Perforation of the right ventricle: a complication of blind placement of a chest tube into the postpneumonectomy space.

We were asked to review a case from an outside hospital in which there was inadvertent perforation of the right ventricle during the percutaneous placement of a chest tube. We present the case in the hopes that by doing so, others will avoid such a complication in the future. After reviewing the case, it appeared that the complication occurred because the physician was not knowledgeable about the anatomy of the postpneumonectomy space and the physician failed to use the safest procedure in placing the tube.

Elective pneumonectomy for benign lung disease: modern-day mortality and morbidity.

This retrospective study of elective pneumonectomy for complicated inflammatory lung disease was done to define modern-day mortality and morbidity. One hundred twenty-four patients received elective pneumonectomy. Patient ages ranged from 6 months to 71 years. Past, recurrent, or new pulmonary tuberculosis was present in 107 patients (86.3%). Clinical presentation involved recurrent infections or severe suppurative sequelae (abscess, empyema). Forty-seven patients had chronic hemoptysis and 25 patients had past or recent massive hemoptysis (> 600 ml of hemoptysis fluid within 24 hours). Nutritional deficiencies were common. One hundred six patients (85.5%) had end-stage destroyed lungs. Evaluative bronchoscopy showed inflammatory endobronchial changes in 106 patients (85.5%), bronchial strictures in 4, and indolent endobronchial tumor in 2. Lung separation was by double-lumen tube in 96 patients, single lung-single tube in 6, bronchus blocker in 6, and prone posture in 9. Extrapleural pneumonectomy was done in 83 patients (66.9%). Fifty-seven of these procedures were left sided and 26 were right sided. Standard transpleural pneumonectomy was done in 41 patients (33.1%): 30 left sided and 11 right sided. Nine pneumonectomies were conducted with the patient in the prone position. Four patients had completion pneumonectomy. Hospital mortality was three deaths (2.4%). Morbidity included postpneumonectomy empyema in 19 patients (15.3%). Seven postoperative bronchopleural fistulas occurred. Empyema in most patients was managed by open pleural drainage (thoracostoma) and later space closure. Pneumonectomy proved effective therapy with low mortality but postpneumonectomy empyema posed serious morbidity.

Pulmonary resection in the prone position for suppurative lung disease in children.

Lung resection for suppurative inflammatory disease is hazardous in children whose small airway diameter precludes the use of standard methods of bronchial separation. A prospective evaluation of the prone position for thoracotomy in 17 children referred for operation with severe inflammatory disease was done. Bronchography showed whole lung bronchiectasis eight, destroyed lung in three, and lobar bronchiectasis five. Pulmonary resections performed with the child prone included left pneumonectomy (nine), right pneumonectomy (four), lingulectomy with lower lobectomy (two), and other lobectomy (two). No endobronchial or intrapleural spillage occurred. One child required reexploration for bleeding and one child developed a postoperative empyema that ultimately caused death. The remaining 16 children were discharged within 8 days of operation, and follow-up of 1 to 18 months records favorable progress.

Mechanisms of relief of exertional breathlessness following unilateral bullectomy and lung volume reduction surgery in emphysema.

STUDY OBJECTIVE: To explore mechanisms of relief of exertional breathlessness following surgery to reduce thoracic gas volume in patients with emphysema. MATERIALS AND METHODS: We studied 8 patients with emphysema (FEV1 = 39 +/- 3% predicted; residual volume [RV] = 234 +/- 12% predicted; mean +/- SEM) who were severely breathless despite optimal pharmacotherapy and who underwent unilateral bullectomy for giant bullae (greater than one third hemithorax); 4 of these also had ipsilateral lung reduction (pneumectomy). Pulmonary function and cycle exercise performance (n = 6) were evaluated before and 13 +/- 3 weeks after surgery. Chronic breathlessness was measured with the Baseline Dyspnea Index and the Medical Research Council dyspnea scale. Exertional breathlessness was measured using Borg ratings at a standardized work rate (BorgSTD). RESULTS: FEV1, FVC, and maximal inspiratory pressures increased postsurgery by 29 +/- 7% (p < 0.05), 24 +/- 10% (p = 0.06), and 39 +/- 12% (p < 0.01), respectively. Plethysmographic total lung capacity, RV, and functional residual capacity fell by 14 +/- 2%, 30 +/- 4%, and 18 +/- 3%, respectively (p < 0.001). All measures of chronic breathlessness improved significantly (p < 0.05). During exercise at a standardized work rate, BorgSTD fell 45% (p < 0.05), end-expiratory lung volume (EELV) fell 22% (p < 0.01), and breathing frequency (F) fell 25% (p = 0.08). By multiple stepwise regression analysis, 99% (p = 0.007) of the variance in symptom relief (delta BorgSTD) was explained by the combination of decreased ratio of the end-expiratory lung volume to total lung capacity, decreased F, and diminished mechanical constraints on tidal volume (tidal volume to vital capacity ratio). CONCLUSION: Reduced exertional breathlessness at a given workload after volume reduction surgery was attributed to a combination of reduced thoracic hyperinflation, reduced F, and reduced mechanical constraints on lung volume expansion.

