"Stripping" to prevent prolonged air leak; is there a future in the past?

BACKGROUND: A number of technical precautions and many synthetic or biological materials have been suggested to reduce the frequency of prolonged air leak (PAL) following lung resection. Preserving the three-dimensional properties of the remaining lung parenchyma may prevent this complication to some extent. This study presents our experience with an old technique called "stripping" for the division of incomplete fissures to preserve the original shape of the remaining lung with the hope that this will minimize PAL-related problems. METHODS: 262 consecutive patients with incomplete fissures underwent lobectomy or bilobectomy. Stripping was employed for the division of incomplete fissures in Group S (Study arm; n = 148) and a cut-and-sew technique or staplers were used in Group C (Control arm; n = 114). To evaluate a possible learning curve effect with this technique, Group S was further divided into two subgroups, designated the initial experience (Group S (IE)) and the late experience group (Group S (LE)) and consisting of the first 1/3 (n = 50) and remaining 2/3 (n = 98) of patients, respectively. The frequency of PAL and other related morbidities were investigated. RESULTS: Morbidity and mortality rates were comparable between Group S and C (10 % vs. 8.7 % and 2 % vs. 2.6 %; P = 0.83 and P = 0.96), as was the frequency of PAL, which occurred in 12 (8.1 %) and 13 (11.4 %) patients ( P = 0.40), respectively. When each of the subgroups was compared with Group C, PAL occurred in 9 (18 %) patients in Group S(IE) ( P = n. s.) but only in 3 (3 %) patients in Group S(LE) ( P = 0.03). There was also more postoperative persistent air space in Group C, without this difference reaching statistical significance. CONCLUSION: This study suggests that preservation of the original shape of the remaining lung might decrease the incidence of PAL in patients with relatively healthy lung tissue. An actual favorable effect of stripping over other techniques emerges only when the technique is precisely applied, which is only possible with experience.

VATS decortication in patients with stage 3 empyema.

We present here a technique for VATS decortication in patients with stage 3 empyema. It was undertaken with satisfactory outcomes in a limited number of patients. In our technique, the fibrous peel at the surface of the lung is completely removed via two or three incisions without parietal decortication. We believe that our technique will be improved with increased experience and may be an alternative to open thoracotomy and decortication in a selected group of stage 3 empyema patients.

A quick technique for division of the first rib using a posterior approach.

Here we describe a simple and quick technique for anterior division of the first rib using a posterior approach. In this technique, the tip of a right angled clamp is introduced through the fibers of the anterior scalene muscle and the rib is turned completely. Then, the clamp is opened wide enough to obtain a space for division of the rib using a bone cutter.

Sedation for fiberoptic bronchoscopy: fewer adverse cardiovascular effects with propofol than with midazolam.

OBJECTIVE: To study the influence of the sedatives propofol and midazolam on cardiovascular parameters in patients undergoing fiberoptic bronchoscopy (FOB). METHODS: 100 patients without a history of cardiac disease undergoing diagnostic FOB were investigated in a prospective-randomized design. After premedication with intramuscular atropine (0.01 mg/kg BW) patients received sedation with either propofol (group P, n = 50) or midazolam (group M, n = 50). Heart rate, arterial oxygen saturation (psaO (2)) and non-invasive blood pressure were recorded prior to and immediately after induction of sedation, when at the level of vocal cords, during the interventional diagnostic procedure (IDP) and 15 min after the end of the FOB. RESULTS: The mean heart rate and systolic pressure were significantly lower in group P when compared with group M when at the level of vocal cords and during the IDP (p < 0.05). The total incidence of major arrhythmias was 10 % and the incidence of minor arrhythmias was 62 %. A decline in psaO (2) < 90 % occurred in 16 patients of group M and 5 patients of group P (p = 0.44). CONCLUSION: Propofol, when used as a sedative for FOB, is associated with lower hemodynamic side effects than in patients undergoing FOB with midazolam. In addition, it is well-tolerated by patients with pre-existing pulmonary disease. Even patients without a history of heart disease should be monitored for cardiac arrhythmia while undergoing FOB for pulmonary disease, especially patients with a FEV (1) of less than 50 % of the predicted value.

Chylothorax: a complication following lung resection in patients with NSCLC - chylothorax following lung resection.

