Combined off-pump coronary surgery and right lung resections through midline sternotomy.

Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.

Oxidative stress after lung resection therapy: A pilot study.

STUDY OBJECTIVES: To investigate whether oxidative stress occurs following lobectomy and pneumonectomy and to evaluate whether markers of oxidative stress might be of value in the assessment of the diagnosis, course, and prognosis of postoperative complications. DESIGN: A prospective study. SETTING: A specialized thoracic surgical unit in a large referral hospital. PATIENTS: Twenty-eight patients with lung carcinoma undergoing thoracotomy. MEASUREMENTS: Exhaled H(2)O(2) concentrations in breath condensate were measured by spectrophotometry, while malondialdehyde (MDA) levels in urine samples collected every 24 h were measured by reversed-phase, ion-pair high-performance liquid chromatography using ultraviolet detection. RESULTS: Our results show increased H(2)O(2) and MDA levels in lobectomy patients compared with pneumonectomy patients. A strong correlation was found between the levels of H(2)O(2) and MDA. CONCLUSION: The present data support the hypothesis that oxidative stress may occur following pulmonary resection.

Effects of formoterol in apparently poorly reversible chronic obstructive pulmonary disease.

This randomized, double-blind, placebo-controlled, crossover study was designed to investigate the effects of the long-acting beta2-adrenoreceptor agonist formoterol fumarate in 12 current or exsmokers having chronic obstructive pulmonary disease, with a mean forced expiratory volume in one second (FEV1) 47% of predicted, poorly reversible (5.1% pred) after terbutaline sulphate inhalation. After inhaling a single dose of formoterol (6 or 24 microg), or placebo via Turbuhaler, FEV1 and pulmonary function parameters measured during quiet breathing (work of breathing (WoB) and airway resistance (Raw)) were recorded over 12 h on three test days. Immediate changes in FEV1 were modest, although each dose of formoterol caused a response >12% pred within 10 min in one subject. Compared to placebo, both doses of formoterol induced a clinically and statistically relevant improvement in WoB (>25%) and Raw (>20%), which occurred within 10 min and lasted over a period of 12 h (p < or = 0.02, analysis of variance). Thus, inhaled formoterol causes long-lasting lung functional improvements in apparently poorly reversible chronic obstructive pulmonary disease. Additional lung function measurements during quiet breathing after forced expiration tests may be useful in such patients to assess beneficial effects of bronchodilators.

Postpneumonectomy pulmonary edema. A retrospective analysis of incidence and possible risk factors.

OBJECTIVE: To analyze the incidence of postpneumonectomy pulmonary edema (PPE) and to determine potential risk factors for PPE. MATERIAL AND METHODS: A group of 197 patients was studied retrospectively, and the incidence of PPE was recorded over a 5-year period. Preoperative, perioperative, and postoperative clinical data were collected, and preoperative and postoperative chest radiographs were reviewed. A scoring system was used to distinguish between premanifest and manifest PPE. Postpneumonectomy patients with pulmonary edema, with no clinically evident cause, were considered to have PPE. RESULTS: The incidence of premanifest PPE was 12.2% (n = 24), and that of manifest PPE was 2.5% (n = 5). Mortality in the group of patients who developed manifest PPE was 100%. Two significant perioperative associations were found in the PPE group. One was the administration of fresh frozen plasma (FFP) transfusions (relative risk, 4.3; 95% confidence interval, 1.3 to 14.4 corrected for age and sex), while the other was higher mechanical ventilation pressures during surgery (relative risk, 3.0; 95% confidence interval, 1.2 to 7.3). CONCLUSION: Our data suggest that FFP transfusions form an important risk factor for PPE. The mechanism may be an increased permeability of the pulmonary vessels due to an immunologic reaction after multiple FFP transfusions. The significantly higher mechanical ventilation pressures we found in the PPE group may be explained as an early sign of the development of PPE.

Pulmonary function and postoperative complications after wedge and flap reconstructions of the main bronchus.

