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Automatic Staplers and Bronchopleural Fistulas
pulmonary function tests to support this hypothesis, as decreased
vital capacity and total lung capacity could he due solely to
parenchymal lung disease. Measurement of transdiaphragmatic pressure would have been one way to further assess respiratory muscle function. Unfortunately our patients pulmonary function had normalized on therapy before the performance of this test could be arranged. The case reported by Drs. Braidy and Poulson demonstrates that respiratory muscle weakness does occur in adult onset Stills disease, as it does in other rheumatologic diseases. I Although the patient we described may represent another case of Stills disease with associated respiratory muscle dysfunction, the presence of parenchymal lung infiltrates decreases the specificity of the available data and therefore does not allow us to make this claim. john ~ Cantor; M.D. University ofCalifomialSan Diego Medical Center, San Diego Reprint requests: Dr. Cantor; 3008 Caminito Armoso, San Diego, 92117.
REFERENCE 1 Gibson GJ, Edmonds J~ Hughes GR~ Diaphragm function and lung involvement in systemic lupus erythematosis. Am J Med 1977; 63:926-32
Serious Complications of Flberoptic Bronchoscopy To the Editor: Fiberoptic bronchoscopy has assumed a major place in the evaluation of pulmonary disease, with low morbidity and rare mortality I Increasingly individuals seek to attribute untoward events surrounding diagnostic or therapeutic procedures to the procedure, lack of skill of the physician, or failure to adequately monitor the patient. We would like to report several would-be complications of fiberoptic bronchoscopy which we have seen during the past year. From 1984 to 1987, pulmonary physicians at the Naval Hospital/ Bethesda have performed over 1,500 diagnostic fiberoptic bronchoscopic examinations (with or without transbronchial biopsy), approximately three-fourths as outpatients, with no mortality or lifethreatening cardiovascular morbidity and no patient experienced myocardial infarction or stroke. In all cases supplemental oxygen was given, and in less than 5 percent was cardiac monitoring used. This experience differs from a recent recommendation that cardiac monitoring be used routinely during fiheroptic bronchoscopy 2 On the other hand, we have seen three patients who experienced life-threatening "complications" within 24 hrs prior to diagnostic bronchoscopy Twopatients developed myocardial infarction at home on the evening prior to the procedure, while one patient experienced a cerebral infarction with aphasia and hemiparesis in the waiting area prior to bronchoscopy While these events in themselves prove little, they accentuate the difficulty in attributing complications to physicians or diagnostic procedures. These events are frequently unavoidable, particularly in an elderly population with a background of heavy tobacco use and risk of generalized atherosclerosis. None of these patients had premonitory symptoms or unstable angina. We report this chance experience not to diminish the importance of peer review and cardiac monitoring in patients deemed at increased risk, but to remind the medical community of the vicissitudes and implications of guidelines to medical practice.
e
LCDR Ronald Sen, MC, USNR, and CAPT 1'homas E. Walsh, MC, USN, Naval Hospital/Bethesda Bethesda, Maryland 222
REFERENCES 1 Credle WF, Smiddy JF, Elliott RC. Complications of fiheroptic bronchoscopy Am Rev Respir Dis 1974; 109:67-72 2 Fulkerson WJ. Fiheroptic bronchoscopy N Eng) J Med 1984; 311;511-15 This opinion is solely that of the authors and does not reflect the officialopinion of the Naval Service, the Naval Medical Department, or the Department of Defense.
