Biomedical subjects
Publications and source records attributed to D Weissberg.
Fifty-seven patients with large recurrent inguinal hernia had undergone repair using Marlex mesh. Fifty-six patients had excellent results, one patient suffered a recurrence. There were two wound infections and no deaths. Polypropylene is an excellent prosthetic material for replacement of attenuated or destroyed posterior wall of the inguinal canal. It is biologically inert and resistant to infection.
Patients with primary lung abscess who do not respond to medical management are usually candidates for a lobectomy. Percutaneous tube drainage, used routinely and with good results before the antibiotic era, has nearly been forgotten. Seven patients with lung abscesses and severe sepsis were in critical condition, not permitting pulmonary resection. They were treated by tube drainage. Prompt clinical recovery occurred in all, with complete resolution of abscesses within 4 to 24 days. When medical therapy of lung abscess fails, tube drainage should be considered in preference to a lobectomy. It is safe and curative and avoids unnecessary loss of functioning lung parenchyma. Lobectomy should be considered in patients who have major life-threatening bleeding or massive pulmonary necrosis.
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The authors performed 480 fine needle aspiration biopsies (FNAB) of breast masses for cytologic diagnosis in 464 patients. Parallel surgical biopsy with histologic examination was carried out in 163 patients; the results were identical in 161. Two hundred eight of 297 benign lesions and 83 of 96 malignant tumors were diagnosed positively by FNAB. In 87 instances FNAB was not diagnostic but excluded malignancy, while in 87 others, the cytologic specimen was inadequate for diagnosis. There was one false-positive and one false-negative result. There were virtually no complications. FNAB of breast masses is a simple and reliable method, easy to carry out in ambulatory patients.
Two hundred fifty patients with bronchogenic carcinoma were followed for at least 5 yr after diagnosis. In 187 (75%), the tumor was diagnosed within 6 mo of the first clinical manifestation. Among 205 patients who were not operated on because of tumor spread or because of poor general condition, 139 (67.5%) died during the first year, 15 (7.5%) during the second year, and 51 (25%) were not available for follow-up and are presumed dead. Forty-five patients underwent curative resection, with one early death. Of the 44 survivors, 30 had lobectomy, 1 had sleeve lobectomy and 13 pneumonectomy. The cancer-free survival rate in this group was 32% at 5 yr and 30% at 7 yr. Except for small cell carcinoma, there was no correlation between tumor histology and prognosis. Due to the late appearance of symptoms, early diagnosis of lung cancer is impossible with present-day methods.
Six patients underwent sleeve lobectomy for bronchial tumors. Five had bronchogenic carcinoma, one had a carcinoid. All neoplastic tissue was resected, with maximum preservation of functioning lung parenchyma. There were no hospital deaths and no complications. Ten months after surgery, one patient died of cancer; one died of apparently unrelated causes 60 mo after surgery; a third was lost to follow-up 14 mo after operation. The remaining three patients are well, without evidence of recurrence. Sleeve lobectomy is a safe operation, enabling adequate resection with maximum preservation of functioning lung parenchyma. It is equally applicable to lung cancer and to other bronchial neoplasms and, when feasible, should be used in preference to pneumonectomy. Careful selection of patients and meticulous operative technique are mandatory.
Open window thoracostomy (OWT) was created in 12 patients with empyema and sepsis after conventional therapy with antibiotics and drainage had failed. After creation of OWT all infections subsided within ten days to four months and all fistulae closed within one to four months. Complete obliteration of the empyema cavity by granulation tissue occurred in 11 of 12 patients within one to eight months, depending upon the size of the space. All patients tolerated the procedure well. Creation of OWT has not caused lung collapse in any of the patients due to fibrosis caused by the preceding infection. There was no complication or death. OWT is a safe procedure recommended in all patients with empyema resistant to conventional therapy. It does not need to be restricted to post-pneumonectomy cases. Operative closure of bronchopleural fistulae, a major surgical undertaking with an uncertain outcome, is usually unnecessary.
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Lung cancer invading extrapulmonary structures was resected in 13 patients, with one hospital death. The 12 survivors lived from 6 months to 53 months; their quality of life markedly improved. Three are still alive, with one apparent cure. In treating advanced lung cancer one must distinguish between local invasion and metastatic spread. In the absence of metastases, there is virtually no limit to resectability of the neoplasm, except extensive invasion of vital organs. Metastases preclude curability; in their presence useless traumatic resections should be avoided. Resectability is not necessarily related to the size of the neoplasm. A very small growth may not be resectable, while a hugh tumor confined to lung parenchyma may be amenable to surgical therapy.
