal resection and reconstruction. Surgical indications included sternal infection in 9 patients, recurrent breast cancer in 6, metastatic carcinoma from an unknown primary in 2, pectus excavatum in 2, and osteogenic sarcoma and eosinophilic granuloma in 1 each. Management included partial sternectomy in 10 patients (group 1) and complete sternectomy in 11 (group 2). Chest wall reconstruction was by various flaps and mesh repairs. Blood transfusions averaged 2 units in group 1 versus 5.5 units in group 2 (p = 0.02). Average number of days until extubation was 2.6 in group 1 versus 7.3 in group 2 (p = 0.04). Average number of intensive care unit days was 4.4 for group 1 versus 9.4 for group 2 (p = 0.03). The number of days until discharge was 14 days for group 1 versus 20 days for group 2. Complications occurred in 40% of group 1 and 82% of group 2 patients. Overall mortality was 9.5%. Sternal resection and reconstruction, particularly complete sternal resections, are a major undertaking with substantial morbidity. Using a multidisciplinary approach (cardiothoracic, plastic and reconstructive, critical care medicine, and infectious disease) and aggressive pulmonary support, acceptable cosmetic and functional results are possible.