Cricotracheal anastomosis for assisted ventilation-induced stenosis

OBJECTIVE: To review the long-term results and our experience with cricotracheal anastomosis via a cervical approach for assisted ventilation-induced stenosis. DESIGN: A case series of 41 patients consecutively treated with cricotracheal anastomosis. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Group 1 consisted of 22 patients with stenosis reaching the lower border of the cricoid cartilage that did not require resection of the cricoid cartilage. Group 2 consisted of 19 patients in whom correction of the stenosis required cricoid resection. MAIN OUTCOME MEASURES: Statistical analysis of airway patency was based on the Kaplan-Meier actuarial life table method. Incidence for the various postoperative complications was presented. Univariate analysis was performed to analyze the relationships between various factors, airway patency, and the incidence for the various complications encountered. RESULTS: The Kaplan-Meier 5-year airway patency estimate was 100% in group 1 patients and 82.5% in group 2 patients. In group 2 patients, complementary treatment with dilatations in 2 patients resulted in an overall 94.8% airway patency rate. In the last patient, the airway patency was not reestablished after cricotracheal anastomosis, and a Montgomery T tube was inserted. Postoperative complications included unilateral inferior laryngeal nerve paralysis (3 patients), cervical neck abscess (2 patients), pneumothorax (1 patient), and major subcutaneous emphysema (1 patient). None of the following variables was statistically related to the airway patency or to the various complications encountered: sex, age, cause for stenosis, delay from initial injury, prior treatment, presence of a tracheotomy, number of tracheal rings resected, type of sutures used, and type of anastomosis performed. CONCLUSIONS: The data reported reemphasized that cricotracheal anastomosis with or without cricoid resection is a safe and reliable procedure for assisted ventilation-induced upper tracheal stenosis reaching and/or involving the subglottis and/or cricoid cartilage.     

Long-term follow-up of immunosuppressive treatment for obstructive airways disease after allogeneic bone marrow transplantation

BACKGROUND: Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. METHODS: A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. RESULTS: Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. CONCLUSIONS: These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.     

Achilles tendon injuries

Massive haemorrhage is an uncommon complication in pancreatitis. Most affected patients suffer from chronic disease with associated pseudocyst. We present five patients (four male) with a mean age of 41 years (range 34-48 years). All patients had alcohol-induced pancreatitis complicated either by haematemesis (3), intraperitoneal haemorrhage (1) or both haematemesis and intraperitoneal haemorrhage (1). Source of bleeding was pseudocyst wall (2), splenic artery pseudoaneurysm (2) and splenic artery rupture (1). Distal pancreatectomy and splenectomy was performed in two patients, intracystic ligation and drainage in two, and packing with subsequent external drainage in one. Rebleeding occurred in two patients and required subsequent distal pancreatectomy and splenectomy in one; the other patient died of splenic rupture. No rebleeding and no mortality occurred after resection. Primary pancreatic resection is recommended whenever possible. Other management options include embolisation and ligation.     

Operative risk and prognostic factors of typical bronchial carcinoid tumors

BACKGROUND: This study estimated operative risk and examined factors determining long-term survival after resection of typical carcinoid tumors. METHODS: From 1976 to 1996, 139 consecutive patients (66 male and 73 female patients with a mean age of 47 +/- 15 years) underwent thoracotomy for typical carcinoid tumor. The tumors were centrally located in 102 patients (73.4%). RESULTS: Radical resection was performed in 106 patients (7 pneumonectomies, 13 bilobectomies, and 86 lobectomies) and conservative resection in 33 (3 segmentectomies, 3 wedge resections, 20 sleeve lobectomies, and 7 sleeve bronchectomies). There were no postoperative deaths. Complications occurred in 19 patients (13.7%). The morbidity rate was not increased after bronchoplastic procedures (chi 2 = 0.033, not significant). Staging was pT1 in 107 patients (77.0%) and pT2 in 32 (23.0%); 13 patients (9.4%) had nodal metastases. Seventeen patients have died (12.2%), during follow-up, but only three deaths were related to the disease. The overall survival rate at 5, 10, and 15 years was estimated to be 92.4%, 88.3%, and 76.4%, respectively; estimated disease-free survival was 100% at 5 years and 91.4% at 10 and 15 years. Estimated survival of patients with lymph node metastasis was 100% at 5, 10, and 15 years. Univariate analysis failed to demonstrate any prognostic significance for sex, tumor size (T1 versus T2), tumor location (central versus peripheral), and type of resection. CONCLUSIONS: These data confirm an excellent prognosis after complete resection of typical carcinoid tumors, including those with lymph node metastases. Parenchyma-saving resections should be preferred.     

Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection

We received the clinical and pathologic features of 22 cases of papillary carcinoma of the thyroid that invaded the trachea and were treated by thyroidectomy and airway resection with or without reconstructive surgery over an interval of 16 years. We studied the fine relationships between lamina propria and lymphatics in the region between the isthmus of the thyroid and the trachea. The manner of invasion of papillary carcinoma of the thyroid was by blunt dissection along blood vessels and collagen fibers oriented perpendicularly to the tracheal lumen between cartilaginous rings. Although lymph node metastases were found in 14 patients (64%), we observed lymphangitic tumor in the tracheal mucosa in only three patients (14%). We devised a staging system for papillary carcinoma of the thyroid based on the extent of invasion of the trachea. Of the 11 patients with stage I, II, or III disease, none of six (0%) followed for 5 years died of thyroid cancer in the 5-year observation period; one patient in this group died later of thyroid cancer. Of the 11 patients with stage IV disease, five of seven (71%) followed for 5 years died of thyroid cancer in the 5-year observation period; one additional patient in this group died later of thyroid cancer.     

The fate of patients with locally advanced bladder cancer treated conservatively with neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy: 10-year experience

PURPOSE: We assess the results of bladder preservation for infiltrating bladder cancer. The potential for neoadjuvant chemotherapy followed by extensive transurethral resection and radiotherapy was evaluated in 40 patients with T2-T4a G2-G3 bladder carcinoma. MATERIALS AND METHODS: From 1983 to 1995, 40 patients with bladder cancer underwent bladder sparing treatment, consisting of neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy. Most patients had T3G3 cancer. A deep transurethral resection biopsy was performed before and after chemotherapy, and an extensive transurethral resection was repeated at the end of radiotherapy. Of the patients 30 received cisplatin and methotrexate and 10 also received vinblastine. Total dose of radiotherapy was 60 to 65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy was considered for persistent or recurrent invasive disease. RESULTS: Complete response occurred in 19 patients (47.5%) after chemotherapy, and in 8 patients after transurethral resection and radiotherapy (67.5%). Within 10 years 8 responding patients (30%) had local recurrences and 3 underwent cystectomy. Of the patients 14 (35%) are alive, including 13 with no evidence of disease (mean survival 65 months), 5 died of unrelated disease and 21 (52.5%) died of distant metastases (mean survival 28 months). Of the 21 patients 14 had residual tumor after radiotherapy, 3 presented with distant metastases after vesical infiltrating recurrence and 4 had distant metastases in the absence of locoregional recurrence. In 22 patients (55%) the bladder was salvaged. Patients with complete response to chemotherapy had a low risk for recurrent infiltrating tumors and metastases. CONCLUSIONS: Complete tumor control was maintained at 5 years in more than 50% of the patients treated conservatively. Bladder salvage is feasible in select patients.     

The diagnosis and treatment of esophageal perforations resulting from nonmalignant causes

Esophageal perforations are extremely difficult to diagnose and treat. We report herein our results of a review of 26 patients with esophageal perforation which were spontaneous in 11, iatrogenic in 11, and caused by a foreign body in 4. Surgical treatment was performed in 7 of the patients with spontaneous rupture, but the remaining 19 patients were treated conservatively. The abnormality was found by plain radiography (X-ray) in 22 (85%) of the 26 patients, and by computed tomography (CT) in all 13 patients who underwent this procedure. The detection rates by esophagography and esophagoscopy were 100%, or all of 25 patients examined, and 60%, or 9 of 15 patients examined, respectively. Of 12 patients with underlying diseases, 4 (33%) died after the perforation, whereas only 1 (7%) of 14 patients without any underlying disease died. Postoperative empyema developed in all of 3 patients treated by intraoperative unfixed intrathoracic drainage (UID), but in none of the 4 treated by fixed intrathoracic drainage (FID). Conservative treatment achieved satisfactory results for spontaneous esophageal ruptures confined to the mediastinum, and for iatrogenic perforations and esophageal perforations caused by foreign bodies, provided there was no serious underlying disease such as advanced cirrhosis. Moreover, intraoperative FID proved useful in helping to prevent postoperative empyema.     