Alcoholism and Hypertension To the Editor: The "Management of resistent hypertension" by Bam' is a comprehensive evaluation of this facet of therapy One additional factor, however, was omitted from his discussion and merits consideration. The medical literature about the association of high blood pressure and chronic alcoholism admittedly is equivocal, but a recent personal study suggests that poor black alcoholic subjects have a 20 percent greater chance of acquiring hypertension than control subjects. 2 The relative risk of high blood pressure associated with alcoholism was 1.20 and the odds ratio was 1.23. Confidence levels were excellent in both calculations. When these values were subjected to chi-square analysis at a P value of o. 05 and one degree of freedom, they were fully acceptable. The study had an estimated 97 percent chance of detecting a 1.2 times increased association of hypertension with alcoholism. The routine investigation of all patients with hypertension should include an inquiry about alcoholism. Abstinence from alcohol alone may permit a reduction of elevated blood pressure in some subjects. Alcoholics may also find compliance with customary drug therapy more difficult because of their alcoholic addiction. Joseph M. Miller, M.D., Acting Director for Medical Education, Liberty Medical Center, Baltimore
REFERENCES 1 Ram CVS. Management of resistant hypertension. Chest 1987; 92:1096-97 2 Miller JM, Miller JM. Association of hypertension with chronic alcoholism. J Nat Med Assoc 1986; 78:391-93
To the Editor: I fully agree with Dr. Millers comment that alcoholism may be an important cause of resistance to antihypertensive therapy I also agree that, in the evaluation, an inquiry about alcoholism should be made. I am grateful to Dr. Miller for bringing up this important, potentially remediable factor. C.
S. Ram, M.D., F.C.C.P., Associate Professor; University ofTexas Health Science Center, ~nkata
Dallas
Automatic Staplers and Bronchopleural Fistulas To the Editor: It is with great interest that I read the article by Smiell and Widmann on "Bronchopleural fistulas after pneumonectomy: a problem with surgical stapling" (Chest 1987; 92:1056~ In this paper, Communications to the Editor
a report by Hakim and Milstein is mentioned as the only negat ive article on bronchial stapling. 1 We have also had negative experiences with the hinged stapling devices; these were also published in 1985. In our small series, we had three cases of bronchopleuraI fistulas in eight consecutive pneumonectomies, but none after lobectomies.' Before and after this period we used parallel firing staplers (fA and TA II 30, 4.8 mm staples). With these instruments, we performed more than 400 bronchial closures (more than 100 of them on main stem bronchi) without a single bronchopleural fistula. We therefore strongly support the recommendation of the authors that only parallel firing screw-down types of stapling devices should be used at the present time . Erich Moritz. M.D . . F.C.C .P.. Salzburg, Austria REFERENCES
Hakim M, Milstein BB. Role of automatic staplers in the etiology of bronc hopIeural fistula. Thorax 1985; 40:27-31 2 Moritz E, Eckersberger F. Endoskopische Klebung postoperativer Bronchusfisteln. Chirurg 1985; 56:125-27
Sarcoidosis and the Diaphragm
a patient on whom an autopsy examination showed asbestosis and sarcoidosis. We reviewed 19 diaphragmatic sections from 19 autopsy cases of multisystem sarcoidosis ; only one had noncaseating granulomas in the diaphragm. This cannot be considered as a true prevalence, particularly when one considers the 50 to 80 percent rate of granulomatous involvement of skeletal muscles. In diagnosis of asymptomatic sarcoidosis of muscle , many serial sections of a generous specimen are advisable because granulomas may be sparse and difficult to find. Discrepancies between subjective, radiologic and physiologic assessment in patients with sarcoidosis is frequently noted . It is not known at present if diaphragm involvement in sarcoidosis is a possible contributory factor in dyspnea in sarcoid patients. A prospective study is required to find out the true prevalence in diaphragm involvement and its possible clinical significance. The observation is. however, of some significance because diaphragmatic granulomas were observed in the patient who showed no dyspnea, tachypnea, or abnormality of diaphragmatic function ieg; Rutter or paradoxic movernent .) In cases where discrepancies between subjective, radiologic and physiologic assessment are noted , one should include the diaphragmatic involvement in the evaluation . Kamlesh P. fundya , M.D .; Edward C. Klatt, M.D ., and Om P. Shanna, M.D ., F.C.C.P., Pulmonary Division, University of Southern California Medical Center, Los Angeles
To the Editor:
In sarcoidosis, involvement of the diaphragm has rarely been mentioned. We report a case of systemic sarcoidosis in which noncaseating granulomas were found in the diaphragm. CASE REPORT
A 56-year-old man died of gastrointestinal bleeding. Autopsy showed a duodenal ulcer with a small blood vessel projecting from it. Microscopic examination revealed multiple noncaseating granulomata in lungs, lymph nodes, gastroesophageal junction, duodenum (from ulcer area), liver, spleen. bone marrow and diaphragm (Fig 1). Acid-fast bacilli and fungi stain results were negative . DISCUSSION
In view of affinity of sarcoidosis for skeletal muscles, it would not be surprising to find non-caseating granulomas in other muscles, including intercostal muscles and the diaphragm. I Still. diaphragmatic involvement in sarcoidosis has not been reported previously Diaphragmatic biopsies are not routinely obtained. nor is the examination of the diaphragm always included in autopsy studies. Skavlem et ai' briefly mentioned the diaphragmatic involvement in
.
