Chest wall resection and reconstruction via a muscle-sparing minithoracotomy for lung cancer.

Five per cent of lung cancers involve the parietal pleura and chest wall. En bloc resections improve survival. Lung resections via muscle-sparing chest incisions have minimized complications and hospital stay. We present a case in which we performed an en bloc lobectomy with chest wall resection and reconstruction through a muscle sparing minithoracotomy in a 48-year-old woman. She was discharged in the fourth postoperative day and remains tumor free and asymptomatic after 4 years.

Muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia: an improved method for major lung resections.

To decrease incisional pain, morbidity, and length of hospital stay (LOS) and, hopefully, to reduce costs, most surgical specialties have turned to minimally invasive procedures to access the body cavities during commonly performed operations. Video-assisted thoracic surgery (VATS) has emerged as the standard approach for a number of diagnostic and therapeutic procedures in thoracic surgery. Major lung resections (lobectomy, bilobectomy, and pneumonectomy), however, can be performed through an incision similar in size to the utility or access thoracotomy used in VATS to remove the specimen. The purpose of this study was to compare an oblique muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia with the standard posterolateral thoracotomy incision and VATS to perform major lung resections. Forty consecutive patients with bronchogenic carcinoma, operated on by a single surgeon, were chronologically divided into two groups, each with equivalent age, sex distribution, physiologic parameters, tumor size, and clinical stage. In addition, data were collected from a MEDLINE search of all published studies in which major lung resections were performed via VATS. The first group (group A, n = 20) underwent posterolateral thoracotomy to access the chest cavity, whereas the patients in the second group (group B, n = 20) underwent oblique minithoracotomy with intercostal nerve cryoanalgesia. Group B compared favorably with group A in LOS (P = 0.002), narcotic requirements (P = 0.001), morbidity (P = 0.042), and cost (P = 0.058). Group B also compared favorably with VATS major lung resection published data regarding LOS and morbidity.

One-day admission for lung lobectomy: an incidental result of a clinical pathway.

BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

Munchausen syndrome with pulmonary manifestations.

Three patients with Munchausen's syndrome were seen with symptoms suggesting serious pulmonary disease. One patient, a student respiratory therapist, simulated respiratory failure which resulted in a tracheostomy and prolonged ventilator support. The second, a licensed practical nurse, feigned a lupus erythematosis syndrome, with alarming, simulated hemoptysis produced by slashing the posterior tongue with a razor blade. The third patient, a nurse, underwent exhaustive testing at three hospitals for profuse "hemoptysis" until she admitted she obtained the blood from her arm by venesection.

Transbronchoscopic lung biopsy in sarcoidosis. Optimal number and sites for diagnosis.

By obtaining five transbronchoscopic biopsies of the lung from each of the right upper and lower lobes, the diagnosis of sarcoidosis was made in 36 of 37 prospectively studied patients. The diagnosis was made in all ten patients with stage-1 disease, but seven of the ten showed diagnostic tissue from only one lobe. Only one of the ten biopsies was diagnostic in four of those patients with a stage-1 disease. In disease of stage 2 and 3, there was good correlation between diagnostic biopsies and the radiographic distribution of infiltrates. Biopsies from the predominantly rather than the lesser involved lobe proved the diagnosis in all of these patients, except for the two patients with nodular sarcoid. We conclude that ten biopsies are optimal for obtaining the diagnosis in stage-1 disease; however, five biopsies may be adequate in non-nodular disease of stage 2 and 3 if the biopsies are of the lobe predominantly involved on the roentgenogram of the chest.

Tuberculosis in Oriental immigrants: a study in military dependents.

Tuberculosis in Oriental immigrants is likely to be resistant to therapy with certain drugs. In 73 military dependents with positive cultures for tuberculosis who immigrated from six Asian countries, the tuberculosis was found to be resistant to isoniazid in 58 percent (42 patients), to streptomycin in 36 percent (26 patients), to p-amino-salicylic acid in 14 percent (ten patients), to rifampin in 7 percent (five patients), and to ethambutol in 7 percent (five patients). Despite the presence of drug-resistant organisms and often extensive disease, negative cultures were attained in all but one patient. Consideration of the high incidence of drug-resistant tuberculosis should be made in planning a program of treatment for these patients. Recognition of cultural differences may also be of value in the successful treatment of this difficult group of patients.