Surgical treatment of thoracic empyema in HIV-infected patients: severity and treatment modality is associated with CD4 count status

OBJECTIVES: Patients infected with HIV have an increased propensity for developing thoracic empyemas secondary to their susceptibility to polymicrobial pulmonary infections. We performed an assessment of the clinical outcomes of HIV patients undergoing surgical treatment of thoracic empyemas and reviewed the microbiology of these infections. METHODS: We completed a retrospective analysis of the patients who had been referred for surgical treatment of thoracic empyemas over an 11-year period, ending in 2002. The patients were treated at a major metropolitan medical teaching facility that cares for a substantial number of HIV-positive patients. RESULTS: Twenty-one HIV-infected patients underwent surgical treatment of thoracic empyemas. There were no immediate deaths. Sixty-two percent of the patients had CD4 counts of < 200 cells/microL. Eight patients had postoperative complications. Six of the patients with complications had CD4 counts of < 200 cells/microL. Patients with lower CD4 counts were at risk for mycobacterial and fungal infections. Additionally, they often had complex empyemas that were not favorable for treatment by video-assisted thoracic surgery. Therefore, these patients often required surgery with lung resection, which necessitated longer periods of postoperative chest tube drainage. CONCLUSIONS: Surgeons can obtain satisfactory operative outcomes when treating thoracic empyemas in HIV patients; however, the treatment strategy should be individualized. Patients with CD4 counts of < 200 cells/microL more commonly have complex empyemas that require surgery with open decortication and drainage. Although these patients have a higher incidence of postoperative complications, we think that HIV patients with thoracic empyemas can be safely and effectively treated with surgical techniques.     

Scintigraphic diagnosis of tricuspid regurgitation

The authors describe a simple technique for diagnosis of tricuspid regurgitation. Red blood cells were labeled in vivo with 99mTc and 22 patients were studied with ECG-gated blood-pool imaging of the liver. A single region of interest was manually drawn around the liver and a time-activity curve obtained. The per cent change in liver counts during the cardiac cycle was found to be significantly higher in the 12 patients with tricuspid regurgitation (Group I) (mean, 4.04 +/- 1.6%; range, 1.3-21.4%) compared with the 10 controls (Group II) (mean, 0.35 +/- 0.16%; range, 0.013-1.3%) (p less than 0.05). Using a 1% change in liver counts as the criterion of a positive study, all 12 cases in Group I were diagnosed correctly, but there was one false positive in Group II; thus the sensitivity was 100% and the specificity 90%.     

Determinants of early and late outcome for reoperations of the proximal aorta

Background

The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome.

Methods

Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%), and ascending aorta in 27 (26.0%). The median interval between operations was 69 months. Retrograde cerebral perfusion was used in 80 (77%) cases.

Results

Chronic dissection was the most common indicator for reoperation in our population, followed by progression of aneurysm and infection. Thirty-day and in-hospital mortality was 13.5% (14 of 104) and 15.4% (16 of 104), respectively. Chronic obstructive pulmonary disease, renal dysfunction, and increased pump time were risk factors for mortality. Median follow-up was 5.02 years. Eight patients died during that period. Estimated survival at 1, 5, and 10 years was 83%, 80%, and 62%, respectively. Freedom from second proximal reoperations was 97.1% (10 of 104). Freedom from subsequent distal thoracic aortic repair was 84.6% (8 of 104).

Conclusions

Reoperations of the ascending aorta and aortic arch can be performed safely with good long-term results. Patients with previous proximal aortic dissection repair need long-term surveillance. Renal dysfunction and chronic obstructive pulmonary disease must be carefully considered before reoperations of the proximal aorta.     

Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm

PURPOSE: Delayed neurologic deficit has been recognized in recent years as a source of morbidity following thoracic and thoracoabdominal aortic repair. We wanted to find risk factors specifically significant for delayed neurologic deficit. In this initial study we looked at preoperative and operative risk factors. METHODS: We performed 854 thoracoabdominal aortic repairs between February 1991 and May 2001. For this study we excluded 26 patients who died before postoperative neurologic status could be evaluated and 38 who had immediate neurologic deficit on initial postoperative evaluation, leaving 790 consecutive patients. We evaluated a wide range of demographic, preoperative physiological and intraoperative data, using univariate and multivariable statistical analyses. RESULTS: Twenty-one of 790 (2.7%) patients had delayed neurologic deficit. Significant univariate predictors included preoperative renal dysfunction (odds ratio 5.9; P <.006), acute dissection (odds ratio 3.9; P <.05), extent II thoracoabdominal aorta (odds ratio 3.0; P <.03), and use of adjuncts (cerebrospinal fluid drainage and distal aortic perfusion; odds ratio 7.7; P <.03). The use of the adjuncts dropped from the multivariable model but all other factors remained. No other significant risk factors were identified. Twelve of 21 (57%) patients recovered neurologic function with optimization of blood pressure and cerebrospinal fluid drainage. CONCLUSION: Preoperative renal dysfunction, acute dissection, and extent II thoracoabdominal aorta are significant predictors of delayed neurologic deficit. Previous studies have demonstrated that the use of adjuncts protects against immediate neurologic deficit. The findings of this study are consistent with the hypothesis that adjuncts reduce ischemic insult enough to prevent immediate neurologic deficit but that a period of increased spinal cord vulnerability persists several days postoperatively.     

