Surgical management of bronchiectasis: analysis and short-term results in 238 patients.

OBJECTIVE: Bronchiectasis is defined permanent dilatations of bronchi with destruction of the bronchial wall. It is still a major cause of morbidity and mortality in developing countries. The aim of this retrospective study is to present our surgical experiences, the early and long-term results of 238 patients with bronchiectasis during a 10-year period. METHODS: We reviewed the medical records of 238 patients who underwent surgical resection for bronchiectasis between January 1992 and December 2001, at Gülhane Military Medical Academy (GMMA) Thoracic Surgery Department. Variables of age, sex, symptoms, etiology, and type of operation, mortality, morbidity and the result of surgical therapy were analyzed. RESULTS: There were 205 (86.13%) male and 33 (13.87%) female patients with an average age of 23.7 and a range of 15-48 years. The presenting symptoms were productive cough in 133 (55.88%), fetid sputum in 116 (48.73%), recurrent infections in 84 (35.29%), and hemoptysis in 39 (12.18%) patients. The disease was bilateral in 31 patients (13.02%) and mainly confined to the lower lobes in 162 (68.06%). The surgical treatment was as follows: pneumonectomy in 13 patients (5.46%), lobectomy in 189 (79.40%), lobectomy+segmentectomy in 31 (13.02%), and wedge resection or segmentectomy in five (2.1%). Staged bilateral thoracotomy was used in 14 patients. There was no operative mortality. Complications occurred in 21 patients and the morbidity rate was 8.82%. Complete resection was achieved in 154 (64.7%) patients. Follow-up data were obtained for 229 (96.21%) of the patients. Nine patients were lost to follow-up. The mean follow-up of these patients was 9 months (range, 3 months to 4 years). The symptoms disappeared in 189 patients (79.41%) and 29 patients (12.18%) had improved, whereas 11 patients (4.62%) had no improvement. Significantly better results were obtained in patients who had undergone a complete resection. CONCLUSIONS: Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality at any age. The involved bronchiectatic sites should be resected completely for the optimum control of symptoms.     

Surgery for bronchiectasis.

OBJECTIVE: The incidence of bronchiectasis has declined markedly in developed countries. However, a reasonable number of patients still need surgery, despite aggressive physiotherapy and antibiotic therapy. We have reviewed our patients to clarify the benefits from surgery and to analyse the complications. MATERIAL AND METHODS: Between 1988 and 1999, we have operated on 119 patients with bronchiectasis, 71 female and 48 male, with a mean age of 42.2 years (range 11--77 years). Surgery was indicated because of unsuccessful medical therapy in 66 patients (55%), 31 (26%) had haemoptysis, 11 (9.2%) had lung abscess, 10 (8.4%) had lung masses, and three (2.5%) had pneumothorax. The most common manifestations were cough with sputum in 90 patients (76%), haemoptysis in 45 (38%) and recurrent infections in 57 (48%). The mean duration of the symptoms was 4 years (range 1--40 years). The lower lobes were diseased in 61 patients and bilateral disease was found in ten. The mean number of involved pulmonary segments was five (range 1-15). A lobectomy was performed in 75 patients (62%), a segmentectomy in 12 (10%), a pneumonectomy in nine (7.4%) and a bilobectomy in four (3.3%). Complete resection of the disease was achieved in 108 cases (91%). RESULTS: There was no operative mortality and perioperative morbidity occurred in 15 patients (15%), including temporary broncho-pleural fistulae in 7 (5.8%), and post-operative haemorrhage and atrial arrhythmias in four (3.3%) each. After a mean follow-up was 4.5 years, 73 patients (68%) of this group were asymptomatic, and 31 (29%) had meaningful clinical improvement, while only four (3.7%) maintained or worsened prior symptoms. The best clinical improvement occurred in patients with complete resection of the disease (P=0.008). There were no differences in the respiratory function, comparing pre- and post-operative data, with a 2-year of minimum interval. The VC was 91 and 89% and the FEV1 was 83% and 81% of expected, respectively before and after surgery, (P=NS). CONCLUSION: Surgery of pulmonary bronchiectasis has few complications and markedly improves symptoms in the great majority of patients, especially when complete resection of the disease is achieved. Pulmonary resection of bronchiectasis does not alter respiratory function.     

