Faculty Bibliography

BACKGROUND: Inflammatory pseudotumors of the lung are rare and often present a dilemma for the surgeon at time of operation. We reviewed our experience with patients who have this unusual pathology. METHODS: Between February 1946 and September 1993, 56,400 general thoracic surgical procedures were performed at the Mayo Clinic. Twenty-three patients (0.04%) had resection of an inflammatory pseudotumor of the lung. There were 12 women and 11 men. Median age was 47 years (range, 5 to 77 years). Six patients (26%) were less than 18 years old. All pathologic specimens were re-reviewed, and the diagnosis of inflammatory pseudotumor was confirmed. Eighteen patients (78%) were symptomatic which included cough in 12, weight loss in 4, fever in 4, and fatigue in 4. Four patients had prior incomplete resections performed elsewhere and underwent re-resection because of growth of residual pseudotumor. Wedge excision was performed in 7 patients, lobectomy in 6, pneumonectomy in 6, chest wall resection in 2, segmentectomy in 1, and bilobectomy in 1. Complete resection was accomplished in 18 patients (78%). Median tumor size was 4.0 cm (range, 1 to 15 cm). There were no operative deaths. Follow-up was complete in all patients and ranged from 3 to 27 years (median, 9 years). RESULTS: Overall 5-year survival was 91%. Nineteen patients are currently alive. Cause of death in the remaining 4 patients was unrelated to pseudotumor. The pseudotumor recurred in 3 of the 5 patients who had incomplete resection; 2 have had subsequent complete excision with no evidence of recurrence 8 and 9 years later. CONCLUSIONS: We conclude that inflammatory pseudotumors of the lung are rare. They often occur in children, can grow to a large size, and are often locally invasive, requiring significant pulmonary resection. Complete resection, when possible, is safe and leads to excellent survival. Pseudotumors, which recur, should be re-resected.

BACKGROUND: Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management. METHODS: An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H2O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H2O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. RESULTS: There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) (p = 0.005), increased age (p = 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) (p = 0.04), increased RV (p = 0.02), and an increased functional residual capacity (FRC) (p = 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients' ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. CONCLUSIONS: Most ALs after pulmonary resection are expiratory only. A low FEV1/FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment.

We present the transesophageal echocardiographic findings in two adult patients with right-sided aortic arch: one without dissection and the other with traumatic aortic injury (dissection). In both patients, the branching pattern was the left common carotid artery and then the right common carotid artery, followed by the right and left subclavian arteries. The technique for the diagnosis of this anomaly and the identification of adjacent vascular structures using contrast echocardiography is described. Three-dimensional reconstruction of the aortic arch also was performed in both patients.

OBJECTIVE: To identify the possible cause(s) of hemolysis after mitral valve repair for mitral regurgitation (MR) and to evaluate the late outcome of surgical treatment. METHODS: We reviewed all patients who had reoperation after valve repair for mitral regurgitation. Ten patients had reoperation because of hemolytic anaemia. The diagnosis of hemolysis was made by decreased serum haptoglobin, elevation of serum lactate dehydrogenase (LDH), and schistocytosis. No other causes of anaemia or hemolysis were identified in these six men and four women (ages 35-84 years; median 59 years). Interval between initial mitral valve repair and reoperation ranged from 40 to 165 days (median 87 days), and prior to reoperation, red cell transfusions (range 2-12 units; median 5 units) were required in all patients. Seven patients were symptomatic: two complained of easy fatigability and five were severely limited. Transesophageal echocardiogram during hemolytic evaluation showed only mild MR in two patients, moderate in five, moderately severe in two and severe in one. RESULTS: Etiology of hemolysis was suggested from echocardiography and confirmed at reoperation. In one patient, an eccentric MR jet struck a pledget of a commissural annuloplasty. In the remaining nine patients, the regurgitant jet struck a non-endothelialized portion of the annuloplasty ring (Carpentier-Edwards n = 5; Duran n = 2; Cosgrove-Edwards n = 2). Seven patients had prosthetic replacement and three patients had re-repair. There were no operative deaths and all patients had resolution of hemolytic anaemia. CONCLUSIONS: Relatively minor degrees of regurgitation after mitral valve repair can produce hemolytic anaemia which is manifested within the first few postoperative months. Most patients are highly symptomatic because of anaemia. The mechanism of red cell destruction is a high velocity eccentric stream of blood impacting on a small area of a prosthetic ring or pledget. This process retards endothelialization of the ring. Reoperation with re-repair or mitral valve replacement is safe and effectively relieves the hemolysis.