Paul D. Kiernan

Descending cervical mediastinitis

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Thoracic esophageal perforations.

Background Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. Methods We retrospectively analyzed all cases of thoracic esophageal perforation diagnosed at our hospital from September 1, 1979, through April 1, 2001. The study group consisted of 62 patients (43 men) with a mean age of 58.8 years (range, 20–92 yr). Results In the group of 39 patients with early diagnosis (≤24 h), hospital survival was 87%, which increased to 93% when early diagnosis was combined with aggressive surgical treatment. Among the 23 patients with late diagnosis (>24 h), survival approached 70%. Yet, in patients who were treated aggressively with surgery, survival was almost 90% despite delayed diagnosis. Conclusion We recommend aggressive, definitive surgery for thoracic esophageal perforations, whether diagnosed early or late. A variety of options are discussed with regard to complicated presentations.

Aneurysm of an Aberrant Right Subclavian Artery: Case Report and Review of the Literature

In this article, we describe a case of a surgically treated aneurysm of an aberrant right subclavian artery. The historical literature to date is summarized, as are the key concepts relative to the anatomy, embryology, diagnosis, and treatment of this uncommonly occurring entity. Although the topic might be expected to be of concern to only a few specialists, all physicians should be aware that a patient with an enlarging aneurysm of an aberrant subclavian artery may experience dyspnea, dysphagia, or sudden collapse from rupture as the initial manifestations. An asymptomatic patient may have a mediastinal mass detected by roentgenography. The diagnosis may be confirmed with computed tomography or magnetic resonance imaging. As with most aneurysms, surgical treatment is recommended, and the benefit-to-risk analysis depends on individual case factors.

Late stage (III and IV) non-small cell cancer of the lung: results of surgical resection at Inova Fairfax Hospital.

One hundred forty-two patients underwent surgery and related treatment for advanced stage (III, IV) non-small cell cancer of the lung. One hundred seventeen patients underwent up-front surgery, with a hospital mortality rate of 1.7% (2/117). Kaplan-Meier 5-year survival in this group was 31% (± 5). Twenty-five patients underwent neoadjuvant therapy followed by surgical resection, with respective rates of hospital mortality, complete pathologic response, and major pathologic response of 0%, 16%, and 64%. Kaplan-Meier 5-year survival in this latter group was 34% (± 11). Of the 16 patients undergoing neoadjuvant therapy who had complete pathologic response or significant downstaging from stage III disease, Kaplan-Meier 5-year survival was 61% (± 15).Three clinical observations of interest emerged regarding survival. First, in those patients with postresection FEV1 < 1.0 L, hospital mortality rate was 20%, and there were no 5-year survivors (P < 0.0001). Second, where neoadjuvant therapy was associated with complete pathologic response or significant downstaging of disease, there was a trend for improved survival in the downstaged group, but it did not reach statistical significance (P = 0.14). Third, adjuvant therapy was associated with improved 5-year survival (P = 0.03), particularly for combination chemotherapy and radiotherapy (P = 0.02).

A pragmatic and successful approach to treating nonsmall-cell lung carcinoma.

Lung cancer is the single leading cause of cancer deaths for men and women combined. Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases. Methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients with NSCLC who were treated from 1991 through 2003 at Inova Fairfax Hospital are discussed. All patients were treated with surgery, some selectively and progressively with a combination of preoperative neoadjuvant therapy, to try to downstage the disease to make complete resection feasible. Outcomes from this data collection period match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date.

Managing the Patient with Perforated Intrathoracic Esophagus

The thoracic perioperative specialty team members at Inova Fairfax Hospital, Falls Church, Va, designed guidelines to improve the management of patients with esophageal perforations. They performed a retrospective analysis of 41 patients who were diagnosed with thoracic esophageal perforations from Sept 1, 1979, through Sept 1, 1996. The review affirmed their philosophy of aggressive, surgical intervention for perforations, particularly for patients diagnosed early (i.e., within 24 hours). The process of examining and communicating the results among OR nurses, anesthesia care providers, and surgeons resulted in the increased efficiency and appropriateness with which patients were incorporated into the hospitals surgical and medical treatment groups.

Bilateral Lung Volume Reduction Surgery

A new surgical approach, bilateral lung volume reduction surgery (LVRS), offers hope for select patients with chronic pulmonary emphysema (CPE). Bilateral LVRS procedures involve excision of emphysematous alveoli, which results in a 20% to 30% reduction in the volume of each lung. The goal of LVRS is to improve the respiratory mechanics of patients with CPE by reexpanding functional lung tissue compressed by overdistended emphysematous alveoli, restoring diaphragmatic mobility, and improving the bellows function of the chest wall structures. Patients undergoing bilateral LVRS procedures experience relief from chronic dyspnea and may note improved pulmonary functions and better quality of life.