Surgical management of childhood bronchiectasis due to infectious disease

BACKGROUND: The purpose of this study was to estimate operative risk and to identify indicators of adverse prognosis in patients undergoing resection for childhood bronchiectasis. METHODS: From January 1985 to February 2001, patients undergoing resection for bronchiectasis were studied. The indications for operation were failure of medical therapy in 33 patients (94.2%) and hemoptysis in 2 (5.7%). The mean duration of symptoms was 4.2 years (range, 1-9 years). Surgical treatment included lobectomy in 17 patients (48.5%), pneumonectomy in 7 (20%), lobectomy plus segmentectomy in 5 (14.2%), bilobectomy in 2 (5.7%), and segmentectomy in 4 (11.4%). RESULTS: The operative mortality rate was 2.8%, and the morbidity rate was 17.6%. The mean follow-up in 34 patients was 5.4 years (range, 1-12 years). Overall, 22 patients (64.7%) were asymptomatic after surgery. Clinical improvement was noticed in 8 patients (23.5%), and no improvement was noticed in 4 (11.7%). Complete resection resulted in a significantly better clinical outcome than incomplete resection (P <.05). CONCLUSIONS: Surgery for childhood bronchiectasis can be performed with low mortality and morbidity. Complete resection should be performed when possible.     

Surgical treatment of bronchiectasis in children

Background purpose

Surgical treatment of childhood bronchiectasis has not been discussed extensively because of decline in prevalence and experience with this disease. It remains controversial as to which children would benefit from surgery and surgical points that may affect the outcome. Therefore, a retrospective series was prepared to evaluate the results of surgical treatment of bronchiectasis in children.

Methods

The records of 54 children who underwent surgery for bronchiectasis between 1991 and 2002 were analyzed retrospectively for age; sex; clinical features; radiologic examinations; details of surgery including type of resection, operative morbidity, and mortality; and outcome.

Results

Fifty-four patients underwent 58 pulmonary resections during the study period. The mean ages at diagnosis of bronchiectasis and at the time of surgery were 7.80 ± 3.70 years (range, 1 to 15 years) and 9.25 ± 3.92 years (range, 1.5 to 17 years), respectively, with a male to female ratio of 5:4. The causes of bronchiectasis were lung infection (n = 39), hereditary and inborn diseases (n = 14), and foreign body aspiration (n = 1). Chest X-rays, bronchography (n = 12) or chest computed tomography (n = 43), and ventilation-perfusion scintigraphy (n = 13) were used, and pulmonary function tests (n = 21) and bronchoscopy (n = 54) were performed. The types of resections were lobectomy (63%), pneumonectomy (18.5%), lobectomy with segmentectomy (11.1%), segmentectomy (3.7%), and bilobectomy (3.7%). Four patients required a second operation. Forty-one patients (76%) had complete resection, and 13 patients (24%) had incomplete resection. Intraoperative and postoperative complications were encountered in 4 (7.4%) and 4 patients (7.4%), respectively. The course after surgery was well in 23 (42.5%), improved in 23 (42.5%), and unchanged or worse in 5 patients (9.4%). The mortality rate was 5.6%.

Conclusions

The decision for bronchiectasis surgery should be made in cooperation with the chest diseases unit. Anatomic localization of the disease should be mapped clearly by radiologic and scintigraphic investigations. The morbidity and mortality rates of bronchiectasis surgery are within acceptable ranges. Most of the children benefit from surgery, especially when total excision is accomplished. Pneumonectomy is well tolerated in children without increase in morbidity and mortality. Therefore, pneumonectomy may be preferred instead of leaving residual disease when bronchiectasis is unilateral.     

Current strategy for surgical management of bronchiectasis.

BACKGROUND: There are few current reports of surgical management for bronchiectasis because of its decline in prevalence, and it remains controversial as to which subgroups of patients would benefit from surgical management. METHODS: We reviewed the medical records of all patients who underwent surgical resection for bronchiectasis between January 1, 1990, and December 31, 1997, at our hospital. RESULTS: Ninety patients underwent 92 operations for bronchiectasis. The mean age was 44.7 years. The presenting symptoms were productive cough in 82 patients, fever in 47 patients, hemoptysis in 35 patients, chest pain in 6 patients, and dyspnea on effort in 4 patients. The disease was bilateral in 13 patients. Complete resection was achieved in 75 patients. There was no operative mortality, and the morbidity rate was 19.6%. Postoperatively the patients were asymptomatic in 45.6%, improved in 38.0%, and showed no improvement in 16.4%. Logistic regression extracted the type of bronchiectasis, the existence of sinusitis, and the type of resection for prognostic discrimination with statistical significance. CONCLUSIONS: Surgery for bronchiectasis can be performed with acceptable morbidity and mortality. Patients with cylindrical bronchiectasis are good surgical candidates and chronic sinusitis is a risk factor for surgical resection. Complete resection should be done whenever possible.     

