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Biomedical subjects

P Goldstraw

Publications and source records attributed to P Goldstraw.

At least 109 records · Page 6Linked to original sources
PubMed1994

Post-pneumonectomy empyema.

Empyema remains a formidable complication following pneumonectomy, and compounds the mortality of such major surgery. Our experience of 41 cases of post-pneumonectomy empyema (PPE) is presented. There is no universally appropriate treatment and management depends upon the patient's general condition and the presence of associated fistulas. Initial management consists of drainage in all cases. This may be continued if the patient is unfit for further procedures or if there is any doubt about the possibility of an early relapse. Since 1979, we have treated 23 cases of PPE not associated with bronchopleural fistula (BPF) ("simple" PPE). All were treated by rib resection and open drainage. Subsequently in four patients, Portovac drainage eradicated the space and infection within 3 and 12 months. One patient died of pulmonary embolus one day after open drainage. Three patients were unfit for further treatment and one patient refused further treatment. One patient underwent Schede thoracoplasty and had no further infection. Thirteen patients were re-admitted after a period of open tube drainage (3-28 weeks), the infected space was irrigated to sterility and closed. This was successful in eight cases which have remained sterile 9 months to 9 years later. Five patients developed recurrent PPE and three patients have remained sterile following repeated irrigation and closure. The management of PPE is further complicated by concurrent fistulas. Since 1979, 18 patients have had PPE complicated by fistula ("complex" PPE), often recurrent following previous unsuccessful attempts at closure. Treatment has been individualized, and has often required further major surgery. Small BPFs closed with drainage and the space was obliterated with Portovac drainage in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

The management of tracheobronchial obstruction: a review of endoscopic techniques.

Tracheobronchial obstruction is a distressing cause of morbidity and mortality in patients with benign and malignant disease. Resection offers curative treatment for a few, but for the majority of patients who are too frail for surgery, and for those benign and malignant cases where the disease is too extensive for resection, there is a need for an effective method of palliation. We retrospectively reviewed the results of a 9-year experience in 86 patients with major airways obstruction (51 malignant and 35 benign) treated on one or more occasions using various endoscopic techniques. Nineteen patients presented as an emergency. Thirty-nine had received other forms of treatment beforehand including external radiotherapy and laser resection (Nd:YAG). Treatment undertaken in our institution was: diathermy resection (36 patients), gold grain implantation (16 patients), bougienage (9 patients), cryotherapy (2 patients), Montgomery T-tube and T-Y stent (28 patients) and varied endotracheal and endobronchial stents (40 patients). Twenty-two patients were treated with more than one modality at the first treatment session. Twenty-one patients required revision of their endobronchial stents or T-tubes because of displacement or partial occlusion by mucous accretions. There were no intraoperative deaths or complications and the average length of stay was 5 days (range: 2 to 14 days). Eighty-three patients reported immediate symptomatic relief. Objective improvement in lung function tests was demonstrated in patients whose condition was less acute and preoperative measurements could be made. In the diathermy resection group there was an average improvement in forced expiratory volume in 1 s (FEV1) of 53.1% and in the forced vital capacity (FVC) of 20.6%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

The non-functioning pleuro-peritoneal shunt: revise or replace?

Pleural malignancy commonly leads to troublesome and recurrent effusion. Cure is not possible and effective palliation is important for the 2-3 months median survival following diagnosis. We have previously emphasised the role of pleuro-peritoneal shunts (PPS) in this situation. A number of shunts (11%) malfunction and we have revised our policy as to how best to deal with this problem. We studied our 70 patients who required the insertion of 71 PPS over seven years: there were 8 cases (11%) of non-functioning shunts necessitating re-exploration. In two cases the shunt was blocked due to infection which may have been present prior to insertion of the shunt. In these cases the shunt was removed and drainage was performed. In one shunt non-function was due to obstruction of the pleural limb and it was re-positioned successfully. The remaining five shunts were found to be blocked by fibrinous tissue. Replacement of two of these led to a functioning shunt until the death of the patients, while the three shunts which were revised failed to function. One shunt became infected and was removed and the other two became blocked again. Following subsequent replacement the function was restored until the death of the two patients. We conclude that non-functioning pleuro-peritoneal shunts should be replaced rather than revised to avoid subsequent complications.

