Exchanging double-lumen for single-lumen endotracheal tubes after thoracotomy.
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Humans↗
Biomedical subjects
V W Rusch
Publications and source records attributed to V W Rusch.
Intrapleural cisplatin and cytarabine in the management of malignant pleural effusions: a Lung Cancer Study Group trial.
Malignant pleural effusions are a common and significant problem in patients with advanced malignancies. Pleurodesis with tetracycline or other sclerosing agents is the usual treatment for malignant pleural effusions. In contrast to this approach, intrapleural chemotherapy has the potential advantage of treating the underlying malignancy in addition to controlling the effusion. Intracavitary cisplatin-based chemotherapy, which is cytotoxic rather than sclerosing, has proven safe and effective via the intraperitoneal route in ovarian cancer and malignant mesothelioma. There has been little previous experience, however, with intrapleural cisplatin-based chemotherapy. As part of a planned series of trials in malignant mesothelioma, the Lung Cancer Study Group first evaluated intrapleural cisplatin and cytarabine in patients with malignant pleural effusions from a variety of solid tumors. From April 1986 to November 1987, 46 patients with cytologically proven, symptomatic, and previously untreated malignant pleural effusions were entered on study. A single dose of cisplatin 100 mg/m2 plus cytarabine 1,200 mg was instilled into the pleural space via a chest tube, which was then immediately removed. Patients were evaluated for toxicity and response at 24 hours; 1, 2, and 3 weeks; and then monthly. No recurrence of the effusion was considered a complete response (CR). Partial response (PR) was defined as a 75% or greater decrease in the amount of the effusion on serial chest radiographs. One patient experienced reversible grade 4 renal toxicity, four patients had grade 3 hematologic toxicity, and five patients had grade 3 cardiopulmonary toxicity. The overall response rate (CR plus PR) at 3 weeks was 49% (18 of 37 patients). The median length of response was 9 months for a CR and 5.1 months for a PR. The outcome of this trial was sufficiently encouraging that this regimen has been incorporated into subsequent trials for malignant pleural mesothelioma.
Adenocarcinoma↗
The optimal treatment of malignant pleural effusions. A continuing dilemma.
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Bleomycin↗
The role of extrapleural pneumonectomy in malignant pleural mesothelioma. A Lung Cancer Study Group trial.
Malignant pleural mesothelioma is usually a fatal cancer for which operation has been the mainstay of treatment because chemotherapy and radiation are relatively ineffective. The choice of operation for malignant pleural mesothelioma remains controversial. Extrapleural pneumonectomy has been advocated because it allows complete removal of gross tumor and can be associated with long-term survival. To evaluate extrapleural pneumonectomy, we conducted a prospective multiinstitutional trial in patients with biopsy-proved previously untreated malignant pleural mesothelioma. Criteria for extrapleural pneumonectomy were (1) potentially completely resectable unilateral disease by computed tomography scan, (2) predicted postresection forced expiratory volume in 1 second greater than 1 L/sec, and (3) no other major medical problems. Patients who were not candidates for extrapleural pneumonectomy had a more limited operation with or without adjuvant therapy or had nonsurgical treatment. From September 1985 to June 1988 83 eligible patients (64 male, 19 female) were entered. The mean age for all patients was 59.7 years. Only 20 of the 83 patients (24%) underwent extrapleural pneumonectomy. Three of these 20 patients (15%) died postoperatively. The recurrence-free survival was significantly longer for the patients undergoing extrapleural pneumonectomy than for the other two groups (p = 0.03), but there was no difference in overall survival among the three groups. In univariate analyses, epithelial versus sarcomatoid and mixed histologic findings and platelet count less than 400,000 were associated with a better overall survival (p = 0.02), and performance status (Karnofsky less than 80) was predictive of recurrence (p = 0.02). In a multivariate analysis, histologic findings, sex, age, extrapleural pneumonectomy, weight loss, and performance status all had no significant impact on survival. Extrapleural pneumonectomy was associated with a greater likelihood of relapse in distant sites than were limited operation and nonsurgical treatment. We conclude that (1) only a small proportion of all patients with malignant pleural mesothelioma are candidates for extrapleural pneumonectomy, (2) extrapleural pneumonectomy carries a significant operative mortality and does not seem to improve overall survival compared with more conservative forms of treatment, (3) extrapleural pneumonectomy alters the patterns of relapse, and (4) factors previously thought to have an impact on survival in other series did not affect outcome in this trial.
Diaphragm↗
Treatment of traumatic rupture of the thoracic aorta. A 15-year experience.