Surgical treatment in bronchiectasis: analysis of 166 patients.

BACKGROUND: Bronchiectasis is usually caused by pulmonary infections and bronchial obstruction. It is still a serious problem in developing countries as our country. We reviewed the morbidity and mortality rates and outcome of surgical treatment for bronchiectasis. PATIENTS AND METHODS: Between 1990 and 2000, 166 patients (92 female and 74 male patients) underwent pulmonary resection for bronchiectasis. The mean age was 34.1 years (range, 7-70 years). Mean duration of symptoms was 5.7 years. RESULTS: Symptoms were copious amount of purulent sputum in 135 patients, expectoration of foul-smelling sputum in 109, hemoptysis in 35 and cough in all patients. The indication for pulmonary resection was failure of medical therapy in 158 patients, massive hemoptysis in five and lung abscess in three. The disease was bilateral in six patients and mainly confined to the lower lobe in 127. One hundred and twenty patients had a lobectomy, 13 had a pneumonectomy, 21 had a segmentectomy and a combination of these approaches in 18. Operative morbidity and mortality were seen in 18 (10.5%) and in three (1.7%) patients, respectively. Follow-up was complete in 148 patients with a mean of 4.2 years. Overall, 111 patients were asymptomatic after surgical treatment, symptoms were improved in 31, and unchanged or worse in six. CONCLUSIONS: Surgical treatment of bronchiectasis is more effective in patient with localized disease. It is satisfactory with acceptable ratio of morbidity and mortality.     

Operative and long term results after surgery for chronic radiation enteritis

BACKGROUND: About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented. METHODS:From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed. RESULTS: Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P <0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively. CONCLUSIONS: Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.     

Stromal sarcoma of the stomach: therapeutic considerations.

OBJECTIVE: To present our experience of the surgical treatment of primary gastric stromal sarcomas and to compare it with reported results. DESIGN: Retrospective study. SETTING: University hospital, Germany. SUBJECTS: 17 patients (13 men and 4 women, median age: 58 years) who were operated on for stromal sarcomas of the stomach from April 1987 to March 1999. MAIN OUTCOME MEASURES: Extent of resection, morbidity and mortality, histopathological features, survival. RESULTS: Stromal sarcomas made up 0.8% of all gastric malignancies. Abdominal pain and gastrointestinal bleeding were the main symptoms. 16/17 were resected succesfully. The main type of resection was total gastrectomy (n = 11, in 6 cases as extended gastrectomy), followed by wide local excision of the stomach wall (n = 4), and proximal gastrectomy (n = 1). Of all resections 10 were radical (R0) and 6 were palliative (R1/R2). 5 patients developed complications. One patient died postoperatively. Median tumour size was 70 mm (range 30-230). The serosa was penetrated in 11 cases, lymph node metastases were found in 3 patients, and distant metastases in 8. Overall median survival was 19 months (2-64) and 5 patients survived 5 years. After radical resection (n = 10) median survival was 39 months (2-64) and the above mentioned 5 patients survived 5 years. CONCLUSION: Stromal sarcomas of the stomach are rare, the resection rate is high and the type of resection varies with the extent of the tumour. Wide local excision may be sufficiently radical. Long-term results after radical resection seem to be better than those after gastric adenocarcinoma.     

