D ow naded rom http/academ ic.p.com /ejcts/articlect/30/2/412/362437 idea as Roth et al. [1] that thymectomy before the pregnancy can improve the evolution of MG during the pregnancy. The most important limitation of the study of Roth et al. [1] is the sample size and due to the unpredictable course of myasthenia gravis during pregnancy the observation about a better prognosis in thymectomizedmothers could be obtained only by chance. The second observation in this study about a better prognosis in babies of mothers with myasthenia gravis should be taken carefully. The prevalence of transient neonatal myasthenia gravis is highly variable in reports, going from 5 to 30% and mainly explained by the different methods to perform the diagnosis but potentially a genetic variation has been suggested [5]. In the study by Roth et al. [1], two newborns had symptoms after the delivery and both belonged to the nonthymectomized group of mothers. Again this observation could be derived only due to the small sample size of the study and not related directly with thymectomy status of the mother. Overall, this study has an interesting observation but more investigation is required.

Background. We have previously shown that intraoperative brachytherapy decreases the local recurrences associated with sublobar resections for small stage la nonsmall-cell lung cancer (NSCLC). In this report, we present the outcomes of sublobar resection with brachytherapy compared with lobectomy in patients with stage Ib tumors.Methods. We retrospectively reviewed 167 stage Ib NSCLC patients: 126 underwent lobectomy and 41 sublobar resection with (125) I brachytherapy over the resection staple line. Endpoints were perioperative outcomes, incidence of recurrence, and disease-free and overall survival.Results. Patients undergoing sublobar resections had significantly worse preoperative pulmonary function. Hospital mortality, nonfatal complications, and median length of stay were similar in the two groups. Median follow-up was 25.1 months. Local recurrence in sublobar resection patients was 2 of 41 (4.8%), similar to the lobectomy group: 4 of 126 (3.2%; p = 0.6). At 4 years, both groups had equivalent disease-free survival (sublobar group, 43.0%; median, 37.7 months; and lobectomy group, 42.8%; median 41.8 months, p = 0.57) and overall survival (sublobar group, 54.1%; median, 50.2 months; and lobectomy group, 51.8%; median, 56.9 months; p = 0.38).Conclusions. Sublobar resection with brachytherapy reduced local recurrence rates to the equivalent of lobectomy in patients with stage Ib NSCLC, and resulted in similar perioperative outcomes and disease-free and overall survival, despite being used in patients with compromised lung function. We recommend the addition of intraoperative brachytherapy to sublobar resections in stage Ib patients who cannot tolerate a lobectomy.

BACKGROUND:The left internal thoracic artery is the ideal conduit for coronary artery revascularization due to superior patency compared with venous grafts. The hemodynamic effects of an arterio-venous fistula on the native in situ internal thoracic artery and the potential for coronary flow steal after revascularization with the internal thoracic artery, are not well-characterized.METHODS:Fifteen chronic hemodialysis patients with functioning left upper extremity arterio-venous fistulas were evaluated with the use of transthoracic color Doppler analysis. Flow characteristics of the left and right internal thoracic arteries at baseline, with arterio-venous fistula occluded, and during hemodialysis were recorded. Peak systolic and diastolic velocities for the right and left internal thoracic arteries were calculated for each fistula state (occluded, open, and on-dialysis). One-way analysis of variance was used to compare the different means.RESULTS:Mean flow velocity calculations failed to identify any statistically significant differences between the ipsilateral and contralateral internal thoracic artery in any fistula state. In addition, mean internal thoracic flow velocities were similar between the different fistula states.CONCLUSIONS:Changes in arteriovenous fistula flow state did not significantly alter Doppler flow hemodynamics of either the ipsilateral or contralateral in-situ internal thoracic artery. Further studies of the possible effects on internal thoracic arteries used as pedicled coronary grafts may be required.

Background. Coronary artery disease represents a significant cause of morbidity and mortality in patients with connective tissue disease. Few reports exist on the results of surgical management of coronary artery disease in these patients.Methods. The medical records of patients with connective tissue diseases who underwent coronary artery bypass grafting at our institution between 1995 and 2002 were reviewed for demographic data, perioperative variables, and postoperative complications. The results were compared with data from The Society of Thoracic Surgeons database.Results. Forty-four patients were identified from a total of 5,496 cases during the study period (0.8%). There were 35 patients with rheumatoid arthritis, 8 with systemic lupus erythematosus, and 1 with scleroderma. Patients with connective tissue diseases were more likely to be women and use immunomodulating agents. They also had a higher incidence of Canadian Cardiovascular Society class IV angina, need for inotropic agents, need for intraaortic balloon pulsation, use of blood transfusions, and leg wound infections. The use of steroids or other immunomodulating agents was associated with increased postoperative complications. Mean follow-up was 35 months. The overall survival and freedom from reintervention at 3 years were 89% and 75%, respectively.Conclusions. Coronary artery bypass grafting is a safe treatment modality in patients with connective tissue diseases, with acceptable early results. Wound complications may be a problem in this patient population. Midterm results are less favorable, and reinterventions are frequently required. © 2005 by The Society of Thoracic Surgeons.

OBJECTIVES:Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS:Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS:There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS:Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.

BACKGROUND:Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair.METHODS:We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test.RESULTS:A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months.CONCLUSION:LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.