Traumatic rupture of the thoracic aorta is increasing in incidence and remains a highly lethal injury. The morbidity associated with this injury also remains high. We retrospectively reviewed the records of all patients admitted to our emergency department with ruptured thoracic aortas during a 15-year period to determine the reason for this persistently high morbidity and mortality and to identify any factors that might improve the outcome. We found that patients who are in unstable condition on arrival in the emergency department or who become unstable before reaching the operating room are not likely to survive. Patients who are injured in automobile accidents have a greater chance of survival than do those injured in motorcycle accidents or car-pedestrian accidents. Patients who are in hemodynamically stable condition after aortic injury survive only if diagnosis and treatment are prompt. Major complications of repair following thoracic aortic injury relate primarily to the length of cross-clamp time, and every effort should be devoted to keeping the cross-clamp time less than 30 minutes.
Adult↗
Diagnosis and treatment of pleural mesothelioma.
Pleural mesotheliomas are uncommon tumors. They can be broadly classified as localized and diffuse. The localized form is a non-epithelial neoplasm that occurs as commonly in women as in men and is not related to asbestos exposure. It is usually asymptomatic, and is occasionally associated with paraneoplastic syndromes. Localized mesotheliomas arise more frequently from the visceral than from the parietal or mediastinal pleura. The long-term outcome of these tumors is determined mainly by their clinical presentation, and by whether or not they can be completely resected. Diffuse pleural mesotheliomas are invariably malignant. They are clearly related to asbestos exposure, and are far more common in men than in women. Histologically, they are completely or partially epithelial tumors. Diffuse mesotheliomas present with dyspnea, chest pain, and weight loss and are not associated with paraneoplastic syndromes. Distinguishing malignant mesothelioma from metastatic adenocarcinoma can be difficult and usually requires a large tissue biopsy on which immunohistochemistry and electron microscopy can be performed. The management of diffuse malignant mesothelioma remains controversial. Treatment appears to prolong survival which ranges from 6 to 12 months with supportive care alone. Surgical resection, either with extrapleural pneumonectomy or by pleurectomy/decortications remains the mainstay of treatment because of the relative ineffectiveness of radiation and chemotherapy. Surgical resection alone, however, is inadequate, so most current treatment regimens combine operation with radiation and/or chemotherapy. Even with aggressive multimodality treatment, the median survival currently ranges from 18 to 24 months. A better understanding of prognostic factors, a better staging system, and innovative treatment strategies are desperately needed in this disease.
Combined Modality Therapy↗
Use of the argon beam electrocoagulator for performing pulmonary wedge resections.
The argon beam electrocoagulator (ABC) is a new form of electrocautery that is thought to be more effective than standard electrocautery. It has been used primarily in procedures associated with major blood loss such as liver transplantation and laparotomy for trauma. It has not been used in thoracic operations. We evaluated the safety and efficacy of the argon beam electrocoagulator for performing pulmonary wedge resections in an animal model by comparing it with standard electrocautery and suture closure. Variables used to compare the three methods of resection included perioperative blood loss, duration of chest tube air leak, and depth of necrosis and severity of inflammatory reaction in the lung at ten days and 3 weeks after resection. The argon beam electrocoagulator was as effective as standard electrocautery and suture closure in controlling air leaks, and caused less acute tissue injury than standard electrocautery. The argon beam electrocoagulator provides a safe and effective method for performing small pulmonary wedge resections, and should be evaluated in the clinical setting for this purpose.
Animals↗
The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review.
Traumatic rupture of the thoracic aorta (TRA) is a rare but highly lethal injury in children that occurs as a result of car versus pedestrian accidents and motor vehicle accidents. TRA is often associated with life-threatening injuries to other organ systems. Therefore children with TRA like adults sustaining TRA must be treated urgently but systematically. The rarity of this injury makes it all the more important for physicians treating pediatric trauma victims to be cognizant of the importance of the injury and the clinical and radiographic signs. Even when TRA is promptly recognized in children it is associated with a high in-hospital mortality. The proper use of child restraint systems and adherence to the 55 M.P.H. speed limit may be important factors in reducing the mortality of TRA in children after MVA.
Accidents, Traffic↗
Massive pulmonary hemangiopericytoma. An innovative approach to evaluation and treatment.
