Lung volume reduction surgery.
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Clinical Trials as Topic↗
Biomedical subjects
P Goldstraw
Publications and source records attributed to P Goldstraw.
Implementation of the British Thoracic Society recommendations for organising the care of patients with lung cancer: the surgeon's perspective.
BACKGROUND: The British Thoracic Society (BTS) recognises that it is of paramount importance to ensure that all patients with a working diagnosis of lung cancer have access to first class care [The Lung Cancer Working Party of the British Thoracic Society Standards of Care Committee. BTS recommendations to respiratory physicians for organising the care of patients with lung cancer. Thorax 1998; 53 (Suppl 1): S1-81. METHODS: A retrospective audit of the time involved in the management of patients with lung cancer referred for consideration of surgery at the Royal Brompton Hospital was carried out. Our performance was compared with the BTS recommendations. RESULTS: The notes from 194 patients were analysed, accounting for 93.7% of patients referred with lung cancer in a 1-year period. A total of 90 patients fulfilled the criteria for analysis as they had potentially resectable disease at referral; 59 (65.5%) underwent thoracotomy, and 31 (34.5%) were considered inoperable. The median interval between the onset of symptoms and their first chest radiograph was 39 days, and between the onset of symptoms and referral to a surgeon by a chest physician was 112 days. The median interval between referral by a respiratory physician and surgical out-patient attendance was 14 days, and between referral by a respiratory physician and the surgical procedure was 32.5 days. The median length of time from surgical out-patient attendance to the surgical procedure was 17 days. There was no association between the interval between the onset of symptoms and the surgical procedure with advanced tumour stage at surgery. CONCLUSIONS: There are a number of sources of delay in the referral process for a patient with potentially resectable lung cancer. Most patients referred to our unit were treated within the time scale recommended by the BTS. Our survey has shown that there are cumulative delays in the overall investigation and management of lung cancer patients, which are not covered by the BTS guidelines, and which result in unacceptable delays for most patients.
Adult↗
Pleuropulmonary blastoma: is prophylactic resection of congenital lung cysts effective?
Pleuropulmonary blastomas (PPB) are rare intrathoracic tumors that can develop in children with preexisting pulmonary cystic lesions, inferring that the prophylactic resection of such cysts might prevent the onset of these malignant tumors. We report a patient who went on to develop PPB in the right lung despite having had resections for bilateral congenital pulmonary cysts 23 months earlier. We therefore question the effectiveness of prophylactic resection of congenital lung cysts on this basis.
Child, Preschool↗
Adenocarcinoma arising in a retained esophageal remnant.
Fistulation between the trachea and an infected mucocele arising from an excluded retained esophageal segment is an interesting and unusual complication of esophageal bypass surgery. We present such a case in which there was also malignant transformation in the cyst wall, manifested by invasive adenocarcinoma and widespread high-grade glandular dysplasia.
Abscess↗
Thoracic metastasectomy in thyroid malignancies.
BACKGROUND: Relatively little evidence exists to guide the decision pathway regarding thoracic metastasectomy for thyroid malignancy. METHODS: Single-institution 10-year review. RESULTS: Sixteen patients had surgical treatment for intrathoracic metastatic thyroid malignancy: 12 men and 4 women, mean age 43.7 years (range 19 to 77). Histopathologic type was papillary in 6 cases, follicular in 4, Hurthle cell in 3, and medullary in 3. Indication was either "bulky" disease (8 patients) or poor response to radiotherapy (8 patients). We performed 11 sternotomies and five thoracotomies. Operative mortality was 6.25%. Operative morbidity was 6.25%. Mean survival was 39.5 months (0 to 144). Nine patients died during follow-up (mean survival of 41.2 months). Six patients survived, 4 free of disease (mean survival 70 months) and 2 with further relapse (mean survival 17 months). Five-year survival was 32.5%. CONCLUSIONS: The cohort studied is one of the largest in the literature on the topic. Surgical treatment achieved a reasonable survival in a small subgroup of patients where radiotherapy had failed or was deemed inappropriate because of the size or location of the tumor. Further follow-up and more observations will be required for evaluating these preliminary findings.
Adult↗
Concurrent cysts of the mediastinum, pleura and neck.
A 14-year-old male was found to have a mediastinal mass on chest radiograph. Chest computed tomography scans showed a cystic lesion behind the left main bronchus. Magnetic resonance imaging revealed additional cystic lesions in the left chest and root of the neck. He underwent excision of mediastinal mass and a pleural cyst. The neck lesion was presumed to be a cystic hygroma. Histological examination of the two lesions resected showed them to be a foregut cyst and a benign mesothelial cyst. We know of no other report of concurrent multicystic lesions in the chest and neck and hypothesize that these cysts may have a common embryonic origin.
Adolescent↗
Structure of general thoracic surgery in Europe.
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Curriculum↗
Intramural neurofibroma of the trachea treated by multiple stents.
The case history is presented of a patient in whom an intramural tracheal neurofibroma developed, causing severe airway stenosis. The patient was treated with multiple stents over a period of 5 years because of progression of the disease and associated airflow limitation. Clinicians should be aware of this rare complication of neurofibromatosis.
