Biomedical subjects
Publications and source records attributed to R Ilves.
Pleuropulmonary blastoma is a rare unilateral intrathoracic tumor of childhood. We report an unusual case of bilateral pleuropulmonary blastoma in a two-month old girl who underwent staged thoracotomies for complete wedge resection of both neoplasm. She remains well and tumor free two years after the operation.
Because long survival after resection of esophageal carcinoma is uncommon, second esophageal cancers are rare. We report the case of a patient in whom adenocarcinoma developed within residual Barrett's esophagus 19 years after esophagectomy for stage IIb Barrett's adenocarcinoma. Implications relative to the type of operation and adequacy of resection are discussed. Long-term survival after Barrett's adenocarcinoma may occur more often if surveillance protocols achieve their aim. Questions concerning the management of such patients are identified.
OBJECTIVE: To describe an unusual case of acute eosinophilic pneumonia (AEP) associated with hemodynamic instability. DESIGN: Case report, clinical. SETTINGS: Tertiary care intensive care unit (ICU). PATIENT: A single patient admitted to the ICU. INTERVENTIONS: Intravenous corticosteroids. MEASUREMENTS AND MAIN RESULTS: Resolution of distributive shock and respiratory failure. CONCLUSIONS: AEP with respiratory failure was first reported in 1989 as a distinct clinical entity. Patients with this variant of eosinophilic lung disease develop acute hypoxemic respiratory failure with a rapid response to treatment with corticosteroids, The characteristic feature of this syndrome is a predominance of eosinophils found in bronchoalveolar lavage fluid and lung biopsy. Despite the increasing number of reported cases, to our knowledge, distributive shock has not been reported as a feature of AEP. We report a unique case of AEP associated with shock and review the pertinent literature.
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Hiatal hernia is a common condition. Many patients are asymptomatic or experience symptoms of gastroesophageal reflux. However, with larger hernias, the hernia and its incarceration are the issues, and most patients with this condition need surgical attention.
An 11-year-old girl was evaluated for chest pain, and chest radiographic findings of multiple nodules throughout both lungs. She underwent resection of several of the lesions from her left lung, which were found at pathologic examination to be bronchioloalveolar carcinoma. Her previous medical history included incomplete resection of a type I congenital cystic adenomatoid malformation in the neonatal period. To our knowledge, this girl is the youngest reported case of bronchioloalveolar carcinoma in a nonimmunocompromised patient, and one of several in which the association of congenital cystic adenomatoid malformation and bronchioloalveolar carcinoma has been observed.
BACKGROUND: Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition. METHODS: From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control. RESULTS: Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods. CONCLUSIONS: Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.
As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.
Antireflux surgery, specifically the Hill procedure, has been shown to be effective management of refractory reflux when assessed in the relatively short term. This study follows 441 patients from the time of their initial operation and reports on assessments conducted after 5 to 10 years and 15 to 20 years. The late study group comprises 167 patients (mean age 71 years) with an average follow-up of 17.8 years; 15.6% of patients had undergone a previous antireflux operation. Overall subjective good and excellent results, as determined by the patients themselves, were seen to improve significantly (p less than 0.02) between the two follow-up periods, 82% and 88%, respectively. No serious late complications such as fistula, bleeding, or obstruction were observed in this series. The Hill antireflux operation, properly performed, provides durable long-term results.
Vertical banded gastroplasty creates a channel by two applications of the TA-90 stapler from an end-to-end anastomosis window above the crow's foot to the angle of His, against a 32 F. tube along the lesser curvature. The caudad end of the channel is restricted by a 5 cm collar. Thirty-one obese patients more than 45 kg overweight were studied by interview, barium swallow, endoscopy, and manometry. These procedures were repeated 13 +/- 5.5 weeks postoperatively, after resolution of operative edema and before extensive weight loss. Preoperative symptoms included heartburn in 24 patients, regurgitation in 17 patients, and aspiration in 2 patients, and barium swallow demonstrated hiatal hernia in 7 patients and reflux in 7 patients (5 with hiatal hernia). In addition, endoscopy detected mild esophagitis in 3 patients, and hiatal hernia in 11 patients. Postoperatively, the incidence of heartburn decreased in all patients, barium swallow showed slow channel emptying but no hiatal hernia or reflux, and endoscopy did not identify any esophagitis. Preoperative lower esophageal sphincter pressure was 14.5 +/- 7.2 mm Hg. Postoperatively, the vertical banded gastroplasty channel had an initial peak (collar) pressure of 19.2 +/- 7.8 mm Hg (p less than 0.01 compared with preoperative lower esophageal sphincter pressure), a channel pressure of 9.5 +/- 6 mm Hg, a lower esophageal sphincter pressure of 20.1 +/- 7.7 mm Hg (p less than 0.005), and a channel length of 6.8 +/- 1.4 cm. Vertical banded gastroplasty creates a high pressure channel, inhibiting reflux of gastric juice without the need for any additional procedure.