Postoperative risk factors for delayed neurologic deficit after thoracic and thoracoabdominal aortic aneurysm repair: a case-control study

OBJECTIVE: Delayed neurologic deficit after thoracoabdominal or thoracic aortic repair is an unusual complication. We previously examined the preoperative risk factors associated with immediate neurologic deficit to consider their relationship to delayed neurologic deficit. In the current study we wanted to determine whether postoperative events influence the likelihood of delayed neurologic deficit, independent of preoperative risk factors. METHODS: We studied postoperative hemodynamics and cerebrospinal fluid (CSF) drain function in patients who had delayed neurologic deficit (cases) and those who did not (controls). Our database contains data for 854 patients with descending thoracic and thoracoabdominal aortic aneurysm. Cases and controls were identified with a random number generator to select controls in an approximate 4:1 ratio. We identified 18 cases and 67 controls. Further data were obtained from medical records. RESULTS: We found no differences between the groups with regard to oxygen transport abnormalities, eg, pneumothorax, repeat intubation, cardiac arrest, atrial or ventricular dysrhythmia, or dialysis. Significant differences between the groups were present for CSF drain complications (eg, kinks, blood in CSF): 6 of 18 (33%) in the case group versus 3 of 67 (4.5%) in the control group (P <.003). Wide fluctuation in mean arterial pressure (MAP) was significant (P <.02), mainly because of very low MAP in the cases (P <.006). When odds ratio was adjusted for preoperative risk factors of extent II thoracoabdominal aortic aneurysm, acute aortic dissection, and chronic aortic dissection, MAP less than 60 mm Hg and CSF drain complications produced the highest odds of delayed neurologic deficit. CONCLUSION: No single risk factor explained the onset of delayed deficit. Rather, a combination of factors, especially lowest MAP and drain complications, produced the highest odds of deficit. Vigilant optimization of hemodynamics and immediate correction of CSF drain malfunction may prevent development of delayed neurologic deficit.     

Surgical management of traumatic pulmonary injury

BACKGROUND: Surgical treatment of traumatic pulmonary injuries requires knowledge of multiple approaches and operative interventions. We present a 15year experience in treatment of traumatic pulmonary injuries. We hypothesize that increased extent of lung resection correlates with higher mortality. METHODS: Surgical registry data of a level 1 trauma center was retrospectively reviewed from 1984 to 1999 for traumatic lung injuries requiring operative intervention. Epidemiologic, operative, and hospital mortality data were obtained. RESULTS: Operative intervention for traumatic pulmonary injuries was required in 397 patients, of whom 352 (89%) were men. Penetrating trauma was seen in 371 (93%) patients. Location of the injuries was noted in the left side of the chest in 197 (50%), right side of the chest in 171 (43%), and bilateral in 29 (7%). Operative interventions included pneumonorraphy (58%), wedge resection or lobectomy in (21%), tractotomy (11%), pneumonectomy (8%), and evacuation of hematoma (2%). Overall mortality was 27%. If concomitant laparotomy was required, mortality increased to 33%. The mortality rate in the pneumonectomy group was 69.7%. CONCLUSIONS: The majority of lung injuries occurred in males due to penetrating trauma. Surgical treatment options ranged from simple oversewing of bleeding injury to rapid pneumonectomy. Mortality increased as the complexity of the operative intervention increased. Rapid intraoperative assessment and appropriate control of the injury is critical to the successful management of traumatic lung injury.     

Relationship between the chest radiograph, regional lung function studies, exercise tolerance, and clinical condition in cystic fibrosis

This study evaluated the accuracy of the interpretation of the chest film in delineating localised abnormalities of ventilation and perfusion, as well as the overall severity of airways obstruction, exercise tolerance, and clinical condition in children with cystic fibrosis. Radiographic findings in various regions of the chest film were compared with the functional values obtained with regional lung function tests which evaluated the arrival and disappearance of boluses of radioactive nitrogen given by inhalation and infusion. While the more severely affected areas on the chest radiograph were found to correlate with similar regions on the lung function tests, as did overall scores, errors occurred in some cases if the x-ray film alone was used as a judge of regional physiological derangement. In addition the degree of airways obstruction, the exercise tolerance on a cycle ergometer, and clinical grading, each correlated significantly with the radiographic score. We conclude that the chest radiograph is a good indicator of the overall severity of the lung disease and that it correlates well with exercise tolerance and clinical condition in cystic fibrosis.     

Hepatic scintigraphy in management of infants and children with liver disease

Scintiscans of liver and spleen using technetium 99m sulphur colloid in 15 infants with extrahepatic biliary atresia and 11 infants with severe obstructive jaundice (7 with genetic deficiency of alpha 1-antitrypsin) showed similar hepatic size, pattern of isotope uptake, and splenic abnormality with no distinguishing features. In 37 older children with a variety of liver disorders, the scan was invaluable in showing filling defects in five instances. Selenomethionine was taken up not only by the two filling defects due to hepatoblastoma but also in a haemangioendothelioma. In the remaining patiens liver scanning confirmed hepatic abnormality and the necessity for more specific invasive diagnostic investigations.