Faculty Bibliography

This case report presents the unusual characteristics of a neuroendocrine thymic carcinoma that probably has metastasized to the left side of the interatrial septum from a primary thymic site.

Small pleural effusions that cannot be assessed by thoracentesis prior to surgery may represent a diagnostic challenge in the patient with a resectable, non-small cell cancer of the lung. Even if the effusion is drained preoperatively and analyzed, the cytology may be falsely negative. We have found that careful inspection of pleural effusions using a single small 2-cm incision and video-assisted thorascopy may reveal a gelatinous piece of clotlike material that resembles a jellyfish. This cohesive particulate piece of material lies in the effusion. This material can be sent for frozen section (unlike cytologic exams in most hospitals), and an immediate answer can be obtained. Cytology results of the surrounding effusion that return 24 hours later confirm the frozen section findings. If malignant, this avoids thoracotomy and pulmonary resection in a patient with unsuspected T4, stage IIIB lung cancer. It also avoids closing a patient with an unsuspected effusion and having to wait 24 hours for the cytology results. We review our experience with this jellyfish-like material.

OBJECTIVE: We streamlined our care after pulmonary resection for quality and cost-effectiveness. METHODS: A single surgeon performed 500 consecutive pulmonary resections through a thoracotomy over a 2(3/4)-year period in a university setting. Patients were extubated in the operating room and sent directly to their hospital room. Chest tubes were placed to water seal and removed on postoperative day 2 if there was no air leak and drainage was less then 400 mL/d. Epidural catheters were used and removed by postoperative day 2. The plan for each day and discharge on postoperative day 3 or 4 was reviewed with the patients and families daily during rounds. The patient went home the day the last chest tube was removed. Persistent air leaks were treated with Heimlich valves. RESULTS: There were 500 patients (338 men), with a median age of 58 years (range, 3-87 years). Of these patients, 293 had pre-existing conditions. Seventy-three (15%) patients had been denied operations by at least one other surgeon. Four hundred nineteen (84%) patients had successful placement of a functioning preoperative epidural catheter. Pneumonectomy was performed in 32 (6%) patients, segmentectomy was performed in 16 (3%) patients, and lobectomy, sleeve lobectomy, and/or bilobectomy was performed in 194 (39%) patients. Nonanatomic resections were performed for metastasectomy. This included a single wedge resection in 161 (32%) patients and multiple wedge resections in 97 (19%) patients. A total of 482 (96%) patients were extubated in the operating room, and 380 (76%) patients were sent to their hospital room. The remaining 120 patients went to the intensive care unit for a median of 1 day (range, 1-41 days). Complications occurred in 107 (21%) patients, and operative mortality was 2.0%. Median day of discharge was postoperative day 4 (range, 2-119 days). A total of 327 (65%) patients left the hospital on postoperative day 4 or sooner. By survey, 97% of patients had excellent or good satisfaction with their care at hospital discharge, and 91% were extremely happy or satisfied at the 2-week follow-up contact. CONCLUSIONS: Most patients who undergo elective pulmonary resection can be extubated immediately after the operation, go directly to their room and avoid the intensive care unit, be discharged on postoperative day 3 or 4, and have minimal morbidity and mortality with high satisfaction both at discharge and at the 2-week follow-up contact. Techniques that seem to accomplish this include the following: the use of a water seal, removal of epidural catheters on postoperative day 2, early chest tube management, treatment of persistent air leaks with Heimlich valves, and daily reinforcement of the planned events for each day, as well as on the date of discharge with the patients and their families.