The use of pleuroscopy in patients with bronchogenic carcinoma has not been reported previously. We performed this procedure in 45 lung cancer patients in whom pleural involvement was suspected. Pleural fluid or mestastases were found in 37 patients, 5 of whom had also major atelectasis due to bronchial obstruction by tumor. Neoplasm penetrating vital structures (aorta, brachial plexus) was found in 3 patients, tumor confining to resectable structures in 3; no pleural abnormalities were disclosed in 2. Based on these findings, 43 tumors were assigned stage III. Only on two occasions pleuroscopy did not aid staging. In 20 patients with massive pleural effusion causing dyspnea we insufflated talc in order to produce pleurodesis. This was fully successful in 16 patients, while in 2 the pleural cavity became only partially obliterated, with symptomatic relief. In 2 patients pleurodesis could not be evaluated because of early death caused by progression of cancer. Pleuroscopy is a highly informative procedure, applicable when involvement of pleura by lung cancer is suspected. It is helpful in clinical staging of the tumor and in assessment of its resectability, particularly in elderly, poor-risk patients. It provides the best way for talc insufflation when pleurodesis is indicated. Pleuroscopy should have an established place in the clinical evaluation and staging of lung cancer.
The use of pleuroscopy in empyema has not been reported before. I performed this procedure in 19 empyema patients. In 7, empyema was found incidentally, while pleuroscopy was done for a variety of other indications. Twelve others had known empyema that did not respond to treatment with drainage and antibiotics. In these patients pleuroscopy was carried out in order to determine lung expansibility, to search for factors possibly responsible for therapy failure, and to aid treatment. Useful information was obtained in every patient. Some findings were totally unexpected and revealing, e.g. a surgical sponge forgotten at an earlier heart operation, undigested food particles traced to an unrecognised perforation of an esophageal tumor, or an unsuspected broncho-pleural fistula. Treatment was modified accordingly. In addition to its diagnostic value, pleuroscopy is an important aid in treatment of empyema. All pus and debris can be aspirated under vision and tube drains can be placed in the most dependent position. In selected patients talc can be insufflated in order to cause pleurodesis. Although the use of talc in empyema has not been described before, our early experience is encouraging. I used it on three occasions, achieving each time complete pleurodesis and prompt cure of empyema. It is concluded that pleuroscopy is a useful diagnostic and therapeutic procedure, applicable in patients with empyema in whom conventional therapy failed. It provides the best way for talc insufflation when pleurodesis is difficult to achieve. Pleuroscopy should have an established place in the management of empyema.
The use of talc for pleurodesis is a controversial issue. I have used talc in patients with malignant pleural effusion, recurrent pneumothorax, chylothorax and in selected cases of empyema. During pleuroscopy talc is insufflated through the lumen of the mediastinoscope. Up to 2 gr of purified talc is sprinkled under vision over the entire pleural surface. Of our total experience with 83 patients, 77 were available for follow up. Among 52 patients with pleural effusion, complete pleurodesis was achieved in 43 and partial pleurodesis in 5, with 4 failures. Of 21 patients with recurrent pneumothorax, complete pleural symphysis was achieved in 17 and partial in 3, with 1 failure. In all patients with empyema and with chylothorax, pleurodesis was complete. In total, obliteration of the pleural space was complete (excellent result) in 64 patients (83%) and partial (fair result) in 8 patients (10.5%). Talc failed to induced pleural symphysis only in 5 patients (6.5%). There were no complications and no deaths related to the procedure. This is attributed to the fact that only purified (British Pharmacopoeia) talc was used and its amount never exceeded 2 gr. The use of talc in pleura is safe and useful. It provides excellent palliation in patients with malignant pleural effusion and cure in the other groups. Excessive concern about complications of using talc is unjustified.
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We performed diagnostic pleuroscopy in 66 patients with pleural effusion and in 14 with pleural masses. The findings were diagnostic in 76 patients (95%). Pleural metastases were found in 63 patients, primary pleural or lung tumor in 5, and less common findings in the remainder. Only 1 minor complication occurred, and there were no deaths. Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 31 of 35 patients. Talc also was used with equal success and without complications in management of recurrent pneumothorax. We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure. It is simple and well tolerated, has a diagnostic yield of 95%, and is virtually free from complications. It provides the best way of insufflating talc for pleurodesis.
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