Lobectomy for Non-Small Cell Lung Cancer after Coronary Artery Bypass Grafting Surgery.

BACKGROUND: The efficacy of video-assisted thoracoscopic surgery lobectomy in patients with previous coronary artery bypass grafting (CABG) surgery is controversial. OBJECTIVES: To investigate whether skeletonized left internal mammary artery (LIMA) mobilization contributes to the development of severe adhesions, which will affect what type of lung surgery (open or closed procedure) will be required in the future. METHODS: Eight patients (mean age 73.9 years) with previous CABG surgery using a LIMA to left anterior descending (LAD) graft underwent left-sided lobectomy for operable non-small cell lung carcinoma. RESULTS: The lobectomy by thoracotomy rate was 62.5% (5 patients), generally in patients with tumors in the left upper lobe or in patients post-neoadjuvant chemotherapy, while the video-assisted thoracic surgery lobectomy rate was 37.5% (3 patients). Mean hospital stay was 8.3 days. There was no mortality or major morbidity, apart from six minor complications in four patients (50%) (air leak, atrial fibrillation, atelectasis, pneumonia). CONCLUSIONS: Patients with operable non-small cell lung carcinoma following CABG surgery who need left upper lobe resection do not benefit from the video-assisted thoracoscopic surgery technique due to significant adhesions between the LIMA to LAD graft and the lung. The method of preserving a small portion of the lung on the LIMA to LAD graft may help during left upper lobe resections. Adhesions in the left pleural space after LIMA mobilization appear to minimally affect left lower lobe video-assisted thoracoscopic surgery.

[Initial treatment of primary spontaneous pneumothorax by a team which does not include a thoracic surgeon].

Primary Spontaneous Pneumothorax (PSP) refers to air in the pleural cavity occurring in the absence of overt underlining pulmonary disease. Smoking is an important predisposing factor for PSP. Once PSP is diagnosed the size of the PSP should be assessed according to a chest radiogram. PSP smaller than 20% with minimal symptoms should be observed on an outpatient basis. Symptomatic patients or those with a larger PSP should be hospitalized and treated initially by an intrapleural catheter or a small chest tube inserted by the Seldiger technique without active suction. If full lung expansion and air leak cessation is not achieved within 24 hours active suction should be applied. Following this treatment up to 90% of large or symptomatic PSP cases can be managed successfully. In cases of failure of the lung to expand or persistent air leak within 3 days, recurrent PSP, or first presentation of bilateral PSP the patient should be referred to a surgical team. The preferred surgical option is VATS while open thoracotomy [either limited muscle sparing or full thoracotomy] should be used in special cases. Following this scheme some PSP cases in early stage can successfully be treated in hospitals which do not have a thoracic surgeon.

Aeromedical transport of a patient with massive chylothorax following pneumonectomy for mesothelioma.

INTRODUCTION: Long-distance transportation of a patient in an unstable condition is a challenging operation. When circumstances require using a commercial flight it is even more so. CASE REPORT: A 57-yr-old man in Israel underwent extrapleural pneumonectomy for mesothelioma, following which he developed a massive chylothorax of more than 6 L x d(-1). Due to the failure of medical treatment and the high operative risk under such conditions, it was decided to transfer him to the United States by commercial flight for a percutaneous, fluoroscopy-guided closure of the thoracic duct. The patient was accompanied by a physician and a nonmedical assistant and occupied a first-class seat enclosed by curtains. He arrived at the departure airport in a hypovolemic state with low cardiac output and blood pressure of 78/60 Torr. During the flight he was treated with intravenous fluids, chest physiotherapy, and oxygen. In addition, fibrin clots blocked the drainage system on two occasions, requiring corrective action. On arrival in the United States the patient's condition had improved: his blood pressure was 123/91 Torr with a capillary oxygen saturation of 95% without supplementary oxygen. During the 18 h in transit (11 h in flight) he had lost more than 5 L of lymph. CONCLUSION: Under carefully controlled circumstances it is possible to use commercial flights to transport patients whose condition is unstable and complicated. Safety can be increased by focusing on the specific problems associated with the clinical condition and anticipating possible adverse events during the flight.

Holocaust survivors coping with open heart surgery decades later: posttraumatic symptoms and quality of life.

OBJECTIVE: History of prolonged traumatization has been associated with reduced quality of life (QoL) and difficulties in coping with major life-threatening conditions. We assessed the association between the impact of Holocaust experience (posttraumatic symptoms) and QoL of patients before and after an open heart surgery. METHOD: Sixty-three Holocaust survivors were interviewed before open heart surgery (at admission), 52 at follow-up at 1 week, and 58 at follow-up at 6 months. The interview included background data, Impact of Event Scale (IES), Mastery scale, and QoL measured by the Nottingham Health Profile. Medical data were retrieved from the patients' charts. RESULTS: The total IES score indicate a high level of posttraumatic symptoms at all the time points (close to a mean of 18), but there was a clear trend of changes in the avoidance subscale: At admission, the patients manifested lower avoidance compared with the levels after the surgery and at the follow-up. No significant differences in IES were found by Holocaust experiences. Significant improvements in most components of QoL were found at the follow-up. In multivariate analyses at each time point, the findings show that those with higher levels of posttraumatic symptoms are more at risk for problems in pain and mobility domains of QoL at admission, for emotional reaction after the surgery, and at the follow-up, these associations are only at trend level, while lower sense of mastery became significant. CONCLUSIONS: The improvement in QoL despite persistence of the impact of the Holocaust may indicate that past severe prolonged traumatization does not necessarily reduce the survivors' ability to cope with and regain physical and psychosocial functioning after a severe life-threatening medical condition. This may be further generalized to other significant crisis situations in life, such as prolonged periods of stress, suffered by many populations throughout the world.

Open Heart Surgery in Octogenarians: A Review.

Until fairly recently, cardiac surgery was controversial in octogenarians. With the improvement of life quality and health services, the number of octogenarians in the population is steadily increasing. Furthermore, the improvement of surgical techniques and perioperative care permit safer cardiac surgery in this age group. Surgery is beneficial especially for patients undergoing coronary revascularization (early mortality rate, 0% to 12%) or isolated valve surgery (early mortality rate, 1.8% to 20%). Great caution should be exercised when considering candidates for combined coronary and valvular or multiple valve surgery as mortality is much higher in this group. Overall, the operative course in the very elderly is more complicated and is associated with various postoperative complications in 57% to 97% of the patients, which is reflected in longer postoperative hospitalization-an average of 10-19 days. Nevertheless, the 5-year survival in these patients is 47% to 71%. With proper selection of patients, carefully planned surgery, and meticulous postoperative care octogenarians can enjoy prolonged life expectancy and improved quality of life following open heart surgery.