Resection of more than 10 lung segments. A 30-year survey of 30 bronchiectatic patients.

A series of 30 bronchiectatic patients, treated by bilateral resection of 11, 12, or 13 lung segments, has been followed up for 30 years. The progress of the patients is analyzed and the results of treatment are evaluated. Ten patients required further resections for persisting collapse, kinking of the apical segment of a lower lobe, or because the previous resection had been too limited. The long-term results of these extensive bilateral resections in our group of patients are excellent. The quantitative function, more than 20 years after the last resection, lies markedly above the predicted value for the number of remaining segments. The qualitative function did not deteriorate over the years. It is clear that extensive bilateral bronchiectasis does not, per se, constitute a contraindication to resection, provided that at least six normal segments can be preserved.

Dilatation, compensatory growth, or both after pneumonectomy during childhood and adolescence. A thirty-year follow-up study.

The ventilatory function of 230 patients with pneumonectomy, performed at ages ranging from 2 to 40 years, has been followed for more than 30 years (mean 33 years). We have tried to analyze whether the available data gave information about the nature and the mechanisms adapting the remaining lung to the larger than normal pleural space and about the persistence of this adaptation in the longer term. There were 32 patients with a persistent, disturbed forced expiration (mean 50% of vital capacity). This group of patients was excluded from the study to answer the above questions, because the subdivisions of the total lung capacity in this group differed significantly from those in the group of 98 patients with a normal forced expiratory volume of 72% (mean) of vital capacity. The data of the 98 patients, who were subdivided into seven age groups at the time of pneumonectomy, permitted the following conclusions: In the youngest age group (0 to 5 years), the ventilatory capacity is hardly smaller than the predicted capacity for two lungs; this suggests that compensatory growth by way of hyperplasia might have been the most important adaptive mechanism in this group. In the age group 6 to 20 years, a significant difference is still found as compared to the group of patients operated on at an older age; this difference indicates that in this period compensatory growth, possibly mainly simple hypertrophy, still played an important but gradually decreasing role. The fact that the effect of the adaptational mechanisms could be observed more than 30 years after ablation of one lung, without loss in quality of function (i.e., forced expiratory volume constituting a normal percentage of the vital capacity), indicates that the adaptive mechanisms also compensate for the loss in lung tissue in the longer term. A striking finding was the stability of the tidal volume/functional residual capacity ratio, which, especially in the younger age groups, was very close to the predicted value for two lungs. This finding is in agreement with the fact that most persons with a healthy remaining lung lead a normal family and social life after pneumonectomy.

Sustained-release terbutaline in nocturnal asthma.

Fifteen adult patients with nocturnal asthma entered a double blind study. They received a single evening dose of one sustained-release (SR) terbutaline tablet à 7.5 mg or an identical placebo tablet for 1 week, each in a randomised cross-over fashion in addition to their usual medication. In the 12 evaluated patients there was no change in evening PEF but a significant improvement in morning PEF (P less than 0.05) and in overnight fall of PEF (P less than 0.01) on active treatment. Symptoms were improved by both placebo and active medication. Three patients experienced tremor as a side effect. A single evening dose of SR-terbutaline can be of help in nocturnal asthma.

Alpha 1-antitrypsin deficiency and the flaccid lung syndrome. The heterozygote controversy.

A significantly higher number of PI ZZ and PI MZ individuals was found in a flaccid lung population as compared to internal and healthy controls. The relative risk for ZZ is 12.5 and for MZ 1.8. We conclude that if a PI MZ individual does develop lung disease, the excess risk due to the deficiency is negligible compared to MM individuals and is highly influenced or modified by other factors, possibly including both environmental and genetic.

Bullectomy for giant bullae in emphysema.

The results of changes in dyspnea and pulmonary function are reported in 27 emphysematous patients followed up for about 10 years after removal of giant bullae, which occupied at least 50% of a hemithorax. In 10 patients bilateral bullectomy was done. The spirographic improvement depends on the type of bulla. Resection of bullae at open communication with the bronchial tree resulted predominantly in improvement of forced expiratory volume as a percentage of vital capacity, whereas after closed bullae were resected, the increase in vital capacity was most apparent. Dyspnea lessened in all patients. Seven older patients died of ventilatory insufficiency. Preoperatively they were clinically and functionally severely disabled. They improved markedly after bullectomy, and their mean survival time was more than 7 years. In all 27 patients improvement of dyspnea and pulmonary function lasted several years and only gradually returned to preoperative values and beyond. No giant bullae recurred in the observation period; neither was there an accelerated progression of the emphysematous process. Our present selection criteria, based on previous experience, are as follows: giant bullae occupying at least 50% of a hemithorax, definite displacement of adjacent lung tissue, exclusion of the presence of vanishing lung syndrome, and absence of chronic purulent bronchitis.

The alpha 1 antitrypsin variant PI WFINNEYTOWN in a family of Caucasian origin.

During a routine screening a slow moving variant PI WFINNEYTOWN was traced in a family of Caucasian origin. The variant is not identical to W SAL and W COL. W FIN was originally detected in an American family of different ethnic origin. It is suggested that heterogeneity exists at the gene level, which is not detectable with conventional methods at the protein level.