Surgery for non-localized bronchiectasis

BACKGROUND: Resection for localized bronchiectasis is a well established therapy. However, there is little information on the role of surgery in non-localized bronchiectasis. METHODS: Between January 1992 and April 2001, 55 patients without cystic fibrosis underwent resection. Forty-eight patients (mean age 45 (range 23-74) years; 32 women) were available for long-term follow-up. Twenty-five patients underwent resection for localized disease (group 1) and 23 had bronchiectasis in at least two different lobes (group 2). RESULTS: Thirty-one of the 48 patients were treated by Video Assisted Thoracoscopic Surgery (VATS) resection. There was no 30-day mortality. Mean duration of hospital stay was 10.9 (range 6-31) days in group 1 and 11.1 (range 5-19) days in group 2. Three of 25 patients in group 1 required reoperation. Only minor complications occurred in group 2 (three patients). Mean follow-up for both groups was 37 (range 6-97) months. Twenty-three of 25 patients in group 1 and 16 of 23 in group 2 reported satisfaction at 6 months after the operation. Recurrent infection was noted in three patients in each group. Haemoptysis recurred in only one patient in group 2. CONCLUSION: The surgical treatment of selected patients with non-localized bronchiectasis was safe and most patients were satisfied with the outcome.     

Management of massive hemoptysis: a single institution experience.

BACKGROUND: Massive hemoptysis is a life threatening condition. Several therapeutic strategies have been applied in the clinical setting, with variable results. We reviewed our recent experience on this subject. MATERIAL AND METHODS: In a 5-year period, fifty-four patients (41 males, mean age 57.9 years) were treated for massive hemoptysis in our unit. The underlying pathology included bronchiectasis (n=31), active tuberculosis (n=9), pneumoconiosis (n=3), lung cancer (n=2) and pulmonary angiodysplasia (n=1). These patients often present with continuous bleeding with large volume of hemoptysis, or with recurrent episodes of bleeding. Bronchoscopic assessment and interventions were performed upon admission in all patients. Surgery was considered if the patient had acceptable pulmonary reserve and a bleeding source was clearly identified. If the patient was not considered fit for surgery, bronchial artery embolization was attempted. RESULTS: Hemoptysis ceased with conservative management in 7 patients (13%) only. Twenty seven (50%) patients received surgical resection. The procedures included lobectomy (n=21), bilobectomy (n=4) and pneumonectomy (n=2). The in-hospital mortality after surgery was 15%. Postoperative morbidity occurred in 8 patients, including prolonged ventilatory support, bronchopleural fistulae, empyema and myocardial infarction. Twenty-one patients not suitable for surgery were treated with bronchial artery embolisation, which was successful in 17 patients without any complications. CONCLUSION: The clinical outcome for massive hemoptysis reflects the generalized nature of a destructive disease process involving both lungs and a limited respiratory reserve. Surgery is associated with high risk of morbidity and mortality, and should be performed only in selected patients. Meanwhile, aggressive conservative therapy including bronchial artery embolization should be pursued.     

Colloid cysts: experience with the management of 84 cases since the introduction of computed tomography

A retrospective review of colloid cysts diagnosed from 1974 to 1986 emphasizes the presenting symptoms of these lesions, their surgical management, and the contribution of modern imaging techniques to their diagnosis and therapy. In this 12-year period, 84 patients (45 men and 39 women) had a colloid cyst diagnosed. The patients' mean age was 46 years (range, 7-82 years). Surgery was performed in 55 patients, 7 of whom had undergone prior surgery elsewhere. The surgical approaches used were transfrontal-transventricular, transcallosal, computer-assisted stereotactic aspiration and resection by stereotactic craniotomy, and shunting of cerebrospinal fluid without removal of the lesion. There was no operative mortality, but complications occurred in 15 patients (27%). Preoperative imaging showed hydrocephalus in 93% of the patients: severe in 43%, moderate in 36%, and mild in 14%. In the surgically treated group, the most common presenting symptoms were headache, change in mental status, ataxia, nausea and vomiting, visual disturbance, emotional lability/inappropriate affect, depersonalization, and hypersomnolence. Twenty-four patients for whom surgery was not recommended are being followed up closely. Most of these patients had normal ventricles. The symptoms in this group included headache, anxiety/nervousness, ataxia, memory impairment, visual disturbance, and seizures. Five autopsy cases of patients with colloid cysts were available during this period and were reviewed. Direct removal of colloid cysts can be accomplished with low morbidity and mortality, avoiding the frequent revisions and complications related to shunt procedures. There is a subgroup of colloid cysts that can be operated upon electively or followed up closely with serial imaging studies.     