Between 1980 and 1989, 8 wedge and 17 flap main bronchoplasties were done in 24 patients (4 carcinoid tumors, 4 benign lesions, 17 carcinomas). Bronchial anastomotic stenoses, pulmonary function, and survival were evaluated. Preoperative ventilation/perfusion scans with preoperative and postoperative spirometry were done in all patients except two who underwent a wedge bronchoplasty. Postoperative bronchoscopy was done in all patients. Follow-up was complete for the patients with carcinoma (N = 17). In the wedge group bronchial anastomotic stenoses occurred in three (38%) of eight patients. All three patients had serious postoperative complications (persistent atelectasis in one, prolonged ventilatory support in two); one patient died and the other two had impaired postoperative pulmonary function. Complete function recovery occurred in only three (38%) of eight patients who underwent wedge bronchoplasty. In the flap group, bronchostenosis occurred in 3 (18%) of 17 patients. The associated complications (mucus retention, minor atelectasis, partial lobar torsion) were mild. Complete pulmonary function recovery occurred in 13 (76%) of 17 patients who had flap bronchoplasty. Actuarial survival, for the patients with carcinoma, was 88%, 47%, and 41% after 1, 3, and 5 years, respectively. The local recurrence rate was 25% (4/16). In our series, flap main bronchoplasties were effective for the resection of bronchial tumors with local involvement of the adjacent main bronchus. Wedge main bronchoplasties, however, were associated with substantial postoperative complications.

Lung function and perfusion after bronchial and pulmonary arterial sleeve resection.

Between January 1985 and December 1991, six patients underwent arterial and bronchial sleeve resections of the left upper lobe. Preoperative and postoperative spirometry, preoperative split pulmonary radionuclide ventilation/perfusion (V/Q) scans and postoperative bronchoscopy were obtained in four patients. Postoperative serial digital vascular images (DVI) of the pulmonary artery were obtained in three patients and one patient had a postoperative V/Q scan. For each patient the preoperative and postoperative forced expiratory volume in is (FEV1) were determined to assess the postoperative ventilatory recovery. At bronchoscopy all patients had a patent bronchial anastomosis. At postoperative DVI, in three patients, vascularization of the residual left lung was delayed and less intense compared with the non-operated right lung. Postoperative V/Q scan, in one patient, showed reduced ventilation and perfusion of the residual lung. Preoperative and postoperative FEV1 of the four patients were 2688/1998 ml, 2154/1752 ml, 2618/2100 ml and 2277/2015 ml. Operative mortality was zero. One patient had a postoperative atelectasis of the left lower lobe. In our series, ventilation and vascularization of the reimplanted and revascularized left lower lobe were reduced. But, in our opinion, the preserved residual lung parenchyma was still a relevant advantage.

Tetraplegia after a tracheal resection procedure.

We describe a 27-year-old patient who was admitted to our hospital for a tracheal stenosis caused by an adenocystic carcinoma. A tracheal resection procedure was performed and the head was fixed to the anterior chest wall by two sutures. Postoperatively he became tetraplegic, from which he completely recovered after the sutures were removed. We think that the decreased blood flow in the arterial spinal artery with flexion of the neck in combination with hypotension was the direct cause of this major complication.

Pulmonary function after sleeve lobectomy.

Preoperative and postoperative pulmonary function of 109 sleeve lobectomy patients (90 right upper lobe, 10 left upper lobe, and 9 left lower lobe) were evaluated over a period of 30 years. Ninety-eight men and 11 women, with a mean age of 60 years, were reviewed. The diagnosis was lung cancer in 97 patients and carcinoid tumors in 12 patients. Indications for operation were anatomic suitability in 103 patients, and impaired pulmonary function (forced expiratory volume in 1 second (FEV1) less than 1,200 mL) in 6 patients. The predicted postoperative FEV1 was calculated and compared with the measured postoperative FEV1. Preoperative spirometry and split pulmonary radionuclide ventilation/perfusion scans were used to calculate the predicted postoperative FEV1. Postoperative spirometry had been performed 125 days after operation (range, 25 to 342 days). Our results showed a gradual improvement in postoperative pulmonary function. A complete and stable condition was reached 4 months after operation. Correlation between the predicted (mean, 2,097 mL) and measured FEV1 (mean, 2,067 mL) was good (linear regression and correlation test; r = 0.72). These values did not differ significantly (Wilcoxon signed rank test; p = 0.81). Our findings indicated a complete recovery of the reimplanted lung lobes after sleeve lobectomy.

