Riivo Ilves

Subxiphoid pericardial drainage for pericardial tamponade

As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.

Treatment of esophageal obstruction with covered, self-expanding esophageal wallstents

BACKGROUNDnConventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition.nnnMETHODSnFrom December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control.nnnRESULTSnFollow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods.nnnCONCLUSIONSnCovered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

Acute eosinophilic pneumonia associated with shock

OBJECTIVEnTo describe an unusual case of acute eosinophilic pneumonia (AEP) associated with hemodynamic instability.nnnDESIGNnCase report, clinical.nnnSETTINGSnTertiary care intensive care unit (ICU).nnnPATIENTnA single patient admitted to the ICU.nnnINTERVENTIONSnIntravenous corticosteroids.nnnMEASUREMENTS AND MAIN RESULTSnResolution of distributive shock and respiratory failure.nnnCONCLUSIONSnAEP with respiratory failure was first reported in 1989 as a distinct clinical entity. Patients with this variant of eosinophilic lung disease develop acute hypoxemic respiratory failure with a rapid response to treatment with corticosteroids, The characteristic feature of this syndrome is a predominance of eosinophils found in bronchoalveolar lavage fluid and lung biopsy. Despite the increasing number of reported cases, to our knowledge, distributive shock has not been reported as a feature of AEP. We report a unique case of AEP associated with shock and review the pertinent literature.

Second primary Barrett's adenocarcinoma after 19 years

Because long survival after resection of esophageal carcinoma is uncommon, second esophageal cancers are rare. We report the case of a patient in whom adenocarcinoma developed within residual Barretts esophagus 19 years after esophagectomy for stage IIb Barretts adenocarcinoma. Implications relative to the type of operation and adequacy of resection are discussed. Long-term survival after Barretts adenocarcinoma may occur more often if surveillance protocols achieve their aim. Questions concerning the management of such patients are identified.

Dysphagia lusoria: a complication following gastric bypass surgery?

A 23-year-old Caucasian female presented with progressive dysphagia beginning 5 months following laparoscopic gastric bypass for morbid obesity. She was diagnosed with an aberrant right subclavian artery and underwent a combined right supraclavicular approach and left thoracotomy for resection, with reimplantation of the vessel to the ipsilateral carotid artery. The patient had complete resolution of symptoms.