Thomas R.J. Todd

The Value of Adjuvant Radiotherapy in Pulmonary and Chest Wall Resection for Bronchogenic Carcinoma

Thirty-five patients, 29 men and 6 women, underwent pulmonary and chest wall resection for treatment of bronchogenic cancer which had extended into the chest wall. Anterior chest wall resection was performed in 6 patients, lateral resection in 2, and posterior resection in 27. Marlex mesh was employed as a prosthetic material in 13 patients. Radiotherapy was given as part of the planned therapeutic regimen in 13 patients. Three patients (8.5%) died in the postoperative period. There was 21 late deaths. Eleven patients are alive 7 months to 12 years after resection. The overall actuarial survival, including operative mortality, is 38% at 5 years. Actuarial survival of the 13 irradiated patients is 56% at 2 and 5 years. We believe that bronchogenic carcinoma with chest wall involvement is not hopeless, and that resection of the lung and chest wall can be performed with an acceptable mortality rate.

Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula

Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml. Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation. High-output thoracic duct fistulas may be handled by supradiphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.

Critical CareThe Timing of Tracheotomy: A Systematic Review

STUDY OBJECTIVEnTo examine the impact of the timing of tracheotomy on the duration of mechanical ventilation, the secondary changes to the trachea, and the clinical course of critically ill patients in the ICU.nnnDESIGNnA systematic review of the literature.nnnMETHODSnTwo independent reviewers conducted a MEDLINE search for relevant literature in the form of randomized or observational controlled clinical studies. Studies were selected for review by criteria determined a priori; and the methodologic quality of selected studies was evaluated by duplicate independent review, also using criteria determined a priori.nnnRESULTSnFive studies were identified, of which three were quasirandomized and none were blinded. Agreement between reviewers of methodologic quality was high (kappa=0.87).nnnCONCLUSIONSnThere is insufficient evidence to support that the timing of tracheotomy alters the duration of mechanical ventilation or extent of airway injury in critically ill patients.

A controlled trial of the effect of parenteral nutritional support on patients with respiratory failure and sepsis.

Energy and protein metabolism was studied in 11 septic patients receiving ventilatory support while on three different intravenous regimens. They received 5% dextrose in water (D5W), and one of two different regimens of parenteral nutritional support (PNS); either amino acid and dextrose (PNA) or amino acid and dextrose and lipid (PNB). All patients were given D5W and PNS in random order. The energy intake was targetted to exceed by 50% the measured metabolic rate. On D5W the mean measured energy expenditure was only 15.2% above the expected energy expenditure (p<0.02). A respiratory quotient of 0.75 while on D5W showed that in the absence of PNS the major part of energy requirements came from fat oxidation. In addition, on D5W these patients were in negative nitrogen and protein (synthesis-catabolism) balance. With PNS the metabolic rate rose significantly (p<0.02). While on PNA, the CO2 production was significantly higher than with PNB, and despite receiving all non-protein energy as glucose, the patients continued to oxidise fat to meet about 30% of their energy requirements. Continued fat oxidation was found to be associated with insulin resistance and high catecholamine levels, suggesting a cause and effect relationship. PNS caused an increase in protein (synthesis - catabolism) and nitrogen balances, and reduced leucine oxidation. The fall in leucine oxidation was greater on PNB than on PNA. Protein and nitrogen balances, expressed per gram of amino acid infused, were significantly better with PNB than PNA. It was concluded that insulin resistance may make fat an efficient source of energy.

The Management of Nonmalignant Intrathoracic Esophageal Perforations

Eight patients with nonmalignant intrathoracic esophageal perforations recognized more than 48 hours (48 hours to 14 days) after rupture were treated at Toronto General Hospital between 1973 and 1978. Perforation was due to postemetic rupture in 7 patients and to instrumentation in 1. The patients were seen with pain (8), vomiting (7), fever (7), shock (4), respiratory insufficiency (5), pleural effusion (7), pulmonary infiltrates (7), and leukocytosis (6). All patients were managed with thoracotomy. Direct suture closure of the perforation was carried out in 4 patients with midesophageal perforations. Postoperative localized leaks developed in 2 of these patients but healed with conservative management. Cervical esophagostomy and esophageal diversion were used in 1 patient in whom a severe empyema developed in the postoperative period. Direct suture closure, reinforced with a gastric patch, was used to close three lower esophageal perforations. None of these patients had a postoperative leak but all developed subsequent reflux esophagitis. All 8 patients survived. In patients with delayed recognition of a nonmalignant intrathoracic esophageal perforation, elimination of continued chemical and bacterial contamination can be achieved by a clear definition and closure of the esophageal mucosal margins. The obliteration of potential pleural spaces by good tube drainage, lung decortication, and the elective use of mechanical ventilation with positive end-expiratory pressure decreases the incidence of uncontrolled intrapleural sepsis.

Aspiration Needle Biopsy of Thoracic Lesions

We reviewed our experience with 2,114 percutaneous aspiration needle biopsies of intrathoracic lesions. Aspiration was performed for cytological diagnosis employing biplane fluoroscopy and a 20 gauge needle, 0.9 mm in outside diameter. A satisfactory specimen was obtained in 88% of biopsies, and the chance of obtaining a correct diagnosis of a malignant lesion was 81.5%. The false positive rate was 2.3%, and the cytologists could always distinguish between primary and secondary neoplasms. A false negative rare of 13.6% (36 patients) resulted in only three delayed thoracotomies and two instances of interval metastases discovered at mediastinoscopy. Cellular specificity in primary tumors was not sufficiently accurate to affect therapy. Pneumothoraces occurred frequently (31.9% of patients) but wee generally small; 10.4% of patients required chest drainage. There were no recorded instances of tumor implantation in needle tracts. We conclude that a rapid and accurate diagnosis of intrathoracic pathology can be obtained by this technique. It is associated with an acceptable morbidity and may greatly expedite both patient care and investigation.

