Ann Thorac Surg

Cardiac operations in patients with cirrhosis.

Klemperer JD. Ko W. Krieger KH. Connolly M. Rosengart TK. Altorki NK. Lang S. Isom OW.
Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, New York 10021, USA.
BACKGROUND: A retrospective review was performed to determine the outcome after cardiac operations in patients with a documented history of noncardiac cirrhosis. METHODS: The charts of patients admitted to the cardiothoracic surgical service between 1990 and 1996 were reviewed, and 13 patients with a preoperative history of cirrhosis were identified. The severity of preoperative liver disease was graded according to the criteria of Child. RESULTS: Most of the cases of cirrhosis were alcohol-related. Eight patients were classified as having Child class A and 5 as having Child class B cirrhosis. One hundred percent of patients with Child class B and 25% of those with Child class A cirrhosis had major complications. The postoperative chest tube output and transfusion requirements of these patients were approximately three times higher than average. The overall perioperative mortality rate was 31%. In patients with Child class B cirrhosis, the mortality rate was 80%. No patient with Child class A cirrhosis died. Deaths were related to gastrointestinal and septic complications, and not to cardiovascular failure. CONCLUSIONS: These findings suggest that patients with minimal clinical evidence of cirrhosis can tolerate cardiopulmonary bypass and cardiac surgical procedures, whereas those with more advanced liver disease should not be offered operation.

Prognosis of adenocarcinoma arising in Barretts esophagus.

Hoff SJ. Sawyers JL. Blanke CD. Choy H. Stewart JR.
Department of Cardiac and Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
BACKGROUND: The rising incidence of adenocarcinoma of the esophagus, as well as its association with Barrett's esophagus, has been reported previously. We report our experience in treating patients with adenocarcinoma arising in Barrett's esophagus. METHODS: A retrospective review was performed of 70 consecutive patients with adenocarcinoma of the esophagus treated between November 1988 and April 1996 with preoperative chemoradiation and resection. Demographics, pathologic features, and survival were compared with patients who developed adenocarcinoma of the esophagus without Barrett's. Statistical analyses was performed using Student's t test, Fisher's exact test, and Kaplan-Meier where appropriate. RESULTS: Thirty-two (46%) patients had adenocarcinoma arising in Barrett's esophagus. During the last 4 years, 72% (23 of 32) of patients with adenocarcinoma had coexistent Barrett's. No differences in patients with or without Barrett's with regard to age, sex, race, tumor location, preoperative chemotherapy, type of operation, or operative stage were observed. Tumors in patients with Barrett's were larger (p = 0.017), had better differentiation (p = 0.002), and were less likely to have a complete response to preoperative chemoradiation (p = 0.05). Actuarial survival, however, was better in the group with associated Barrett's esophagus (p = 0.033). CONCLUSIONS: The incidence of adenocarcinoma of the esophagus arising in Barrett's esophagus appears to be increasing. It may be distinct clinically and biologically from adenocarcinoma of the esophagus that does not develop in association with Barrett's epithelium. Long-term survival was better in our patients with adenocarcinoma associated with Barrett's esophagus.

Esophageal compression by the aorta after arterial switch.

McElhinney DB. Reddy VM. Reddy GP. Higgins CB. Hanley FL.
Department of Radiology, University of California, San Francisco, USA.
Extrinsic compression of the esophagus in children most often occurs in the presence of a congenital vascular ring. We recently operated on a patient in whom esophageal compression had developed that was severe enough to require feeding via a gastrostomy tube several years after the arterial switch operation. Aortopexy and extensive mediastinal mobilization were performed twice with transient relief and gradual return of symptoms. Almost 3 years after the first aortopexy, lasting relief was achieved by transposing the esophagus into the right side of the chest.

Four multiple primary malignant neoplasms of the aerodigestive tract.