Aged↗
PubMed1994

Removal of a dental post from the bronchus by interventional cardiovascular techniques.

Foreign bodies lodged in the bronchial tree are normally retrieved by bronchoscopy, but if this fails then thoracotomy is necessary. The case history is presented of a patient who had inhaled a dental post which could not be retrieved either by flexible or rigid bronchoscopy. Using biplane screening and intravascular retrieval devices introduced via an endotracheal tube, the dental post was removed successfully without the need for thoracotomy.

Bronchi↗
PubMed1994

Surgical management of non-small-cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease).

Between 1979 and 1989, 876 patients with non-small-cell lung carcinoma were referred to our unit for surgical treatment. One hundred forty-six patients were judged not suitable for surgical treatment on clinical, radiologic, or bronchoscopic findings. Cervical mediastinoscopy or anterior mediastinotomy (or both) showed that 151 patients had mediastinal involvement by invasion or metastases into the ipsilateral (N2 disease) or contralateral (N3 disease) superior mediastinal lymph nodes and were therefore deemed inoperable. Except for one patient who had involvement of a single nodal station at mediastinoscopy, all other patients (n = 578) undergoing thoracotomy were thought, on the basis of computed tomographic scan or mediastinal exploration (or both) not to have N2 disease. Despite our efforts to avoid surgery on patients with N2 disease, at thoracotomy routine mediastinal node dissection disclosed that 149 patients had unsuspected N2 disease. Resection was possible in 130 (87.3%) by pneumonectomy (n = 72), bilobectomy (n = 7), lobectomy (n = 49), or lesser resection (n = 2). In three patients the resection was incomplete (2.3%), but in 127 a complete resection was performed (85%). Histologic examination in these 149 patients showed that 72 tumors were squamous cell carcinoma, 54 adenocarcinoma, 14 large-cell carcinoma, and 9 of mixed type. Eight patients died in the hospital after thoracotomy. Adjuvant therapy was not used after complete resection. Complete follow-up was obtained in 134 patients and the mean follow-up period was 27.25 months (1 to 116 months). The actuarial 5-year survival for those having complete resection was 20.1%. There was a statistically significant difference favoring long-term survival in those patients with squamous cell carcinoma (p < 0.01) and those in whom only one nodal station was involved (p < 0.05). Neither the extent of resection nor the involvement of any specific nodal station influenced long-term survival. Despite rigorous preoperative investigations, routine mediastinal node dissection demonstrated mediastinal node metastasis for the first time at thoracotomy in 26% of our patients. We believe resection is justified in these patients, who have already necessarily incurred the morbidity and mortality of thoracotomy, so long as complete resection is possible.

Carcinoma, Non-Small-Cell Lung↗
PubMed1993

Role of mediastinoscopy in superior vena cava obstruction.

BACKGROUND: The role of mediastinoscopy in superior vena cava obstruction (SVCO) is not clearly defined. The authors set out to examine the efficacy and safety of mediastinoscopy in SVCO. METHODS: They reviewed 14 patients referred to one surgical team over an 8-year period (1982-1990) who required mediastinoscopy to establish a histologic diagnosis after other less invasive procedures had not established the diagnosis. RESULTS: Of the 14 patients, 11 had lung cancer, 2 had lymphoma, and 1 had malignant thymoma. Definitive tissue diagnosis was obtained in 13 cases. Mediastinoscopy was unsuccessful in one of the cases because no pathologic tissue could be identified at the time of the procedure. Tissue diagnosis could only be obtained in this patient after mediastinotomy, and a lymphoma was found. There was one complication of mediastinoscopy; one patient had arterial bleeding from the innominate artery that required limited sternotomy to control the bleeding. CONCLUSIONS: The authors believe that mediastinoscopy is a safe and effective technique for establishing a histologic diagnosis in SVCO when less invasive techniques have been unsuccessful. The use of blind radiation therapy cannot be justified on an emergency basis; failure to obtain a histologic diagnosis will result in up to 20% of patients receiving inappropriate radiation therapy, making subsequent tissue diagnosis very difficult.

