Faculty Bibliography

BACKGROUND: Resection of a mainstem bronchus with pulmonary preservation is a therapeutic option when disease is limited to the mainstem bronchus. We reviewed our experience with this procedure to determine the operative morbidity, mortality, and long-term outcome. METHODS: From January 1965 through January 1995, 22 patients (13 male, 9 female) underwent circumferential mainstem bronchial sleeve resection without removal of pulmonary parenchyma. Median age was 37 years (range, 12 to 70 years). The right mainstem bronchus was involved in 12 patients and the left, in 10. Nineteen patients (86%) were symptomatic; symptoms included cough in 5, dyspnea in 5, wheeze in 3, hemoptysis in 3, and a combination of these in 3. Conventional tomography was done in 8 patients and identified every lesion. Bronchoscopy was diagnostic in all patients. Resection was for cancer in 15 patients (68%), benign stricture in 5 (23%), and an impacted broncholith in 2 (9%). The cancer was a carcinoid in 9 patients, a mucoepidermoid carcinoma in 3, squamous cell carcinoma in 2, and adenoid cystic carcinoma in 1. Fourteen patients were postsurgically classified as stage IIIA (T3 NO MO) and 1 patient as stage IIIB (T4 N2 M0). The median length of the resected bronchus was 2.0 cm (range, 1.0 to 4.0 cm). Two patients required hilar release maneuvers. The bronchial anastomosis was reinforced with pleura in 10 patients, pericardium in 2, and serratus anterior muscle in 1. RESULTS: There were no operative deaths. Three patients (14%) had postoperative complications. Follow-up was complete and ranged from 6 months to 25.7 years (median follow-up, 10.2 years). Twenty-one patients are currently alive. All patients are asymptomatic except 1 patient, who required a stent for an anastomotic stricture. No patient has had recurrence of cancer. CONCLUSIONS: In properly selected patients, mainstem bronchial sleeve resection with lung preservation can be performed safely and provides excellent relief of symptoms with good long-term survival.

Between May 1983 and March 1, 1995, 50 patients had replacement of an obstructed pulmonary ventricle-pulmonary artery conduit with an autologous tissue reconstruction in which a prosthetic roof was placed over the fibrous tissue bed of the explanted conduit. The roof was constructed with xenograft pericardium (most recently) (n = 42), homograft dura mater (n = 5), or Dacron fabric (n = 3). Patient ages ranged from 5 to 34 years (median 16 years). The explanted conduits were Hancock conduits (n = 33), Tascon conduits (n = 6), homograft (n = 4), Dacron tube (n = 3), and others (n = 4). Preoperative maximum systolic gradients ranged from 44 to 144 mm Hg (median 78 mm Hg). Thirty-seven concomitant cardiac procedures were done in 29 patients. When a valve was necessary (n = 15), it was possible to place a large-sized valve in the autologous tissue reconstructions (range 22 to 29 mm, median 26 mm). Cardiopulmonary bypass times ranged from 34 to 223 minutes (median 84 minutes), and aortic crossclamp times ranged from 0 (in 32 patients) to 109 minutes (median 0 minutes). Intraoperative postrepair peak systolic gradients from pulmonary ventricle to pulmonary artery ranged from 0 to 33 mm Hg (median 13 mm Hg). There was one early death (2%) in a patient who had additional cardiac procedures. Follow-up was complete in all patients and ranged from 1 month to 11.8 years (median 7.5 years). There were two sudden late deaths: conduits in both were known to be free from obstruction. Forty-four of the 47 surviving patients had evaluation of the gradient by echocardiography or cardiac catheterization 1 month to 11 years (median 7 years) after operation. The gradients ranged from 5 to 45 mm Hg (median 20 mm Hg). None of the conduits developed an obstructive peel, valve obstruction, or valve incompetence. At 10 years, the freedom from reoperation for conduit obstruction was 100%, and freedom from reoperation for any cause was 81%. This technique simplifies conduit replacement, allows for a generous-sized outflow tract, has a low risk, and yields late results that appear superior to those of cryopreserved homografts or other types of extracardiac conduits.