Keshishian A. Sarkar FH. Kucyj G. Just-Viera JO.
Department of Pathology, St. Joseph Mercy Hospital, Pontiac, Michigan 48321, USA.
Multiple primary cancers of the head, neck, and upper aerodigestive tract have been documented in patients previously treated for oropharyngeal cancer. There generally is no causal relationship established between the different tumors. Two synchronous or metachronous cancers are common, three are unusual, and four are very unusual. We describe the treatment of a patient with tonsillar and synchronous esophageal and pulmonary cancers followed by a tongue cancer over a 6-year period.

Catastrophic transcatheter baffle fenestration for failing Fontan physiology.

Henneveld HT. Hutter P. Hitchcock FJ. Sreeram N.
Department of Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
Transcatheter fenestration and balloon dilation of an atrial baffle created from native atrial tissue was attempted in a 15-year-old girl with failing Fontan physiology and protein-losing enteropathy. After transseptal puncture, initial dilations with a 10-mm and 12-mm diameter balloon resulted in an inadequate fenestration, with no significant decrease of right atrial pressure or systemic arterial saturation. Dilation of the fenestration with a 16-mm-diameter balloon produced a tear of the atrial septum and subsequent death. Balloon dilation of native atrial tissue may result in uncontrolled tears of the atrial septum.

Esophageal carcinoma: depth of tumor invasion is predictive of regional lymph node status.

Year 1998
Rice TW. Zuccaro G Jr. Adelstein DJ. Rybicki LA. Blackstone EH. Goldblum JR.
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA. ricet@cesmtp.ccf.org
BACKGROUND: The depth of tumor invasion (T) and regional lymph node status (N) are two factors that define the stage of an esophageal carcinoma. However, the arrangement of staging groups assumes that these factors are independent variables. A retrospective review of 359 consecutive patients undergoing esophageal resection was conducted to define the relationship between T and N and to determine whether T is a significant predictor of regional lymph node metastasis (N1). METHODS: Primary treatment was operation without preoperative therapy. There were 295 (82%) adenocarcinomas, 55 (15%) squamous cell carcinomas, and 9 (3%) adenosquamous carcinomas. T status was Tis in 29 (8%) patients, T1 in 65 (18%), T2 in 37 (10%), T3 in 219 (61%), and T4 in 9 (3%). N status was N0 in 161 (45%) patients and N1 in 198 (55%). M status was M0 in 327 (91%) patients and M1 in 32 (9%). Stage was 0 in 29 (8%) patients, I in 58 (16%), IIA in 70 (20%), IIB in 22 (6%), III in 148 (41%), and IV in 32 (9%). RESULTS: The likelihood of N1 disease occurring with increasing T was tested using the trend test. The percentage of patients with N1 disease is 0% for Tis, 11% for T1, 43% for T2, 77% for T3, and 67% for T4 (p < 0.001). This relationship existed for both adenocarcinoma and squamous cell carcinoma. Multivariable analysis identified increasing T, adenocarcinoma, and lack of well-differentiated histologic features as significant predictors of N1 disease. Compared with a T1 patient, a T2 patient is 6 times more likely to have N1 disease, a T3 patient 23 times, and a T4 patient 35 times. CONCLUSIONS: We conclude that for patients with esophageal carcinoma, T is an important predictor of N and this association should be included with other established factors used in clinical staging and treatment decisions.

Thoracoscopic splanchnicectomy for control of intractable pain in pancreatic cancer.

Year 1998
Le Pimpec Barthes F. Chapuis O. Riquet M. Cuttat JF. Peillon C. Mouroux J. Jancovici R.
Service de Chirurgie Thoracique, Hopital Laennec, Paris, France.
BACKGROUND: Pain is the most distressing feature of pancreatic cancer. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain. METHODS: Twenty patients underwent splanchnicectomy for pancreatic cancer pain over a period of 50 months. All were opiate dependent and unable to pursue normal daily life activities. We evaluated the type of splanchnicectomy performed and the long-term results procured. RESULTS: The number of splanchnicectomies was 24: unilateral videothoracoscopic splanchnicectomy, n = 11; unilateral videothoracoscopic splanchnicectomy with associated vagotomy, n = 5; and bilateral videosplanchnicectomy, n = 4. There was no postoperative complication. Pain was totally relieved and drug addiction stopped in 16 patients: 10 with unilateral videothoracoscopic splanchnicectomy, 2 with unilateral videothoracoscopic splanchnicectomy and associated vagotomy, and 4 with bilateral videosplanchnicectomy. Pain was not relieved after 4 unilateral videothoracoscopic splanchnicectomies, but bilateralization was not attempted in that subgroup. CONCLUSIONS: Unilateral videothoracoscopic splanchnicectomy is the treatment of choice of intractable pancreatic pain, affording drug cessation and recovery of daily activity in most patients. Failure may be treated secondarily by bilateralization with excellent results. Bilateral videosplanchnicectomy need not be performed by first intention.

Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy.

Year 1998
Collard JM. Romagnoli R. Goncette L. Otte JB. Kestens PJ.
Department of Surgery, Louvain Medical School, Brussels, Belgium.
BACKGROUND: The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture. METHODS: A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GIA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies. RESULTS: The cross-sectional area was 225 +/- 15.7 mm2 (mean +/- standard error of the mean) for the 16 semimechanical anastomoses versus 136 +/- 15 mm2 for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 +/- 13.5 mm2 in 29 patients without dysphagia to 107.5 +/- 4.7 mm2 in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 +/- 16 mm2 in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 +/- 5.5 mm2 to 174.6 +/- 8.1 mm2, with concomitant symptomatic relief (p = 0.0277). CONCLUSIONS: The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. Inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy.

Long-term results after repeated surgical removal of pulmonary metastases.

Year 1998
Kandioler D. Kromer E. Tuchler H. End A. Muller MR. Wolner E. Eckersberger F.
Department of Cardio-Thoracic Surgery, University of Vienna Medical School, Austria.
BACKGROUND: Although surgical resection is accepted widely as first-line therapy for pulmonary metastases, few data exist on the surgical treatment of recurrent pulmonary metastatic disease. In a retrospective study, we analyzed patients who were operated on repeatedly for recurrent metastatic disease of the lung with curative intent over a 20-year period. METHODS: From 1973 to 1993, 396 metastasectomies were performed in 330 patients. The study population included patients with any histologic tumor type who had undergone at least two (range, 2 to 4) complete surgical procedures because of recurrent metastatic disease. Surgical and functional resectability of the recurrent lung metastases and control of the primary lesion served as objective criteria for reoperation. A subgroup of 35 patients that included patients with histologic findings such as epithelial cancer and osteosarcoma then was analyzed retrospectively to calculate prognosis and define selection criteria for repeated pulmonary metastasectomy. RESULTS: The 5- and 10-year survival rates after the first metastasectomy were 48% and 28%, respectively. The overall median survival was 60 months. A mean disease-free interval (calculated for all intervals, with a minimum of two) of greater than 1 year was significantly associated with a survival advantage beyond the last operation. Univariate analysis failed to show size, number, increase or decrease in number or size, or distribution of metastases as factors related significantly to survival. CONCLUSIONS: Although patients with different histologic tumor types were included, the study population appeared to be homogeneous in terms of survival benefit and prognostic factors, and it probably represented the selection of biologically favorable tumors in which histology, size, number, and laterality are of minor importance. We conclude that patients who are persistently free of disease at the primary location but who have recurrent, resectable metastatic disease of the lung are likely to benefit from operation a second, third, or even fourth time.

Comparison of conventional and wire mesh expandable prostheses and surgical bypass in patients with malignant esophagorespiratory fistulas.

Year 1998
Low DE. Kozarek RA.
Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
BACKGROUND: Patients who present with malignant esophagorespiratory fistula continue to provide a significant palliative challenge to gastroenterologists and surgeons. METHODS: This retrospective series reviewed 29 patients treated with conventional prostheses (13 patients), expandable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995. RESULTS: Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also significantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgical bypass and esophageal exclusion was undertaken. These patients demonstrated good palliation with minimal morbidity and no mortality. CONCLUSIONS: Both conventional and expandable prostheses are safe and reasonably straightforward treatment modalities for patients with esophagorespiratory fistulas. Because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treatment of these difficult patients; however, conventional prostheses will remain a good alternative, especially in patients with extrinsic esophageal compression. When stent placement is either unsuccessful or inadvisable, physiologically fit patients can undergo surgical bypass and esophageal exclusion with good palliation and minimal morbidity and mortality.