'
-.
.
'
., ..
,
FIGURE 1. Section of diaphragm showing noncaseating granulomata.
REFERENCES
Sharma OP. Sarcoidosis: clinical management. London : Butterworths, 1984. 2 Skavlem JH, Ritterhoff RJ. Coexistent pulmonary asbestosis and sarcoidosis. Am J Pathol 1946; 22:493-99
Ring Calcification of Coronary Artery Aneurysms To the Editor:
We read with interest the article by Doi and colleagues (Chest 1987;92:1118-20)describing an adolescent with a ring of calcification in a coronary artery aneurysm. 1 We have been caring for a 10-year-old boy who was diagnosed in infancy as having infantile polyarteritis nodosa, which may be identical to Kawasaki disease.' Cardiac catheterization at 17 months of age demonstrated an aneurysm in the proximal anterior descending coronary artery. At six years of age, a 6 mm ring of calcification was noted on chest roentgenogram (Fig 1). Coronary angiography at 10 years of age confirmed that this calcification is in the wall of an aneurysm of the anterior descending coronary artery. There was mild diffuse disease of the distal branches of the left coronary artery. The proximal right coronary artery was completely obstructed, but the distal right coronary artery was opacified via collateral vessels. Both Dr. Dois patient and our patient had unusually severe coronary arteritis, as demonstrated by late obstruction of a coronary artery contralateral to the aneurysm. We agree that the plain chest roentgenogram should not be overlooked in following patients who had Kawasaki disease or infantile polyarteritis nodosa. Although it is difficult to draw conclusions from only two cases, a calcified coronary artery aneurysm may suggest severe coronary artery disease and warrant coronary angiography. CHEST I 94 I 1 I JULY, 1988
223
vital capacity and total lung capacity could he due solely to
parenchymal lung disease. Measurement of transdiaphragmatic pressure would have been one way to further assess respiratory muscle function. Unfortunately our patients pulmonary function had normalized on therapy before the performance of this test could be arranged. The case reported by Drs. Braidy and Poulson demonstrates that respiratory muscle weakness does occur in adult onset Stills disease, as it does in other rheumatologic diseases. I Although the patient we described may represent another case of Stills disease with associated respiratory muscle dysfunction, the presence of parenchymal lung infiltrates decreases the specificity of the available data and therefore does not allow us to make this claim. john ~ Cantor; M.D. University ofCalifomialSan Diego Medical Center, San Diego Reprint requests: Dr. Cantor; 3008 Caminito Armoso, San Diego, 92117.
REFERENCE 1 Gibson GJ, Edmonds J~ Hughes GR~ Diaphragm function and lung involvement in systemic lupus erythematosis. Am J Med 1977; 63:926-32
Serious Complications of Flberoptic Bronchoscopy To the Editor: Fiberoptic bronchoscopy has assumed a major place in the evaluation of pulmonary disease, with low morbidity and rare mortality I Increasingly individuals seek to attribute untoward events surrounding diagnostic or therapeutic procedures to the procedure, lack of skill of the physician, or failure to adequately monitor the patient. We would like to report several would-be complications of fiberoptic bronchoscopy which we have seen during the past year. From 1984 to 1987, pulmonary physicians at the Naval Hospital/ Bethesda have performed over 1,500 diagnostic fiberoptic bronchoscopic examinations (with or without transbronchial biopsy), approximately three-fourths as outpatients, with no mortality or lifethreatening cardiovascular morbidity and no patient experienced myocardial infarction or stroke. In all cases supplemental oxygen was given, and in less than 5 percent was cardiac monitoring used. This experience differs from a recent recommendation that cardiac monitoring be used routinely during fiheroptic bronchoscopy 2 On the other hand, we have seen three patients who experienced life-threatening "complications" within 24 hrs prior to diagnostic bronchoscopy Twopatients developed myocardial infarction at home on the evening prior to the procedure, while one patient experienced a cerebral infarction with aphasia and hemiparesis in the waiting area prior to bronchoscopy While these events in themselves prove little, they accentuate the difficulty in attributing complications to physicians or diagnostic procedures. These events are frequently unavoidable, particularly in an elderly population with a background of heavy tobacco use and risk of generalized atherosclerosis. None of these patients had premonitory symptoms or unstable angina. We report this chance experience not to diminish the importance of peer review and cardiac monitoring in patients deemed at increased risk, but to remind the medical community of the vicissitudes and implications of guidelines to medical practice.
