Inflammatory abdominal aortic aneurysms: A case-control study

AbstractPurpose: This study was designed to identify significant differences in the clinical and radiologic characteristics and outcome between patients with inflammatory and noninflammatory abdominal aortic aneurysms (AAAs).Methods: We reviewed 29 consecutive patients who underwent repair of an inflammatory AAA between 1985 and 1994. This group was matched in a case-control fashion by date of surgery and by the performing surgeon to a group of 58 patients who underwent repair of noninflammatory AAAs.Results: The two groups had comparable characteristics of age, gender, and cardiovascular risk factors. Patients with inflammatory AAAs were significantly more symptomatic than those with noninflammatory AAAs (93% vs 9%, p < 0.001), were more likely to have a family history of aneurysms (17% vs 1.5%, p = 0.007), and tended to be current smokers (45% vs 24%, p = 0.049). Thi most significant laboratory difference was an elevated sedimentation rate in patients with inflammatory AAAs (mean, 53 mm/hr vs 12 mm/hr, p < 0.00001). Inflammatory AAAs also were significantly larger than noninflammatory AAAs at presentation (6.8 cm vs 5.9 cm, p < 0.05). Although operative mortality was low in both groups, patients with an inflammatory AAA tended to have higher morbidity, including sepsis ( p < 0.01) and renal failure ( p = 0.04). Five-year survival rates, however, were similar for the two groups (79% for inflammatory and 83% for noninflammatory AAAs). On follow-up computed tomographic scans, the retroperitoneal inflammatory process resolved completely in 53% of the patients, but 47% of patients had persistent inflammation that involved the ureters in 32% and resulted in long-term solitary or bilateral renal atrophy in 47%.Conclusions: This case-control study provides preliminary evidence that inflammatory AAAs may have a relatively strong familial connection and that current smoking may play an important role in the inflammatory response. The study also documents that persistent retroperitoneal inflammation may be more prevalent than has been previously reported, and stresses the need for an improved understanding of the pathogenesis and long-term management of inflammatory AAAs. (J Vasc Surg 1996;23:860-9.

Completely resected N1 non–small cell lung cancer: Factors affecting recurrence and long-term survival

ObjectiveN1 disease in non–small cell lung cancer represents a heterogeneous patient subgroup with a 5-year survival of approximately 40%. Few reports have evaluated the correlation between N1 disease and tumor recurrence or which subgroup of patients would most benefit from adjuvant chemotherapy.MethodsFrom 1997 through 2002, all patients with pathologic T1-4 N1 M0 non–small cell lung cancer who had a complete resection with systematic mediastinal lymphadenectomy were retrospectively analyzed and evaluated for factors associated with recurrence and long-term survival.ResultsOne hundred eighty patients with N1 disease were evaluated. Sixty-six (37%) patients had either locoregional recurrence (n = 39 [22%]), distant metastasis (n = 41 [23%]), or both during follow-up. Univariate analysis demonstrated that visceral pleural invasion and age were associated with locoregional recurrence, whereas visceral pleural invasion, distinct N1 metastasis (as opposed to direct N1 invasion by the primary tumor), and multistation lymph node involvement were associated with distant metastasis (P < .05). Multivariable analysis demonstrated that visceral pleural invasion, multistation N1 involvement, and distinct N1 metastasis were the only independent predisposing factors for locoregional recurrence and distant metastasis. Overall 5-year survival was 42.5%. Survival was significantly decreased by advanced pathologic T classification (P = .015), visceral pleural invasion (P < .0001), and higher tumor grade (P = .014).ConclusionsIn patients with N1-positive non–small cell lung cancer, visceral pleural invasion, multistation N1 disease, and distinct N1 metastasis are independent predictors of subsequent locoregional recurrence and distant metastasis. Advanced T classification, visceral pleural invasion, and higher tumor grade were predictors of poor survival. These patients represent a subgroup of patients with N1 disease who might benefit from additional therapy, including adjuvant chemotherapy

Reconstruction of the superior vena cava: Benefits of postoperative surveillance and secondary endovascular interventions

AbstractPurpose: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown. Methods: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted. Results: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively. Conclusions: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts. (J Vasc Surg 1998;27:287-301.