Pulmonary resection after pneumonectomy in patients with bronchogenic carcinoma.

Eight patients with a previous pneumonectomy for bronchogenic carcinoma underwent an additional resection because of a second primary carcinoma in the remaining lung. One patient died of pulmonary embolism in the postoperative period. The postoperative course was otherwise uneventful except for prolonged air leak. Two patients died after 3 months (bone metastasis) and 5 months (recurrent small-cell carcinoma). Two patients were alive at the time this article was written but had evidence of recurrence after 18 months (distant metastasis) and 21 months (local recurrence at the site of positive resection margins). Three patients were alive and doing well without evidence of disease after 16, 17, and 40 months. After careful selection, even patients with a previous pneumonectomy may be good candidates for additional resection of a second primary bronchogenic carcinoma.

Hemorrhage due to inflammatory erosion of the pulmonary artery stump in postpneumonectomy bronchopleural fistula.

Bleeding from the pulmonary artery in patients with a bronchopleural fistula after pneumonectomy is a rare but devastating complication. The incidence is unknown, but our data suggest an incidence of 4% in all postpneumonectomy bronchopleural fistulas. Two case histories are presented in which the anterior transpericardial approach was used to stop the pulmonary bleeding by direct suturing. Nevertheless, 1 patient died 5 days later because of irreversible brain damage; the other patient recovered well after a protracted convalescence.

Pneumothorax. Results of thoracoscopy and pleurodesis with talc poudrage and thoracotomy.

A retrospective study was performed of the evaluable data in 710 patients with a spontaneous pneumothorax. The male:female ratio was 3.4:1. A thoracoscopy was performed in 622 patients. The two main therapeutic strategies were pleurodesis with talc poudrage (n = 356) and thoracotomy (n = 248). The success rate of talc poudrage was 88 percent, and in the group failures who have undergone surgery afterwards, we found unexpected bullous structures in 20 of 37 patients. The success rate of operation (bullectomy, pleurectomy, or resection) was 97 percent. Our conclusion is that aggressive therapy in spontaneous pneumothorax is acceptable, with a high success rate with very few complications. The diagnostic thoracoscopic evaluation needs to be in experienced hands, especially to inspect the apical lobes with the Valsalva maneuver.

Sulphasalazine-induced eosinophilic pneumonia.

Eosinophilic pneumonia and skin rash developed in a 21-yr-old man while taking sulphasalazine. After discontinuation of the drug and treatment with steroids the pulmonary infiltrates and rash resolved completely. A short review of the literature concerning sulphasalazine-induced lung disease is presented.

[Late manifestation of a right-sided diaphragmatic rupture]. / Late manifestatie van een rechtszijdige diafragmaruptuur.

Diaphragmatic rupture is commonly of traumatic origin and can complicate thoracoabdominal injuries. Some cases are diagnosed after a delay of years. We present three patients with a rupture of the right hemi-diaphragm with herniation of liver fragments, and discuss the diagnostic and therapeutic challenge.

Postpneumonectomy syndrome in adulthood. Surgical correction using an expandable prosthesis.

The postpneumonectomy syndrome is a rare complication occurring after right pneumonectomy and is seen mainly after pneumonectomy in childhood. The presenting symptoms are dyspnea, stridor, and recurrent pulmonary infections. The syndrome is caused by the shifting and rotation of the heart and mediastinum into the right hemithorax, and anterior herniation of the left lung. This causes tortuosity and stretching of the trachea and compression of the left main bronchus and left lower lobe bronchus, eventually resulting in secondary tracheobronchomalacia. This report reviews two cases of postpneumonectomy syndrome following pneumonectomy in adulthood. After implantation of an expandable prosthesis, an anatomic correction of the shifted mediastinum was achieved, which in both cases resulted in instantaneous and sustained relief.

Transfusion-related acute lung injury.

Noncardiogenic pulmonary edema after transfusion therapy is an infrequent but hazardous complication. The occurrence of this entity is linked to the presence of circulating leukoagglutinins. The clinical features are described on the basis of four cases. The hemodynamic changes, underlying mechanisms and therapeutic strategies are discussed.