e
LCDR Ronald Sen, MC, USNR, and CAPT 1'homas E. Walsh, MC, USN, Naval Hospital/Bethesda Bethesda, Maryland 222
REFERENCES 1 Credle WF, Smiddy JF, Elliott RC. Complications of fiheroptic bronchoscopy Am Rev Respir Dis 1974; 109:67-72 2 Fulkerson WJ. Fiheroptic bronchoscopy N Eng) J Med 1984; 311;511-15 This opinion is solely that of the authors and does not reflect the officialopinion of the Naval Service, the Naval Medical Department, or the Department of Defense.
Alcoholism and Hypertension To the Editor: The "Management of resistent hypertension" by Bam' is a comprehensive evaluation of this facet of therapy One additional factor, however, was omitted from his discussion and merits consideration. The medical literature about the association of high blood pressure and chronic alcoholism admittedly is equivocal, but a recent personal study suggests that poor black alcoholic subjects have a 20 percent greater chance of acquiring hypertension than control subjects. 2 The relative risk of high blood pressure associated with alcoholism was 1.20 and the odds ratio was 1.23. Confidence levels were excellent in both calculations. When these values were subjected to chi-square analysis at a P value of o. 05 and one degree of freedom, they were fully acceptable. The study had an estimated 97 percent chance of detecting a 1.2 times increased association of hypertension with alcoholism. The routine investigation of all patients with hypertension should include an inquiry about alcoholism. Abstinence from alcohol alone may permit a reduction of elevated blood pressure in some subjects. Alcoholics may also find compliance with customary drug therapy more difficult because of their alcoholic addiction. Joseph M. Miller, M.D., Acting Director for Medical Education, Liberty Medical Center, Baltimore
REFERENCES 1 Ram CVS. Management of resistant hypertension. Chest 1987; 92:1096-97 2 Miller JM, Miller JM. Association of hypertension with chronic alcoholism. J Nat Med Assoc 1986; 78:391-93
To the Editor: I fully agree with Dr. Millers comment that alcoholism may be an important cause of resistance to antihypertensive therapy I also agree that, in the evaluation, an inquiry about alcoholism should be made. I am grateful to Dr. Miller for bringing up this important, potentially remediable factor. C.
S. Ram, M.D., F.C.C.P., Associate Professor; University ofTexas Health Science Center, ~nkata
Dallas
Automatic Staplers and Bronchopleural Fistulas To the Editor: It is with great interest that I read the article by Smiell and Widmann on "Bronchopleural fistulas after pneumonectomy: a problem with surgical stapling" (Chest 1987; 92:1056~ In this paper, Communications to the Editor
a report by Hakim and Milstein is mentioned as the only negat ive article on bronchial stapling. 1 We have also had negative experiences with the hinged stapling devices; these were also published in 1985. In our small series, we had three cases of bronchopleuraI fistulas in eight consecutive pneumonectomies, but none after lobectomies.' Before and after this period we used parallel firing staplers (fA and TA II 30, 4.8 mm staples). With these instruments, we performed more than 400 bronchial closures (more than 100 of them on main stem bronchi) without a single bronchopleural fistula. We therefore strongly support the recommendation of the authors that only parallel firing screw-down types of stapling devices should be used at the present time . Erich Moritz. M.D . . F.C.C .P.. Salzburg, Austria REFERENCES
Hakim M, Milstein BB. Role of automatic staplers in the etiology of bronc hopIeural fistula. Thorax 1985; 40:27-31 2 Moritz E, Eckersberger F. Endoskopische Klebung postoperativer Bronchusfisteln. Chirurg 1985; 56:125-27
Sarcoidosis and the Diaphragm
