Maruf A. Razzuk

Paget-Schroetter syndrome: what is the best management?

BACKGROUNDnThe evaluation of 312 extremities in 294 patients with Paget-Schroetter syndrome (effort thrombosis of the axillary-subclavian vein) over 30 years provides the basis for optimal management determination.nnnMETHODS AND RESULTSnGroup I (35 extremities) was initially treated with anticoagulants only. Twenty-one developed recurrent symptoms after returning to work, requiring transaxillary resection of the first rib. Thrombectomy was necessary in eight. Group II (36 extremities) was treated with thrombolytic agents initially, with 20 requiring subsequent rib resection after returning to work. Thrombectomy was necessary only in four. Of the most recent 241 extremities (group III), excellent results accrued using thrombolysis plus prompt first rib resection for those evaluated during the first month after occlusion (199). The results were only fair for those if seen later than 1 month (42).nnnCONCLUSIONSnAn early diagnosis (less than 1 month), expeditious thrombolytic therapy, and prompt first rib resection are critical for the best results.

Median Sternotomy as a Standard Approach for Pulmonary Resection

Pulmonary resection was performed electively through a median sternotomy in 174 patients. The first 61 of these patients were compared with an equal number having pulmonary resection through a lateral thoracotomy. Both groups were similar in regard to sex, age, pathological condition, and type of resection. The patients undergoing median sternotomy had a shorter operative time and less postoperative pain, and were discharged from the hospital sooner than the patients having resection through a lateral thoracotomy. The cardinal technical essentials to expeditious pulmonary resection through a median sternotomy involve unilateral pulmonary ventilation with a double-lumen endotracheal tube, arterial pressure and gas monitoring, and proper lung packing and retraction. Two patients died, 1 of infection and 1 of bleeding; neither death was related to the incision. Certain pulmonary procedures are better performed through a lateral thoracotomy, and these include resection of a superior sulcus carcinoma, pulmonary resection with posterior chest wall extension, and left lower lobe resection in patients who demonstrate obesity, cardiomegaly, or an elevated diaphragm.

Objective Diagnosis (Ulnar Nerve Conduction Velocity) and Current Therapy of the Thoracic Outlet Syndrome

Abstract Analysis of 155 operations in 138 patients with thoracic outlet syndrome demonstrates the validity of resection of the first rib as the optimal method of therapy in patients who are not relieved by conservative management. The ulnar nerve conduction velocity (UNCV) study has provided a reliable, positive, objective method for diagnosis, selection, and evaluation of therapeutic modalities in patients with thoracic outlet syndrome. Median and musculocutaneous nerve compression can be the etiological factor in patients with atypical pain distribution in whom the UNCV is normal. Conduction study of these nerves confirms the diagnosis of thoracic outlet compression. The transaxillary approach allows complete resection of the first rib with decompression of the neurovascular bundle and is associated with a reduced morbidity and hospital stay.

Sclerosing mediastieitis: Improved management with histoplasmosis titer and ketoconazole

Recognition that many patients with benign sclerosing mediastinitis have smoldering disease responsible for failure of surgical procedures or for development of collateral circulation in patients with superior vena caval obstruction has markedly improved management of these difficult patients. Histoplasmosis complement fixation titers have been used to detect unsuspected subacute disease and to follow the therapeutic adjunctive management with ketoconazole, an oral antifungal agent. Twenty-two patients with benign sclerosing mediastinitis demonstrated a variety of symptoms relating to the area of compression: superior vena cava, 13; esophagus, 3; pulmonary artery and pericardium, 3; and trachea, 3. Histoplasmosis was documented in 12 patients. Operation is used initially for diagnosis, to rule out carcinoma, and to treat the complications: superior vena caval reconstruction, 6; tracheal decompression, 2; right middle lobectomy, 1; esophageal decompression, 2; division of tracheoesophageal fistula, 1; and release of pericardial effusion and cardiac tamponade, 1. Postcardiotomy syndrome occurred in 1 patient and wound infection in another. No deaths resulted. In 6 cases of histoplasmosis, symptoms recurred in 100% of patients and were successfully managed with ketoconazole treatment, and then clinical progress was monitored with serial histoplasmosis complement fixation studies. One patient had four superior vena caval reconstructions at an outside hospital, each 1 year apart, with symptoms recurring each time. With ketoconazole therapy alone, she has been asymptomatic for more than 2 years. Vigorous search for a fungal cause may even obviate the necessity for surgical intervention. If an operation is necessary, preoperative and postoperative use of ketoconazole has assured success.

Dual Primary Bronchogenic Carcinoma

Abstract Thirty-four cases of double primary bronchogenic carcinomas, 5 simultaneous and 29 consecutive, were encountered among 2,664 patients treated for bronchogenic carcinoma. Criteria used for establishing the independent nature of these tumors included: (1) the absence of an extrapulmonary primary tumor of a similar histopathology, (2) the presence of bronchial communication, (3) simultaneous appearance of two tumors, and (4) a long interval between consecutive tumors. The interval between two primary tumors ranged from 9 months to 15 years, with the average being 5 years and the highest incidence at the second and fifth years. The tumors in 15 patients were operable; 3 patients are alive at 1 to 4 years and 1 at 5 years. The prognosis in this kind of patient is grave; operation offers the best chance for cure.

