Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk factors, and clarified the relationship between postoperative AKI and outcome in patients undergoing lung resection surgery.
A retrospective, observational study of patients who underwent lung resection surgery between January 2006 and March 2010 in a tertiary care academic center was conducted. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network creatinine criteria. Logistic regression was used to model the association between perioperative factors and the risk of AKI within 72 hours after surgery. The relationship between postoperative AKI and patient outcome including mortality, days in hospital, and the requirement of reintubation was investigated.
A total of 1129 patients (pneumonectomy n = 71, bilobectomy n = 30, lobectomy n = 580, segmentectomy n = 35, wedge resection/bullectomy n = 413) were included in the final analysis. Patients were an average of 61 years (SD 15) and 50% were female. AKI was diagnosed in 67 patients (5.9%) based on Acute Kidney Injury Network criteria (stage 1, n = 59; stage 2, n = 8; and stage 3, n = 0) within 72 hours after surgery, and only 1 patient required renal replacement therapy. Multivariate analysis demonstrated an independent association between postoperative AKI and hypertension (adjusted odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.1-3.8), peripheral vascular disease (OR 4.4, 95% CI: 1.8-10), estimated glomerular filtration rate (OR 0.8, 95% CI: 0.69-0.93), preoperative use of angiotensin II receptor blockers (OR 2.2, 95% CI: 1.1-4.4), intraoperative hydroxyethyl starch administration (OR 1.5, 95% CI: 1.1-2.1), and thoracoscopic (versus open) procedures (OR 0.37, 95% CI: 0.15-0.90). Development of AKI was associated with increased rates of tracheal reintubation (12% vs 2%, P
Palmar, axillary, and plantar hyperhidrosis is often socially, emotionally, and physically disabling for adolescents. The authors report surgical outcomes in all adolescents treated for palmar hyperhidrosis via bilateral thoracoscopic sympathectomy at the Barrow Neurological Institute by the senior author.
A prospectively maintained database of all adolescent patients undergoing bilateral thoracoscopic sympathectomy between 1998 and 2006 (inclusive) was reviewed. Additional follow-up was obtained as needed in clinic or by phone or written questionnaire.
Fifty-four patients (40 females) undergoing bilateral procedures were identified. Their mean age was 15.4 years (range 10-17 years). Average follow-up was 42 weeks (range 0.2-143 weeks). Hyperhidrosis involved the palms alone in 10 patients; the palms and axilla in 6 patients; the palms and plantar surfaces in 17 patients; and the palms, axilla, and plantar surfaces in 21 patients. Palmar hyperhidrosis resolved completely in 98.1% of the patients. Resolution or improvement of symptoms was seen in 96.3% of patients with axillary and 71.1% of those with plantar hyperhidrosis. Hospital stay averaged 0.37 days with 68.5% of patients discharged the day of surgery. One patient experienced brief intraoperative asystole that resolved with medications and had no long-term sequelae. Otherwise, no serious intraoperative complications occurred. No patient required chest tube drainage. The percentage of patients who reported satisfaction and willingness to undergo the procedure again was 98.1%.
Biportal, bilateral thoracoscopic sympathectomy is an effective and low-morbidity treatment for severe palmar, axillary, and plantar hyperhidrosis.
Since the fall of 1999, a new endemic focus of Cryptococcus gattii serotype B infection has emerged on Vancouver Island (Victoria, British Columbia), with infections occurring in both animals and humans. In the human cases, symptoms have manifested as pulmonary nodules, meningitis or both. This organism has added a new nonmalignant cause of pulmonary nodules to the literature, resulting in a change in the management of these nodules by health care professionals.
A search of the number of cases recorded and treated in hospitals of the Vancouver Island Health Authority, along with a review of the literature regarding this emerging organism, was undertaken. The pathology, epidemiology and clinical course of this previously uncommon fungus was determined, and representative cases were chosen for illustration.
More than 130 cases were recorded in the six-year period from late 1999 to mid-July 2006. The number of cases increased steadily over this period, but appears to be levelling off. Representative cases with medical imaging, along with photos of the pathology, are included. Recommendations for diagnosis, treatment and follow-up are outlined.
The emergence of cryptococcal lung and central nervous system lesions on Vancouver Island have made it important to include travel to or residence of the island as part of the history in patients with pulmonary nodules. A registry of patients from Vancouver Island has been established, and it may be of value to include nonisland patients who are found to be infected with this organism.