OBJECTIVE: To present our experience with mediastinal parathyroid cysts and summarize previously reported cases. DESIGN: We retrospectively reviewed medical records and reviewed the pertinent literature. MATERIAL AND METHODS: The clinical, operative, and pathologic findings in 7 cases of mediastinal parathyroid cysts encountered at one institution and 31 cases previously reported in the literature are described. RESULTS: Rarely, cysts may arise from an aberrant mediastinal parathyroid gland. Such cysts may manifest as a symptomatic mass, as an asymptomatic finding on roentgenography, or during the assessment of a patient with hyperparathyroidism. The diagnosis may be made by fine-needle aspiration or by excision and pathologic examination. CONCLUSION: Functioning parathyroid cysts represent degeneration of a hyperfunctioning gland, such as an adenoma, and are usually removed through a cervical approach. Nonfunctioning cysts in asymptomatic patients with normal serum calcium levels are considered indeterminate and should be managed accordingly. Excision is usually recommended.

Between 1985 and 1993, 32 patients (24 male and 8 female) underwent colon interposition for replacement of the esophagus at the Mayo Clinic. Median age was 58.5 years (range, 1 to 79 years). The colon was used because of an inadequate stomach in 27 patients (84%) and as the conduit of choice in 5 (16%). Esophageal cancer was present in 15 patients (47%). The left colon was used in 20 patients (63%) and the right, in 12 (38%). The colon was placed substernally in 19 patients (59%) and in the esophageal bed in 13 (41%). The operative mortality was 9%; cause of death was ischemic necrosis of right colon conduits in 2 patients and adult respiratory distress syndrome in 1 patient. Major complications occurred in 4 additional patients and included ischemic colitis of a right colon conduit, Roux-en-Y limb obstruction, chylothorax, and an anastomotic leak. Follow-up was complete for all patients and ranged from 15 months to 7 years (median follow-up, 2.3 years). Eleven patients died during follow-up. The cause of death was metastatic esophageal cancer in 9 patients, myocardial infarction in 1 patient, and respiratory failure in 1 patient. At last follow-up, 26 of the 29 operative survivors had little or no difficulty eating. Two patients had dumping symptoms, and 1 patient had severe dysphagia. Seven patients required dilation of the esophagocolonic anastomosis. We conclude that colon interposition for esophageal replacement provides acceptable long-term function; however, early morbidity and mortality are considerable.

Between 1965 and 1989, 96 consecutive patients (64 men and 32 women) underwent complete pulmonary resection for metastatic renal cell carcinoma. Median age was 63 years (range, 33 to 82 years). Median time between nephrectomy and pulmonary resection was 3.4 years (range, 0 to 18.4 years). Forty-eight patients had solitary metastasis, 16 had two, 18 had three, and 14 had more than three. Wedge excision was performed in 62 patients, segmentectomy in 3, lobectomy in 25, bilobectomy in 3, and pneumonectomy in 3. Fourteen patients had repeat thoracotomy for recurrent metastasis; 34 other patients also had complete resection of limited extrapulmonary disease. There were no operative deaths. Median follow-up was 3 years (range, 70 days to 19.0 years). Overall 5-year survival was 35.9%. Patients with solitary metastasis had a 5-year survival of 45.6% compared with 27.0% for patients with multiple metastases (p < 0.05). Patients with a tumor-free interval greater than the median of 3.4 years had a better survival (p = 0.05) than those with a tumor-free interval less than or equal to 3.4 years. Five-year survival for patients who underwent repeat thoracotomy or had complete resection of extrapulmonary disease did not differ from overall survival. We conclude that resection of renal lung metastasis is safe and effective, that patients with solitary metastasis have a better survival than those with multiple metastases, that resectable extrapulmonary disease does not necessarily contra-indicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

We undertook a multi-institutional, retrospective study of 51 patients with adrenal tumors (pheochromocytomas, functioning and nonfunctioning cortical adenomas, cysts and carcinomas). All patients had computed tomography (CT) with a maximum of 5 millimeter cuts the week before undergoing complete adrenalectomy. Pathologists were asked to measure the tumor to the nearest 0.1 centimeter. Tumor size obtained from pathologic reports (actual size) and CT reports (estimated size) were compared. Adrenal tumors were divided into two groups on the basis of size--tumors with actual size of 6 centimeters or greater and tumors with actual size of less than 6 centimeters. Statistical analysis was performed with Newman-Keuls analysis of variance. After controlling for tumor type and for the institution at which the measurement was made, we found that CT consistently underestimated adrenal tumor size in both tumor groups. Moreover, the average, underestimated difference for tumors 6 centimeters or greater was 32 percent, but 47 percent for tumors less than 6 centimeters (p = 0.060). CT seemed to underestimate the size of small adrenal tumors more than large tumors. Because the decision to operate on solid, nonfunctioning adrenal tumors is based on tumor size and because CT is currently the standard technique used to estimate size, our findings need to be considered before undertaking surgical treatment.