Thirty-five patients underwent resection of primary bronchogenic carcinoma of the left upper lobe or left main bronchus in the presence of metastatic disease in subaortic lymph nodes. No patient had metastatic disease in other mediastinal node stations. There was 1 postoperative death. Complete follow-up is available on 34 patients. Three-year and five-year actuarial survival for the entire group is 44% and 28%, respectively. For 23 patients undergoing complete resection, five-year actuarial survival is 42%. Resection of primary bronchogenic carcinoma in the presence of subaortic nodal metastases is associated with improved survival relative to reports of survival following resection of metastatic disease in other mediastinal node stations. Resection should be undertaken in these patients especially when it is judged that the resection is likely to be complete.
A silicone collar containing circumferential tape was tied around the cardio-esophageal junction in eight patients with symptomatic, refractory reflux, who were not good candidates for a standard antireflux procedure. A fine polypropylene tie or clip secured the knot. In two patients with large hiatal defects, the crura were approximated loosely. Mean operating time, including one cholecystectomy and one ventral hernia repair, was 51 minutes. Patients who underwent this simple operation had a combination of hypertension, heart disease, obesity and old age, and two had undergone horizontal gastroplasty previously for morbid obesity. The reflux was associated with hiatal hernia in seven of the eight patients. Preoperative studies included barium swallow roentgenography in all eight patients, and endoscopy, manometry and Bernstein test in six. All the studies were repeated postoperatively. Follow-up ranged from 17 to 48 months (mean 37.8 +/- 10.6 months). Postoperatively, there was a significant (p less than 0.01) improvement in symptoms, endoscopic findings and lower esophageal sphincter pressures. No prosthesis has migrated yet.
Ten years' experience with surgical treatment of thymoma in 52 patients is reported, 25 patients with myasthenia gravis and 27 without. Twenty-five patients had noninvasive tumors (Stage I) and 27 had invasive tumors (Stages II and III). Of the 52 patients, 29 had surgical resection as the only treatment and the remaining 23 had surgical resection with adjunctive preoperative or postoperative radiotherapy. Currently, 39 patients are alive (20 with myasthenia and 19 without), 10 are dead (none dying of myasthenia or tumor), and three patients have been lost to follow-up. The mean follow-up time for all patients was 5.6 years. There were no operative deaths in this series. The 5 year cumulative survival rate for the entire group of 52 patients is 81%; for patients with myasthenia it is 92%; and for those without myasthenia, 71%. This series suggests that the prognosis following resection of thymoma relates primarily to the stage of the tumor and is not significantly influenced by the presence or absence of coexisting myasthenia gravis. The improved survival rate, in contrast to a 1973 report, is a reflection of improved long-term medical management of myasthenia gravis and better postoperative supportive care.
We have found that 24-hour esophageal pH monitoring is clinically useful in the evaluation of reflux-related symptoms but that the application of this diagnostic tool is limited by lack of simplicity and easy portability of equipment, a time-consuming method for data analysis, and the necessity to hospitalize patients for the study. We have resolved the first two problems with the development of a lightweight, portable, solid-state system for recording and analyzing the data. To assess the feasibility of utilizing an 8-hour study applicable to outpatients, we studied 30 unselected patients referred for 24-hour pH monitoring. We separately analyzed the data from the first 8 hours of the study and the data from the entire 24-hour period. The correlation between the results obtained with each analysis was excellent, indicating that the 8-hour study can be used to quantitate reflux accurately. An 8-hour outpatient protocol was developed and applied to 25 healthy volunteers to determine the normal range of values. From this, a simplified scoring system was created for assessing the results of 8-hour pH studies.