To assess the diagnostic accuracy and the safety of medical thoracoscopy (MT) performed with the semirigid thoracoscope.
We retrospectively evaluated patients who underwent MT with semirigid thoracoscope under local anesthesia for unexplained exudative pleural effusion from March 1, 2009 to September 1, 2013 in Denmark.
Sixty-nine patients were retrospectively studied. In 13 patients it was not possible to perform the scheduled MT, in 9 cases due to an insufficient pneumothorax, in 3 due to an insufficient pleural effusion, and in 1 due to a purulent pleuritis. In 56 patients in whom MT was completed, the procedure was diagnostic in 44 cases: malignancy was reported in 26 patients and a benign diagnosis in 18. In the remaining 12 patients a definite diagnosis was not reached, and further testing was required.In an "intention-to-treat analysis" (69 patients in total), the diagnostic accuracy of MT was 63%, the sensitivity for malignancy was 59% [95% confidence interval (CI)=43%-73%], the specificity was 100% (95% CI=86%-100%), and the negative likelihood ratio was 0.41 (95% CI=0.29-0.58). Considering the 56 patients in whom it was possible to complete the procedure, the diagnostic accuracy was 78%, the sensitivity for malignancy was 74% (95% CI=54%-87%), the specificity was 100% (95% CI=83.75%-100%), and the negative likelihood ratio was 0.27 (95% CI=0.15%-0.45%). No mortality was reported.
MT performed under local anesthesia with a semirigid scope is a simple and safe procedure with an acceptable sensitivity for malignancy.
BACKGROUND: Current guidelines for interstitial lung disease support a surgical biopsy for optimal diagnosis and treatment, yet only a minority of patients undergo such biopsy. Our objectives were to address the properties of a surgical lung biopsy for suspected interstitial lung disease, the diagnostic yield of the procedure, and whether it resulted in changes in diagnosis and treatment. METHODS: A retrospective nationwide study including 73 patients (mean age, 57.3 years; 58% males) who underwent a surgical lung biopsy for suspected interstitial disease in Iceland between 1986 and 2007 was conducted. Patient records and histologic specimens were reviewed. Before the surgical biopsy a transbronchial or computed tomography-guided biopsy had been performed in two thirds of the patients. RESULTS: The complication rate for surgical lung biopsy was 16%, and 30-day operative mortality was 2.7%, both significantly higher in patients with preoperative respiratory failure. After the procedure, a definite histopathologic diagnosis was obtained in 81% of the patients. Usual interstitial pneumonia was the most common diagnosis (31%). The clinical diagnosis was changed for 73% of the patients, and in 53% of the patients the biopsy resulted in changes in treatment. CONCLUSIONS: Surgical lung biopsy is a powerful tool for diagnosis of suspected interstitial lung disease. It results in a specific diagnosis for the majority of patients and changes in treatment for more than half. Operative morbidity and mortality are low but still significant, so patients should be carefully selected for the procedure, especially those with respiratory failure.
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Comment In: Ann Thorac Surg. 2009 Jul;88(1):23219559231
The incidence of thoracic empyema is increasing. Early treatment of empyema should focus on optimal drainage and antibiotics. If conventional therapy fails, surgical intervention has to be considered and approximately 30% of all patients require surgery. In a three-year period (2011-2013), 182 patients were operated at Helsinki University Hospital due to pleural empyema. Thoracoscopic decortication was performed on 44% of the patients and 56% underwent open surgery. After thoracoscopy, the patients had a shorter hospital stay and fewer reoperations. Thoracoscopic decortication should therefore be the first-line procedure in the surgical treatment of pleural empyema.
The necessity for thoracoscopy became apparent with the adhesions that limited the success of Forlanini's introduction in 1882 of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. Thoracoscopy and division of adhesions (intrapleural pneumonolysis) then spread all over the world, with reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new explosion of thoracoscopic surgery. Surgeons, in whose hands the procedure now rests, should nevertheless be aware of the five unacceptable thoracoscopic disasters--wrong side, kebab lung, "clotted hemothorax," artificial lunchothorax, and aorto-pleuro-cutaneous fistula.
[Main results of implementation of the special research program "Development and introduction of rapid methods of diagnosis and early detection of tuberculosis, novel technologies in the treatment of patients with tuberculosis in various sites and reliable means for improving control of tuberculosis epidemiology", 1996-2000].