Adult↗
PubMed1993

Primary malignant mediastinal germ cell tumours: improved prognosis with platinum-based chemotherapy and surgery.

A retrospective analysis was performed of 18 patients with primary malignant germ cell tumours of the mediastinum treated with platinum-based chemotherapy between 1977 and 1990. All seven patients with pure seminoma were treated initially with chemotherapy and four of these patients received additional mediastinal radiotherapy. Only one patient relapsed; his initial therapy had included radiotherapy and single-agent carboplatin and he was successfully salvaged with combination chemotherapy. With a follow-up of 11 to 117 months (median 41 months) all seven patients with seminoma remain alive and disease free giving an overall survival of 100%. Eleven patients had malignant non seminoma; following chemotherapy eight of these had elective surgical resection of residual mediastinal masses. Complete remission was achieved in nine (82%) patients, however, one of these patients died from bleomycin pneumonitis. With a follow-up of 12 to 113 months (median 55 months) eight of 11 (73%) patients with malignant mediastinal teratoma remain alive and disease free.

Adult↗
PubMed1993

Bronchoscopic diathermy resection and stent insertion: a cost effective treatment for tracheobronchial obstruction.

BACKGROUND: Major airways obstruction is a distressing cause of morbidity and mortality. For disease that is extensive and recurrent, there is a need for a safe and cost effective technique for palliation. METHODS: The results of 29 patients with tracheobronchial obstruction (24 malignant and five benign) treated by diathermy resection alone or in combination with endobronchial stenting have been reviewed. RESULTS: The major site of obstruction was the trachea in 14, main carina in seven, right main bronchus in six, and left main bronchus in two patients. Fifteen had received other forms of treatment beforehand including external radiotherapy, endoscopic dilatation, and laser resection (Nd:YAG). Five patients required two or more treatment sessions for symptom recurrence. Ten patients also received additional treatment with a stent (nine) or insertion of gold grains (one). There were no intraoperative deaths or complications and the average length of stay was five days (range 2-14). Twenty eight patients reported immediate symptomatic relief, and objective improvement in the results of lung function tests was seen in eight patients whose condition was less acute and where preoperative lung function tests could be undertaken (average improvement in FEV1 of 53.1% and in FVC of 20.6%). CONCLUSIONS: Bronchoscopic diathermy resection is an effective and safe method for relieving the symptoms of tracheobronchial obstruction at appreciably less cost than laser resection.

Adult↗
PubMed1993

Gastropleural fistula following pulmonary resection.

A 77 year old man with an eight month history of polymyalgia rheumatica treated by steroids underwent left lower lobectomy for a non-small cell carcinoma. Following discharge he developed a pneumothorax, empyema, septicaemia, and acute renal failure. Reinvestigation and reoperation showed this to be caused by a non-malignant non-traumatic direct gastropleural fistula.

Aged↗
PubMed1993

Tracheal paraganglioma.

The trachea is an unusual site for paragangliomas, only four cases having been documented previously. A fifth case is presented here, together with immunohistochemical evidence that the tumour is biologically benign.

Female↗
PubMed1993

Tracheal approach to pulmonary artery sling associated with funnel-shaped tracheal stenosis.

Pulmonary artery sling with concomitant funnel-shaped tracheal stenosis is a rare but potentially lethal congenital condition. Conventional surgical division and reanastomosis of the aberrant left pulmonary artery to the main pulmonary artery carries a high risk of postoperative ventilatory difficulty from an uncorrected tracheal stenosis. A primary tracheal approach via a right thoracotomy without pulmonary bypass is described.

Bronchoscopy↗
PubMed1992

Attitudes of cardiothoracic surgeons in the UK to human immunodeficiency virus.

