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.     

Unilateral absence of pulmonary artery and ventricular septal defect in an infant

A 2-month-old boy was diagnosed as having a rare combination of absence of left pulmonary artery and ventricular septal defect. He underwent intracardiac repair at the age of 8 months. Reconstruction of the left pulmonary artery was impossible because it could not be visualized through a median sternotomy. Although his early postoperative course was uneventful, he needed ipsilateral pneumonectomy 3 months later because of unremitting hemoptysis. Hilar left pulmonary artery, which used to exist, was not found even by histologic examination.     

Median sternotomy: the preferred incision for resection of lung metastases

OBJECTIVE: To describe our experience with median sternotomy for resection of lung metastases and to assess whether computer tomography (CT) accurately predicts the number and extent of lung metastases. DESIGN: Retrospective case record study. SETTING: University hospital/Cancer Centre, The Netherlands. SUBJECTS: 78 patients with pulmonary metastases from various histological types of tumours who were operated on through a median sternotomy during the 10-year period January 1985-January 1995. INTERVENTION: Median sternotomy for resection of lung metastases with the intention to cure. Extension of the incision in case of extended disease. MAIN OUTCOME MEASURES: Presence of unilateral or bilateral metastases in relation to preoperative CT. RESULTS: 78 patients underwent a total of 82 sternotomies. CT did not accurately diagnose the extent of disease in 38 patients (49%). In 72 cases metastases were excised. In 58 patients (81%) histological examination showed tumour-free margins microscopically. 36 patients had bilateral metastases. CT showed unilateral disease in 49 patients. 14 (29%) had bilateral involvement. 4 patients required lobectomy and in two patients anterolateral extension of the sternotomy was necessary. Eleven patients (15%) developed minor complications. There was no operative mortality. CONCLUSION: Bilateral staging and finding of occult metastases, complete surgical clearance in a one stage procedure, and lower morbidity are the reasons that we suggest that median sternotomy is the procedure of choice of resection of pulmonary metastases. For eligible patients the choice of surgical approach should not be made conditional on the results of CT alone.     

Progression of interproximal caries in the primary dentition

In the patients with invasion to the aortic window, we performed operation via median sternotomy combined with anteroaxillar thoracotomy. In such patients with T4 invasion, conventional pneumonectomy could not be performed because of the extensive invasion near the main pulmonary artery trunk. In these patients in this study, complete resection of the involved pulmonary artery could be performed using a vascular clamp without CP bypass. Operative technique was as follows: first, the pericardium was opened and taping of the aorta was applied. When the uninvolved part of the intrapericardial pulmonary artery was long enough to cut, we could use a stapling device, but the stapling device could not be used in many cases because the length of the uninvolved segment was too short to cut the left pulmonary artery. In order to carry out complete resection, it was necessary to clamp the central part of the main pulmonary artery diagonally from the left lower side to the right upper side. The pulmonary arterial stump was closed with continuous 4-0 monofilament mattress and over and over suture. We recommend an aggressive surgical approach for the tumor with invasion to the aortic window, because the prognosis is dismal in nonresected locally advanced lung cancer.     

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.     

Postpneumonectomy syndrome: recognition and management

STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.     

Safety of absorbable suture for sternal closure after pulmonary or mediastinal resection

The reliability of polyglyconate monofilament (Maxon) suture for sternal closure was tested on 216 consecutive sternotomies, performed on 208 patients in our department from January 1986 to December 1990. The reason of sternotomy was primary lung cancer in 34 cases (16%), lung metastases in 127 (59%), and disorders of the thymus in 55 (25%). Mean age was 38 years (range 3 to 78 years); multiple lung resections were performed in 102 patients (average 7 lesions, range 2 to 30); maximum extent of the operation was pneumonectomy in 2 cases, lobectomy in 53, segmentectomy in 27, and wedge resection in 74. Prior chemotherapy had been administered in 75 cases (35%). A second sternotomy was performed in 8 cases. No cases of sternal dehiscence, sternal infection, or empyema were observed, after a median follow-up of 27 months. Overall perioperative mortality was 0.9% (2/216). Our series demonstrates the safety of polyglyconate monofilament (Maxon) suture for sternal closure. Absorbable sutures appear to be a safe alternative to steel wire closure in patients undergoing extended pulmonary or mediastinal resection.     

Etest for routine clinical antimicrobial susceptibility testing of rapid-growing mycobacteria isolates

Tumors depend on their blood supply for growth. The blood supply to metastatic neoplasia of lung is usually from the pulmonary circulation or both the pulmonary and systemic circulation. The antineoplastic effect of pulmonary artery occlusion was investigated in a rat model of methylcholanthrene-induced metastatic pulmonary sarcoma. Left pulmonary artery ligation was performed on day 7 after tumor inoculation, and animals were sacrificed on day 14. The tumor burden of the left lung decreased 44% when compared with the control group. The survival of non-tumor-bearing rats undergoing left pulmonary artery ligation for 24 hours followed by right pneumonectomy after 2 weeks was also studied. No significant lung damage after a period of left pulmonary artery ligation was seen, as evidenced by both survival after contralateral right pneumonectomy and histology. Balloon occlusion of pulmonary artery, together with regional chemotherapy for patients with lung metastases, may warrant investigation.     

Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma

BACKGROUND: After pneumonectomy for bronchogenic carcinoma, the residual lung may be the site of a new lung cancer or metastatic spread. METHODS: From 1989 to 1995, 13 patients with carcinoma on the residual lung after pneumonectomy for lung cancer were operated on. Three segmentectomies and 7 simple wedge resections were performed, 2 patients had multiple wedge resections, and 1 patient had an exploratory thoracotomy. Nine patients had a primary metachronous bronchogenic carcinoma, 3 had metastases from bronchogenic carcinoma, and no definite conclusion was reached in 1 case. RESULTS: No postoperative mortality was observed. Four patients had postoperative complications. The mean postoperative hospital stay was 14 days. Seven patients are alive, including 5 patients without evidence of disease. Six patients died of their disease, all with pulmonary recurrences. The overall median survival was 19 months, with a probability of survival at 3 years (Kaplan-Meier) of 46% (95% confidence interval, 22% to 73%). CONCLUSIONS: Limited pulmonary resection for lung cancer after pneumonectomy for bronchogenic carcinoma is feasible with very low morbidity. In highly selected patients, surgical resection might prolong survival.     

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.     

Halasz syndrome revealed in the newborn infant by pulmonary arterial hypertension. Study of 4 cases

In the 4 studied patients presenting with an Halasz's syndrome, the disease was complicated since the neonatal period by pulmonary arterial hypertension and heart failure. Three out of the 4 infants rapidly died, one after pneumonectomy. The fourth is surviving and benefitted solely from medical cardiotonic treatment. The pathogenesis of early pulmonary arterial hypertension in Halasz's syndrome is complex. The possibly associated cardiac malformations, the persistance of fetal obstructive hypertension due to the increase of the flow in the left pulmonary artery, the left to right shunt induced by the abnormal venous return and predominantly by the systemic blood supply to the right lung, are responsible, at various degrees, for pulmonary hypertension. Among surgical procedures to be proposed, the simple ligation of abnormal arteries which take their origin from the aorta seems to be preferable to pneumonectomy.     

Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis

BACKGROUND: The effectiveness of lung volume reduction for the treatment of patients with emphysema is well established, but data about the surgical approach, the postoperative management, and complications are limited. We report a comparison of patients undergoing bilateral lung volume reduction (BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on hospital course and complications. METHODS: All patients undergoing BLVRS at Hospital of University of Pennsylvania were analyzed for mortality and morbidity, using a combination of prospective data analysis and retrospective chart review. RESULTS: Patients undergoing BLVRS via median sternotomy were older than those undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9+/-6.89 vs 59.3+/-9.4 years, p = 0.005). Operating time was longer for the VATS procedure (147 versus 129 minutes, p = 0.006) while estimated blood less was greater for median sternotomy (209 versus 82 L, p = 0.0000017). Significant differences were found in intensive care unit stay, days intubated, life-threatening complications, respiratory complications, requirement for tracheostomy, and death that favored VATS BLVRS. When only later cohorts of patients were compared, more life-threatening complications and deaths were found in patients undergoing BLVRS by median sternotomy. There were no differences between early and late median sternotomy BLVRS patients. Twenty-six percent of the lethal complications in median sternotomy BLVRS patients were bowel perforations, equally divided between duodenal ulcers and colons. CONCLUSIONS: Managing patients after BLVRS remains complex. Bilateral video-assisted volume reduction offers equivalent functional outcome with potentially decreased morbidity and mortality. Gastrointestinal perforations can complicate the management of these patients.     

Use of the "chimney patch" technique for Norwood stage I procedures

The Norwood stage I procedure is often used for the initial treatment of infants with hypoplastic left heart syndrome. This procedure creates a systemic arterial to pulmonary artery shunt to establish pulmonary blood flow. We describe a method to facilitate placement of this shunt by attaching a polytetrafluoroethylene shunt to a pulmonary artery homograft patch before performing the median sternotomy. This technique facilitates the performance of the proximal shunt anastomosis and expedites the procedure.     