Resection of the trachea infiltrated by thyroid carcinoma

Twenty-four thyroid carcinoma patients with infiltration of the trachea were treated surgically. The histological diagnosis in these cases included papillary adenocarcinoma in 22 different patients, medullary carcinoma in one patient, and undifferentiated carcinoma in one patient. In 19 of the patients hemoptysis was noted, and dyspnea was present in ten patients. In 14 of the 24 patients the carcinoma was diagnosed by radiographs of the neck, while in seven patients it was demonstrated bronchoscopically. In three patients tracheal infiltration by thyroid carcinoma was diagnosed by biopsy of the tracheal wall at operation. When the tracheal wall was infiltrated by thyroid carcinoma, treatment consisted of circumferential resection of the involved segment of the trachea followed by an end-to-end anastomosis. Of the 24 patients, 17 survived and six died. In the 17 patients who survived, 13 were disease free. Of this number, six survived more than five years after the initial tracheal resection.     

Tracheobronchial injuries in blunt thoracic trauma

Tracheobronchial lesions after blunt chest injury are seldom (0,5-0,7%). Diagnostic and therapeutic strategies in 16 own cases and a review of the literature are presented. Own experiences: Locations of the lesions were main bronchus (10), bronchus intermedius (2), and trachea (4). Rupture was total in five cases, and partial in seven. In four patients the mucosa only was ruptured. Initial symptoms: Subcutaneous emphysema (13), pneumothorax (9), respiratory insufficiency (5), lung lesion (5), but tracheal bleeding in five cases only. Diagnosis mainly by bronchoscopy (8 early, 4 late), but in 4 cases after thoracotomy. Treatment: In cases of total rupture, there were three anastomoses of the bronchus and one of the trachea, and one pneumonectomy. In all partial ruptures, there was suturing of the lesion. Mucosa lesions were treated conservatively. RESULTS: 1 empyema, 2 ex. leth. (bilateral pneumonia 7.d., multiple organ failure 20. d). FOLLOW UP: 9 patients free of symptoms, 5 patients with respiratory problems. The symptoms "mediastinal emphysema and continuous air leakage through the chest tube or persistent atelectasis of the lung" are indications for urgent bronchoscopy and early surgery. Long-term results are good in 70%-90% of the cases. Not diagnosed lesions can result in tracheobronchial stenosis and infections of the lung later on, to be treated by lung resection only. Total bronchial ruptures can result in strictures and non-infected atelectasis, resection of the stricture and reinflation of the lung being successful in 60%-70% of these late diagnosed cases.     

Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents

PURPOSE: To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions. MATERIALS AND METHODS: Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound. RESULTS: With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P < .0001) was observed 1 year later. CONCLUSION: Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.     

Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults

Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.     

Iliac artery stenoses after percutaneous transluminal angioplasty: follow-up with duplex ultrasonography

PURPOSE: To assess iliac artery stenosis before and up to 1 year after percutaneous transluminal angioplasty (PTA) with duplex ultrasound (DUS) to determine the incidence of residual and recurrent stenoses and correlate these findings to clinical outcome. PATIENTS AND METHODS: Sixty-one patients with 70 iliac artery segments treated with PTA were examined. The peak systolic velocity (PSV) ratio (PSV ratio = PSV in stenosis divided by PSV proximal or distal to stenosis) was determined by DUS before PTA and 1 day, 3 months and 1 year after PTA. Three categories of results were identified by using PSV ratios at the site of the treated stenosis 1 day and 1 year after PTA (good result, residual stenosis, and recurrent stenosis). The DUS-determined anatomic result was correlated with the clinical outcome at 1 year. Clinical outcome was classified according to Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. RESULTS: Good results with DUS (PSV ratio 1 day and 1 year after PTA > or = to 2.5) were found in 45 of 70 segments (64.3%), residual stenoses (PSV ratio > or .5 1 day after PTA) in 15 of 70 segments (21.4%), and recurrent stenosis (PSV ratio 1 day after PTA < 2.5 and 1 year after PTA > or = 2.5) in 10 of 70 segments (14.3%). PSV ratios of residual stenoses decreased significantly between 1 day and 1 year after PTA because some residual stenoses improved hemodynamically in time. Clinical results were significantly better in patients with a good result compared with other patients. However, the clinical outcome of patients with residual stenoses was not significantly different from the patients with good DUS results. CONCLUSION: Some residual stenoses improved sonographically after PTA. Clinical results at 1 year are highly variable within different groups. Clinical outcome of patients with residual stenoses did not differ from patients with good DUS results, whereas clinical outcome in patients with recurrent stenoses was worse than in the other groups.     