Kidney cancers with supra-diaphragmatic invasion. Surgical treatment using extracorporal circulation with heart arrest

STUDY AIM: The study aim was to report results of nephrectomy with resection of cavo atrial thrombus in 6 patients with a renal carcinoma and supra-diaphragmatic vena cava extension and to discuss limits of the surgical indications. PATIENTS AND METHOD: Six patients, five adults (mean age: 57 +/- 10 years) and a four-year old girl, were operated on for a renal cell carcinoma with supra-diaphragmatic vena cava extension. The venous extension was detected in all cases by abdominal ultrasonography. The superior extent of the thrombus was effectively visualized by CT scan in three cases, and by ultrasonography and magnetic resonance imaging in all cases. All the patients were operated on, using cardio-pulmonary bypass, without circulatory arrest, four in normothermia, two in moderate hypothermia at 28 degrees C. RESULTS: Hospital mortality was 0%. Average intensive care unit stay was 3.8 days. During the following period, all the patients developed metastatic disease. Mean survival rate of the five adult patients who had loco-regional invasion was 9.4 months (range: 6 to 19). The young girl underwent a wedge excision of two pulmonary metastases one year later and was still alive 7 years later. CONCLUSIONS: With cardio-pulmonary bypass, surgical resection of cavo-atrial thrombi may be performed with a low mortality and morbidity rate but late results were disappointing. Surgery should be limited to patients without loco-regional invasion or distant metastatic disease, and therefore accurate preoperative staging is mandatory.     

The role of surgery in Caroli's disease

BACKGROUND: Caroli's disease is a rare congenital disorder characterized by multifocal segmental dilation of the intrahepatic bile ducts. Whether conservative or surgical strategies should be preferred is still a matter of debate. The aim of this study was to evaluate the role of surgery in the management of Caroli's disease. STUDY DESIGN: From April 1998 until August 2005, 12 consecutive patients with Caroli's disease were treated in the Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Germany. All patients were intended to receive liver resections or liver transplantations. RESULTS: There were seven men and five women, with a median age of 39 years (range 7 months to 70 years). Eight patients had monolobar and four patients had bilobar liver involvement. All patients had a history of recurrent cholangitis, with up to 16 unsuccessful conservative treatment attempts. Nine patients (75%) underwent liver resection and two (17%) had liver transplantation. Intraoperatively, three patients (25%) were found to have cholangiocarcinoma, of which one was unresectable. There was no mortality and only low morbidity (16%) postoperatively. After a median followup of 31 months, 11 patients are well with no recurrent symptoms. CONCLUSIONS: Surgery can offer a definite therapy, with an acceptable morbidity and virtually no mortality in localized Caroli's disease. In diffuse disease, the use of extended resections or liver transplantation can provide good longterm results.     

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management

BACKGROUND: Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management. STUDY DESIGN: From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications. RESULTS: Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n= 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications. CONCLUSIONS: Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.     

Management of pulmonary hydatid cysts in a tertiary care centre in Northeast India

Background

Hydatid cysts are the most common parasitic disease of the lungs. We reviewed our experience with pulmonary hydatid cysts focusing on clinical symptoms, diagnostic methodology, operative management and their outcome in our centre.

Methods

Between October 2008 and September 2013, 37 patients were operated in our department for lung parenchymal hydatid cysts. Twenty-six patients were female and 11 were male. The mean age of the patients was 30.6 years with a range of 16–44 years. The cysts were located in the right lung in 22 (59.46 %) patients, left lung in 14 (37.84 %) and bilaterally in 1 (2.70 %). We performed enucleation and capitonnage in 29 cases, cystotomy-drainage and capitonnage in 6 cases, wedge resection in 1 case and lobectomy in 1 case. Albendazole was given postoperatively to selected patients considered to be at high risk for recurrence.

Results

Chest X-ray, computerized tomographic scanning of the thorax was done in all cases for diagnosis. Most of the patients presented with solitary pulmonary cysts. One patient had bilateral pulmonary cysts and four patients had concomitant liver cysts. Postoperatively, there was no major morbidity. There was no in-hospital or 30-day mortality. The follow-up data was complete for 29 of the 37 patients. The mean follow-up period was 2.6 years with a range of 6 months to 5 years. During the said period, none of the patients had shown any recurrence.

Conclusion

Surgery for hydatid cysts of the lung can be safely performed, with low morbidity and a negligible mortality rate and is the treatment of choice.     