Between 1960 and 1980, 53 patients with massive incarcerated hiatal hernia were treated surgically. In 24 of the 53 patients, there was an associated organoaxial volvulus. The following symptoms and signs, which are almost peculiar to massive, incarcerated hernias, were observed: postprandial precordial distress in 43 patients, upper gastrointestinal bleeding (manifest or occult) in 24 patients, severe dyspnea in 13 patients, and complete obstruction associated with organoaxial volvulus in 4. In only 1 of the 53 patients was the hernia of the true paraesophageal type with the esophagogastric junction remaining in its normal, intraabdominal location. The remainder were all believed to be advanced stages of an ordinary sliding hiatal hernia. Operative treatment consisted of gastroplasty and partial fundoplication in 36 patients, standard Belsey repair in 14, and transabdominal Nissen repair in 3. Gastroplasty and partial fundoplication were used much more frequently during the 1970s, when it was realized that there is a significant incidence of chronic peptic esophagitis and shortening in these patients. Postoperative complications were few in spite of the advanced age of many of the patients. There was one operative death. Only 1 patient was lost to follow-up, and of the 51 patients remaining for analysis, follow-up has extended from 1 to 16 years, with a mean of 6.2 years. No patient has developed recurrent precordial pain, evidence of upper gastrointestinal bleeding, iron deficiency anemia, or severe dyspnea. Seven patients have residual dysphagia; this condition is minimal in 5, and is significant in 2 who require interval esophageal dilation. Nine patients have symptomatic reflux, which is minimal in 5 patients, moderate in 2 patients, and severe in 2 others who were subsequently reoperated on. Contrary to popular concept, our observations indicate that almost all of these patients represent advanced degrees of sliding hiatal hernia with intrathoracic displacement of the esophagogastric junction. This implies a need for an adequate antireflux reconstruction in all patients undergoing operation, as well as an awareness that unanticipated cicatricial changes may be present in the distal esophagus and may prejudice the success of some of the standard hiatal repairs.
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To assess the role of operation in the treatment and prevention of local recurrence in limited small cell lung cancer, we analyzed retrospectively 35 patients undergoing surgical resection for small cell lung cancer between 1976 and 1982. Twenty-eight patients underwent resection for presumed non-small cell histology. Seven later patients had planned combined modality therapy consisting of chemotherapy and prophylactic cranial irradiation followed by surgical resection and irradiation to the primary site. Twenty-four patients received adjuvant postoperative chemotherapy and/or radiotherapy. All patients have been treated and followed up for a minimum of 1 year. There were 19 patients in Stage I and 16 in Stages II and III. In 15 patients, relapse has occurred. The commonest site of first relapse was brain (7/15). Five of these patients had received prophylactic cranial irradiation. In only two patients was there a relapse locally in the hemithorax and/or mediastinum--one with NO disease and one with N1 disease. No local recurrence was noted in six patients with N2 disease. Only two relapses have occurred beyond 1 year--both in brain. In those patients surviving more than 2 years, no relapses have occurred. The median survival time for patients with Stage I disease is 158 weeks and for those with Stages II and III, 92.4 weeks. The median survival time for the whole group is 92.4 weeks with a projected 5 year survival rate of 24%. It appears that surgical resection may help to prevent local recurrence in small cell lung cancer, even in N1 and N2 disease. In our series, projected 5 year survival rates are similar to those seen in the surgical treatment of patients with non-small cell lung cancer. The eventual role of operation in the prevention of local recurrence and improvement in overall survival of limited small cell lung cancer awaits prospective randomized trials.
Postpneumonectomy empyema, with or without bronchopleural fistula, remains an infrequent but serious complication of pulmonary resection. We reviewed our experience with the Clagett procedure in 31 patients with postpneumonectomy empyema. Seven had empyema alone and 24 had empyema with bronchopleural fistula. Ten patients died of metastatic disease without attempted closure of the thoracostomy window. In eight patients the total Clagett procedure was completed; window closure was permanent in two patients, but the remaining six had recurrence of empyema (four of whom had persistent occult fistulas). In eight further patients, persistent infection prevented attempted closure of the window. Five patients refused further surgical procedures. In only two of 31 patients were we able to achieve permanent closure of the thoracostomy window. Based on this experience, we conclude that open window thoracostomy provides adequate drainage and an excellent interim or permanent treatment of the infected pneumonectomy space. However, the presence of persistent bronchopleural fistula prevents successful completion of the total Clagett procedure. In our series, there were no deaths related to empyema or the surgical procedures performed for it.