Kenneth Stewart

Pulmonary Resection for Lung Trauma

BACKGROUND Pulmonary resection is rarely required for trauma, and its mortality is reportedly high. METHODS A 10-year retrospective review of pulmonary resections for trauma was done. RESULTS Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001). CONCLUSIONS Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.

Novel Fixation Technique for the Surgical Repair of Lung Hernias

We describe a novel technique for dealing with the rare complication of post-traumatic or post-thoracotomy lung herniation. The method uses techniques and fixation devices that have been developed for stabilization and fixation of the spine and surgical management of scoliosis. It allows for a secure, reliable, and easily reproducible fixation of the chest-wall in patients with large intercostal lung hernias using standard spinal instruments.

Risk factors and outcomes for the development of malignancy in lung and heart-lung transplant recipients.

BACKGROUND Many factors may limit survival from lung and heartlung transplantation, including malignancy. OBJECTIVE To investigate factors associated with the development of malignancy following transplantation and its effect on survival by retrospectively reviewing a population of lung transplant recipients. METHODS Data from 342 consecutive lung transplant patients were collected. Results were analyzed by fitting variables into a multivariate logistic regression model predicting the development of post-transplant malignancies. Covariates were selected based on crude associations that reached a level of significance at P ≤ 0.10. Length of survival was analyzed using the Kaplan-Meier method. RESULTS Fifty-eight subjects developed post-transplant malignancies, which were the cause of death of 14 patients. Twenty-one patients had a pretransplant malignancy, of whom six developed a malignancy posttransplant--of these, two were fatal recurrences. No risk factors were significantly associated with all forms of post-transplant malignancy. When adjusted for age at transplantation and donor smoking history, Epstein-Barr virus seropositivity at the time of transplant was significantly associated with a reduced risk of a post-transplant lymphoproliferative disorder (OR 0.17; 95% CI 0.05 to 0.59). The median survival time in individuals without a post-transplant malignancy was significantly shorter than in those with a post-transplant malignancy (P = 0.018 Wilcoxon [Breslow]). This may be secondary to the length of time required to develop malignancy and the fact that not all malignancies that developed were fatal. The median time to develop malignancy was greater than two years. In addition, the 14 patients who died as a result of their malignancy had a significantly shorter survival time than the 44 who died because of nonmalignant causes (P < 0.001). CONCLUSIONS Malignancy was not associated with an overall decrease in survival time when compared with those who did not develop a malignancy. Risk factors specific for the development of malignancies remain difficult to specify.

Treatment of a tuberculous empyema with simultaneous oral and intrapleural antituberculosis drugs.

A 71-year-old man was diagnosed with an uncomplicated tuberculous (TB) empyema. Differential penetration of anti-TB drugs, believed to explain the phenomenon of acquired drug resistance in TB empyema, was confirmed by measurement of serum and pleural fluid anti-TB drug concentrations. Simultaneous oral and intrapleural anti-TB drugs were administered and a cure was achieved. The present case is discussed in the context of the literature on acquired drug resistance in TB empyema. It is argued that high-end doses of oral drugs or combined oral plus intrapleural drugs, along with tube thoracostomy or intermittent thoracentesis, will cure uncomplicated TB empyema without threatening to induce drug resistance or having to resort to surgery.

Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis.

Talc lung granulomatosis results from the intravenous use of medication intended for oral use. Talc (magnesium silicate) acts as filler in some oral medications; when injected intravenously, it deposits in the lungs leading to airflow obstruction and impaired gas exchange. Allocation of donor lungs to previous intravenous drug users is controversial. After a careful selection process, 19 patients with talc lung granulomatosis have received lung allografts in our program. Long-term survival for these patients is excellent and our results suggest the previous use of intravenous drugs should not necessarily preclude lung transplantation.

Managing a solitary fibrous tumour of the diaphragm from above and below

Solitary fibrous tumours are rare spindle-cell neoplasms that usually arise from visceral and parietal pleura and peritoneum and are likely of either mesothelial cell origin or fibroblast/primitive mesenchymal cell origin. They are typically found in the chest and occasionally the abdominal cavity but have been reported in the parotid gland, pericardium, ovary, liver, intestine, lung, orbit, upper respiratory tract, bladder and periosteum. Solitary fibrous tumours involving the diaphragm arising from overlying pleura or underlying peritoneum have been occasionally described but never with such intimate involvement. A 32-year-old female smoker presented with clinical features typical for gallstones. An ultrasound of her biliary system confirmed cholelithiasis but also noted a large heterogeneous solid hypoechoic mass medial to the spleen in the left upper quadrant. Beyond issues with symptoms related to gallstones, she denied any other problems including breathlessness, atypical chest pain or referred pain. She had no night sweats or weight loss, and clinical examination was unremarkable. A chest computerized tomography (CT) demonstrated a large mass in intimate contact with the left hemidiaphragm (Fig. 1a,b). Following standard general anaesthesia and single lung ventilation, a left video-assisted thoracoscopic assessment showed the mass appearing to be within the diaphragm or pushing up from the abdomen. A laparoscopy was performed, which confirmed the mass was within the diaphragm itself (Fig. 2) and completely separate form underlying abdominal viscera. Following left thoracotomy, a full thickness excision of the hemidiaphragm with the tumour contained within its leaves was completed. The hemidiaphragm was reconstructed using Gore-Tex (Flagstaff, AZ, USA). The patient went on to make an uneventful recovery, and following discharge at one-year follow-up, was fully recovered with a chest CT showing no evidence of recurrence. Tumour inspection found grossly normal diaphragmatic tissue covering both sides of the specimen. Immunoperoxidase stains demonstrated strong diffuse cytoplasmic positivity for CD34 as well as vimentin, Bcl-2 and S100, but a lack of strong cytokeratin positivity. The morphologic and immunophenotypic features were those of a solitary fibrous tumour.

Is lobectomy superior to sublobar resection for early-stage small-cell lung cancer discovered intraoperatively?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Is lobectomy superior to sublobar resection (SLR) for early-stage (cT1/2N0) small-cell lung cancer (SCLC) discovered intraoperatively? Altogether, more than 360 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Surgical treatment was shown to be superior to non-surgical treatment for early-stage SCLC in 8 papers. Seven papers showed that among patients treated surgically, lobectomy is associated with improved survival compared to SLR. One paper demonstrated both improved survival and improved freedom from local recurrence. However, 1 paper showed no difference when lobectomy was compared to anatomical segmentectomy. Three papers demonstrated significant rates of upstaging in surgical patients. Although both lobectomy and SLR are associated with improved survival compared with non-surgical treatment in early-stage SCLC, lobectomy is superior. Lobectomy was associated with improved median and overall survival, better upstaging and decreased local recurrence compared to SLR, although there is potential for selection bias and stage migration. Lobectomy should be considered the optimal approach for patients with early-stage SCLC.

A late complication of a traumatic flail segment: colonic herniation

A 64-year-old man was a multiple trauma victim following a motor vehicle accident. He sustained injuries to his head, left leg, a burst fracture of the L4 vertebra and left haemopneumothorax with an associated flail segment involving ribs 8–11 that required a thoracostomy drain. …