Bronchopleural fistula after stapled closure of bronchus.

The incidence of bronchopleural fistula after stapling among 2,243 pulmonary resections at the Rush-Presbyterian-St. Luke's Medical Center has been reviewed. There were 35 fistulas in 1,773 stapled and in 470 sutured bronchi (segmentectomy, 2; lobectomy, 1; bilobectomy, 9; and pneumonectomy, 23). We have found that the stapler is expedient and simple to use, and that it produces a hermetic and uniform closure. The stapler is contraindicated when the bronchus is thickened, inflamed, or of insufficient length. The overall incidence of bronchopleural fistula was 1.6%. Approximately two thirds of the patients with bronchopleural fistula had preoperative radiation therapy or chemotherapy or both.

Preoperative radiation therapy in regionally localized stage III non-small cell lung carcinoma: long-term results and patterns of failure.

Seventy-four patients from January 1975 through December 1982, with clinical Stage III Mo non-small cell carcinoma of the lung were treated at our Medical Center with a course of pre-operative radiation therapy to be followed by surgical resection. Radiation therapy consisted of delivering a total dose of 40 Gy with 200 cGy per fraction over a period of 4 weeks to the primary tumor in the lung and the regional lymph nodal areas. Surgical resection was attempted 4 weeks later. Fifty-eight percent of the patients had squamous cell carcinoma whereas the remaining had other histologies like adenocarcinoma, large cell carcinoma, or a combination thereof. All the patients except two were followed up to a minimum of 5 years or until death. Sixty-four patients (82%) had T3 tumors whereas mediastinal nodal involvement was found in 41 patients (55%). Fifteen patients (20%) did not have the operation because of tumor progression, patient's refusal or death. All but two surgically treated patients had tumor resection. Of these 19% had histologically negative specimens, 9 patients (16%) had microscopic disease only, and 37 patients had gross residual disease at the time of surgery. The actuarial 5-year survival and recurrence-free survival rates for the entire group were 20% and 24%, respectively. Patients with a pathologic response had an actuarial recurrence-free survival rate of 53% at 5 years whereas only 17% of those with gross residual disease at surgery had remained recurrence-free at 5 years. One-half of the patients with clinically uninvolved nodes were living recurrence-free at 5 years whereas only 20% of the patients with N2 disease did so. The patterns of failure according to the histology and stage of the disease will be presented.

Miniresection of small peripheral carcinomas of the lung.

A total of 499 miniresective procedures were done for lung carcinoma over a 29-year period to July 1986. The operations were carried out in three groups: patients in whom a previous resection had been done, patients with stage III carcinoma, and those with stage I or II disease. Overall, perioperative mortality was 2.4 per cent. Cumulative survival in 296 patients with stage I or II carcinoma was 52 per cent at 5 years, 31 per cent at 10 years, and 11 per cent at 15 years.

Simultaneous cisplatin fluorouracil infusion and radiation followed by surgical resection in regionally localized stage III, non-small cell lung cancer.

Sixty-four patients with stage III (M omicron) non-small cell lung cancer were treated with cisplatin fluorouracil infusion chemotherapy and simultaneous radiation therapy for 5 days every other week. A total of 4 cycles (40 Gy) was followed by attempted surgical resection. Clinical response to the preoperative treatment included 5 (8%) complete and 32 (48%) partial responses. Thirty-nine (61%) underwent the planned operation, and in 9 (23%) of these patients the resected specimens were histologically negative. Clinical assessment failed to predict histological response. With 17 months median follow-up (range, 2.4-29 months), estimated 1-year survival was 61% and median survival was 16 months for all patients.

Extrapleural pneumonectomy for diffuse, malignant mesothelioma.

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

Sleeve lobectomy for bronchogenic carcinoma: the Rush-Presbyterian-St. Luke's Medical Center experience.

One hundred and fifteen various types of sleeve lobectomy procedures were performed from 1961 to June 1985 with a perioperative mortality of 1.7%. Six of the eight patients who required completion procedures were considered as technical failures, a failure rate of 5%. Cumulative survival is 33% at five years and 22% at ten years.

Pulmonary resection in patients after pneumonectomy.

In 15 patients with a previous pneumonectomy (eight on the right and seven on the left), a new "lesion" developed in the remaining lung. Fourteen had the pneumonectomy for carcinoma (13 men and 1 woman), and 1 woman had a pneumonectomy for blastomycosis. At the second operation (4 months to 16 years after the pneumonectomy), limited resection of a primary or metastatic malignancy was done. The excision ranged from lobectomy to multiple wedges. One patient died on the sixth postoperative day, presumably a cardiac death. Eight patients died 2 to 33 months postoperatively. Six patients are now living: 3 have no evidence of disease (18, 35, and 70 months), and 3 have recurrent disease (26, 41, and 73 months). There is evidence that pulmonary resection after pneumonectomy is feasible with a low operative mortality and that resection of these "secondary" tumors can result in prolonged, worthwhile survival.

The evaluation of various bioabsorbable materials on the titanium fiber metal tracheal prosthesis.