Late outcome after surgical management of carotid body tumors from a 20-year single-center experience

Background and aims  Surgical resection is the treatment of choice for carotid body tumors. The aim of this study was to assess not only the perioperative, but also the long-term outcome after surgical treatment. Patients/methods  All patients that were operated on a carotid body tumor at our institution between 1986 and 2006 were reviewed. Data collection included patient profile, intraoperative findings and postoperative outcome. Results  Seventeen patients (11 female, six male) with 17 carotid body tumors (12 right, five left sided) were identified. Mean patient age at treatment was 49 years (range 19 to 76 years). Eight patients (47.1%) had large Shamblin type III tumors. Complete tumor resection was achieved in 16 of 17 cases (94.1%). Malignacy could not be proven in any patient. The 30-day mortality and stroke rates were 0. The incidence of temporary and permanent cranial nerve deficit was 41.2% and 11.8%, respectively. Patients with type III tumors had significantly higher risk of neurologic complications than patients with smaller tumors (p = 0.0152). The median postoperative follow-up was 6.4 years (range 1.5 to 20 years). The overall survival rate was 82.4%; the disease-specific survival rate was 94.1% (16 of 17 patients). One patient (5.6%) died of local tumor recurrence 3 years after a R1 resection. All the other patients showed no signs of local recurrence or metastases. Conclusions  The surgical therapy of carotid body tumors shows low long-term morbidity, mortality, and recurrence rates. Cranial nerve injury is mostly temporary but a relevant procedure-related complication. Surgical resection is indicated also for small, asympomatic tumors, because of the uncomplicated resectability of these tumors. Presented at the Annual Scientific Congress of the German, Swiss and Austrian Societies for Vascular Surgery, Basel Switzerland, September 2007.     

Indications and outcome of surgery for pulmonary aspergilloma

BACKGROUND: The indications and the outcome of surgery for pulmonary aspergilloma remain highly controversial. The short term and long term results of lung resection or cavernostomy in 24 patients with pulmonary aspergilloma are reported. METHODS: The case notes of 27 consecutive patients referred for surgical assessment for pulmonary aspergilloma at the Royal Brompton Hospital over the last 14 years were reviewed. Patients were categorised into four classes according to their fitness for lung resection and the severity of their symptoms. Severe symptoms were defined as life threatening haemoptysis or other symptoms requiring more than one hospital admission. Class I (n = 1), fit individual with mild or no symptoms; class II (n = 17), fit individuals with severe symptoms; class III (n = 1), unfit individual with no symptoms; and class IV (n = 8), unfit individuals with severe symptoms. Two asymptomatic patients and one on an IVOX pump were not accepted for surgery. Lung resection was performed in all 17 patients with class II disease, comprising segmentectomy only in five patients, lobectomy and segmentectomy in seven, and a completion pneumonectomy in five patients. Cavernostomy was performed in seven patients with class IV disease. RESULTS: Surgery was often complicated by prolonged air leakage and infection of residual space. There was no operative mortality in the group treated by resection whereas two of those who underwent cavernostomy died in the early postoperative period. All survivors were followed up for a median of 17 months (range 1-72 months); 19 were alive and had no symptoms attributable to aspergilloma. Late recurrence occurred in two patients in the cavernostomy group. The only late death occurred in the resection group five months postoperatively and was attributed to end stage renal disease. CONCLUSIONS: Lung resection in selected patients with complicated aspergilloma can be performed with low operative mortality. Cavernostomy is associated with high mortality and morbidity and should therefore only be performed in patients with life threatening symptoms who are unfit for lung resection.     

