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Biomedical subjects

P Goldstraw

Publications and source records attributed to P Goldstraw.

At least 91 records · Page 5Linked to original sources
PubMed1995

Management of recurrent malignant pleural effusions. The complementary role talc pleurodesis and pleuroperitoneal shunting.

BACKGROUND: Recurrent pleural effusions in patients with advanced cancer is a common problem that causes significant morbidity and can negatively affect patients' quality of life for their remaining months. Several palliative treatment options are available. METHODS: The results of a 10-year experience with 180 patients referred for the surgical palliation of their condition were retrospectively reviewed. Their mean age was 60 years (range, 20-90 years). One hundred and thirty-four patients (74%) had been treated before referral with one or more of the following modalities: repeated needle thoracocentesis (87 patients), tube thoracostomy (24 patients), chemical or biologic pleurodesis (22 patients), and pleurectomy (1 patient). One hundred and seventeen patients demonstrated full lung expansion at thoracoscopy/mini-thoracotomy and underwent talc pleurodesis, whereas the other 63 patients had the "trapped lung syndrome" and required the insertion of a pleuroperitoneal shunt (Denver, Biomedical, Inc). RESULTS: There were no intraoperative deaths and the early death rate was 5.9% for the talc pleurodesis group and 3.2% for the group that received shunts. The mean hospital stay for the patients receiving talc and shunts was 7.3 days (range, 3-15 days) and 5.9 days (range, 2-12 days), respectively. Follow-up data were available in 60% of the patients and showed that effective palliation was achieved in more than 95% of patients in each group. There were eight patients (12%) with blocked shunts (five requiring replacement or renovation and three requiring removal and open drainage) at 1 week to 4 months after insertion. Two patients (one from each group) required one further episode of treatment by thoracocentesis. The median survival for the talc and shunt groups was 4.9 months (range, 1-36 months) and 5.4 months (range, 1-53 months). Patients with effusions because of secondary breast carcinoma or lymphomas survived the longest. CONCLUSION: In patients with malignant pleural effusions in whom pleurodesis is precluded by limited lung expansion, effective palliation can be achieved by pleuro-peritoneal shunt insertion.

Adult↗
PubMed1995

The role of mediastinoscopy in superior vena caval obstruction.

The role of mediastinoscopy in superior vena caval obstruction is not defined. To examine the safety and efficacy of mediastinoscopy, we reviewed 34 patients with superior vena caval obstruction who required mediastinoscopy to establish a histologic diagnosis after less invasive techniques had failed. They were referred to one surgical team between 1982 and 1993. Of the 34 patients, 26 had lung cancer, 6 had lymphoma, 1 had malignant thymoma, and 1 had fibrosing mediastinitis. Definitive tissue diagnosis was obtained in all patients. There was one complication of mediastinoscopy where arterial bleeding from the innominate artery occurred and limited sternotomy was required to control the bleeding. We conclude that mediastinoscopy is a safe and effective technique for establishing histologic diagnosis in superior vena caval obstruction when less invasive techniques have been unsuccessful. The use of blind radiotherapy means that patients with lymphoma and small cell carcinoma will not receive optimum therapy with chemotherapy and patients with benign lesions will receive inappropriate therapy.

Adult↗
PubMed1995

Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Abdominal Muscles↗
PubMed1995

Role of covered esophageal stents in malignant esophagorespiratory fistula.

Malignant esophagorespiratory fistulas are distressing for patients who already have a limited prognosis. Palliative treatment by surgical bypass is often unjustified, and although the use of esophageal stents is more appropriate, their results are variable due to their inability to provide a tight seal. We have managed 2 patients with self-expanding covered esophageal stents, which appear to offer excellent prospects for palliation.

Aged↗
PubMed1995

Completion pneumonectomy: indications and outcome.

