Lung resection after pneumonectomy for bronchogenic carcinoma

AIMS/BACKGROUND: TIPS, an effective procedure applied for the treatment of complications of portal hypertension, is potentially followed by worsening of the hyperdynamic circulation of cirrhosis and the impairment of liver function. The aim of the present study was to evaluate short-term changes of functional liver plasma flow after application of TIPS, using the hepatic (extrarenal) clearance of D-sorbitol (S-HCl). METHODS: Twenty-five cirrhotic patients submitted to TIPS for prevention of variceal rebleeding entered the study. At steady-state, during constant infusion of a solution of D-sorbitol (25 mg/min), appropriate blood and urine samples were collected in order to calculate S-HCI before and 120 min after TIPS opening. In addition, the hepatic extraction ratio of D-sorbitol was directly measured at the level of the right (Er), where TIPS was applied, and of the left (El) hepatic veins; meanwhile the portocaval gradient (PCG) was registered, before and after stent dilation. A comparison of values obtained before and after TIPS application was performed by Student's t-test for paired data. RESULTS: After application of TIPS, a substantial reduction was observed in PCG (12.1+/-4.2 vs 24.8+/-4.3 mmHg; p<0.001) and Er values (20.6+/-14.8 vs 57.5+/-22.3 %; p<0.001) but not El values (47.4+/-22.0 vs 53.4+/-21.4 %; p=0.178). S-HCl measured 120 min after TIPS opening was not statistically different from pre-TIPS values (389.2+/-212.1 vs 394.6+/-152.7 ml/min; p=0.892), although S-HCl variations in Child-Pugh class B patients were positively correlated with portal pressure variations (r=0.63, p=0.016). CONCLUSION: Our results demonstrate that in patients with advanced cirrhosis, TIPS procedure, while effective in reducing portal hypertension, does not lead to alterations in the functional liver plasma flow within the first 2 h.     

Long-term survival after resection for bronchogenic carcinoma

Of 915 resections for bronchogenic carcinoma over a 25-year period (1945-1969), 249 patients survived over 5 years; 127 of the patients eligible survived over 10 years, 61 over 15 years, and 22 over 20 years. The case material was divided into three time periods: 1945-49, 1950-59 and 1960-69, as well as by extent of resection. Lobectomy became the operation of choice, pneumonectomy being reserved for the more extensive lesions. Observed survival rates at 5, 10 and 15 years for 561 patients in the lobetomy series were 35, 22 and 15%, respectively, but strikingly increased to 41, 28 and 19% in the 1960-69 period. Observed rates for 354 patients having pneumonectomies were similar for three time periods, being 16, 8 and 6% at 5, 10 and 15 years, respectively. Relative survival rates for the lobectomy series at 5, 10 and 15 years rose from 33, 28 and 26%, repectively, in the 1950-59 period to 50, 39 and 35% in the last time period, becoming a near horizontal curve segment after 5 years. Dominant factors in survival were extent of the lesion and stage of nodal involvement, histologic type and location being less significant.     

Sleeve pulmonary arterial resection for bronchogenic carcinoma

Two cases of bronchogenic carcinoma undergone left upper lobectomy (R 3) with bronchoplasty and sleeve pulmonary arterial resection via mid-sternotomy were reported. Both cases were squamous cell carcinoma originated in the orifice of the left upper lobe. Case 1 was stage IIIB (T2N3M0) bronchogenic carcinoma, its postoperative course was uneventful and died of distant lymphatic metastasis thirty-three months after operation. Case 2 was stage II (T2N1M0) bronchogenic carcinoma and its postoperative management was laborious because of hard expectoration of the sputum but is doing well fifteen months after operation. In order to preserve adequate pulmonary function and to maintain reasonable quality of life (QOL) for the patients with impaired pulmonary function, this angioplastic procedure seems to be acceptable. It is still under discussion to perform this procedure for the patients who would be able to withstand undergoing pneumonectomy, therefore we adopt this method only for every patient for whom it is difficult to maintain desirable QOL after pneumonectomy. Namely, for the patient whose predicted one second forced expiratory volume (FEV1.0) after pneumonectomy is less than 900 ml/m2, we'll be likely to try this angioplastic procedure at first.     

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.     