Bronchoscopy↗
Management of malignant pleural effusions.
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Antineoplastic Agents↗
Surgical oncologic principles.
In this article, there is a return to the beginning of the last century, retracing the evolution of the lung cancer epidemic. As lung cancer increased in frequency, the steps developed to investigate and treat the disease are recalled. At the beginning of the new millennium, the position of surgery in the management of lung cancer is summarized. The role of the surgeon in the investigation and treatment of lung cancer, whether with curative or palliative intent, is evaluated. The principles of surgical management are enunciated, how these principles are presently understood is discussed, and how the disease, its prevention, and treatment may develop in the new millennium is addressed.
Forecasting↗
Early experience with PET scanning in thoracic tumours.
BACKGROUND: Positron emission tomography (PET) scan is an imaging technique which relies on metabolic properties of the lesions. In this study, we evaluated the potential contribution of PET for thoracic malignancy in a consecutive series of patients presenting with multiple lesions or equivocal diagnosis. METHODS: PET with 2-18 F fluorodeoxyglucose (FDG) was carried out in 41 patients. The diagnosis was primary intrathoracic malignancy in 22 (Group 1). On routine staging using CT scan we found 29 additional lesions and assessed these using PET scan. PET was performed to evaluate the number of metastatic lesions in the lung in 11 (Group 2), to characterise undiagnosed pathology in the chest in 4 (Group 3), to search clinically suspicious extrathoracic spread in 4 patients with known intrathoracic malignancy. RESULTS: In Group 1, the sensitivity and specificity of PET was 81.2% and 92.3%. The accuracy of PET in the confirmation of metastatic disease to the chest was 73%. PET was falsely positive in a patient with chronic inflammatory disease in Group 3 and highly accurate to characterise unknown pathology in Group 4. CONCLUSIONS: Even though infection may cause false positive results, PET is a useful imaging technique for the evaluation of patients with thoracic tumours.
Adult↗
Effect of lung-volume-reduction surgery in patients with severe emphysema.
BACKGROUND: Although many patients with severe emphysema have undergone lung-volume-reduction surgery, the benefits are uncertain. We conducted a randomized, controlled trial of the surgery in patients with emphysema. Patients with isolated bullae were excluded because such patients are known to improve after bullectomy. METHODS: Potentially eligible patients were given intensive medical treatment and completed a smoking-cessation program and a six-week outpatient rehabilitation program before random assignment to surgery or continued medical treatment. After 15 patients had been randomized, the entry criteria were modified to exclude patients with a carbon monoxide gas-transfer value less than 30 percent of the predicted value or a shuttle-walking distance of less than 150 m, because of the deaths of 5 such patients (3 treated surgically and 2 treated medically). RESULTS: Of the 174 subjects who were initially assessed, 24 were randomly assigned to continued medical treatment and 24 to surgery. At base line in both groups, the median forced expiratory volume in one second (FEV1) was 0.75 liter, and the median shuttle-walking distance was 215 m. Five patients in the surgical group (21 percent) and three patients in the medical group (12 percent) died (P=0.43). After six months, the median FEV1 had increased by 70 ml in the surgical group and decreased by 80 ml in the medical group (P=0.02). The median shuttle-walking distance increased by 50 m in the surgical group and decreased by 20 m in the medical group (P=0.02). There were similar changes on a quality-of-life scale and similar changes at 12 months of follow-up. Five of the 19 surviving patients in the surgical group had no benefit from the treatment. CONCLUSIONS: In selected patients with severe emphysema, lung-volume-reduction surgery can improve FEV1, walking distance, and quality of life. Whether it reduces mortality is uncertain.
Adrenergic beta-Agonists↗
Thymic hemangioma presenting with recurrent pleural effusion.
Thymic hemangiomas are rare mediastinal tumors. In all reported cases, the diagnosis was only established after resection. Our case presented with recurrent pleural effusions mimicking advanced malignancy. Despite careful evaluation and biopsies, the diagnosis was only established after resection. We have undertaken a literature review of such unusual tumors and emphasize the importance of surgical exploration in any patient in whom a tumor lacks histological confirmation.
Hemangioma↗
Acute lung injury and acute respiratory distress syndrome after pulmonary resection.
BACKGROUND: In this study we investigate the frequency and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) after pulmonary resection. METHODS: Patients that underwent pulmonary resection at the Royal Brompton Hospital between 1991 and 1997 were included. The case notes of all patients developing postoperative complications were retrospectively reviewed. RESULTS: The overall combined frequency of ALI and ARDS was 3.9%. The frequency was higher in patients over 60 years of age, males and those undergoing resection for lung cancer. ALI/ARDS caused 72.5% of the total mortality after resection in this series. CONCLUSIONS: In our experience ALI and ARDS are major causes of mortality after lung resection.
Adolescent↗
Age does not influence early and late tumor-related outcome after surgery for bronchogenic carcinoma.
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Age Factors↗
The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions.
