Chest Surg Clin N Am

Current management of colorectal metastases to lung.

Year 1998
McCormack PM. Ginsberg RJ.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
Colorectal carcinoma is the second most common visceral cancer in the United States, in both incidence and fatality rate. Of patients with colorectal carcinoma, 45% undergo resection and are cured. In cases of recurrence, 2% are restricted to lung only. A select group of 287 patients over 30 years at Memorial Sloan-Kettering Cancer Center underwent a surgical approach, which produced a survival rate of 40% at 5 years and 32% at 10 years.

Imaging evaluation of the diaphragm.

Year 1998
Gierada DS. Slone RM. Fleishman MJ.
Mallinckrodt Institute of Radiology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
The diaphragm performs most of the physiologic work of inspiration, and forms an anatomic barrier between the thoracic and abdominal cavities. Disorders of the diaphragm can be related to impairment of either of these functions, and most have radiologic manifestations. Both intrathoracic and intra-abdominal disease processes can alter the normal radiologic appearance of the diaphragm. Abnormalities are usually first detected on chest radiographs, often incidentally in asymptomatic patients, and many require further characterization by other imaging studies for definitive diagnosis. Fluoroscopy, CT, and MR imaging are frequently the most useful additional studies, whereas ultrasonography, barium contrast studies, and liver-spleen scintigraphy are occasionally helpful. Selection of the most appropriate radiologic technique in a given clinical situation can greatly facilitate the diagnosis of diaphragm abnormalities.

Surgical anatomy of the diaphragm and the phrenic nerve.

Year 1998
Fell SC.
Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, Bronx, New York, USA.
In this article, the anatomy of the diaphragm and phrenic nerves is discussed, together with related surgical implications. Since the major cause of phrenic nerve injury is surgery, usually for congenital or acquired heart disease, incisions in the diaphragm that do not injure major branches of the phrenic nerve are also discussed. Diaphragmatic plication is usually required in infants less than 3 months of age, and older children may be managed by ventilatory support if electrophysiologic studies document the possibility of return of nerve function. In adults with normal pulmonary function, unilateral diaphragmatic paralysis is usually asymptomatic.

Congenital diaphragmatic hernia.

Year 1998
Langer JC.
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA. langerj@msnotes.wustl.edu
CDH is a developmental abnormality resulting in a diaphragmatic defect which permits abdominal viscera to enter the chest. Most cases occur through the posterolateral foramen of Bochdalek. The mortality rate associated with CDH remains high due to the presence of associated anomalies, pulmonary hypoplasia, and pulmonary hypertension in those with adequate lung parenchyma to initially support life. A large number of approaches have been used to manage these infants, including delayed surgical repair, pharmacologic treatment of pulmonary hypertension, high frequency oscillation, ECMO, and surfactant therapy. New, and as yet unproven, innovations such as permissive hypercapnea, fetal surgery, and liquid ventilation may provide greater hope in the future for severely affected infants. Although most surviving children with CDH do well, a significant incidence of gastrointestinal and neurologic morbidity still exists.

Eventration of the diaphragm.

Year 1998
Deslauriers J.
Department of Surgery, Laval University, Sainte-Foy, Quebec, Canada.
Eventration of the diaphragm is a condition where the muscle is permanently elevated, but retains its continuity and attachments to the costal margin. It is rare, seldom symptomatic, and often requires no treatment. In symptomatic patients, plication of the diaphragm may offer relief of the symptoms.

Adult presentation of unusual diaphragmatic hernias.

Year 1998
Naunheim KS.
Division of Cardiothoracic Surgery, Saint Louis University Health Sciences Center, Missouri, USA. naunheks@wpogate.slu.edu
The vast majority of diaphragmatic hernias occurring in adults are either standard hiatal hernias or those presenting acutely due to traumatic disruption of the diaphragm. The remaining small fraction represent unusual cases such as congenital hernias (Morgagni or Bochdalek) presenting in adulthood or traumatic hernias presenting months to years after the traumatic (or surgical) event. The recognition and management of these rare cases are discussed.

Hiatus hernia. The condition.

Year 1998
Ilves R.
Department of Surgery, Albany Medical College and Center, New York, USA.
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.

Open repair of hiatus hernia: abdominal approach.

Year 1998
Moores D. Hill LD.
Department of Surgery, Albany Medical College, New York, USA.
Open hiatus hernia repair can be accomplished with very low mortality and excellent long-term results. The vast majority of hiatus hernias, including those with peptic structure, can be repaired transabdominally. The Hill repair, the Nissen, and the Collis-Nissen are well-established techniques for repairing a hiatus hernia that have stood the test of time and are associated with good long-term results. The technical aspects of these repairs are discussed in detail within this article.

Open repair of hiatus hernia: thoracic approach.

Year 1998
Allen MS.
Department of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Open repair of a hiatal hernia remains an excellent method for correction of symptomatic gastroesphageal reflux. This article gives a technical description of the performance of the Belsey Mark IV hiatal herniorrhaphy and the uncut Collis-Nissen repair. A brief description of preoperative evaluation and results is also included.

Tumors of the diaphragm.

Year 1998
Weksler B. Ginsberg RJ.
Division of Thoracic Surgery, Hospital Barra D'Or, Rio de Janeiro, Brazil.
Primary tumors of the diaphragm are rare, and more than half are benign. Diaphragmatic tumors arise from mesenchymal tissue because of their mesodermal origin, and all varieties of these tumors have been reported. An interesting paraphenomenon is hypertrophic osteoarthropathy, most commonly seen in tumors of neurogenic origin. In most instances, these tumors are small and can be excised with a primary repair anticipated. Secondary involvement of the diaphragm from lung cancer is more common, but is rarely associated with a resectable lesion. Direct extension from other intra-abdominal or intrathoracic tumors can occur, commonly from mesothelioma, lung cancer, and hepatic carcinoma. In some cases, en bloc excision of the diaphragm is required, and in many instances diaphragmatic replacement is necessary using a variety of thin plastic prostheses, if a wide resection is required. Attempts at primary repair under tension, especially on the left side, may lead to diaphragmatic rupture and herniation.

Porous diaphragm syndromes.

Year 1998
Kirschner PA.
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, City University of New York, New York, USA.
Porous diaphragm syndromes are a group of seemingly disparate clinical symptom complexes involving a wide variety of unrelated medical specialties. However, they are linked by a common anatomical feature, a defect in the diaphragm. They usually present with thoracic symptomatology--pleural effusions, pneumothorax, hemothorax, empyema--mediated by this defect. Management of these syndromes utilizes principles of thoracic surgical practice including thoracotomy and thoracoscopy.