Combined lung resection for advanced thoracic esophageal carcinoma

We performed lung resection together with esophagectomy in 2 patients with advanced thoracic esophageal cancer. Both patients survived more than 2 years with no evidence of disease. The first case was a 60-year-old man who had a cancer lesion in middle of the intra-thoracic esophagus (Im) and the right lower lobe of the lung was involved. In March 1989, right lower lobectomy of the lung was performed with esophagectomy. Pathologic examination showed well differentiated squamous cell carcinoma invading the lung parenchyma and intrapulmonary lymph node. Postoperatively, 44 Gy of radiation and Peplomycin cancer chemotherapy was performed. The patient survived 51 months after surgery and died of chronic myelogenous leukemia. The second case was a 60-year-old man who underwent thoracic esophagectomy with resection of the involved pericardium and right lung in February 1992. Pathologic examination showed N3 lymph node metastasis. Postoperatively, the patient received 48 Gy of radiation and was free from cancer after 30 months. In conclusion, better surgical results are expected in cases of advanced thoracic esophageal cancer with lung involvement which can be completely resected en bloc with the primary tumor even in a3 cases than in those with aortic or tracheobronchial involvement.     

Perfusion lung scan patterns in 100 patients with bronchogenic carcinoma

The relationship between size of the perfusion defect as seen by perfusion lung scan (PLS) and size of the mass lesion as seen radiologically was correlated with the presence of regional adenopathy in 100 consecutive patients with bronchogenic carcinoma. All patients underwent scanning before open thoracotomy or mediastinotomy and had histologic documentation of the disease. Each perfusion lung scan was classified as follows: (1) perfusion defect larger than the mass lesion. (2) perfusion defect of the same size as the mass lesion, or (3) no focal defect seen. Among patients with a larger perfusion defect 84 per cent were found to have regional lymph node involvements, whereas among patients in whom a larger defect was not present only 23 per cent had such extensions of the disease.     

Contralateral pneumothorax after lung resection

Nine hundred and seventy-three consecutive patients were referred to our hospital for thoracotomy to treat chest diseases between January 1, 1981, and December 31, 1995. Of these patients, 20 males were readmitted within a mean of 20 months with a diagnosis of contralateral pneumothorax. Sixteen of the patients with a mean age of 28.5 years (range 16-76 years of age) had been operated on for bullous lung disease. The remaining four, with a mean age of 60.8 years (range 54-71), had been operated on for lung cancer. All of the 20 patients had received unilateral thoracotomy for lung resection. One patient had undergone pneumonectomy for lung cancer; three had undergone lobectomy; and 16 had been treated by partial lung resection. The patient who had undergone pneumonectomy was found to have contralateral pulmonary metastasis of lung cancer. In the other 19 patients, emphysematous bulla was the origin of the contralateral pneumothorax. The mean value of body mass index (BMI) of the group was 18.4 as compared to 21.7 in the patients who did not go on to develop contralateral pneumothorax, a significant difference (p < 0.05). In conclusion, postoperative contralateral pneumothorax was correlated to the existence of emphysematous changes of the lung and a significantly lower BMI. We conclude that patients with BMIs less than 20 may be at increased risk of developing postoperative contralateral pneumothorax.     

Quality of life after surgical therapy of bronchogenic carcinoma

Quality of life (QL) after the "curative" resection of non-small cell bronchogenic carcinoma was assessed by patients using the EORTC QL questionnaire (QLQ) and by a psychologist using the Spitzer Index. Quality of life was assessed in 52 patients on one occasion 12 months postoperatively and in 20 patients regularly starting with a preoperative assessment. Self- and external evaluation showed a significant correlation (r = 0.41), but QL was assessed as being higher by the external observer. After surgery it was mainly affected by restrictions related to physical activities, job and household tasks, and disease symptoms, whereas limitations in emotional, social, and financial domains were found less frequently and less severely. Of the different medical (surgical procedures, tumor recurrence) and social factors (sex, marital and employment status), only tumor recurrence was determined to have a significant and negative influence on postoperative QL (P < 0.02). When compared to the preoperative assessment, QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively in disease-free patients.     

A case of survival for 50 months after resection of cerebellar metastasis of squamous cell lung carcinoma

The patient was a 64-year-old male with squamous cell carcinoma of the left lung, associated with intrapulmonary metastasis. Eleven months after lobectomy, a single metastasis occurred in the left cerebellum. This was resected, and radiation therapy was performed. Fifty months after the resection, the patient is still alive without recurrence. Based on the present case, we consider that, in the case of single brain metastasis, surgical therapy is desirable because long-term survival can be expected with surgical resection even for a cerebellar metastasis.     

Photodynamic therapy for early stage bronchogenic carcinoma

Photodynamic therapy utilizing Photofrin has proved to be an effective modality that can be used in the treatment of a wide variety of solid tumors and luminal cancers. The effectiveness of photodynamic therapy (PDT) was demonstrated in our institution in 1980 for the treatment of lung cancers, and increasing attention has been focused on this new treatment technique. Over the past decade, 240 patients (283 lesions) with central type lung cancers have been treated in our hospital. Overall complete remission was obtained in 39.6% of the 112 lesions, partial remission in 59.4%, and no remission was obtained in 1.0%. However, among 95 early stage lesions, CR was obtained in 79 (83.2%) and 71 cases were disease free at 3 to 176 months. We conclude that PDT is efficacious in the treatment of superficial lung cancer where complete remission may be achieved.     