Thoracic enhanced recovery with ambulation after surgery: a 6-year experience

OBJECTIVES Our institution implemented a protocol known as thoracic enhanced recovery with ambulation after surgery (T-ERAS) in thoracic operations. The objective was early ambulation starting in the postoperative ambulatory care unit. METHODS Video-assisted thoracoscopic surgery lobectomy patients are placed on a chair in the preoperative area and then walked to the operating room. Postoperatively, patients are placed on a chair as soon as possible. Our target ambulation goal was 250 feet within 1 h of extubation. Patients then walk to their hospital room. T-ERAS adoption and outcomes were compared to a pre-T-ERAS period, in addition to the comparing early and late T-ERAS cohorts. RESULTS Over 6 years, 304 patients on T-ERAS underwent a planned video-assisted thoracoscopic surgery lobectomy. Median age was 67 years (range 41-87 years). The target goal was achieved in 187 of 304 (61.5%) patients and 277 of 304 (91.1%) patients ambulated 250 feet at any time in the postoperative ambulatory care unit. The T-ERAS period had a median length of stay of 1 day vs 2 days in the pre-T-ERAS period (P < 0.001). There were low rates of pneumonia (2/304, 0.7%), atrial fibrillation (12/304, 4.0%) and no postoperative mortalities for T-ERAS. The target goal was achieved at a greater rate in the late (92/132, 72.0%) versus early (28/75, 37%) T-ERAS cohort. The mean time to ambulation was reduced in the late cohort (46-81 min). CONCLUSIONS Early postoperative ambulation was feasible and considered key in achieving low morbidity after video-assisted thoracoscopic surgery lobectomy. Adoption of T-ERAS improved over time. Further studies will help define adoptability at other sites and validate impact on improving outcomes.

Commentary on "pneumonectomy for non-small cell lung cancer: outcomes analysis".

Pneumonectomy is associated with the highest morbidity and mortality rates of all elective pulmonary resections; thus, Kalathiya and Saha’s retrospective outcomes analysis is a welcome addition to this month’s issue of the Southern Medical Journal. The postpneumonectomy results of 100 consecutive patients were retrospectively reviewed from 1998 to 2009. Postoperative mortality was defined as any in-hospital death or within 30 days of surgery if the patient had been discharged. Major morbidity was experienced by 39%, most commonly atrial fibrillation. Operative mortality was 11%. Mortality was highest after neoadjuvant therapy (14.3%), with factors being right-sided surgery (17.4%) and patients older than 70 (18.2%). The authors have economically summarized (see their Table 4) many other institutions’ experience for comparison. I concur with their assessment that inferences are difficult to make, given the innumerable variables. Nevertheless, respiratory failure, bleeding, and cardiac dysrhythmias were dominant regarding both morbidity and mortality. Preoperative, intraoperative, and postoperative attentions to ventilatory, hematologic, and cardiac status are most likely to pay positive dividends because patients are selected carefully for the ultimate physiologic lung resection. The authors state that bleeding accounted for 27% of mortality, yet they share no details. How and why did the bleeding present/occur? Was bleeding related to technical factors because they are perhaps related to extended resections (eg, carinal, intrapericardial, extrapleural), or were hematologic factors in play, having to do with transfusion volumes, coagulopathy, and/or neoadjuvant therapy? Age older than 70 was one of the factors they associated with mortality. Yet, without any breakdown of underlying preoperative pulmonary and cardiac performance status, age may well correlate but not be the significant element regarding risk. The authors unfortunately make no comment as to physiologic risk, which may be identified preoperatively by quantitative assessment of forced expiratory volume in 1 second, carbon monoxide diffusing capacity, and cardiac stress testing. The importance of cardiorespiratory reserve for patients undergoing significant pulmonary extirpation has been well documented. Missing in the overview are even general comments, much less specific data, regarding forced expiratory volume in 1 second, diffusion capacity, and cardiac stress test results. Other factors equally mysterious by their absence include styles of pneumonectomy (eg, completion, intrapericardial, extrapleural, carinal) with/without chest wall resection, with/without bronchial stump coverage, type of bronchial coverage, and stage of disease. To be even more critical, because the number of all of the therapeutic lung resections performed (the denominator) is unknown during the time period outlined, one has difficulty assessing whether pneumonectomy was used more or less often than other techniques, too frequently, or perhaps at too late a stage. In any analysis, everything should be evaluated before arriving at conclusions as to what matters. The authors conclude that despite the risks associated with the procedure (if appropriately selected), pneumonectomy offers the best (perhaps only) chance of cure for many patients who have been diagnosed as having nonYsmall cell lung cancer. I concur, as long as no lesser procedure suffices. I further agree with the philosophy that researchers may choose not to try to establish cutoff criteria. 3 Rather, every decision must be made on individual case merits. ‘‘To assure [sic] optimum results it is critical that the surgeon performs all appropriate performance testing and assure [sic] him/herself that the surgeon, patient, and family share a common understanding (of the risks) and commitment to do whatever it takes to achieve full recovery.’’ In any outcomes analysis, one should be able to assess risks versus outcomes, for only then may one realistically assess performance and contemplate improvements. Invited Commentary