Completion pneumonectomy has been associated with higher rates of morbidity and mortality and this is reflected in the selection of cases and the indications for the procedure. During a period of 14 years from January 1980 to November 1993, 38 completion pneumonectomies were done by our surgical team, representing 5.1% of all pneumonectomies. There were 24 right and 14 left completion pneumonectomies done in 26 male and 12 female patients with an average age of 61 years (range from 29 to 77 years). Lung malignancy accounted for 26 of these cases in which the indication included local recurrence in 10, second primary tumor in 9, malignancy that developed after resection for benign disease in 2, and pulmonary metastasectomy in 5 cases. Benign diseases were the indication in 12 cases: tuberculosis in 4, bronchiectasis in 4, aspergillosis in 1, and postoperative complications in 3. Additional surgical procedures were necessary in 7 cases: chest wall resection with insertion of prosthesis in 3, thoracoplasty in 2, and omental flap in 2. There was 1 early postoperative death after 5 weeks from adult respiratory distress syndrome. There was no occurrence of bronchopleural fistula, and the 18% associated morbidity rate was a result of bleeding necessitating reexploration in 3 cases, prolonged ventilation in 2, and chronic empyema in 2. Six of these complications (86%) occurred in the group with benign disease. Completion pneumonectomy can be done with an acceptable morbidity in selected patients. Careful technique is important to secure hemostasis and to avoid fistulas. The complication rate is higher when infective disease is involved.

Adult↗
PubMed1995

Bronchopleural fistula after pneumonectomy for lung cancer.

Bronchopleural fistula (BPF) after pneumonectomy is a life-threatening complication. Over a period of 14 years (January 1980 to November 1993), 471 pneumonectomies were performed byone surgical team using a uniform suture technique for primary lung cancer. Non-small cell lung cancer accounted for 451 cases and 20 cases were small cell cancer. All operations were performed using a uniform hand suture technique. There were seven cases of BPF giving an incidence of 1.5%. All fistulas occurred within 15 days postoperatively and there were no late fistulas. The bronchial stump was free of tumor in all cases. No fistula occurred in the 24 (5.1%) completion pneumonectomies. The experience of the surgeon was important as the senior author performed 374 pneumonectomies with two fistulas (0.5%) while other surgeons in training performed 97 pneumonectomies with five fistulas (5.1%). Bronchial dehiscence was confirmed by bronchoscopy in all cases and an attempt at resuturing the stump through the same thoracotomy incision was made within 2 days of the diagnosis. Closure was successful in five patients, while the other two developed fatal complications. We conclude that suture closure to the bronchial stump after pneumonectomy provides a cheap and reliable technique, it is applicable in all situations and can be taught to surgeons in training with an acceptable risk.

Adult↗
PubMed1995

Dieulafoy's disease of the bronchus.

Dieulafoy's vascular malformation has not been described outside the gastrointestinal tract. Two cases are reported in which this vascular abnormality arose in right lower lobe bronchi, both of which presented with massive haemoptysis.

Adult↗
PubMed1995

Combined pulmonary and thoracic wall resection for stage III lung cancer.

BACKGROUND: Carcinoma of the lung with thoracic wall involvement constitutes stage III disease. The management of patients with this condition is complicated. However, improvement in perioperative care coupled with advances in surgical technique have enabled a more aggressive approach to the problem to be adopted. METHODS: A retrospective review was carried out of 58 patients (40 men) of mean age 63 years who underwent thoracotomy for lung cancer with chest wall invasion between 1980 and 1993. RESULTS: Chest wall resection was performed in 55 patients (94.8%); in three patients the discovery of N2 disease at operation precluded resection. The TNM status was T3N0M0 in 38 patients, T3N1M0 in 13, and T3N2M0 in seven. Squamous cell carcinoma was the commonest cell type (26 patients). Reconstruction of the chest wall was performed in 29 patients (Marlex mesh in six, Marlex-methacrylate in 22, myocutaneous flap in one patient). The morbidity and mortality were 22.4% and 3.4% respectively. Follow up was complete in 51 patients. Nineteen (37.2%) survived > or = 5 years. The absolute five year survival for N0 and N1 disease was 44.7% and 38.4%, respectively. No patients with N2 disease survived five years. CONCLUSIONS: In patients with carcinoma of the lung and chest wall invasion, combined pulmonary and thoracic wall resection offers the prospect of cure with minimal morbidity and mortality. The prognosis of patients with coexistent N2 disease remains poor.

Adult↗
PubMed1995

Lung injury in patients following thoracotomy.