OBJECTIVE: Over the last 15 years we have managed patients with malignant pleural effusion, using a single procedure with thoracoscopy and talc pleurodesis or shunt as appropriate. Talc pleurodesis remains our primary treatment option but in those patient shown to have the 'trapped lung syndrome', in whom pleurodesis would fail, we have been using a pleuroperitoneal shunt. METHODS: This retrospective review was undertaken to evaluate the mortality and morbidity of pleuroperitoneal shunts in the management of malignant pleural effusions and to assess their long-term results. Three hundred and sixty patients were treated for malignant effusions during the period 1983-1998, 160 (44.4%) of whom had a pleuroperitoneal shunt inserted. There were no intraoperative deaths and the hospital mortality was three patients (1.87%). Follow up was available for 88.1% of patients. The median survival of all malignant cases was 7.7 months (range 1-72 months). Mesothelioma patients survived somewhat longer with a median survival of 10.1 months. RESULTS: Shunt complication occurred in 21 patients (14.8%). Twelve patients developed shunt occlusion, requiring revision in five and replacement in seven. The shunt was removed in eight patients due to skin erosion in one patient and infection in seven patients. The distal limb of shunt was broken in one patient and the shunt was replaced. One patient developed malignant seeding along the chest wall at the site of shunt insertion but there were no incidences of peritoneal deposits. Effective palliation was achieved in 95% of patients. CONCLUSIONS: Pleuroperitoneal shunt insertion provides effective and safe palliation for malignant pleural effusion when associated with the 'trapped lung syndrome'. There are however complications which require revision or shunt removal. There is no evidence that peritoneal deposits result from pleuroperitoneal shunting.
Adult↗
The feasibility of conservative resection for carcinoid tumours: is pneumonectomy ever necessary for uncomplicated cases?
OBJECTIVE: To assess the feasibility of a policy of conservative resection for carcinoid tumours, to validate this by a study of recurrence rates and survival, and to assess those factors that might frustrate such a policy. METHODS: Over 20 years, 95 patients with a final histological diagnosis of carcinoid tumour were assessed for surgery. During this time we had a policy of conservative resection for such tumours, with preservation of functional lung parenchyma wherever possible. RESULTS: The mean age at presentation was 51 years (range 14-81). Symptoms were present in 62 patients (65.3%). Fifty-eight tumours (61.1%) were central in position. Surgical resection was performed in 92 patients. Three patients (3.3%) underwent pneumonectomy: in two because the situation was complicated by destruction or severe damage to the distal lung parenchyma, and in one the initial biopsy was interpreted as lung cancer. Less than 50% of patients were referred with the correct histological diagnosis. In 18% preoperative biopsies were interpreted as non-small cell lung cancer (NSCLC). At thoracotomy similar confusion remained with 26% of frozen section reports suggesting NSCLC. In those patients coming to thoracotomy, lymph node involvement was present in 15 patients (16.3%) (N1 in 13 patients, N2 in two patients) being found in 11 of 81 (13.6%) patients whose tumours showed typical histological features, and four of the 14 patients whose tumours (28.5%) displayed atypical features. During follow-up from 6 months to 12 years (mean 3.9 years) four of the 92 operated patients were found to have local recurrence and underwent further surgery and three others developed distant metastases (3.2%), two of whom have died. CONCLUSIONS: Bronchial carcinoid is now considered to be a low-grade, but malignant tumour. Despite this we have found over the last 20 years that a policy of conservative resection is feasible and safe whenever the true histology is known and the distal lung parenchyma is functional. This is not affected by the presence of nodal involvement or atypical features and the long-term results of conservative resection are not affected by the presence of nodal disease. These factors should not influence the extent of surgical resection.
Adolescent↗
The pathogenesis of lung injury following pulmonary resection.
Postpneumonectomy pulmonary oedema (PPO) develops in approximately 5% of patients undergoing pneumonectomy or lobectomy, and has a high associated mortality (>50%). In its extreme form, PPO follows a clinical and histopathological course indistinguishable from acute respiratory distress syndrome. Perioperative fluid overload, impaired lymphatic drainage following node dissection and trauma caused by surgical manipulation have been implicated in the pathogenesis of PPO. However, PPO more probably represents the pulmonary manifestation of a panendothelial injury consequent upon inflammatory processes induced by the surgical procedure, which involves collapse and re-expansion of the operative lung to permit hilar dissection and pulmonary resection. High inspired oxygen concentrations are required to overcome the effects of shunt. Animal studies have shown that pulmonary ischaemia/reperfusion can result in oedema formation, possibly due to the generation of pro-oxidant forces. Moreover, plasma taken from patients undergoing lobectomy or pneumonectomy (but not lesser resections) shows evidence of oxidative damage. Such evidence suggests either that the high inspired oxygen concentrations associated with one-lung ventilation, or ischaemia/reperfusion injury, may modulate post-pneumonectomy pulmonary oedema. Mechanisms by which redox imbalance may result in tissue damage and postpneumonectomy pulmonary oedema are discussed.
Female↗