Diagnosis and management of acute and chronic lung rejection.
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Graft Rejection↗
Biomedical subjects
T W Rice
Publications and source records attributed to T W Rice.
Aneurysmal saphenous vein graft presenting as an anterior mediastinal mass.
A 58-year-old male presented with an anterior mediastinal mass which was found to be secondary to an aneurysmal dilatation of the saphenous vein graft to his circumflex artery. This represents an unusual presentation of an aneurysmally dilated saphenous vein graft.
Aneurysm↗
Single-lung transplantation with atrial septal defect repair for Eisenmenger's syndrome.
Heart-lung transplantation has been used successfully for patients with pulmonary vascular disease but its application has been very limited due to the scarcity of donors. We report a patient with Eisenmenger's syndrome who underwent right single-lung transplantation with closure of atrial septal defect; postoperative convalescence was uneventful. Serial magnetic resonance imaging examinations demonstrate improved right heart function.
Adult↗
Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT.
The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.
Adult↗
Barrett's esophagus. A review of the pathologist's role in diagnosis and management.
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Barrett Esophagus↗
Esophageal ultrasound and the preoperative staging of carcinoma of the esophagus.
Esophageal ultrasound allows the esophageal wall to be viewed as five discrete layers. Lymph nodes are easily identified, and their size, shape, margin, and internal structure can be assessed. This provides an alternative method of preoperative (clinical) evaluation of the primary tumor [T] and the regional lymph nodes [N] of patients with carcinoma of the esophagus. Esophageal ultrasound was attempted in the clinical staging of 28 patients with carcinoma of the esophagus. Six patients (21%) were not assessed because of the inability to pass the esophageal ultrasound probe through the malignant stricture. The staging system for carcinoma of the esophagus developed by the International Union Against Cancer and the American Joint Committee on Cancer was used. Twenty-two patients had the true T determined by pathologic review of the resected esophagus. Esophageal ultrasound correctly identified T in 13 patients (59% accuracy). In four patients (18%) the disease was overstaged by esophageal ultrasound; all these patients had early T1 tumors confined to the submucosa. In five patients (23%) the disease was understaged by esophageal ultrasound; all of these patients had advanced tumors (four T3 and one T4) that invaded beyond the esophageal wall. Seven of the nine incorrect esophageal ultrasound determinations were called T2 (three T1, three T3, one T4), which suggests that the borders of the muscularis propria require careful attention when evaluated by esophageal ultrasound. Twenty patients had the true N determined by pathologic review of the resected specimen. Esophageal ultrasound correctly identified N in 14 patients (70% accuracy). Three patients were falsely identified as having N1 disease and three were falsely identified as having N0 disease. The sensitivity, specificity, positive predictive value, and negative predictive value for N assessment by esophageal ultrasound were 70%. Esophageal ultrasound provides an alternative method of visualization of the esophageal wall and regional lymph nodes. Our early experience shows promise for esophageal ultrasound in the clinical staging of carcinoma of the esophagus.
Aged↗
Intrathoracic lymph node evaluation by CT and MRI with histopathologic correlation in non-small cell bronchogenic carcinoma.
Twenty patients with non-small cell bronchogenic carcinoma were prospectively studied for intrathoracic lymphadenopathy using computed tomography (CT) and magnetic resonance imaging (MRI). The CT and MRI results were correlated with the surgical histopathology results of 103 harvested lymph nodes. Based on node dimension (utilizing a 1-cm cutoff value), neither imaging modality was accurate in predicting the histopathology of the nodes. CT had a sensitivity of 21%, specificity of 95%, and an overall accuracy of 85%; MRI had a sensitivity of 14%, specificity of 97%, and an overall accuracy of 85%. Moreover, CT and MRI detected preoperatively only 17% and 14%, respectively, of the harvested nodes. In summary, lymph node sizes measured by CT and MRI are inaccurate in predicting the benignity or malignancy of lymph nodes. Lymphadenopathy can be present even with a "negative" CT or MRI scan of the thorax.
Carcinoma, Bronchogenic↗
Methemoglobinemia from topical benzocaine.
Acute cyanosis and methemoglobinemia developed following topical application and partial ingestion of benzocaine for esophagogastroduodenoscopy. A diagnosis of acute toxic methemoglobinemia should be considered when cyanosis, with or without neurologic symptoms, occurs following the use of local anesthetics in the absence of cardiopulmonary disease. Laboratory tests should include oxygen saturation and methemoglobin concentration. Management includes supplemental oxygen administration and intravenous methylene blue.
Administration, Topical↗
Utility of frozen-section evaluation of lymph nodes in the staging of bronchogenic carcinoma at mediastinoscopy and thoracotomy.
