Comparison of late pulmonary function after posterolateral and muscle-sparing thoracotomy.

Muscle-sparing thoracotomy incisions have received considerable recent attention. There have, however, been few clinical and functional comparisons between the various approaches. The present study assessed early clinical results and late pulmonary function changes in 79 patients undergoing pulmonary operations by posterolateral, limited lateral, or transverse axillary thoracotomy. With the exception of wound seromas in the limited lateral group, there was no difference in rates of death or complications. Patients with muscle-sparing incisions showed significantly better late preservation of forced vital capacity and flow during the midportion of the forced vital capacity but not of other pulmonary volumes and flows. We conclude that limited incisions may result in slightly better late pulmonary function, but that the differences are small and of no apparent clinical advantage in the average patient.

Pleuroperitoneal shunting for intractable pleural effusions.

Pleuroperitoneal shunts were implanted in 17 patients with intractable pleural effusions, 15 of which were malignant and 2 benign. Complicating factors included 13 instances of severe trapped lung and 3 cases of synchronous ascites. There was one hospital death. Palliation of dyspnea at rest was achieved in all patients, although 3 required oxygen with exertion. Four shunts became occluded between 1 and 10 months after placement. Two of these were replaced. The remaining conduits continued to function to the present or until the patients' deaths between 1 and 28 months. Shunting allowed hospital discharge and provided symptomatic relief in a group of patients in whom other approaches had failed or were not applicable.

Transaxillary thoracotomy revisited.

Transaxillary thoracotomy is a well-known but underused approach to both benign and malignant conditions in the chest. The traditional posterolateral thoracotomy affords little advantage over this incision in terms of staging of disease or therapeutic resection. Previous reports have emphasized the wide range of conditions for which this approach is suitable, but advances in the technique and design of stapling devices and routine use of the double-lumen endotracheal tube have further enhanced its indications. We have reviewed 54 consecutive patients who have undergone transaxillary thoracotomy over a 2 1/2-year period. The wide range of procedures performed up to and including pneumonectomy indicates the versatility of the approach. We now consider transaxillary thoracotomy to be the incision of choice for most pulmonary and mediastinal lesions and an attractive alternative to mediastinoscopy for the identification and staging of chest tumors.

Effect of beta-adrenergic blockade on the growth rate of abdominal aortic aneurysms.

We retrospectively identified 136 patients with abdominal aortic aneurysms (AAAs) who were initially evaluated as outpatients. Twenty-seven of these patients met the following criteria for eligibility in the study: (1) roentgenographic documentation of an AAA larger than 3 cm, (2) at least two serial ultrasound size determinations over a minimum six-month interval, and (3) a documented medication history. Of these 27 patients, 12 received long-term beta-blockade, while 15 received no beta-blockade. The two groups were comparable with respect to age, sex, initial aneurysm size, mean systolic and diastolic blood pressure, and duration of follow-up (mean, 34 months). Among patients with beta-blockade, the mean growth rate was 0.17 cm/y. The rate for the controls was 0.44 cm/y. One patient of 12 (8%) in the beta-blocker group had a rate that exceeded the mean for the overall group compared with eight patients of 15 (53%) in the group with no beta-blockade. This difference was statistically significant. Thus, beta-blockade may be associated with a decreased AAA growth rate in this small, retrospective study.

Distal splenorenal shunt vs. portal-systemic shunt: current status of a controlled trial.

A prospective controlled comparison of portal-systemic (PSS) and distal splenorenal shunts (DSRS) in cirrhotic patients who had survived hemorrhage from esophagogastric varices was undertaken 5 yr ago at five hospitals by the Boston-New Haven Collaborative Liver Group. The clinical and endoscopic criteria for massive hemorrhage were satisfied in 155 patients. Thirty-four patients were excluded, primarily because of uncontrolled hemorrhage. Thirty-four were rejected because the were poor operative risks and 21 because they did not satisfy criteria. Thirteen patients refused to participate; the remaining 53 were randomized; 29 to receive PSS and 24, DSRS. The two groups were similar in clinical, laboratory, and manometric characteristics. The DSRS group was older and tended to have had more previous hemorrhages. Followup ranged from 1 to 56 months (mean 21). After PSS, which was performed by 10 different surgeons, 6 patients died during the hospital admission (21%) compared to 2 after DSRS (12%). There were 6 late deaths in the PSS group and 4 in the DSRS group. Portal-systemic encephalopathy occurred in 5 of the 23 survivors of PSS (23%), and in 6 of the 19 who survived DSRS (32%. Two patients in the PSS group bled (9%), 1 after thrombosis and 1 after stenosis of the shunt. Three patients in the DSRS group bled (16%) and all had thrombosis of the shunt. PSS was associated with an unexplained but inordinately high operative mortality. Although the DSRS was accomplished with an acceptably low operative mortality, it was associated with frequent portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage. Similar incidences of portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage were observed in the PSS group. More patients and longer followup are necessary to determine which of these portal decompressive procedures is superior.

Catamenial pneumothorax.

Five patients with catamenial pneumothorax are reported, four of whom had proven diaphragmatic defects. Two had microscopic diaphragmatic endometrial implants in the area of the defects. No specimen was obtained in two others. A fifth patient with the condition, as well as with extensive pelvic endometriosis, was treated successfully by closed thoracostomy followed by hysterectomy and salpingo-oophorectomy. Patients with recurrent catamenial pneumothorax should be assumed to have diaphragmatic defects and be considered for treatment by thoracotomy and closure of these defects if the severity of the condition warrants it.

Splenic artery aneurysm rupture in pregnancy. A review and case report.

The fourth case of fetal and maternal survival following rupture of a splenic artery aneurysm is presented among 90 reported cases occurring during pregnancy. The previously reported cases are reviewed. A high level of awareness and careful review of history and physical findings in the absence of evidence of the more common causes of concealed hemorrhage may lead to the diagnosis. Ligation of the aneurysm and splenectomy is the indicated therapy.

Pulmonary embolism and intracardiac shunt: a unique indication for operation.

Pulmonary embolism with right-to-left intracardiac shunt presents a special problem for the clinician. A review of the literature and 4 personal cases, all diagnosed antemortem, are presented. On the basis of this information certain conclusions are drawn, and we suggest the problem to be a unique indication for the consideration of surgical intervention.