a patient on whom an autopsy examination showed asbestosis and sarcoidosis. We reviewed 19 diaphragmatic sections from 19 autopsy cases of multisystem sarcoidosis ; only one had noncaseating granulomas in the diaphragm. This cannot be considered as a true prevalence, particularly when one considers the 50 to 80 percent rate of granulomatous involvement of skeletal muscles. In diagnosis of asymptomatic sarcoidosis of muscle , many serial sections of a generous specimen are advisable because granulomas may be sparse and difficult to find. Discrepancies between subjective, radiologic and physiologic assessment in patients with sarcoidosis is frequently noted . It is not known at present if diaphragm involvement in sarcoidosis is a possible contributory factor in dyspnea in sarcoid patients. A prospective study is required to find out the true prevalence in diaphragm involvement and its possible clinical significance. The observation is. however, of some significance because diaphragmatic granulomas were observed in the patient who showed no dyspnea, tachypnea, or abnormality of diaphragmatic function ieg; Rutter or paradoxic movernent .) In cases where discrepancies between subjective, radiologic and physiologic assessment are noted , one should include the diaphragmatic involvement in the evaluation . Kamlesh P. fundya , M.D .; Edward C. Klatt, M.D ., and Om P. Shanna, M.D ., F.C.C.P., Pulmonary Division, University of Southern California Medical Center, Los Angeles
To the Editor:
In sarcoidosis, involvement of the diaphragm has rarely been mentioned. We report a case of systemic sarcoidosis in which noncaseating granulomas were found in the diaphragm. CASE REPORT
A 56-year-old man died of gastrointestinal bleeding. Autopsy showed a duodenal ulcer with a small blood vessel projecting from it. Microscopic examination revealed multiple noncaseating granulomata in lungs, lymph nodes, gastroesophageal junction, duodenum (from ulcer area), liver, spleen. bone marrow and diaphragm (Fig 1). Acid-fast bacilli and fungi stain results were negative . DISCUSSION
In view of affinity of sarcoidosis for skeletal muscles, it would not be surprising to find non-caseating granulomas in other muscles, including intercostal muscles and the diaphragm. I Still. diaphragmatic involvement in sarcoidosis has not been reported previously Diaphragmatic biopsies are not routinely obtained. nor is the examination of the diaphragm always included in autopsy studies. Skavlem et ai' briefly mentioned the diaphragmatic involvement in
.
'
-.
.
'
., ..
,
FIGURE 1. Section of diaphragm showing noncaseating granulomata.
REFERENCES
Sharma OP. Sarcoidosis: clinical management. London : Butterworths, 1984. 2 Skavlem JH, Ritterhoff RJ. Coexistent pulmonary asbestosis and sarcoidosis. Am J Pathol 1946; 22:493-99
Ring Calcification of Coronary Artery Aneurysms To the Editor:
We read with interest the article by Doi and colleagues (Chest 1987;92:1118-20)describing an adolescent with a ring of calcification in a coronary artery aneurysm. 1 We have been caring for a 10-year-old boy who was diagnosed in infancy as having infantile polyarteritis nodosa, which may be identical to Kawasaki disease.' Cardiac catheterization at 17 months of age demonstrated an aneurysm in the proximal anterior descending coronary artery. At six years of age, a 6 mm ring of calcification was noted on chest roentgenogram (Fig 1). Coronary angiography at 10 years of age confirmed that this calcification is in the wall of an aneurysm of the anterior descending coronary artery. There was mild diffuse disease of the distal branches of the left coronary artery. The proximal right coronary artery was completely obstructed, but the distal right coronary artery was opacified via collateral vessels. Both Dr. Dois patient and our patient had unusually severe coronary arteritis, as demonstrated by late obstruction of a coronary artery contralateral to the aneurysm. We agree that the plain chest roentgenogram should not be overlooked in following patients who had Kawasaki disease or infantile polyarteritis nodosa. Although it is difficult to draw conclusions from only two cases, a calcified coronary artery aneurysm may suggest severe coronary artery disease and warrant coronary angiography. CHEST I 94 I 1 I JULY, 1988
223