BACKGROUND: Postoperative lung injury is a recognised complication of thoracotomy for which there are few data regarding incidence and outcome. METHODS: In a case controlled study the notes of all adult patients who developed acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) following thoracotomy between 1991 and 1994 were examined and classified according to the guidelines of the American Thoracic Society/European Respiratory Society for ALI/ARDS. The predictive value of a routine preoperative assessment and duration of anaesthesia in determining those patients most likely to develop ALI/ARDS was assessed. RESULTS: Between 1991 and 1994 231 lobectomies, 103 pneumonectomies, and 135 wedge resections and segmentectomies were performed. The overall incidence of lung injury was 5.1%; 17 patients developed ARDS (two survived) and seven developed ALI (five survived). There was no significant difference compared with case matched controls in preoperative spirometric values, arterial oxygen tension (PaO2), or duration of anaesthesia. None of these parameters was useful in predicting those patients most likely to develop lung injury. CONCLUSION: Lung injury after thoracotomy is associated with a high mortality. Conventional parameters for preoperative assessment do not predict those patients most likely to develop ALI/ARDS in these circumstances.

Anesthesia, General↗
PubMed1995

The surgical treatment of emphysema. The Brompton approach.

The vast majority of patients suffering with emphysema cannot be helped by surgery. A fortunate minority, consisting of specific subsets of patients, can benefit, but to do so the surgeon must have a flexible approach and select the optimal procedure for each patient. There is no one operation that is ideal in all circumstances. A major exploratory thoracotomy remains the approach of choice in specific situations (1) when dealing with the rare patient who has a congenital air cyst in the context of otherwise normal lungs. Local excision usually is possible but lobectomy may be necessary; (2) when dealing with an infected bulla in which the situation can only be ascertained at operation, where adhesions may cause difficulty and drainage may prove inappropriate, and lung resection is necessitated; and (3) when operating for a pneumothorax in which the situation can only be assessed at operation, and control of air leak is mandatory by ligation, bullectomy, or intracavitary drainage. The future role of video-assisted operations in this context must await the longer follow-up of larger series. In the elective management of patients with emphysema, those with a dominant bulla we continue to treat by intracavitary drainage. The Brompton technique offers a simple, safe, and effective therapeutic option in carefully selected patients. We believe the advantages to be threefold. Firstly, the use of CT scanning, important in patient selection, allows one to plan the incision so that a minithoracotomy can be performed, reducing the morbidity and mortality formerly associated with thoracotomy in patients with poor respiratory reserve. Secondly, the approach obviates the need to resect adjacent lung tissue, which in a generalized and progressive disease may be physiologically of disproportionate importance. Finally, pleurodesis allows any future recurrent bullae to be intubated and drained percutaneously under local anesthetic with minimal risk of pneumothorax. In those patients who have generalized emphysema without significant bullae, the role of volume-reduction surgery is being investigated. We await longer-term follow-up but fear that with wider application this major operation will accumulate significant mortality. Transplantation remains an option that must be limited to the youngest patients and those who are close to the terminal phase of their illness.

Drainage↗
PubMed1994

Review of blood transfusion practices in thoracic surgery.

Between September 1, 1989, and August 31, 1990, 516 patients were admitted to the Royal Brompton National Heart and Lung Hospital for thoracic operations. A prospective audit recorded the nature and extent of operation, the histologic diagnosis, and the number of units of blood prepared and transfused during hospitalization. Cross-matched blood was requested in 243 patients but only 16.1% of these received transfusion. In total, 1,295 units of whole blood or red cell concentrate were cross-matched and made immediately available in the operating suite at the time of operation. Only 322 units were administered (cross-match to transfusion ratio of 4.02:1). Almost half of the patients who received transfusions received 2 units or less, a third received 3 or 4 units, 10% between 5 and 10 units, and 8.4% required more than 10 units during their hospital stay. The nature and extent of resection was an indicator of the need for transfusion. Other important predisposing factors included a previous thoracic operation, resection for inflammatory disease, decortication of empyema thoracis, chest wall resection, or thoracoplasty. Other thoracic procedures such as pleurodesis, pleurectomy, open lung biopsy, pectus correction, operation for bullous lung disease, and mediastinoscopy had a negligible transfusion requirement. The data suggest that understanding risk factors for transfusion requirements of patients undergoing thoracic surgical procedures should optimize present resources. This is critical when exploiting the limited availability of donated blood and blood products. Similarly, anticipation of transfusion requirements takes best advantage of manpower within the blood bank and minimizes unnecessary and avoidable blood wastage and expenditure.