We conducted a retrospective analysis of the utility of frozen-section diagnoses in determining lymph node status at mediastinoscopy in 122 consecutive patients with bronchogenic carcinoma. Thirty-five of 122 patients had one or more lymph nodes with frozen-section evaluation positive for metastatic carcinoma. Subsequent nodal sections not in the original frozen-section study revealed metastatic carcinoma in two additional patients. The false-negative rate was 1.6%. Sensitivity was 94.6%. Predictive value of negative frozen-section evaluation results was 97.7%. Because there were no false-positive frozen-section results, specificity and predictive value for positive results of frozen-section evaluation were 100%. The statuses of individual lymph nodes from these 122 patients were also evaluated. Six hundred twenty lymph nodes were sampled from the mediastinum at mediastinoscopy. Frozen-sections in 47 lymph nodes were positive. Subsequent nodal sections not in the original frozen-sections examination revealed metastatic carcinoma in four additional lymph nodes. The false-negative rate was 0.6%. Sensitivity was 92.2%. Predictive value of negative results from frozen-section evaluation was 99.3%. Because there were no false-positive frozen-section results, specificity and predictive value for positive results of frozen-section examination were 100%. We conclude that frozen-section evaluation of lymph nodes at mediastinoscopy reliably indicates lymph node status, thus enabling the physician to decide whether to proceed to thoracotomy. Thus staging of the carcinoma and definitive surgery can be accomplished during a single anesthetic procedure. Combining mediastinoscopy and thoracotomy with frozen-section diagnostic control also reduces both the length and cost of hospitalization.
Biopsy↗
Severe intraoperative myocardial ischemia following manipulation of the heart in a patient undergoing esophagogastrectomy.
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Adenocarcinoma↗
Pericardial disease: current diagnosis and management methods.
Diseases of the pericardium can be indolent or have a sudden onset. They may be primary, but more often are secondary to a systemic disease or previous therapy. Pericardial diseases imitate more common cardiac diseases and therefore can be difficult to diagnose. This paper's four case presentations illustrate use of recently developed methods that facilitate diagnosis. Magnetic resonance imaging is useful for the diagnosis of congenital absence of the pericardium. Echocardiography and computed tomography are useful for the diagnosis of pericardial cysts. Diagnosis of cardiac tamponade is aided by echocardiography, and Doppler echocardiography can help diagnose constrictive pericarditis. Effective management of pericardial diseases requires an understanding of the pathophysiology and natural history of each disease entity, knowledge of the individual patient, and realistic application of therapy.
Adult↗
Systemic vascular effects of epinephrine administration in man.
Although the peripheral vascular effects of epinephrine have been characterized in animal models, similar studies have not been carried out in man. To determine the vascular effects of epinephrine the systemic circuit must be conceptually and surgically opened to allow for independent control of flow and pressure. This unique situation exists in man only while on total cardiopulmonary bypass with an external reservoir and pump interposed between the right atrium and the aorta. Under these conditions, peripheral vascular compliance, arteriolar and venous resistance, and the systemic time constant (a measure of the drainage characteristics of the vascular bed, in units of time) can be determined directly. Nine anesthetized patients undergoing normothermic cardiopulmonary bypass were studied before and during epinephrine infusion (5 micrograms/kg/min) after the aorta was cross-clamped and the heart had been isolated from the rest of the peripheral circulation. At constant blood flow epinephrine infusion increased blood pressure and reservoir volume (effectively decreasing blood volume) by an average of 360 ml. Although systemic vascular compliance decreased (due to venoconstriction), resistance to venous return decreased. Analysis of transient blood volume changes after a step change in right atrial pressure at constant blood flow revealed that blood was effectively draining from two vascular compartments with different time constants, as previously demonstrated in animal experiments. Epinephrine caused redistribution of blood flow away from the compartment with the longest time constant by constricting the arterioles leading to it. This accounts for the major increase in venous return and is almost entirely the mechanism of increased cardiac output in the normal individual after its administration, independent of its effects on the heart. In an attempt to localize the long and short time constant vascular compartments, three normal volunteers were studied. Thallium-201 whole body imaging at rest and after maximal treadmill exercise showed redistribution of blood flow away from the mesenteric bed and towards the muscle compartments. Although two similar compartment models of the circulation have been suggested by others, to our knowledge this type of analysis has not been carried out in man.
Blood Pressure↗
Cardiovascular effects of positive pressure ventilation in humans.