Late complications of major thoracic surgery.

Long-term consequences of major lung surgery were evaluated by: a prospective study of 206 pneumonectomy patients operated upon between 1947 and 1952 for tuberculosis; a retrospective study of 449 pneumonectomy patients operated upon between 1946 and 1974 for bronchial carcinoma at an age of 60 or over; a prospective study of 80 patients who underwent bilateral resection for bronchiectasis between 1940 and 1974. The main conclusions of these studies are: After pneumonectomy for non-malignant disease, life expectancy is slightly reduced in comparison with a matched group from the general population. Thoracoplasty and pneumonectomy proved less favorable. From the spirographic data the actual vital capacity (VC) showed the closest relation to life expectancy. In patients with bronchial carcinoma there was no relation between survival and the postoperative spirographic data. Preoperative and postoperative mortality was the same in the elderly as in the younger group of patients. Survival depended mainly on the malignancy itself. In bronchiectasis the results were good when a normal qualitative function was present. Unsatisfactory results were found in patients with chronic obstructive pulmonary disease. The VCs after surgery are well above the predicted values for the remaining segments. The presence from early youth on of non-functioning lung tissue, and its removal apparently result in a compensatory increase of the VC of the remaining segments. Life expectancy is good, even if the number of resected segments surpasses that of a right-sided pneumonectomy.

Lamellar bodies isolated from adult human lung tissue.

Lamellar bodies, the intracellular storage form of pulmonary surfactant, were isolated from adult human lung tissue. As shown by electron microscopy, the isolated human lamellar bodies resembled the lamellar bodies isolated from experimental animals. Chemical analysis revealed that the lamellar bodies consisted largely of lipids, particularly phospholipids (85%). The major phospholipid was phosphatidylcholine, which accounted for 71% of the total phospholipids. Phosphatidylglycerol and phosphatidylethanolamine were 10 and 8%, respectively, of the lamellar body phospholipid. Phosphatidylserine, phosphatidylinositol, lysophosphatidylcholine, and sphingomyelin were minor components. Cholesterol was found to represent 60% of the neutral lipids or 9% of the total lipids. Phosphatidylcholine contained largely saturated fatty acids, of which palmitic acid was the most abundant. Disaturated phosphatidylcholines comprised 67% of the total phosphatidylcholines. Phosphatidylglycerol and phosphatidylethanolamine contained considerably less saturated fatty acids. Only 24% of phosphatidylglycerol was disaturated. The chemical composition of adult human lamellar bodies was very similar to that of lamellar bodies derived from experimental animals. The similarities in morphology and chemical composition of lamellar bodies suggest that surfactant metabolism in human lung may be similar to that of other mammals.

Lung function data on 123 persons followed up for 20 years after total pneumonectomy.

Consecutive spirographic data of 123 pneumonectomized patients obtained before pneumonectomy, at discharge from hospital, in 1955 (CU1) and in 1975 (CU2) are presented. The mean observation time was of more than 20 years. The loss in inspiratory vital capacity (VC) proved considerably smaller than predicted from transversal studies. It was most pronounced in patients with thoracoplasties and in persons with left remaining lungs. The FEV1 as a percentage of total lung capacity (FEV1%TLC) evidently obviated the qualitative pulmonary function loss over the years. At the same time, data from 25 of 33 patients who died between CU1 and CU2 are reported (mean survival time 15.1 years). The survival rate of the initial group of 168 persons at CU1 was 14% below that of a control group of the same population. Life expectancy in pneumonectomized patients proved to depend more on the quantity of the lung parenchyma available, i.e. the actual inspiratory VC than on the quality as judged from the FEV1 in relation to lung volume.

Lobectomy with sleeve resection in the treatment of tumors of the bronchus.

We evaluated the results of right upper lobectomy with a sleeve resection of the right main bronchus in 50 patients with a bronchial neoplasm. Four patients (8 percent) died during surgery or postoperatively. Eight of the 22 patients who underwent surgery for carcinoma between the years 1960 and 1974 had tumor-positive hilar lymph nodes. They died as a result of subsequent extension of the resected carcinoma. Fourteen of the 22 patients had no lymph node metastasis and nine of them (64 percent) were alive after five years without detectable recurrence. The finding of positive hilar lymph nodes contraindicates sleeve resection. In these cases, when pneumonectomy is impossible from a functional point of view, sleeve resection is to be regarded as a palliative procedure.

Postpneumonectomy oesophagopleural fistula.

Patients with oesophagopleural fistula after a pneumonectomy present a difficult therapeutic problem. There are two types of presentation, early and late. We report three cases in addition to the 49 previously published. All three patients developed their fistulae after right-sided pneumonectomy (one month, four years, and 21 years respectively) and presented with the features of an empyema. The existence of an oesophagopleural fistula can be demonstrated by the discovery of food particles in the pleural aspirate, by direct visualisation during oesophagoscopy after instilling methylene blue into the pleural cavity, by barium swallow, or by identification of helium in the pleural space after swallowing a mouthful of helium. After the initial treatment of empyema we believe that surgical repair of the oesophagopleural fistula is the treatment of choice.