Studies suggest that screening with spiral computed tomography can detect lung cancers at a smaller size and earlier stage than chest radiography can. To evaluate low-radiation-dose spiral computed tomography and sputum cytology in screening for lung cancer, we enrolled 1,520 individuals aged 50 yr or older who had smoked 20 pack-years or more in a prospective cohort study. One year after baseline scanning, 2,244 uncalcified lung nodules were identified in 1,000 participants (66%). Twenty-five cases of lung cancer were diagnosed (22 prevalence, 3 incidence). Computed tomography alone detected 23 cases; sputum cytology alone detected 2 cases. Cell types were: squamous cell, 6; adenocarcinoma or bronchioalveolar, 15; large cell, 1; small cell, 3. Twenty-two patients underwent curative surgical resection. Seven benign nodules were resected. The mean size of the non-small cell cancers detected by computed tomography was 17 mm (median, 13 mm). The postsurgical stage was IA, 13; IB, 1; IIA, 5; IIB, 1; IIIA, 2; limited, 3. Twelve (57%) of the 21 non-small cell cancers detected by computed tomography were stage IA at diagnosis. Computed tomography can detect early-stage lung cancers. The rate of benign nodule detection is high.

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Between July 1987 and May 1995, 11,315 patients underwent general thoracic surgical procedures at our institution. In 47 of these patients (0.42%), postoperative chylothorax developed. There were 32 men and 15 women with a median age of 65 years (range 21 to 88 years). Initial operation was for esophageal disease in 27 patients, pulmonary disease in 13, mediastinal mass in six, and thoracic aortic aneurysm in one. All patients were initially treated with hyperalimentation, cessation of oral intake, medium chain triglyceride diet, or a combination. Nonoperative therapy was successful in 13 cases (27.7%), and oral intake was resumed a median of 7 days later (range 2 to 15 days). Reoperation was required in the remaining 34 cases. The reoperation rate varied according to the type of initial operation. Twenty-four of the 27 patients (88.9%) who had undergone an esophageal operation required reoperation, versus only five of 13 patients (38.5%) who had undergone pulmonary resection (p < 0.001). Lymphangiography was performed in 16 patients and identified the site of the leak in 13. The thoracic duct was ligated in 32 of the 34 patients who required reoperation (94%). The remaining two patients were treated with mechanical pleurodesis and fibrin glue. Reoperation was successful in 31 of the 34 patients (91.2%). The single death among the 47 patients (2.1%) occurred in the reoperated group. Complications occurred in 18 patients (38.3%). Factors that predicted the need for reoperation were initial esophageal operation and average daily postoperative drainage greater than 1000 ml/day for 7 days. We conclude that postoperative chylothorax is an infrequent complication. Some cases can be managed without operation; however, we recommend early reoperation when drainage is greater than 1000 ml/day or if the chylous fistula occurs after an esophageal operation. The fistula can usually be controlled by ligation of the thoracic duct.

Our experience with 500 consecutive chest-wall reconstructions over the past 18 years is reviewed. Of the 500 patients, 286 were male and 214 were female. Their ages ranged from 1 day to 85 years (average 55 years). Among the patients, 275 had chest-wall tumors, 142 had infected median sternotomies, 119 had radiation necrosis, and 121 had combinations of the three. Skeletal resection of the chest wall was done in 443 patients. An average of 3.9 ribs were resected in 241 patients. Total or partial sternectomies were performed in 231 patients. Four-hundred and seven patients underwent 611 muscle flaps: 355 pectoralis major, 141 latissimus dorsi, and 115 others, including serratus anterior, rectus abdominis, and external oblique. The omentum was transposed in 51 patients. Chest-wall skeletal defects were closed with polytetrafluoroethylene soft-tissue patch in 116 patients, polypropylene mesh in 55, and autogenous rib in 13. The 500 patients underwent an average of 2.3 operations. Hospitalization averaged 21 days. There were 15 perioperative deaths. Twenty-three patients required tracheostomy. The average duration of follow-up was 57 months. There were 229 late deaths; the cause of death was cancer in 147 patients, cardiac in 49, pulmonary in 7, and other in 26. Four-hundred and three of the 485 patients (83.1 percent) who were alive 30 days after the operation had excellent results and had a healed, asymptomatic chest wall at the time of death or last follow-up. We conclude that chest-wall reconstruction is safe, durable, and associated with long-term survival.

The cause of splenic artery aneurysms and the indications for their treatment remain controversial. Splenic artery aneurysms occur more frequently in women and are associated with pregnancy and multiparity. Whether arteriosclerosis is the cause of the aneurysm or is a secondary phenomenon is unknown. Patients not treated do well, especially if the aneurysm is less than 2 cm in diameter. The rate of rupture is approximately 3%, and it appears to be decreasing as more patients are found to have this type of aneurysm. The mortality rate for ruptured splenic artery aneurysm is greatly increased if the patient is pregnant. Indications for removal include presence of symptoms, pregnancy or plan to become pregnant, increasing size, and a diameter of 2 cm or greater. Depending on the medical condition of the patient, aneurysms that are less than 2 cm in diameter can be removed electively, or they can be left and the patient followed closely. The risk of elective removal is extremely low and has minimal morbidity. In the treatment of this type of aneurysm, the spleen should be preserved if possible; splenectomy is reserved for those aneurysms found in the hilus of the spleen or during emergency situations.