Massive hemoptysis. Review of 123 cases.

Case histories of 123 patients with massive hemoptysis were reviewed. The causes of hemorrhage were active pulmonary tuberculosis (47), bronchiectasis (37), chronic necrotizing pneumonia (11), lung abscess (six), lung cancer (six), bronchovascular fistula (five), primary pulmonary fungal infection (four), and miscellaneous (seven). Conservative management was used in 66 patients, with 21 deaths (31.8%). Surgical management was used in 34 patients, with six deaths (17.6%). Endobronchial iced saline lavage was used in 23 patients, with one death. All patients treated by lavage stopped bleeding, and further therapy, either surgical (five) or medical (18), was given as appropriate. The early control of tracheobronchial hemorrhage by endoscopic means is an effective though transitory holding procedure. The unpredictability of massive hemoptysis is underscored by eight deaths from sudden, engulfing hemorrhage in seemingly stable patients awaiting endoscopy or operation.

Adenoid cystic carcinoma (cylindroma) and mucoepidermoid carcinoma of the bronchus. Factors affecting survival.

A review was made of the presentation, treatment, and follow-up of 20 patients with adenoid cystic carcinoma and 12 patients with mucoepidermoid carcinoma of the bronchus who were seen at the Mayo Clinic during the 50 year period 1927 through 1977. Three forms of therapy were employed: complete surgical resection, radiation therapy alone, and radiation therapy after endoscopic removal of tumor tissue. Superior results were obtained in the group with adenoid cystic carcinoma, when complete resection was possible. Significant survival and palliation of sepsis was achieved with subtotal resection. The mucoepidermoid carcinomas in this series were classified on the basis of histologic differentiation. Mucoepidermoid carcinoma of Grade 1 was managed by conservative pulmonary resection. Mucoepidermoid carcinoma of Grades 2 and 3 showed a greater propensity for malignancy. Widespread dissemination caused death with unresectable high-grade mucoepidermoid carcinomas of Grades 2 and 3.

Pharyngoesophageal barotrauma in children: a report of six cases.

Pharyngeal and pharyngoesophageal penetrating injury occurred in six children following the explosive discharge of compressed carbon dioxide into their mouths. The gas was contained in plastic, screw-cap soft-drink containers overpressurized by the addition of dry ice. Three children were managed surgically and three conservatively. All recovered fully, and at follow-up of from 3 to 52 months, swallowing is normal.

Acute submucosal esophageal hemorrhage.

Two cases of acute submucosal esophageal hemorrhage are reported. This condition is uncommon and presents an urgent diagnostic dilemma. Its presentation, diagnosis, and management are reviewed. The underlying pathology and causative factors are researched and clarified. Conservative management is safe and effective.

Pessimism concerning palliative bypass procedures for established malignant esophagorespiratory fistulas: a report of 18 patients.

Eighteen patients with established malignant esophagorespiratory fistulas due to primary esophageal cancer were managed by substernal gastric bypass and isolation of the cancerous esophageal segment. Seven fistulas were esophagotracheal and 11 were esophagobronchial. Ten patients died in the hospital between two days and six weeks after operation. Eight patients left the hospital, surviving an average of 3 1/2 months, but 2 patients lived 5 and 7 months, respectively. Unrelenting respiratory infection and clinical inanition caused 7 hospital deaths in patients reestablished on oral alimentation with their fistulas disconnected. Anastomotic leaks occurred in 5 patients; three of these leaks closed. In the other 2 patients, cervicomediastinal sepsis and bilateral pneumonia with respiratory failure caused death. One patient died of anoxic cardiac arrest 48 hours postoperatively. Fifteen of the 18 patients resumed oral alimentation, but the overall results of palliative surgical therapy achieved in this series were not observably worthwhile for the majority.