Prevalence of malaria in Dakar, Senegal. Comparative study of the plasmodial indices in pregnant and non-pregnant women

One hundred ASA I orthopaedic surgical patients (four randomized groups) were anaesthetized using continuous propofol and intermittent fentanyl (TIVA), with controlled ventilation via a tracheal tube in groups 1 and 2, and a laryngeal mask airway (LMA) in groups 3 and 4. Neuromuscular blockers were used in groups 1 and 3 only. There were no significant differences between groups in total anaesthetic requirements, as assessed by cardiovascular variables and movement. Coughing interfered with surgery and made controlled ventilation difficult to manage. In contrast, movement not associated with coughing did not impair surgery or ventilation. Patients in group 2 (tracheal tube, no neuromuscular blocker) required more interventions for coughing than the other groups, while patients in group 4 (LMA, no neuromuscular blocker) needed more boluses for movement than groups 1 and 3. Groups 1 and 2 (tracheal tube) had significantly higher heart rates and mean arterial pressures than groups 3 and 4 for varying periods up to 5 min after insertion of the airway management device. There was no correlation between mean arterial pressure and plasma concentrations of catecholamines related to insertion of either the tracheal tube or LMA. The LMA was found to be a highly effective device for controlled ventilation in TIVA and easier to manage than the tracheal tube in the absence of neuromuscular blockers.     

Successful treatment of solitary extracranial metastases from non-small cell lung cancer

BACKGROUND: Recurrence after resection of non-small cell lung carcinoma is generally associated with a poor outcome and is treated with either systemic agents or palliative irradiation. Recently, long-term survival has been reported after resection of isolated brain metastases from non-small cell lung carcinoma, but resection of other metastatic sites has not been explored fully. METHODS: We have identified 14 patients who had solitary extracranial metastases treated aggressively after curative treatment of their non-small cell lung carcinoma. The histology was squamous carcinoma in 5, adenocarcinoma in 8, and large cell carcinoma in 1. Initially, 3 patients had stage I, 5 stage II, and 6 stage IIIa disease. RESULTS: The sites of metastases included extrathoracic lymph nodes (six), skeletal muscle (four), bone (three), and small bowel (one). The median disease-free interval before metastases was 19.5 months (range, 5 to 71 months). Complete surgical resection of the metastatic site was the treatment in 12 of 14 patients. Two patients received only curative irradiation to the metastatic site, with complete response. The overall 10-year actuarial survival (Kaplan-Meier) was 86%. To date, 11 patients are alive and well after treatment of their metastases (17 months to 13 years), 1 has recurrent disease, 1 died of recurrent widespread metastases, and 2 died of unrelated causes. CONCLUSION: Long-term survival is possible after treatment of isolated metastases to various sites from non-small cell lung carcinoma, but patient selection is critical.     

Primary tracheal tumors

A 33-year study (from 1963 through 1995) was conducted on 144 patients who underwent surgery for primary tumors of the trachea: 70 females and 65 males aged between 7 and 69 years. In 77 patients the tumor was in the thoracic trachea, in 26 in the cervical trachea, and in 41 at the tracheal bifurcation. The tumor was benign in 24 and malignant in 120. The most frequent malignant tumors were adenoidcystic carcinoma (more than 50%), squamous cell carcinoma, and carcinoid. The main diagnostic methods used were lateral and oblique roentgenography, tracheobronchoscopy and in the last 10 years, CT scans. One hundred forty-six operations were performed (2 patients underwent surgery twice). In 60, sleeve resection with anastomosis was made; in 37, different kinds of carinal resections were performed. Total hospital mortality was 15%. After resection for malignant tumors, 3-year, 5-year and 10-year survival rates were 47.5%, 35.9%, and 27.1%, respectively.     