Operation for chronic pulmonary thromboembolism accompanied by thrombophilia in 8 patients

BACKGROUND: Medical therapy for chronic pulmonary thromboembolism is limited, and surgical treatment has become more frequent recently. We have performed pulmonary thromboendarterectomy on 8 patients with chronic pulmonary thromboembolism accompanied by thrombophilia. METHODS: The patients were 6 men and 2 women aged 21 to 56 years (mean, 35 years). Five patients had antiphospholipid syndrome, 2 had protein C deficiency, and 1 had congenital antithrombin III deficiency. The preoperative condition was New York Heart Association functional class III in 5 and class IV in 3. Hypoxemia, marked pulmonary hypertension (mean pulmonary artery pressure, 47+/-6.7 mm Hg), and low cardiac output were observed in all patients. After a median sternotomy, deep hypothermia was induced using a cardiopulmonary bypass, and pulmonary thromboendarterectomy in the bilateral pulmonary arteries was performed under intermittent circulatory arrest. RESULTS: There were no operative deaths. Long-term respiratory management was needed postoperatively by 3 patients. In the remaining 5 patients, no reperfusion injury was observed. The arterial blood oxygen concentration improved, and the mean pulmonary pressure decreased to 16+/-5.5 mm Hg. The cardiac output also increased, and New York Heart Association functional class improved to I in 4 and II in 4 patients. CONCLUSION: Pulmonary thromboendarterectomy under deep hypothermic intermittent circulatory arrest was effective for chronic pulmonary thromboembolism accompanied by thrombophilia for which medical treatment is of limited value.     

The superior approach for correction of the supracardiac type of total anomalous pulmonary venous return

An alternative approach for correction of supracardiac (type I) total anomalous pulmonary venous return is described. A median sternotomy is used. The posterior wall of the left atrium and the common pulmonary venous trunk are exposed through the transverse sinus. A direct anastomosis between these structures, ligation of the systemic-venous connection (vertical vein), and closure of the interatrial septal defect results in a one-stage repair. In our experience with the supracardiac anomaly in 20 patients, we have found that this approach consistently affords better exposure than other techniques currently in use for surgical correction of this anomaly.     

Postpneumonectomy pulmonary edema. A retrospective analysis of associated variables

STUDY OBJECTIVE: Evaluate the correlation between intravenous fluid administration and postpneumonectomy pulmonary edema. DESIGN: Retrospective chart review. SETTING: Large multispecialty group practice hospital. PATIENTS: Adults who had a pneumonectomy performed between 1977 and 1988. MEASUREMENTS AND RESULTS: Patients were identified who had postpneumonectomy pulmonary edema (PPE). Fluid administration and fluid balance information was found in records and compared with age- and sex-matched control patients who did not develop PPE. The side of pneumonectomy was noted for patients in each group. Autopsy findings were recorded for patients who died. Twenty-one patients met PPE criteria. No significant difference was found between groups for fluid administration or fluid balance. Patients who had right pneumonectomy had a significantly higher incidence of PPE. Patients with PPE had a 100 percent mortality rate and histologic evidence of the adult respiratory distress syndrome (ARDS) at autopsy. CONCLUSIONS: PPE is caused by noncardiogenic pulmonary edema rather than excess intravenous fluid administration. There is a greater incidence of the syndrome with right pneumonectomy for unknown reasons. The mortality rate is high despite interventions for ARDS.     

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.     

Aggressive surgical management of testicular carcinoma metastatic to lungs and mediastinum

During the past six years, more than 200 patients were treated with chemotherapy for disseminated testicular cancer with a 70% complete remission rate. In 22 patients who were 17 to 46 years old, there was persistent thoracic disease, which was treated surgically. Six required a median sternotomy for bilateral pulmonary involvement or mediastinal metastasis. In 8 patients, chemotherapy had altered the histological appearance of the metastases from that of an undifferentiated primary tumor to a mature cystic teratoma. Five patients had nodules in the lungs, which were necrotic and fibrosed with no evidence of tumor. Nine showed embryonal cell carcinoma metastases in the lungs. All who had cystic teratoma are alive and free from disease. Three of the 5 with nodules and 1 of the 9 with metastases are currently free from disease. Agressive surgical intervention is important in this unique group of patients in order to determine the precise pathological category of the lesions, to remove intrathoracic malignancy, and to assess the need for additional chemotherapy. An operative mortality of zero and a low morbidity justify this approach.     

Plication of paralyzed hemidiaphragm after right sleeve pneumonectomy

Right diaphragmatic plication was performed in a 62-year-old man who underwent right sleeve pneumonectomy and then required prolonged mechanical ventilation owing to right diaphragmatic paralysis. The plication was very effective in allowing him to be weaned from the ventilator. The transdiaphragmatic pressure, the ratio of gastric to esophageal pressure swing, and the work of breathing per liter of ventilation improved remarkably after plication. Our experience indicates the beneficial effect of such a plication on contralateral lung function from the standpoint of clinical and respiratory mechanics.     

Treatment of patients with chronic pulmonary tuberculosis with expectoration--evaluation of effectiveness

Two patients with multidrug-resistant pulmonary tuberculosis were surgically treated after 3 and 7 years of unsuccessful chemotherapy. There was pneumonectomy in one case and lobectomy with segmentectomy in the second. Pneumonectomy was complicated by bronchopleural fistula. Both patients become sputum culture negative after surgical treatment but first patient died 5 months after surgery because of acute hepatitis.