Blood Grouping and Crossmatching↗
PubMed1994

Bronchopleural fistula after pneumonectomy with a hand suture technique.

We have reviewed the incidence of bronchopleural fistula among 530 consecutive pneumonectomies, all carried out by one surgical team using a uniform suture technique between January 1980 and November 1993. There were 7 fistulas (1.3%); all of them occurred within 15 days postoperatively. There were no cases of late fistula during a mean follow-up period of 23 months. The pathology for which pneumonectomy was undertaken was primary lung malignancies in 488 cases (92.1%), metastatic disease in 15 cases (2.8%), and benign diseases in 27 cases (5.1%). All fistulas developed after pneumonectomy for lung cancer. Other risk factors included age, preoperative radiotherapy, and the surgeon's level of experience, as only two fistulas occurred with the consultant who performed 410 pneumonectomies (0.5%). The bronchial stump was free of tumor in all cases. There were no fistulas in the 37 completion pneumonectomies (7%). All fistulas were treated within 2 days of diagnosis by resuturing the stump through the initial thoracotomy incision. That was successful in 5 patients, whereas fatal complications developed in the other 2 patients. We believe that suture closure of the bronchial stump at pneumonectomy provides a cheap and reliable technique that gives good results in all situations.

Adult↗
PubMed1994

Surgical treatment of bullous emphysema: experience with the Brompton technique.

The technique first described by Monaldi has been modified for the treatment of discrete emphysematous bullae. Fifty-eight patients (median age, 56 years) underwent this procedure between 1983 and 1992. The operative mortality was 6.9% (4 patients). Fifty-two patients (89.6%) noted symptomatic improvement, as measured using the modified Medical Research Council of Great Britain dyspnea scale, from a mean value of 3.7 preoperatively to 2.1 postoperatively. Two patients remained unchanged symptomatically. In all patients, amelioration of symptoms was accompanied by an objective improvement in lung function. A mean increase of 28% was noted in the forced expiratory volume in 1 second (p < 0.05), and a 12.3% improvement in the total lung capacity was observed (p < 0.002). The residual lung volume-total lung capacity ratio declined from a mean of 70% to 57% after operation. A forced expiratory volume in 1 second of less than 500 mL (p < 0.05) and carbon dioxide tension of greater than 6.5 kPa (p < 0.05) were significant predictors of poor prognosis. The median follow-up period has been 1.9 years (range, 0.5 to 9 years). Two patients have returned for further drainage of new bullae on the operated side, and this was carried out percutaneously in both. We conclude that this technique offers a simple, safe, and effective method for the treatment of discrete bullous disease in patients with emphysema.

Aged↗
PubMed1994

Renal impairment after thoracotomy: incidence, risk factors, and significance.

One hundred thirty patients undergoing major thoracotomy between June 1991 and June 1992 at The Royal Brompton Hospital, London, were analyzed; renal impairment developed in 31 patients (24%). The mortality and morbidity was significantly greater for the renal impairment group. Six patients (19%) with renal impairment died after operation, in contrast to 0 of the 99 patients in whom renal impairment did not develop. The average length of hospital stay for the patients with renal impairment was 12 days compared with 8 days for the normal renal function group (p << 0.001). Five factors were highly significantly associated with renal impairment: a past history of renal impairment or diuretic intake, undergoing pneumonectomy, postoperative infection, and blood loss (p < 0.001). The most important of these appears to be postoperative infection or blood loss, as they also were associated with death (p = 0.01). Other factors less significantly associated with renal impairment included a past history of hypertension, ischemic heart disease, intraoperative gentamicin, and epidural analgesia (p < 0.01). This study emphasizes that thoracotomy must be considered carefully in patients with these predisposing factors, particularly if pneumonectomy is likely. Care must be taken in the use of aminoglycosides and epidural analgesia. Maintenance of renal blood flow by careful control of hemodynamic indices appears to be the most important intervention.

Female↗