Staging and management of lung cancer: sleeve resection

Sleeve lobectomy is a lung-saving procedure usually indicated for central tumors for which the alternative is a pneumonectomy. It preserves normal lung tissue and may enable pulmonary resection to be done in selected patients with inadequate cardiac or pulmonary reserve. One experience extends from January 1972 to December 1991, during which time 142 patients underwent a variety of sleeve resections for bronchogenic neoplasms. The majority of operations were upper-lobe sleeve resections (N = 110) and most procedures were considered complete and potentially curative (87%). There were three postoperative deaths (surgical mortality of 2.5%) and prolonged atelectasis was the most common major complication (N = 9). Follow-up was complete for the 139 survivors (mean follow-up time of 2,149 days) and overall survival was 46% at 5 years and 33% at 10 years. Five- and 10-year survivals for patients with stage I disease were 63% and 52%, respectively, while only 14% of patients with stage III disease survived 5 years. Local recurrences occurred in 23% of patients but when the resection had been complete, this incidence was 17% (21/124). These results indicate that sleeve resection is an adequate cancer operation for both compromised and uncompromised patients. Operative mortality, survival, and incidence of local recurrence are not different than what is seen after more conventional procedures.     

Carinal resection for bronchogenic cancer

Acquired, nonmalignant tracheoesophageal fistulae usually result from erosion of the tracheal and esophageal walls by endotracheal or tracheostomy tube cuffs, especially when a rigid nasogastric tube is in place. This has become an infrequent occurrence with the use of high-volume, low-pressure cuffs, but it still represents a life-threatening condition. Spontaneous recovery is exceptional. Most are diagnosed while patients still are mechanically ventilated and, due to the negative effects of positive pressure ventilation on tracheal suture lines, repair should be delayed until patients are weaned. After the patients is weaned from the ventilator, a one-staged anterior approach including esophageal closure, segmental tracheal resection, and primary reconstruction definitely corrects the fistula and removes concurrent tracheal disease and should be preferred to simple division and closure of the fistula.     

Laparoscopic colorectal surgery. The first experiences from the Central Hospital of Akershus

Between November 1993 and August 1997, 49 patients (29 women and 20 men) were selected to 51 laparoscopic and laparoscopic-assisted colonic or rectal operations. Five operations were converted to open surgery because of technical problems and adhesions. 46 operations could be performed as planned. The median age was 67 years (20-88 years). A variety of procedures were carried out, including construction of deviating sigmoideostomas without resection (n = 17), segmental resections of colon (n = 15), rectopexi (n = 6), stoma closure (n = 4), abdominoperineal resection (n = 3) and suture of an iatrogenic perforation of the large bowel (n = 1). Eight of the patients with a bowel resection had carcinoma. The median duration of the procedures was 112 minutes (38-293 minutes) and the length of hospitalisation eight days (2-40 days). 13 patients (28%) developed complications. One of these patients died and four were reoperated. These first experiences show that we are able to perform a variety of colorectal surgery laparoscopically. An experienced, well organised operating team with modern laparoscopic equipment is essential to this type of surgery. Prospective, randomised studies have to be done to assess the efficacy of the laparoscopic approach.     

Mammalian glial cells in culture synthesize acetylcholine

OBJECTIVE: To evaluate the postoperative outcome and long-term results of patients who underwent iterative and extended pulmonary resection leading to completion pneumonectomy for pulmonary metastases. METHODS: From January 1985 to December 1995, 12 patients (mean age 45 years) underwent completion pneumonectomy for pulmonary metastases. These patients represent 1.5% of all pulmonary metastases operated on. There were 5 sarcoma and 7 carcinoma patients. Before completion pneumonectomy, 8 patients had only one pulmonary resection (wedge resection, 2; segmentectomy, 2; lobectomy, 4), 3 patients had two operations and finally, 1 patient had multiple bilateral wedge resections and 1 lobectomy. The median interval time between the last pulmonary resection and completion pneumonectomy was 13.5 months (range 1-24 months). RESULTS: There were 10 left and two right completion pneumonectomies. Three patients had an extended resection (1 carina; 1 chest wall; 1 pleuropneumonectomy). Intrapericardial dissection was used in 3 patients. Two patients died within 30 days of the operation: 1 died of postoperative complications (8.3%) whereas the other died of rapidly evolving metastatic disease. The remaining 10 patients had an uneventful postoperative course. Only 1 patient is still alive and free of disease 69 months after completion pneumonectomy. One patient is alive with disease, another was lost to follow-up; 9 patients died of metastatic disease. The median survival time after completion pneumonectomy was 6 months (range 0-69 months). The estimated 5-year probability of survival was 10% (95% CI: 2-40%). CONCLUSIONS: Indications for both iterative and extended pulmonary resection for PM may be discussed only in highly young selected patients; the extremely poor outcome of our subgroup of patients should lead to even more restrictive indications of CP for pulmonary metastatic disease.