Intraoperative whole-lung torsion producing pulmonary venous infarction.

Pulmonary venous infarction and whole-lung torsion are both rare, life-threatening complications of thoracic operations. A case of whole-lung torsion with resultant pulmonary venous infarction of the entire lung after a nonpulmonary thoracic operation is reported.

Thoracoscopic lobectomy with endoarterial vascular control: an experimental study in swine.

BACKGROUND: Video-assisted lobectomy lacks vascular control and presents the potential for serious hemorrhage in a closed cavity. The use of a lighted, flow-directed balloon catheter in the pulmonary artery as an endovascular control device was evaluated. METHODS: A modified light-bearing Swan-Ganz catheter was placed in the left or right pulmonary artery using fluoroscopy. The lit catheter was identified easily through the arterial wall at thoracoscopy. Its inflation allowed the control of proximal blood flow as required. Fully thoracoscopic lobectomy was carried out by isolating and dividing the lobar branches of the pulmonary artery, the pulmonary vein, and the bronchus in anesthetized swine. RESULTS: Forty-two video-assisted anatomic lobectomies were completed in 30 pigs with balloon catheter control of the pulmonary artery. The balloon effectively controlled experimental hemorrhage caused by puncturing arterial branches (n = 4). It allowed the transection of unlooped lobar arteries (n = 42) and the main interlobar pulmonary artery (n = 3). Catheter displacement back to the heart occurred in 5 animals and balloon catheter technical failures occurred in 3. CONCLUSIONS: The lighted, flow-directed balloon catheter was an effective means of avoiding acute hemorrhage and achieving vascular control in a swine lobectomy model.

Retrosternal gastric bypass for inoperable esophageal cancer: a report of 71 patients.

Palliative substernal gastric bypass was performed in 71 patients with unresectable cancer of the intrathoracic esophagus. Fifty-six patients (78.9%) left the hospital, 53 eating normally and 3 on a soft diet. There were 15 hospital deaths (21%), 8 due to respiratory failure and pulmonary sepsis with tracheoesophageal fistulization. The remaining 7 deaths were due to aspiration and respiratory failure in 2 patients, anastomotic leakage with sepsis in 2, subphrenic abscess and septicemia in 1, mediastinitis in 1, and intestinal obstruction in 1. Anastomotic leakage occurred in 17 patients (23.9%), 5 of whom died. Wound infections developed in 28 patients (39.4%), 3 with mediastinal esophagocutaneous fistulas. Reestablishment of unimpeded swallowing, relief of respiratory aspiration, isolation of cancerous tracheobronchial infiltration, and freedom from incident-prone endoesophageal tubes were achieved in all patients leaving the hospital. Information is presented on 25 patients who were available for follow-up.

Surgical management of the redundant transposed colon.

Redundancy of the transposed thoracic colon is not uncommon. Rarely, however, when accompanied by severe symptoms, it may necessitate surgical correction. We describe herein a surgical technique that allows the stretching and straightening of the redundant transposed organ.

Pulmonary hydatid disease: a four-year experience in an urban black hospital.

Intrathoracic hydatid disease is rarely seen in black patients hospitalized in the Johannesburg area. Eleven patients with pulmonary hydatid disease were treated during 4 years at a major referral center for black patients. The clinical features and management of these patients are described.

Experimental use of an illuminated and magnetic tip, flow-directed pulmonary artery catheter for lung resection.

The authors performed a study to design and evaluate a device giving the surgeon added protection against pulmonary artery injury in a closed thoracic compartment. Eleven swine were used for a total of 12 lobectomies. A light-bearing, magnetic-tipped, modified Swan-Ganz catheter was passed through the jugular vein into the left pulmonary artery. By using magnetic guidance through a port site and balloon inflation, cessation of flow in the pulmonary artery was documented by Doppler. Twelve video-assisted lobectomies were performed. Nine of 12 (75%) lobectomies were completed successfully by using the magnetic-tipped, illuminated balloon catheter. In 4 cases, the catheter displaced because of the short left main pulmonary artery in swine. In one case, the balloon was recovered, and successful lobectomy was performed. The use of a magnetic-tipped, flow-directed device may provide an effective means of endovascular control during thoracoscopic pulmonary arterial dissection.