A survey was carried out into attitudes of cardiothoracic surgeons in the UK to human immunodeficiency virus type 1 (HIV-1) infection associated with clinical situations that would normally have been managed surgically with low operative mortality rates and long median survival times. The survey response rate was 72.4 per cent. In patients with acute valvular insufficiency or with continuing angina despite maximal medical therapy (unstable angina) who were HIV-1 antibody positive, 75.8 and 80.8 per cent, respectively, of surgeons would operate. If the patient had end-stage infection, acquired immune deficiency syndrome (AIDS), 29.7 per cent and 34.7 per cent, respectively, would consider surgical intervention. When asked to perform simple procedures such as open lung biopsy or pleurectomy on a patient with AIDS, more than half of surgeons would operate (52.2 and 65.6 per cent respectively). In patients with operable carcinoma of the lung and asymptomatic HIV-1 infection 52.3 per cent would operate. This fell to 15.0 per cent if the patient had a diagnosis of AIDS. The majority of surgeons (77.2 per cent) felt patients should have an HIV-1 antibody test before operation and this rose to 95.6 per cent if patients were in a high-risk group; 60.2 per cent of surgeons had changed their surgical practice to reduce the risks of blood-borne infection.

Attitude of Health Personnel↗
PubMed1992

Results of operation without adjuvant therapy in the treatment of small cell lung cancer.

The role of surgery in the treatment of small cell lung cancer remains a subject of debate. We carried out a retrospective review of 87 patients with small cell lung cancer referred to one surgeon for staging and treatment. Thirty patients (34.5%) were deemed suitable for thoracotomy. Fourteen patients had stage I disease, 5 patients had stage II disease, and 11 patients had stage III disease. Twenty-eight of the 30 patients (93.3%) went on to have surgical resection. The actual overall 5-year survival in all patients who underwent thoracotomy was 43.3%. The actual 5-year survival for patients in stages I and III was 57.1% and 55.5%, respectively. No patients with stage II disease survived 5 years. We conclude that there is a small group of patients with small cell lung cancer in whom, with careful preoperative staging, the prospects of cure by operation are similar to those with non-small lung cancer.

Adult↗
PubMed1992

Pulmonary torsion: a questionnaire survey and a survey of the literature.

Pulmonary torsion is a rare but life-threatening complication of thoracic operations and trauma. A questionnaire was sent to 140 thoracic surgeons in the United Kingdom to examine its incidence, particularly torsion of the middle lobe after right upper lobectomy. The answers from 117 thoracic surgeons (84%) were collected and analyzed. Thirty-five responders (30%) had seen one or more cases of pulmonary torsion. The majority of cases occurred after pulmonary resection, and most of these instances involved middle lobe torsion after right upper lobectomy. In total, 39 cases were reported; 1 (3%) occurred spontaneously in an azygos lobe, 2 (5%) were seen after trauma, 28 (72%) were seen after pulmonary resections and 8 (21%), after other procedures. In this group of responders, 27 (77%) routinely fix the middle lobe to the remaining lobe after right upper or lower lobectomy, upper lobe fixation being required only if the transverse fissure is well developed. Of the 82 responders who had never seen instances of pulmonary torsion, only 47 (57%) routinely do this fixation.

Humans↗
PubMed1992

Sequential silastic and expandable metal stenting for tracheobronchial strictures.

The risks and limitations of surgical resection and reconstruction for tracheobronchial strictures demand consideration of other therapeutic options that can alleviate the distressing symptoms of tracheobronchial obstruction. One alternative is to stent the obstructive lesion until surgical advances allow primary reconstruction or replacement of the critically diseased airway or until an ideal endoprosthesis is found. The latter requires uniformity in the distribution of expansile force, conformability and stability within the tracheobronchial tree, and ease of placement. Here we report our experience with the placement of expandable metal stents (Wall-stent) used in conjunction with our Silastic (Dow Corning) endobronchial stents in 5 patients with recurrent tracheal or bronchial strictures. The major site of obstruction was the trachea in 1 patient and a main bronchus or both bronchi in 4 patients. Three patients had a benign bronchial stricture (anastomotic stricture in 2, idiopathic polychondritis in 1), and 2 patients had an obstructive airway neoplasm. Placement of the stents was performed under rigid bronchoscopic guidance. We had no complications from our technique of stenting. There has been no evidence of restenosis or occlusion within the stented segment of airway. The complementary use of expandable metal and Silastic endobronchial stents provided symptomatic and functional improvement in our patients during follow-up ranging from 5 to 24 months.

Adult↗