The authors report the case of a 39-year-old woman with a massive malignant pulmonary hemangiopericytoma. The clinical presentation and histologic findings were typical of this rare entity, but workup and treatment were challenging because of the size and location of the tumor. Magnetic resonance imaging (MRI) proved to be critical in the preoperative evaluation because of its unique ability to delineate the precise anatomical extent of this highly vascular neoplasm. Previous treatment of this patient with exploratory thoracotomy and chemotherapy had been unsuccessful. The authors used an innovative approach to treatment which included complete surgical resection via combined median sternotomy and thoracotomy, along with intraoperative and postoperative radiotherapy. The patient is disease-free 28 months after surgery.
Adult↗
The role of prophylactic cranial irradiation in regionally advanced non-small cell lung cancer. A Southwest Oncology Group Study.
Lung cancer is the most common malignant disease in the United States. Only the few tumors detected very early are curable, but there has been some progress in the management of more advanced non-small cell lung cancer, particularly in regionally inoperable disease. Prevention of central nervous system relapse is an important issue in this group of patients because brain metastases ultimately develop in 20% to 25% of them. Seventy-three patients with regionally advanced non-small cell lung cancer were entered into a Phase II trial of neutron chest radiotherapy sandwiched between four cycles of chemotherapy including cisplatin, vinblastine, and mitomycin C. Prophylactic cranial irradiation was administered concurrently with chest radiotherapy (3000 cGy in 10 fractions in 15 patients; 3600 cGy in 18 fractions in the remaining 50 patients). Patients underwent computed tomographic scan of the brain before treatment and every 3 months after treatment. The initial overall response rate was 79%, but 65 of the 73 patients have subsequently died of recurrent disease. Median follow-up is 9 months for all 73 patients and 26 months for eight long-term survivors. No patient who completed the prophylactic cranial irradiation program had clinical or radiologic brain metastases. Toxic reactions to prophylactic cranial irradiation included reversible alopecia in all patients, progressive dementia in one patient, and possible optic neuritis in one patient. Both of these patients received 300 cGy per fraction of irradiation. The use of prophylactic cranial irradiation has been controversial, but its safety and efficacy in this trial supports its application in a group of patients at high risk for central nervous system relapse. Further evaluation of prophylactic cranial irradiation in clinical trials for regionally advanced non-small cell lung cancer is warranted.
Brain↗
The performance of four pleural drainage systems in an animal model of bronchopleural fistula.
In order to compare the performance of four pleural drainage units (PDU [Emerson Post-Operative Pump, Pleur-Evac, Sentinel Seal, Thora-Klex]), we created an animal model of bronchopleural fistula that simulated the type of air leak seen clinically (mean maximal flow = 5 L/min). The PDU were tested at 0 cm (water seal), -20 cm and -40 cmH2O suction. Compared to water seal, -20 cmH2O suction significantly increased the ability of all four PDU to evacuate air via the chest tube and abolished small differences in chest tube air leak seen among the PDU at water seal. An increase in suction to -40 cmH2O did not significantly alter flow via the chest tube. Previously demonstrated differences among the PDU in handling large air flows were not seen in this lower flow model of bronchopleural fistula. However, because of their higher resistance, use of the Sentinel Seal and of the Thora-Klex was technically impractical even at air leaks of 4 to 5 L/min.
Animals↗
The role of computed tomography scanning in the initial assessment and the follow-up of malignant pleural mesothelioma.
Between October 1983 and April 1987, 20 patients with malignant mesothelioma underwent computed tomography scans of the chest and upper abdomen to evaluate the extent of disease before treatment. Twelve of these 20 patients deemed to have some potential for long-term survival had scans performed every 3 months after operation to help detect recurrent disease. Anatomic correlation of computed tomography scan findings was available in all 20 patients. The limitations of computed tomography in initial evaluation were its difficulties in assessing (1) chest wall involvement (nine patients), (2) mediastinal lymph nodes (four patients), (3) transdiaphragmatic extension of tumor (four patients), and (4) peritoneal studding and solid organ metastases less than 2 mm in size (one patient). Computed tomography was helpful in detecting recurrent disease in the 12 patients having long-term follow-up. In six of eight cases with histologically proved recurrence, computed tomography detected tumors from 1 to 8 months before the onset of signs or symptoms. Although computed tomography is known to provide far more information about the extent of disease than plain radiographs, it remains an imperfect tool for the staging of disease in patients with malignant mesothelioma. Despite its limitations, computed tomography is probably the most accurate way to provide follow-up for patients during treatment.
Follow-Up Studies↗
Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease.