Pulsus paradoxus is the pathological exaggeration of the normal transient decrease in arterial blood pressure that occurs during spontaneous inspiration. The transient increase in arterial pressure associated with positive pressure inspiration is termed reversed pulsus paradoxus (RPP). Cardiorespiratory interactions and the mechanism of these effects have been studied extensively in animals, and to a lesser extent, in humans. In this clinical investigation pulsus paradoxus and RPP were studied in 10 postoperative cardiac patients with invasive monitoring and mediastinal pressure catheters placed intraoperatively. From end-expiration to end-inspiration, RPP was accompanied by decreased transmural pressures in the right atrium, left atrium, and aorta. Left ventricular end-systolic volume measured by radionuclide studies diminished during a positive pressure inspiration, without a significant change in end-diastolic volume. These results are consistent with decreased left ventricular afterload as the major mechanism of RPP. During spontaneous breathing, inspiration was associated with converse effects, a fall in arterial pressure and an increase in transmural right atrial, left atrial, and aortic pressures from end-expiration to end-inspiration. End-systolic volume was significantly larger at end-expiration than end-inspiration, with no change in end-diastolic volume. These findings suggest that an increase in left ventricular afterload during inspiration is responsible for the observed pulsus paradoxus.
Blood Pressure↗
Tube drainage of lung abscesses.
We treated 14 patients who had complicated lung abscesses (all over 4 cm in diameter); 9 patients had concomitant respiratory failure requiring mechanical ventilation. A percutaneous tube was inserted in 11 patients (3 subsequently underwent rib resection) and 3 underwent rib resection with operative insertion of the tube. The resultant bronchopleural fistulas did not interfere with respiratory management despite the use of mechanical ventilation, and only 2 patients required subsequent surgical closure. Eleven patients were discharged from the hospital. Complications were minimal and consisted of 2 episodes of hemorrhage, 1 during operative debridement of the abscess and 1 delayed. Both complications were managed successfully. Three patients died in the hospital, only 1 from complications of the lung abscess. We have concluded from this review that tube drainage can be safe, simple, and efficacious. We recommend it for the treatment of complicated lung abscesses even when associated with respiratory failure and mechanical ventilatory support.
Bronchial Fistula↗
Simultaneous occurrence of chylothorax and subarachnoid pleural fistula after thoracotomy.
A left chylothorax complicated elective left posterolateral thoracotomy and emergency decompressive laminectomy carried out on a 32-year-old woman with a benign neurofibroma. Failure of conservative therapy necessitated ligation of the thoracic duct and this in turn unmasked the concomitant subarachnoid-pleural fistula. Surgical repair and lumbar subarachnoid drainage were required to close the second fistula. The clinical setting, diagnosis and management of this uncommon condition are reviewed.
Adult↗
Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe.
Despite a common misconception, bronchogenic carcinoma of the left upper lobe frequently metastasizes to lymph nodes not only in the anterior mediastinum (para-aortic and subaortic) but also in the superior mediastinum. Anterior (parasternal) mediastinotomy can be used to assess only the former compartment. This procedure alone, if not done in conjunction with standard cervical mediastinoscopy, will fail to disclose technically unresectable N2 or N3 disease of the left upper lobe involving the superior mediastinum. We have developed a technique to explore and sample nodes from both regions by extending a standard cervical mediastinoscopy, eliminating the need for a second incision when the anterior mediastinal compartment requires assessment. We have prospectively analyzed the first 100 procedures that we performed. This technique has been found to be accurate and exceptionally safe with one superficial wound infection as the only complication. We can recommend this single staging procedure for preoperative assessment of bronchogenic carcinomas of the left upper lobe.
Adult↗
Effects of plasmapheresis and of hypoproteinemia on lung liquid conductance in awake sheep.
The Starling equation, which describes net transvascular liquid flow, does not include the possibility that a reduction in plasma protein concentration may have a direct effect on lung liquid conductance or microvascular protein permeability. Nevertheless, both effects have been reported. Since these results were not predictable, we wondered whether the changes were due to the decrease in plasma protein concentration or to the process by which protein depletion was accomplished (batch plasmapheresis which involves considerable handling of blood). To separate these factors, we did control (sham) and protein removal plasmapheresis in awake sheep by two plasmapheresis methods (batch and continuous-flow). We monitored pulmonary hemodynamics, measured lung lymph flow, and determined protein concentrations in lymph and plasma. We calculated or measured the protein osmotic pressures of plasma and lymph. After control plasmapheresis, lymph flow increased and lymph:plasma protein concentration decreased but had returned to baseline levels by 4 hours. After protein removal plasmapheresis, the changes persisted for 24 hours. However, lung microvascular conductance (filtration coefficient) was not increased, except during the first 4-hour period. The changes in lymph flow and protein concentration ratio are explained using a simple two-pore model. We conclude that, over the range studied, hypoproteinemia does not increase lung microvascular liquid conductance or protein permeability.
Animals↗