A new type of tracheal prosthesis was studied. It consists of a rigid, porous cylinder of titanium fiber metal coated with a polymer that provides an initial air seal and then is absorbed to permit subsequent fibrous tissue ingrowth and reepithelialization. Fifteen such cylinders measuring 50 mm by 26 mm were coated with one of the following polymers: polycaprolactone 700 (3 coated internally and 3 externally); a copolymer of 75% poly-L-lactic acid and 25% polyglycolic acid (3 coated internally and 3 externally); and polyglactin 910 (3 coated externally). Fifteen kennel-conditioned mongrel dogs, each randomly assigned to one of these five groups, underwent implantation of the prosthesis through a right thoracotomy into a 5-cm defect in the distal intrathoracic trachea. There were no immediate postoperative deaths, and no instances of major air leak from the prosthesis. One animal died after two weeks secondary to a lower respiratory tract infection. Bronchoscopic evaluation revealed varying degrees of tissue ingrowth into the prostheses, with no evidence of infection or distal accumulation of secretions. Histological evaluation showed superior tissue ingrowth and reepithelialization with internally coated prostheses; two out of three polymers gave good results.

Survival following resection for second and third primary lung cancers.

The performance of sequential resections and the consideration of new lesions as second or third primary lung cancers remain controversial issues. Criteria to define these as new primary lesions depend upon a difference in histologic types, a prolonged interval between initial and second or third resections, and location in the contralateral lung or a different ipsilateral lobe. Ninety patients have undergone multiple resections for bronchogenic carcinoma from 1960 to December, 1983. There were 10 examples of synchronous lesions and the remaining 80 were metachronous with the longest interval between resections being 17 years, 4 months. The initial surgical procedure was pneumonectomy in 11, lobectomy in 43, sleeve lobectomy in eight, segmentectomy in 27, and carinal resection in one. At the second operation, the procedures were segmentectomy in 55, lobectomy in 11, completion lobectomy in six, and completion pneumonectomy in 15. Two patients had sternotomy with bilateral resections and one patient had a tracheal resection. At the third operation, the procedures were segmentectomy in seven, completion lobectomy in two, and completion pneumonectomy in two. In 20 patients undergoing the second procedure and three undergoing a third resection, a different cell type was identified. The perioperative mortality following the second operation was seven of 90 patients (8%) and there were no deaths in those patients undergoing three resections. The cumulative survival rate following second resection in 80 patients with metachronous tumors was 33% at 5 years and 20% at 10 years. These data support continued aggressive surgical approach to second and third primary lung cancers.

Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique.

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. Pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculous main-stem bronchial stenosis treated with sleeve resection.

The unusual complication of bronchial stenosis from scarring due to tuberculosis developed in a 33-year-old woman, despite otherwise effective antibiotic therapy. She then was treated successfully with conservative surgical management by sleeve resection of the involved segment. This unusual sequela and its workup contain important implications for the management of tuberculosis.

Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients.

Sleeve lobectomy for bronchogenic carcinoma is an alternative to pneumonectomy. The extent and location of the tumor must be such that a sleeve procedure is feasible. The conservation of lung tissue benefits both compromised and uncompromised patients. From 1961 to 1982, 101 patients underwent sleeve lobectomy for bronchogenic carcinoma of the lung. There were 58 procedures on the right side and 43 on the left. Life-table analysis of 94 of the patients shows a 5-year survival of 30% and a 10-year survival of 22%. Preoperative irradiation was utilized in 51 patients with a 5- and 10-year survival of 25% and 16%, respectively. The sleeve lobectomy group that did not have radiation therapy demonstrated a 5-year survival of 36% and a 10-year survival of 28%. There were 2 operative deaths (2%). Completion pneumonectomy was required in 7 patients because of anastomotic dehiscence in the early postoperative period in 6 and tumor at the margin in 1. Other major complications included empyema and granulation tissue at the anastomosis that were successfully managed by bronchoscopic dilation and suture removal. Tumor recurred locally in the area of the anastomosis in 9 patients. Sleeve lobectomy is a safe procedure and when technically feasible can be considered the procedure of choice for bronchogenic carcinoma.

The biological implications of bronchial tumors.

Seventy-six consecutively resected primary pulmonary tumors were assessed first by routine light microscopy and subsequently by electron microscopy and immunohistochemical staining techniques to precisely identify features of differentiation. In 66% of the cases, this assessment provided information that modified or revised the histologic diagnosis provided by light microscopy alone. The following conclusions were reached: (1) The term "large cell undifferentiated carcinoma" has been applied to a heterogenous group of tumors, most of which have ultrastructural and immunohistochemical features of differentiation not identifiable by routine light microscopy. (2) Forty percent of the tumors previously called "large cell undifferentiated carcinoma" have predominantly neuroendocrine differentiation and appear to have a clinical course comparable to that of small cell neuroendocrine carcinoma. (3) The majority of pulmonary carcinomas (especially those previously called "poorly differentiated" or "undifferentiated") may simultaneously demonstrate more than one pattern of differentiation when studied by electron microscopy and immunohistochemistry. (4) The frequency of neuroendocrine neoplasms of the lung, as determined by these and previous studies, is considerably greater than suspected on the basis of light microscopic studies alone. These comprise a clinical and morphologic spectrum ranging from bronchial carcinoid to small cell carcinoma, all of which have immunohistochemically demonstrable hormone production, although paraneoplastic hormonal syndromes are manifested in only a small minority of cases.