Over a 3 year period, 52 patients underwent thoracoscopy for the diagnosis and management of a variety of pleural diseases. In 46 of the 52 patients, thoracoscopy was performed under regional anesthesia. The procedure was associated with no operative deaths and essentially no morbidity. In all 52 patients, thoracoscopy averted the need for formal thoracotomy. Thoracoscopy proved valuable as (1) the ultimate diagnostic tool for determining the presence or absence of pleural malignancy in patients with recurrent pleural effusions; (2) a method for obtaining tissue in cases where cytologic study was inadequate for diagnosis; (3) a highly successful approach to chemical pleurodesis in patients with malignant pleural effusions, multiloculated effusions, or failed tetracycline pleurodesis; (4) a means for determining whether a loculated fluid collection was intrapleural or parenchymal in location when radiologic study had failed to clarify this; (5) a way to completely drain the pleural space in patients with multiloculated empyemas not amenable to tube thoracostomy; and (6) an alternative to open lung biopsy in the immunosuppressed patient with diffuse pulmonary infiltrates. Thoracoscopy is a safe, effective, and relatively simple procedure which can be easily performed under regional anesthesia, even in ill or elderly patients. It is an often overlooked alternative to thoracotomy and should be used more widely.
Adult↗
Effect of furosemide on fully established low pressure pulmonary edema.
It has been shown that furosemide, via nondiuretic vascular effects, reduces pulmonary shunt and lung water during the development of oleic acid permeability edema. We studied this effect in a fully established stable model of oleic acid permeability edema. Sixteen anesthetized mongrel dogs, mechanically ventilated with a FIO2 of 0.5, were studied 24 hr after induction of pulmonary capillary leak by intravenous oleic acid (0.06 cc/kg). After stabilization of pulmonary capillary wedge pressure (PCWP) in the range of 0.5-3 mm Hg, bilateral ureteral ligation was performed. Furosemide (2 mg/kg) was then administered intravenously to eight dogs (treated group). An equivalent volume of saline was given to eight control dogs (control group). Pulmonary artery (PAP) and capillary wedge pressures (PCWP), thermodilution cardiac output (Qt), thermal dye lung water (LW), venous admixture (Qva/Qt), arterial and mixed venous blood gases (PaO2, MVO2) were then measured at hourly intervals for 4 hr. During this period of time, central hemodynamics (PCWP, PAP, Qt) remained stable in both groups. Indices of gas exchange and edema formation (Qva/Qt, LW, PaO2) did not change significantly in either control or treated animals. We conclude that furosemide, previously shown to reduce pulmonary shunt and lung water in the early phase of oleic acid permeability edema, does not have any effect once the pulmonary injury is well-established.
Animals↗
Endodermal sinus tumor of the mediastinum. Report of apparent cure in two patients with extensive disease.
Primary endodermal sinus tumor (EST) of the mediastinum has been regarded as a rare and rapidly fatal germ cell neoplasm. We describe two cases of extensive EST treated with a new high-dose sequential combination chemotherapy regimen (CISCA-VB) followed by radical surgical excision. They are alive at 11 and 20 months, respectively, postoperatively. These cases stand in marked contrast to previously reported series. A new approach to the management of this tumor is proposed.
Adult↗
Natural history of incidental appendectomy in patients with Crohn's disease who required subsequent bowel resection.
The records of 20 patients with Crohn's disease who underwent incidental appendectomy and later required bowel resection were reviewed and the following conclusions ascertained. If the patient had had abdominal pain for less than 1 week, appendectomy is followed by minimal problems. If the patient has had abdominal pain for longer than 1 week, incidental appendectomy is followed by an 83 percent incidence of fistula or sinus tract, arising not from the appendiceal stump but from the terminal ileum. The natural history of patients with resection after appendectomy includes more medication and a higher symptom recurrence rate and perhaps operative recurrence rate than their counterparts who have not undergone incidental appendectomy.
Adolescent↗
Resection of stage III non-small cell lung cancer following induction therapy.
Approximately 25%-30% of all patients with non-small cell lung cancer (NSCLC) present with stage III tumors. Except for specific subsets, these tumors are not usually amenable to complete surgical resection and are associated with a 5-year survival of 10% or less. Because patients with stage III NSCLC die of distant metastases, recent efforts to improve the prognosis of these tumors have focused on neoadjuvant therapy using chemotherapy or chemoradiotherapy as induction treatment and subsequent surgical resection for local control. Many trial have now shown the feasibility of neoadjuvant therapy and suggest that overall survival is approximately double that seen after surgical resection or radiation alone. Future clinical trials will define whether surgical resection after induction therapy provides better local and control and survival than chemotherapy and high-dose radiation alone.
Antineoplastic Combined Chemotherapy Protocols↗