Results of reoperation on the upper esophageal sphincter

AbstractObjective: Reoperation on the upper esophageal sphincter is infrequent. We reviewed our experience in patients who underwent reoperation on the upper esophageal sphincter. Methods: This is a retrospective report of accumulative series from 2 separate institutions. Results: From September 1, 1976, to February 28, 1997, 37 patients underwent reoperation on the upper esophageal sphincter for recurrent or persistent obstructive symptoms. There were 29 men and 8 women. The median age was 69 years (range, 38-87 years). The original indication for the operation was a pharyngoesophageal (Zenker's) diverticulum in 33 patients (89.2%), oculopharyngeal dystrophy in 3 patients (8.1%), and muscular dystrophy in 1 patient (2.7%). One prior upper esophageal sphincter operation had been performed in 26 patients (70.3%), two operations in 9 patients (24.3%), and three operations in 2 patients (5.4%). All patients were symptomatic; 35 patients (94.6%) had dysphagia; 23 patients (62.2%) had regurgitation; and 12 patients (32.4%) had episodes of aspiration. Thirty of the patients (91.0%) with Zenker's diverticulum were found to have a recurrent or persistent diverticulum at reoperation. A diverticulectomy and cricopharyngeal myotomy were performed in 23 patients (62.2%); cricopharyngeal myotomy alone, in 7 patients (18.9%); diverticulopexy and cricopharyngeal myotomy, in 6 patients (16.2%); and diverticulectomy alone, in 1 patient (2.7%). There were no operative deaths. Complications developed in 10 patients (27.0%). Follow-up was complete in 34 patients (91.9%) and ranged from 2 to 149 months (median, 39 mo). Thirty-two patients (94.1%) were improved. Functional results were classified as excellent in 26 patients (76.5%), good in 2 patients (5.9%), fair in 4 patients (11.7%), and poor in 2 patients (5.9%). Conclusions: Reoperation for patients who have persistent or recurrent symptoms after an operation on the upper esophageal sphincter is associated with acceptable morbidity and mortality rates. Resolution of symptoms occurs in most patients. (J Thorac Cardiovasc Surg 1999;117:28-31

Surgical management of sternoclavicular joint infections

AbstractObjective: Sternoclavicular joint infections are rare, and their management is controversial. We reviewed our experience with the surgical management of this condition. Methods: From August 1988 to August 2001, 26 patients (16 men and 10 women) were treated surgically for infected sternoclavicular joints. The median age was 56 years (range, 20-77 years). Patients who had a recent previous median sternotomy were excluded. Results: All patients were symptomatic. Pain was present in 21 patients, swelling in 14 patients, fever in 11 patients, and erythema in 9 patients. Associated conditions included recent or ongoing infections in other areas in 12 patients (pneumonia in 4 patients, multiple joint infections in 2 patients, and other in 6 patients) and an indwelling central venous catheter in 1 patient. Five patients had a history of trauma in the region of the joint. Four patients had prior joint incision and drainage. Unilateral sternoclavicular joint resection was done in 18 patients, bilateral resection in 2 patients, and incision and drainage with debridement in 6 patients. Wound culture results were positive in 24 patients, and the most common organism isolated was Staphylococcus aureus (n = 17). Eleven patients had transposition of the ipsilateral pectoralis major muscle to obliterate residual space and to reconstruct the chest wall. Two (7.7%) patients had complications, and 1 died (operative mortality, 3.8%). Follow-up was complete in all 25 operative survivors and ranged from 2 months to 10 years (median, 25 months). Twenty-one patients are alive without symptoms, infection, or limitations in range of motion. Four patients have died as a result of causes unrelated to their joint infections. Conclusions: Symptomatic sternoclavicular joint infections often require surgical intervention. Surgical resection combined with muscle transposition provides effective long-term outcome.J Thorac Cardiovasc Surg 2003;125:945-