Combined coronary bypass and liver transplantation: technical considerations.

Year 1998
Massad MG. Benedetti E. Pollak R. Chami YG. Allen BS. DeCastro MA. Wiley T. Layden TJ.
Department of Anesthesiology, University of Illinois at Chicago, 60612, USA.
Combined coronary artery bypass grafting and orthotopic liver transplantation was carried out successfully in a 58-year-old man with angina pectoris and end-stage liver disease. To date, only 2 similar cases have been documented worldwide whereby the transplantation was performed either during cardiopulmonary bypass or with femoral-to-axillary venovenous bypass initiated at the termination of cardiopulmonary bypass. In this report we describe our experience with a simplified one-exposure approach for the combined operation using cardiopulmonary bypass in tandem with percutaneous femoral-to-right atrial venovenous bypass.

Heterotopic pancreas of the esophagus associated with a rare type of esophageal atresia.

Year 1998
Yamagiwa I. Obata K. Ouchi T. Sotoda Y. Shimazaki Y.
Second Department of Surgery, Yamagata University School of Medicine, Japan. yamagiwa@med.id.yamagata-u.ac.jp
An infant with a rare type of esophageal/tracheal anomaly associated with heterotopic pancreas of the esophagus is herein reported. The upper pouch containing heterotopic pancreas reached 1.5 cm below the tracheal carina, and the distal esophagus connected to the trachea 2 cm above the tracheal carina and thus formed a partial duplication of the esophagus. Heterotopic pancreas of the esophagus is extremely rare, with only 7 cases previously reported. Here we report the combination of heterotopic pancreas and esophageal atresia with tracheoesophageal fistula.

Delayed presentation of traumatic parasternal lung hernia.

Year 1998
Jacka MJ. Luison F.
Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada. mjjacka@nbnet.nb.ca
Traumatic lung herniation is an unusual clinical problem. This case report describes a morbidly obese individual who sustained significant chest trauma in a motor vehicle accident. Lung herniation was noted at the time of delayed respiratory failure necessitating ventilation. The significance of the lung hernia in this patient's respiratory failure is uncertain. The lung hernia was repaired surgically to relieve pain, prevent incarceration, and optimize respiratory function. After a brief period of postoperative ventilation, the patient recovered markedly and has been well since.

Video-assisted repair of a traumatic intercostal pulmonary hernia.

Year 1998
Reardon MJ. Fabre J. Reardon PR. Baldwin JC.
Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA. reardonm@bcm.tmc.edu
A case of traumatic right lung herniation to an area of anterior costal sternal separation and right hemothorax is presented. Application of a thoracoscopic approach to a traumatic lung hernia of the chest wall in this case is discussed.

Cantrells syndrome: a challenge to the surgeon.

Year 1998
Vazquez-Jimenez JF. Muehler EG. Daebritz S. Keutel J. Nishigaki K. Huegel W. Messmer BJ.
Thoracic and Cardiovascular Surgery and Pediatric Cardiology, Rheinisch-Westfalische-Technische Hochschule Aachen, Germany.
We present a case of partial Cantrell's syndrome with ventricular septal defect, left ventricular diverticulum, dextrorotation of the heart, an anterior diaphragmatic defect, and a midline supraumbilical abdominal wall defect with omphalocele. At the age of 20 months, the patient underwent a successful cardiac surgical procedure. To detect risk factors and to define therapeutic strategies, we analyzed the spectrum and the frequency of malformations described in 153 patients with Cantrell's syndrome. Despite modern surgical standards, Cantrell's syndrome represents a challenge to the surgeon because of the wide spectrum of anomalies, the severity of the abdominal and cardiac malformations, and the high mortality.