BACKGROUND: Chylothorax following lung resection is not as rare as a postoperative complication as previously reported due to systematic lymph node dissection in patients undergoing lung resection for NSCLC. METHODS: We retrospectively reviewed our cases that had undergone lung resection for NSCLC and investigated the frequency and outcome of chylothorax in these patients. The factors investigated were the site and type resection, technique of systematic lymph node dissection, tumour histology and disease stage. RESULTS: Seven of 673 patients that had undergone lung resection were complicated by chylothorax (1.04 %), following lobectomy in 5 (1.28 %) and pneumonectomy in 2 (0.7 %) (p = 0.36). The fistula closed spontaneously in 5 patients between 4 - 17 days postoperatively (71 %). One of the patients in the conservative management group died on the 28th day postoperatively due to pneumonia (14 %). The remaining 2 patients underwent rethoracotomy on the 5th and 6th days. CONCLUSIONS: These results suggest that the site of operation, type resection, and technique of systematic nodal dissection, tumour histology and disease stage do not influence the development of chylothorax in patients with NSCLC. The chylous fistula following lung resection for NSCLC tends to close spontaneously.

[Thoracic trauma: analysis of 987 cases]. / Gögüs travmalari: 987 olgunun analizi.

In Izmir Chest Diseases and Thoracic Surgery Training Hospital, Department of 1st Thoracic Surgery, between 1988 and 1998, 987 patients who were treated for their chest trauma were retrospectively reviewed in regard to their age, sex, cause of trauma, associated organ injuries, treatment modality, complication rate and mortality. In 710 (72%) cases of chest injuries were related to blunt trauma and 277 (28%) patients sustained penetrating trauma. 402 (41%) patients underwent tube thoracostomy only. While majority of patients (553 pts, 56%) were managed conservatively, only 32 (3%) underwent thoracotomy. Complication rate in our series was 4.6% and the most frequently atelectasis was seen. 13 patients died due to trauma related causes (mortality: 1.3%). There was no difference between blunt and penetrating trauma patients in view of morbidity and mortality rates (p = 0.29 and p = 0.10, respectively). Mean hospital stay among all patients was 9.6 +/- 8.6 days. This period was 10.0 +/- 8.5 days in blunt trauma group, and 8.4 +/- 8.6 days in penetrating trauma group. However this difference has reached statistical significance at a p value of 0.0068.

Results of pneumonectomy for cancer in patients with limited ventilatory function.

It is well established that patients with compromised pulmonary function have a greater incidence of morbidity and mortality following lung resection. The prognosis of 36 (9.7%) patients with poor respiratory function (forced expiratory volume in ls (FEV1) and FEV1/FVC (forced vital capacity) ratio were equal to or less than 50% of the predicted value) of a total of 369 patients who underwent pneumonectomy due to non-small cell lung carcinoma over 10 years were reviewed. All but three patients were male with a median age of 62.5 years. Right pneumonectomy was carried out in 12 (33%) and left in 24 (67%) patients. Median FEV1 and FEV1/FVC were 1.51 (46%) and 46.5% respectively. Three (8%) patients died within 30 days of surgery. The postoperative complication rate in patients with poor respiratory function was 44%. Nine (27%) of the hospital survivors died due to non-malignant causes (recurrent chest infection/respiratory failure) and 12 (36%) due to recurrent tumour. The cause of death in one patient was second primary lung tumour and it was unknown in three (9%) patients. Eight (24%) long-term surviving patients did not have severe respiratory symptoms; their FEV1 and FEV1/FVC were remeasured and revealed a median 1.05 l (38%) and 50%, respectively of the predicted value. Actuarial 5-year survival was 29%. Poor respiratory function is associated with postoperative complications and non-malignant deaths arising secondary to respiratory failure. The survival profile demonstrates that patients were successfully treated with pneumonectomy and suggests that surgery should not be withheld from those with limited lung function if detailed investigations predict adequate residual lung function.

Fate of patients with residual tumour at the bronchial resection margin.

The presence of microscopic deposits of tumour cells at the bronchial resection margin (BRM) may adversely affect the prognosis of patients. Residual tumour cells were identified at the BRM in 40 (5.4%) of 735 patients who had been operated on for non-small cell lung carcinoma (NSCLC). The extent of disease was stage I in 7 (17.5%), stage II in 21 (52.5%), stage IIIa in 10 (25%) and stage IIIb in 2 (5%) patients. Malignant cells were found to have infiltrated the submucosal lymphatics in 5 (12.5%) cases and the peribronchial tissue in the remaining 35 (87.5%). Fifteen (37.5%) patients received adjuvant radiotherapy (RT). Recurrence of the disease was diagnosed in 29 (72.5%) patients after a median of 17 months (range 3-111). The recurrence was local in 17 (59%) and distant in 12 (41%). The 5-year overall actuarial survival rate was 21.6% and was not affected by RT (P = NS). Only patients with stage IIIa disease and a positive bronchial stump had a significantly reduced 5-year survival rate compared to those with a negative stump, 0% vs 17% (P < 0.001). Tumour cells at the resection margin did not affect the survival in this cohort except those with stage IIIa disease, and the addition of adjuvant RT did not significantly affect its recurrence in patients with NSCLC.