Evaluation of right heart catheterization in critically ill patients ONTARIO INTENSIVE CARE STUDY GROUP

ObjectiveTo determine physicians assessment of the therapeutic effect and patient benefit of data obtained from right heart catheterization. DesignBefore/after study. SettingOne medical and one surgical academic ICU in two medical centers. PatientsA total of 107 critically ill patients with uncertain hemodynamic status. Data CollectionPhysicians looking after the patients were asked to evaluate the extent to which results of right heart catheterization resulted in changes in therapy and outcome. The same questions were asked of academic intensivists, two of whom reviewed each chart. ResultsAgreement regarding whether right heart catheterization had changed therapy was poor (chance corrected agreement [kappas] of −0.02 to 0.33). Treating physicians were more inclined than chart reviewers to conclude that management changes based on right heart catheterization improved outcome. Agreement on which patients benefited was poor (kappas of 0.03 to 0.32). ConclusionsPhysicians assessment of the effect of right heart catheterization on treatment decisions and patient outcomes is not reliable. Credible information regarding the benefits of right heart catheterization will require randomized trials.

Physician-accompanied transport of surgical intensive care patients

During a one-year period, 107 critically ill adult patients were transferred by a physician-accompanied transport system (PATS). Most patients required both tracheal intubation (82 per cent) and mechanical ventilation (71 per cent), while continuous vasopressor support was required in 27 per cent of transfers. Patients were classified as either potential organ donors (n = 21) or nondonor patients (n = 86). Nondonor patients had a mean time of patient transfer documented from the initial telephone contact to final arrival of the patient in the ICU of 345 ± 221 min (range 65-1350 min); the mean time the patients were out-of-hospital was 73 ± 58 min (range 5-330 min); the average distance travelled by the patient and PATS was 342 ± 692 km (range 1-4000 km), ultimate nonsurvivors of ICU admission (36 per cent) had shorter out-of-hospital times, shorter travel distances, and increased interventional support, as assessed by the Therapeutic Intervention Scoring System applied over the telephone and prior to departure at the referring hospital. Significant interventions were undertaken by PATS in 23 per cent of the nondonor patients prior to departure. During the transport process, there was at least a seven per cent morbidity (arrhythmia, hypotension, and vehicular difficulties) and a 0.9 mortality rate. We conclude that PATS offered significant advantages to this patient population through its ability to maintain acceptable morbidity and mortality rates white transferring patients over long distances and for prolonged periods of time.RésuméPour une période ďun an 107 patients adultes en état critique ont été transférés avec un système de transport accompagné ďun médecin (PATS). La majorité des patients ont requis une intubation trachéale (82 pour cent) et une ventilation mécanique (71 pour cent), alors qu’une perfusion continue de vasopresseurs était requise chez 27pour cent des patients transférés. Les patients étaient classifiés soit en donneurs ďorganes en puissance (n = 21) ou en non-donneurs (n = 86). Le temps moyen du transfert des patients non-donneurs documentés à partir du contact téléphonique initial à ľarrivée du patient aux soins intensifs était de 345 ± 221 min (écart 65-1350 min). Le temps moyen où les patients étaient en dehors de ľhôpital était de 73 ± 58 minutes (écart de 5-330 min). La distance moyenne parcourue par le patient était de 342 ± 692 km (écart de 1-4000 km). Les patients qui n’ont pas survécu à leur admission aux soins intensifs (36 pour cent) avaient une plus courte durée de séjour en dehors de ľhôpital, ont parcouru une plus courte distance et ont nécessité des interventions de support tel qu’évalué par le Therapeutic intervention Scoring System appliqué au téléphone et avant le dépari de ľhôpital. Des interventions majeures étaient entreprises par le PATS chez 23 pour cent des patients non-donneurs avant le départ. Pendant le processus de transport il y avait au moins sept pour cent de morbidité (arythmies, hypotension et difficultés de transport) et 0.9 pour cent de mortalité. On conclut que le PATS offrait des avantages significatifs à ce groupe de patients par sa capacité de maintenir un taux de mortalité et de morbidité acceptable tors ďun transfert des patients pour de longues distances et des durées de tempts prolonge.

Middle mediastinal parathyroid: diagnosis and surgical approach

We report two cases of middle mediastinal parathyroid ectopia associated with chronic renal disease. In both patients the diagnosis was delayed and prolonged due to the unusual location of the ectopic parathyroid tissue. The surgical approach was in error in 1 patient and corrected during the second procedure. We describe the surgical technique for exposing and excising parathyroid tissue from this area.

Injury to the middle lobe bronchus and pulmonary artery: an unusual pattern.

Abstract An unusual bronchovascular injury at the level of the middle lobe bronchus is reported. Three patients with middle lobe bronchial avulsion associated with rupture of the pulmonary artery are discussed. Treatment emphasizes prophylactic control of the proximal pulmonary artery.