Shed mediastinal blood transfusion after cardiac operations: a cost-effectiveness analysis.

Year 1998
Kilgore ML. Pacifico AD.
Department of Pathology, University of Alabama at Birmingham 35233-7331, USA. kilgore@wp.path.uab.edu
BACKGROUND: Cardiac surgical patients consume a significant fraction of the annual volume of allogeneic blood transfused. Scavenged autologous blood may serve as a cost-effective means of conserving donated blood and avoiding transfusion-related complications. METHODS: This study examines 834 patients after cardiac operations at the University of Alabama Hospital. Data were collected on patients receiving unwashed, filtered, autologous transfusions from shed mediastinal drainage and those receiving allogeneic transfusions. The data were incorporated into clinical decision models; confidence intervals for parameters were estimated by bootstrapping sample statistics. Costs were estimated for transfusing both allogeneic and autologous blood. RESULTS: The study found a 54% reduction in transfusion risk or a mean reduction of 1.41 allogeneic units per case (95% confidence interval, 1.04 to 1.79 units). The process saved between $49 and $62 per case. CONCLUSIONS: The use of autologous blood has the potential to significantly reduce the costs and risks associated with transfusing allogeneic blood after cardiac operations.

The role of esophagectomy in the management of esophageal perforations.

Year 1998
Altorjay A. Kiss J. Voros A. Sziranyi E.
Department of Surgery, Postgraduate Medical University, Budapest, Hungary.
BACKGROUND: Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial. METHODS: Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied. RESULTS: Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints. CONCLUSIONS: Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.

Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty.

Year 1998
Bonavina L. Chella B. Segalin A. Luzzani S.
Department of Surgery, University of Milan School of Medicine, Ospedale Maggiore Policlinico IRCCS, Italy.
Redundancy of the interposed colon used as an esophageal substitute is a common finding in the long-term follow-up of these patients. When symptoms caused by food retention in the colonic loop occur, surgical correction is necessary to improve quality of life and to prevent aspiration. We report a technique to straighten the redundant colon that consists of a side-to-side colocolic anastomosis using a linear stapler. This obviates the need for a redo cologastric anastomosis. Compared with resection of the loop, the operation is quick, safe, and easy to perform, and it may decrease the risk of injury to the marginal vessels of the colon graft.

MIDCABG followed by a gastrointestinal operation in the same anesthetic setting.

Year 1998
Zolfaghari D. Pfister AJ.
Division of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC, USA.
Cardiovascular complications continue to be a significant source of morbidity and mortality in patients having noncardiac operations. This especially is true in patients with known coronary artery disease facing intraabdominal operations. Minimally invasive direct coronary artery bypass grafting allows coronary artery grafting without cardiopulmonary bypass or a median sternotomy incision. Also, in combination with angioplasty (the "hybrid procedure"), it is possible to offer complete revascularization with far less surgical trauma. We present 2 cases of patients who had minimally invasive direct coronary artery bypass grafting followed by major gastrointestinal operations in the same anesthetic setting.

Broncholithiasis and thoracoabdominal actinomycosis from dropped gallstones.

Year 1998
Noda S. Soybel DI. Sampson BA. DeCamp MM Jr.
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
We report a case of successfully managed invasive, thoracoabdominal actinomycosis caused by the intraperitoneal spillage of gallstones during laparoscopic cholecystectomy. The infected gallstones traversed the diaphragm, migrated into the lung parenchyma, and obstructed a segmental bronchus, causing pneumonia. Treatment involved retrieval of the obstructing stone, debridement and drainage of the pleuroperitoneal phlegmon/abscess, and intravenous antibiotics. The case illustrates the need to remove gallstones at the time of cholecystectomy.

Descending cervical mediastinitis.

Year 1998
Kiernan PD. Hernandez A. Byrne WD. Bloom R. Dicicco B. Hetrick V. Graling P. Vaughan B.
Section of Thoracic Surgery, INOVA Health Systems, Annandale, Virginia, USA.
Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.