Video-assisted thoracoscopic closure of the delayed bronchial rupture after thoracoscopic resection of mediastinal bronchogenic cyst

Video-assisted thoracoscopic surgery (VATS) is an effective and less invasive modality for management of mediastinal disorders, but various complications can result from the procedure. This report describes a case of delayed rupture of the bronchus intermedius which occurred on postoperative day 1 after the patient underwent complete thoracoscopic removal of a mediastinal bronchogenic cyst (BC) with pericystic adhesions to the bronchus. The bronchial rupture was successfully treated by conventional surgical instruments through limited thoracotomy with video-assisted thoracoscopic guidance. In recognition of this possibility, VATS for a BC with adhesions should be carefully performed. Additionally, the role of VATS in bronchial repair is beneficial.     

Natriuretic peptides in the lung modulated by pneumonectomy

BACKGROUND: Natriuretic peptides are vasodilator hormones involved in the regulation of blood pressure and volume homeostasis. However, the mechanism of these peptides after pneumonectomy remains obscure. METHODS: We investigated changes in the pulmonary arterial pressure and the localization and changes in the atrial (A-type) natriuretic peptide (ANP) and the C-type natriuretic peptide (CNP) in the lung, using immunohistochemistry and radioimmunoassay (RIA) in anesthetized dogs. Furthermore, we examined guanosine 3', 5'-monophosphate (cGMP) levels in plasma and in the contralateral lung. RESULTS: Pulmonary arterial pressure was significantly increased after pneumonectomy. The immunoreactivities of both ANP and CNP were detected in the endothelium of the pulmonary artery. In the contralateral lung, the concentrations of ANP and CNP were both significantly increased. In plasma, only ANP levels were significantly increased. In contrast, the plasma and lung cGMP levels were significantly reduced after pneumonectomy. CONCLUSIONS: We postulate that the processes from secretion in the vascular endothelial cells to the action via ANP and CNP receptors are effected in the contralateral lung tissue at the acute stage of pneumonectomy.     

Energy balance in nonsmall cell lung carcinoma patients before and after surgical resection of their tumors

BACKGROUND: The purpose of this study was to investigate whether surgical removal of a tumor influences energy balance, body weight, and body composition in lung carcinoma patients. METHODS: In 53 nonsmall cell lung carcinoma (NSCLC) patients, resting energy expenditure (REE, measured by ventilated hood), energy intake (EI, determined by diet history), body weight, and body composition (fat free mass [FFM], measured by bioelectrical impedance analysis) were all determined before tumor resection. In 39 of 53 patients, REE, EI, body weight, and body composition were also measured 3, 6, and 12 months after tumor resection. RESULTS: Thirty-six of 53 patients (68%) were found to be hypermetabolic. Fourteen patients were excluded from the repeated measurements. Patients with curative tumor resection (n = 30) showed an increase in body weight over a 1-year period, in contrast to patients with tumor recurrence (n = 9), who lost weight (+3.5 vs. -3.6 kg, P < 0.005). The weight gain was caused predominantly by an increase in fat mass (FM), while the weight loss was caused for more than half by a decrease in FFM. Body weight was increased in hypermetabolic patients (n = 20) as well as patients with normal metabolism (n = 10) 1 year after successful removal of their tumors. However, although EI/REE was significantly increased in hypermetabolic patients (from 106% to 140%, P < 0.05), it was not changed in patients with normal metabolism. CONCLUSIONS: Hypermetabolic NSCLC patients undergoing curative resection show an improvement in energy balance caused by both a decrease in REE and an increase in EI. This positive energy balance results in weight gain, which is caused predominantly by an increase in FM.     

Treatment for dehiscence of pancreaticojejunostomy after pancreaticoduodenectomy: is resection of the residual pancreas necessary?

BACKGROUND/AIMS: Partial or total disruption of pancreaticojejunostomy (PJ) is a rare but serious complication after pancreaticoduodenectomy (PD). The recommended option of treatment is completion pancreatectomy. However, the mortality remains high as most patients were too critical to withstand the procedure. PATIENTS AND METHODS: 12 consecutive patients with dehisced PJ after PD were treated by oversewing the pancreatic stump without resection of the residual pancreas. RESULTS: Although a high morbidity rate (75%) occurred after our management, ten patients survived reoperation, without recurrent pancreatic fistula or the need for insulin injection. CONCLUSION: A complete pancreatectomy is not necessary for a dehisced PJ, if acute pancreatitis is not found in the residual pancreas.