Survival in patients undergoing tracheal sleeve pneumonectomy for bronchogenic carcinoma.

Thirty-four patients underwent tracheal sleeve pneumonectomy during the years 1964 through 1981. In 30 patients, simultaneous resection of the right lung and carina was performed with an anastomosis established between the left main bronchus and trachea. In four patients a previous pneumonectomy had been performed (two right and two left) and, because of recurrence in the stump, resection of the stump and carina was carried out with either right or left bronchotracheal anastomosis. Preoperative irradiation was given in 28 of the patients in the group, and tumor sterilization occurred in six of those so treated. Four of 30 patients are long-term survivors: Two are still alive and free of cancer at 7 and more than 11 years postoperatively. One patient in the group of four with stump recurrence is alive more than 11 years postoperatively. All long-term survivors had epidermoid carcinoma and all received preoperative irradiation. The most frequent complications were fistula formation and pneumonia, resulting in 10 deaths in the perioperative period for a mortality of 29%. The 5 year survival rate of the entire group was 15%, and the survival rate by life-table analysis in the 30 patients with lung and carinal resection was 13.3% at 5 and 8.8% at 10 years.

Survival following resection for second primary bronchogenic carcinoma.

A second resective procedure has been done on 64 patients with multiple primary bronchogenic carcinoma, and a third operation has been performed in six. Fifty-three initial resections and all repeat procedures were performed at Rush-Presbyterian-St. Luke's Medical Center. Six patients had synchronous primary cancers, and in the 58 with metachronous disease the cumulative probability of tumor-free interval was 47% at 3 years. The initial resection performed was pneumonectomy in seven, lobectomy in 40, and segmentectomy in 17 patients. At the second operation, segmental resection was done in 41, lobectomy in six, completion lobectomy in four, and completion pneumonectomy in 13 patients. At the third operation, segmentectomy was done in three, completion lobectomy in two, and completion pneumonectomy in one patient. Ten patients had a tumor of different histologic type identified at the second procedure, but all patients with three operations had the same tumor cell type in each specimen. Six patients died following the second operation (a postoperative mortality of 9.3%), but there were no deaths in the six patients undergoing three procedures. Cumulative survival following the second resection was 36% at 5 years, 22% at 10 years and 13% at 15 years. In summary, second or third surgical efforts for reappearing bronchogenic cancers are justified and have significantly prolonged survival. The use of segmental or subsegmental resective techniques have provided superior survival results.

Thoracotomy in patients over age seventy years: ten-year experience.

Recent reports have demonstrated satisfactory long-term survival following pulmonary resection in the elderly. However, the high operative risk commonly cited in patients over 70 years of age has led some authors to conclude that advanced age is a contraindication to pulmonary resection. During 1969 to 1978, 218 thoracotomies were performed in patients over the age of 70 years. Operations performed include 175 pulmonary resections and 43 miscellaneous thoracic surgical procedures. Primary or metastatic cancer was the indication for 174 operations (pulmonary resection, 150 cases; exploration and biopsy, 16 cases; pleurectomy, eight cases). One hundred thirty-seven patients (63%) had a benign course, whereas 74 patients experienced a total of 83 complications. Minor complications of atrial fibrillation, air leaks persisting for 7 to 14 days, and successfully managed retention of secretions were seen in 34 patients (16%). Nonfatal major complications were predominantly cardiac and respiratory in nature and occurred in 40 patients (18%). The overall hospital mortality was 3% (seven patients). Lung-sparing procedures were utilized whenever possible among the 150 patients undergoing pulmonary resection for carcinoma (sleeve lobectomy, 13 cases; segmental resection, 52 cases; wedge resection, 12 cases). The hospital mortality of 4% among these 150 patients was significantly lower (p < 0.001) than the 17% mortality among 308 elderly patients compiled from five series reported by other centers between 1973 and 1978. Long-term follow-up was obtained in 129 of the 139 (93%) available patients surviving pulmonary resection for cancer. The overall 5 year survival rate is 27%, ranging from 13% for patients having pneumonectomy to 42% for those having segmental resection.

Median sternotomy for synchronous bilateral pulmonary operations.

Since 1975 10 patients at Rush Medical Center have undergone synchronous bilateral pulmonary operations by median sternotomy. Nine had pulmonary metastases and one had bullous emphysema with recurrent spontaneous pneumothorax. Between three and 20 metastases were removed by wedge resection per patient, but right upper lobe anterior segmentectomy and left upper lobectomy were required in one patient. Bilateral bullae resections and plications improved pulmonary function in the patient with emphysema. The average hospital stay was 9 days, and the only complication was one reoperation for postoperative bleeding. Median sternotomy has been advantageous in selected patients with bilateral pulmonary disease because it allows one-stage completion of the required pulmonary procedures with minimal impairment of pulmonary function, shortened hospital stay, and maximal patient recovery.