Objective: Deep vein thrombosis (DVT) represents a major cause of morbidity in surgical patients. Controversial reports exist on the incidence of DVT in burn patients. We report our experience over a 10-year period. Methods: Patients admitted to our Burn Unit over the period 1991-2001 and diagnosed with DVT were identified. Their records were retrospectively reviewed for demographic factors, extent and severity of burn injury and outcome. Results: A total of 4102 patients were admitted to the WPH Burn unit during the study period. All patients received routine subcutaneous heparin prophylaxis. Ten patients were diagnosed with DVT (0.25%). Compared to our total burn population, these patients were older (mean age 47 +/- 22.7 years versus 35 +/- 22 years P = 0.14) and had more extensive burns (mean total body surface area (TBSA) 34.7 +/- 25.3% versus 12 +/- 15.7% P = 0.02). Two patients developed non-fatal pulmonary embolism (PE). There were three deaths, none due to thromboembolic disease. There were no complications from the routine administration of subcutaneous heparin. Conclusion: The incidence of DVT in our study is much less than the incidence reported in other critically ill patients and less than that of most reports on burn patients. In our experience, routine heparin prophylaxis is effective for the prevention of DVT in burn patients. (C) 2004 Elsevier Ltd and ISBI. All rights reserved.

INTRODUCTION: Aortobronchial fistula is a rare but frequently lethal cause of hemoptysis. The most common causes are expanding descending thoracic aortic aneurysm, previous aortic surgery or neoplasm.

Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. Management can be quite challenging, as surgical intervention other than tube thoracostomy poses significant risks. We report a case of spontaneous pneumothorax that did not resolve with conventional management, necessitating thoracoscopic bleb resection with the use of cardiopulmonary bypass.

Background: The effectiveness of gastric conduit construction using hand-aasisted laparoscopic surgery (HALS) for esophageal cancer was objectively evaluated.Methods: Twentytwo patients underwent radical esophagectomy, among whom the construction of a gastric conduit was performed by HALS in 12 patients and by open surgery in 10.We evaluated the operative time, blood loss, number of resected abdominal lymph nodes, duration of postoperative ventilatory support, duration of bed stay, postoperative respiratory function and complications.Results: In the HALS group, operative time during the abdominal phase was 120 min, which was significantly longer than that in the Open group at 77 rain (p=0.0009).However, the former data also include early cases when the procedure was not yet totally mastered.In the last 5 cases, the mean operative time was 103 min which was significantly shorter than that in the initial 5 cases, at 136 rain (p = 0.028).No significant differences were noted between the two groups in blood loss during the abdominal phase, number of resected abdominal lymph nodes, duration of ventilatory support or duration of bed stay.On day 7 after surgery, forced vital capacity (VC) was 74 % of the preoperative value in the HALS group which was significantly lower than that in the open group at 46 % (p = 0.002).On day 30 after surgery, however, VC recovered in the Open group to almost the same level as in the HALS group.On day 7 after surgery, forced expiratory volume in one second (FEV1.0)value was also signiflcamly lower than in the Open group at 49 %, as compared to the HALS group at 72 % (p = 0.002), but on day 30, there was no difference between the two groups.In 3 patients of the Open group, severe respiratory complications including pneumonia, pulmonary edema were recognized, but no such complications were found in any cases of the HALS group.Conclusion: We believe that construction of a gastric conduit using HAL S enables the same level of surgery as obtained by open surgery.Not only does it preserve respiratory function by reducing pain, and reducing respiratory complications, it also makes early recovery possible, and is effective in improving quality of life after surgery.

Steal syndrome is a well-known complication of arteriovenous (AV) access placement. To assess the derangement in hemodynamics of the upper extremity after AV access creation, brachial and digital pressures were performed before and after operation. Thirty-five patients (ages 20-88 years) with end-stage renal disease requiring new upper extremity hemodialysis AV access were prospectively evaluated. Values were obtained preoperatively, on the day of surgery, and 1 month postoperatively. Follow-up at 1 year was obtained on all patients. Of the 35 patients, 19 (54%) were diabetic and 9 (26%) had had a prior AV access. The AV accesses created included the following: autogenous brachial-cephalic (n = 14, 40%), autogenous radialcephalic (n = 10, 29%), brachial-basilic transposition (n = 5, 14%), prosthetic brachial-antecubital forearm loop (n = 3, 9%), autogenous brachial-axillary saphenous vein translocation (n = 2, 6%), and 1 (3%) prosthetic brachial-axillary. After AV access creation the digital brachial index (DBI) dropped in 28 (80%) of the 35 patients. Six patients (17%) developed a symptomatic steal, 3 of which (9%) eventually required revision. In those patients without ischemic steal symptoms (n = 29) the mean DBI decreased from 0.9 to 0.7 (p < 0.01) immediately and decreased no further at 1 month. For those with a symptomatic steal the DBI decreased from 0.8 to 0.4 (p < 0.01) immediately and decreased no further at 1 month. Utilizing a DBI less than 0.6, the sensitivity was 100%, the specificity 76%, the positive predictive value 46%, and the negative predictive value 100%. Hemodynamic steal after AV access creation is very common, with symptomatic steal occurring nearly a fifth of the time. Utilizing digital pressure measurements, a DBI less than 0.6 obtained on the day of surgery can reasonably predict which patients are at risk for the development of a symptomatic steal.