Primary retroperitoneal tumors. Treatment modality and prognostic factors

BACKGROUND: Primary Retroperitoneal Tumors (PRT) form a heterogeneous group of malignant mesenchymal and neuroectodermal neoplasms making up only 1% of all solid neoplasms. METHODS: From 1965 to 1997, 27 patients (16 females and 9 males, age range 19-79 years) underwent operations at the General and Cardiovascular Institute of University of Milan for primary retroperitoneal tumors (22 malignant and 5 benign, sarcomas represented 68% of all malignant tumors). A retrospective analysis of these patients was performed to determine the prognostic parameters associated with a favourable prognosis. All patients were admitted with severe abdominal pain or a palpable mass, other symptoms included fewer and weight loss. The median duration of symptoms before presentation was 16 months (range 15 days-5 years). Before surgical treatment abdominal and pulmonary CT scanning and MRN were undertaken on all patients with PRT to define the size of the tumor and the involvement of other retroperitoneal structures. RESULTS: Complete resection was possible in 54% of malignant tumors (n = 12), incomplete resection was performed in 14% (n = 3) and in 31% (n = 7) only biopsy was possible. Recurrent tumor developed in 25% of patients with total resection (n = 3), (median time to recurrence 5 years). Independent treatment variables (size, signs and symptoms, histopathologic findings and grade) and treatment-dependent variables (type of surgical treatment and adjuvant chemotherapy) were analyzed. Patients with complete resection had a 12 month survival of 100% (n = 12) compared to 50% (n = 1) for those undergoing partial resection and 14.2% (n = 1) for those with simple biopsy. A 24-month survival of the patients undergoing complete resection was 25% (n = 3). Median survival for type of surgical treatment was 28 months for complete resection compared to 14 months for partial resection and only 8 months for biopsy. Twelve-months survival for tumor grade was 100% (n = 7) for low grade tumor (G1), compared to 66.6% (n = 4) for median differentiated tumors (G2), and 37.5% (n = 3) for high grade tumors (G3). Twenty-four-months survival was 28.5% (n = 2) for low grade tumors compared to 16.6% (n = 1) of median differentiated tumors. High grade tumors were associated with a 35-month median survival time compared to 17 months for median differentiated tumors and 10 months for low grade tumors. Other variables (histopathologic findings, size, symptoms) had not significant impact on survival. Operative mortality rate was 3.7% (n = 1). The overall 2 years survival rate in patients with totally resected tumors was 25% (n = 3), (2G1, 1G2), while the 5 year survival rate was 16.6% (n = 2), (2G1). CONCLUSIONS: Complete surgical excision and low grade of the tumor are the most important parameters of survival. Recurrent disease is a vexing problem; a careful and prolonged follow-up based on the use of CT and MRN is recommended.     

Desmoid tumors of the chest wall.

OBJECTIVE: Desmoid tumors of the chest wall are uncommon fibromatous tumors characterized by their local invasion and frequent recurrences. They are considered low-grade malignant sarcomas. We analyze our results and evaluate our experience in their surgical treatment. PATIENTS AND METHODS: From 1980 and 1999, eight patients were operated in our service for desmoid tumors of the chest wall. There were five males and three females with a mean age of 32 years old (17-52 years). The diagnosis was established on the basis of clinical signs and imaging studies (Chest X-ray and computed tomography). Surgery was done by direct approach of the tumors. RESULTS: None of the patients had Gardner's syndrome. Complete resection was done in seven of the eight cases. Histology confirmed all cases. The follow-up ranged from 24 and 180 months, for a mean of 82 months. There was one death from cardiac and renal failure 3 months after a fifth resection associated with adjuvant radiation therapy. No other post-operative complications were observed. Recurrences occurred in 50% of cases, all treated by surgery, associated to radiotherapy in one case. CONCLUSION: Surgical treatment of primary desmoid tumors of the chest wall requires wide local resection. In cases of recurrences, multimodality therapies should be considered.     

Surgical treatment of bronchiectasis: early and long-term results

Management of bronchiectasis remains controversial and information on long-term results of surgical treatment is poor. Clinical records of 45 patients, who underwent surgery for bronchiectasis in an 8-year period, were retrospectively reviewed. Bronchiectasis focus was isolated in 24 cases, associated with a limited homolateral or controlateral focus in 9 and 11, respectively; two patients had bilateral evident foci. Bronchiectasis was responsible for lobe destruction in 23 cases. All patients had symptoms: haemoptysis (n=7), recurrent pneumonia (n=7), persistent bronchorrea with recurrent infection (n=15), hemoptysis and recurrent infection (n=16). A total of 23 lobectomies, 11 lobectomies+segmentectomies, 2 bi-lobectomies, 9 segmentectomies and 1 pneumonectomy were carried out. There were no perioperative deaths; complications occurred in 5 patients (postoperative pneumonia in 2, prolonged air-leak, residual air-space and bronchial infection 1 each). Symptoms disappeared in 32 patients, 10 patients experienced a significant improvement. Exercise tolerance remained stable or improved in 33 and 2 cases, respectively, a slight impairment was observed in 9. Out of 32 evaluable patients 11 had an unchanged FEV(1), 15 had a limited FEV(1) lowering (<15%), and 9 had a more important functional loss. Surgical treatment of bronchiectasis obtains satisfactory long-term results, with acceptable morbidity rates.