Poland's Syndrome: Improved Surgical Management

Single-stage reconstruction of the chest wall combined with simultaneous augmentation mammoplasty and transfer of an island pedicle myocutaneous flap of latissimus dorsi muscle are major improvements over previous multiple-stage procedures that provide less satisfactory cosmetic results in management of patients with Polands syndrome. Utilization of the single-stage technique in 2 patients demonstrated its efficacy as proven by excellent cosmetic results. In 1 patient with absent second, third, and fourth costal cartilages and ribs, Marlex mesh covered with a synthetic dura mater graft was employed to stabilize the chest wall. Simultaneously, an island pedicle myocutaneous flap of latissimus dorsi with its neurovascular bundle preserved was transferred to cover the prosthesis. The other patient had a coexistent pectus carinatum defect, which was repaired by resection of the costal cartilages and osteotomy of the sternum without use of Marlex. The breast implant was covered concomitantly with the myocutaneous flap of latissimus dorsi. No morbidity or mortality occurred. The cosmetic and functional results are superior to those obtained with standard techniques.

Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina)

Abstract Forty-four patients presenting with chest pain suggesting coronary artery disease had normal exercise stress tests and selective coronary angiography and subsequently were found to have an unsuspected thoracic outlet syndrome. Thirteen additional patients had both significant coronary artery disease and thoracic outlet syndrome. Esophageal and pulmonary disease were ruled out and the diagnosis of brachial plexus compression in the thoracic outlet established by a reduction of the ulnar nerve conduction velocity (UNCV) below normal, the normal value being 72 meters per second. Clinical improvement from thoracic outlet compression resulted either from physical therapy if the UNCVs were above 55 m./sec, or from transaxillary surgical extirpation of the first rib if the UNCVs were below 55 m./sec. Thirteen patients with coronary artery disease and thoracic outlet syndrome required therapy for both problems before improvement ensued. Although the usual symptomatology for thoracic outlet syndrome involves pain and paresthesias of the shoulder, arm, and hand, the chest wall is frequently involved. If the chest pain is predominant with minimal shoulder-hand symptoms, the diagnosis is not suggested clinically and can only be established by the high index of suspicion, positive UNCV reduction, and a normal coronary angiogram. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm.

Upper Plexus Thoracic Outlet Syndrome: Optimal Therapy

BACKGROUNDnPreviously, transaxillary first rib resection alone was not considered adequate therapy for upper plexus (median nerve) thoracic outlet syndrome. It was thought that the combined approach with upper plexus dissection through a supraclavicular incision in addition to the transaxillary approach was necessary. However, with better understanding of anatomy--that the median nerve receives fibers from C8 and T1 as well as the upper plexus and that muscles that compress the upper plexus attach to the first rib--it is now recognized that first rib removal alone will relieve upper plexus compression.nnnMETHODSnAssessment of 2,210 operations for thoracic outlet syndrome revealed 250 patients (11%) had symptoms and nerve conduction velocity slowing of the median nerve only (upper plexus), whereas 452 (20%) patients had both median and ulnar nerve compression (upper and lower), and 1,508 patients exhibited compression symptoms and nerve conduction velocity slowing of the ulnar nerve alone (lower plexus).nnnRESULTSnTransaxillary first rib resection relieved symptoms of median nerve (upper plexus) compression as well as it did for ulnar nerve (lower plexus) compression. Treatment outcome comparisons of patients with median and ulnar compression show no significant differences.nnnCONCLUSIONSnThese data refute the need for supraclavicular or combined supraclavicular and transaxillary approaches to treat patients with upper plexus (median) thoracic outlet syndrome compression as previously recommended. The transaxillary approach alone is satisfactory.

Surgical Advantages of Selective Unilateral Ventilation

Abstract Two hundred major thoracic operations have been performed using controlled selective unilateral pulmonary ventilation with no morbidity or mortality related to this technique. A group of 20 patients ventilated selectively with a double-lumen endotracheal tube and 5 additional patients ventilated with a single-lumen tube were studied to determine the physiological effects of each technique. Blood gases and physiological shunt determinations showed better values with selective ventilation, whereas some derangement was noticed in the group ventilated with a single-lumen tube. The physiological and technical advantages provided by the double-lumen endobronchial tube make selective ventilation safer and more practical.

Giant Fibrovascular Polyp of the Esophagus

A case of giant fibrovascular polyp of the esophagus with a review of the literature is presented. The lesion is benign and pedunculated and may attain giant proportions. Symptoms are related to esophageal obstruction. Death by asphyxia can occur. Small lesions can be removed endoscopically with a snare. Larger lesions should be excised using a formal surgical approach.