Rudy P. Lackner

Improved results of lung transplantation for patients with cystic fibrosis

Patients with cystic fibrosis pose particular challenges for lung transplant surgeons. Earlier reports from North American centers suggested that patients with cystic fibrosis were at greater risk for heart-lung or isolated lung transplantation than other patients with end-stage pulmonary disease. During a 3 1/2 year period, 44 patients with end-stage lung disease resulting from cystic fibrosis underwent double lung transplantation at this institution. During the same interval, 18 patients with cystic fibrosis died while waiting for lung transplantation. The ages of the recipients ranged from 8 to 45 years, and mean forced expiratory volume in 1 second was 21% predicted. Seven patients had Pseudomonas cepacia bacteria before transplantation. Bilateral sequential implantation with omentopexy was used in all patients. There were no operative deaths, although two patients required urgent retransplantation because of graft failure. Cardiopulmonary bypass was necessary in six procedures in five patients and was associated with an increased blood transfusion requirement, longer postoperative ventilation, and longer hospital stay. Actuarial survival was 85% at 1 year and 67% at 2 years. Infection was the most common cause of death within 6 months of transplantation (Pseudomonas cepacia pneumonia was the cause of death in two patients), and bronchiolitis obliterans was the most common cause of death after 6 months. Actuarial freedom from development of clinically significant bronchiolitis obliterans was 59% at 2 years. Results of pulmonary function tests improved substantially in survivors, with forced expiratory volume in 1 second averaging 78% predicted 2 years after transplantation. Double lung transplantation can be accomplished with acceptable morbidity and mortality in patients with cystic fibrosis.

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear. METHODS VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report. RESULTS VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities. CONCLUSIONS Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.

Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure

Reexpansion pulmonary edema is a well-described complication of treatment for pleural effusion and pneumothorax. It is very rarely described in association with anesthesia and video-assisted thoracoscopic surgery. The etiology is unclear but several mechanisms have been proposed. We report a case of reexpansion pulmonary edema after video-assisted thoracoscopic surgery treated successfully with continuous positive airway pressure.

Cystic adenomatoid malformation involving an entire lung in a 22-year-old woman

Congenital cystic adenomatoid malformation is an uncommon cause of respiratory distress in infants and is a rare entity in adults. Presentation in older patients is that of recurrent pulmonary infections. Usually a single lobe is involved. This report describes congenital cystic adenomatoid malformation involving the entire right lung in a 22-year-old woman presenting with gastrointestinal bleeding due to cavernous transformation of the portal and splenic veins.

Is there a role for routine mediastinoscopy in patients with peripheral T1 lung cancers

BACKGROUND The role of surgical staging of patients with non-small cell lung cancer (NSCLC) continues to evolve. This report describes our findings utilizing routine cervical mediastinoscopy in the evaluation of peripheral T1 (<3 cm) lung tumors. METHODS Retrospectively 30 patients with peripheral T1 lesions and CT scans negative for pathologic adenopathy were identified over a 3-year period. Cervical mediastinoscopy was performed prior to VATS/thoracotomy during the same operative session. RESULTS Mediastinoscopy was performed in 29 of 30 patients. For patients with malignancy (27 of 30), 3 of 27 (11%) had mediastinoscopy positive for malignancy and no further resection performed. Overall the subgroup of patients with bronchogenic carcinomas had positive mediastinal involvement identified in 5 of 24 (21%) after mediastinoscopy or complete resection. CONCLUSION A significant number of patients with small peripheral lung cancers harbor radiographically occult lymph node involvement. Mediastinoscopy facilitates identification of patients with regionally advanced disease prior to resection, allowing neoadjuvant therapy and avoiding unnecessary resections.

Seizures in Lung Transplant Recipients

Summary: Purpose: We wished to assess organ transplant recipients, who incur a significant risk for seizures.

The Surgical Implications of Purpura Fulminans

Purpura fulminans is an uncommon catastrophic syndrome that occurs in children, typically one to four weeks after a seemingly benign infectious process. The child usually presents with a high fever, purpuric ecchymosis, hypotension, disseminated intravascular coagulation, and gangrene of the extremities. We have recently treated six children, whose mean age was 22 months; three were male and three were female. Five of the six had a change of mental status upon initial examination. Their mean temperature was 104° F. All six children had purpuric involvement of their extremities; three had involvement of their hands, two had involvement of their faces, and two had involvement of their trunks. All had absent palpable pulses and sluggish capillary refill in the involved hands and feet. Two patients died shortly after admission as a result of severe end-stage sepsis. The platelet counts in these two patients, and the white blood cell counts were markedly depressed. The mean platelet count of the survivors was 370,000 and the mean white blood cell count was 25,000. Lumbar punctures were positive for bacterial meningitis in five patients and viral meningitis in one patient. All patients were treated with intravenous heparin. Of the four survivors, two lost significant tissue and required multiple plastic reconstructive procedures, and two improved on heparin alone with no tissue loss. In addition to systemic support and intravenous antibiotics, the mainstay of treatment is one of immediate heparinization and a continuous heparin drip. Heparin prevents subsequent small vessel thrombosis and limits tissue loss due to ongoing purpura. Conservative management of the purpuric lesions is the treatment of choice until final demarcation occurs.

Intrathoracic desmoid tumor mimicking primary lung neoplasm.

Most reported thoracic desmoid tumors originate from the chest wall. However, intrathoracic desmoid tumors are rare. The pathogenesis of these tumors is unclear but antecedent trauma and operation have been implicated. Desmoid tumors can present either with pain or be incidentally detected on radiographic studies. We describe the case of a 60-year-old woman with an intrathoracic desmoid detected on a routine screening chest roentgenogram who underwent complete surgical resection of the tumor.

Prevention of Stress-Induced Erosive Gastritis by Parenteral Administration of Arachidonic Acid

Stress-induced mucosal ulcerations are associated with a decreased synthesis of mucosal prostaglandin (PG) E2. This phenomenon is poorly understood. To investigate whether it is due to a decreased availability of the necessary substrates to the mucosa, four groups of 10 Holtzman rats were studied: group 1 received normal saline by intraperitoneal (ip) injection; group 2 also received ip normal saline, then were submitted to stress, by the cold restraint method; group 3 received a solution of arachidonic acid (AA) ip; and group 4 also received ip AA, then were submitted to stress. After sacrifice, the number of gastric ulcerations were counted and specimens of nonulcerated mucosa were assayed for PGE2 by high-performance liquid chromatography; the mean numbers of ulcers were 0, 5.8, 0.8, and 3 and the mean levels of PGE2 were 55, 41, 125, and 62 pg/mg of wet tissue for groups 1, 2, 3, and 4, respectively. It is concluded that parenteral administration of AA reduces but does not completely eliminate stress-induced gastric ulcerations and that the stressed animals synthesized half as much PGE2 as the nonstressed ones after ip administration of equal amounts of AA, suggesting that stress reduces the availability of AA to the gastric mucosa, possibly by vascular spasm.

Lung cancer screening, version 3.2018

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.