Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion.

A case of postoperative torsion of the left upper lobe following thoracotomy for removal of a large mediastinal tumor is presented. Diagnosis was made on the sixth postoperative day by axial computerized tomography. At rethoracotomy the upper lobe, well delimited against the lower lobe by deep fissure, was found to be twisted by 180 degrees in clock-wise direction. It was hemorrhagically infarcted and had to be resected. The patient, a 37-year-old woman, made an uneventful recovery thereafter. In a recent epidemiological study in the United Kingdom it could be shown that postoperative torsion occurs more frequently than hitherto presumed. 35 of 117 thoracic surgeons responding to a questionnaire had observed this complication 36 times. In reviewing the literature for welldocumented cases, four cases of spontaneous, five of posttraumatic, and 17 cases of postoperative pulmonary torsion were found. Of these cases and the case reported 12 torsions occurred after partial lung resection and six following other thoracic operations. Especially the right middle lobe is endangered after upper lobectomy and should be fixed to the lower lobe during surgery. The outcome was fatal in 4 of the 18 cases. Prevention and treatment are discussed.

[Surgical treatment of metapneumonic pleural empyema]. / Chirurgische Behandlung des metapneumonischen Pleuraempyems.

During a period of 13 years 54 patients have been treated for metapneumonic pleural empyema, namely 3 children (all boys), 31 men and 20 women. One patient was admitted in extremis heavily intoxicated after unsuccessful attempt at closed drainage. He died during thoracotomy for open drainage. All the remaining 53 patients were cured, 3 out of 18 by closed thoracostomy (Bülau), 12 out of 16 by open drainage and 37 by decortication which had to be combined with pulmonary resection 13 times. Local treatment of pleural empyema is aimed at the obliteration of the pleural space. This goal can best be accomplished: in the acute exudative stage of the disease (according to the American Thoracic Society) by closed thoracotomy, in the fibrino-purulent phase by open thoracotomy with rib resection and in the chronic organizing stage by decortication.

[Results of resection treatment of locally limited bronchial carcinoma (Stages I and II)]. / Resultate der Resektionsbehandlung des lokal beschränkten Bronchuskarzinoms (Stadium I und II).

Of 238 patients operated upon for bronchogenic carcinoma between 1977 and 1985 the tumor was locally limited in 108, of whom, according to the new international staging system, 66 patients were in stage I (T1N0 + T2N0) and 42 in stage II (T1N1 + T2N1). 89 were male and 19 (18%) female. The mean age was 61.6 years in stage I und 63 years in stage II patients. 26 patients (24%) were aged over 70. All patients underwent potentially curative excision of the tumor. This was accomplished by partial lung resection in 97 patients, of whom 84 underwent lobectomy with 2 postoperative deaths (2.4%). Operative mortality amounted to 5.5% in the whole group (6/108), with 3% (2/66) in stage I and 9.5% (4/42) in stage II patients. The absolute survival rate at 5 years was 50% for all 108 patients, 59% for the 66 patients in stage I and 39% for the 42 patients in stage II. It was 70% for 15 patients with bronchioloalveolar carcinoma, 54% for 20 patients with adenomatous cancer and 49% for 56 patients with squamous carcinoma. At present 62 of the 108 patients are still alive (57.4%), i.e. 45 out of 66 in stage I (68%) and 17 out of 42 in stage II (40.5%). This retrospective study therefore confirms former reports that long term results are encouraging in the locally limited stages of pulmonary cancer. In addition, operative mortality is low because almost all these tumors can be removed by partial lung resection. In stage I lobectomy is the method of choice.

[Results of the surgical treatment of locally-advanced bronchus carcinoma (stage III)]. / Resultate der operativen Behandlung des lokal fortgeschrittenen Bronchuskarzinoms (Stadium III).

117 patients with stage III bronchogenic carcinoma (AJC) underwent thoracotomy after careful staging between 1977 and 1985. 13 patients were found to be inoperable, while in 104 resection was performed. Operative mortality was 8.5% for 82 patients with curative resection and 27% for 22 patients with non-curative resection. Histologically there were 64 epidermoid and 23 adenomatous carcinomas. 79 of the 117 patients had lymph node metastases, 49 of them in mediastinal (N2) nodes of whom 42 could be resected. The absolute 5-year survival rate amounted to 9% for all 104 patients, 12% for 82 patients following curative resection and 0% for 22 patients following non-curative resection. 14% of the latter patients survived for two years. Survival rate after to years was 29% for patients in stage T3N0 + T3N1 and 35% for those in stage T1, T2, T3N2, but 15% and 0% respectively after five years. 5-year survival rate was 15% for patients with epidermoid carcinoma, but 0% for adenomatous carcinoma. Mean survival time for the 58 patients who died late following curative resection was 14.3 months, for those with epidermoid carcinoma 15.9 months and with adenomatous carcinoma 15.4 months, following pneumonectomy 13.1 months and following partial resection 17 months, and for the 16 patients who died late after non-curative resection 12.7 months. It was not influenced by postoperative irradiation in 20 patients (13 months). No statistical significance could be demonstrated for all these results. Nevertheless, they seem to indicate that in stage III bronchogenic carcinoma patients with epidermoid type have a fairly good prognosis, while with mediastinal lymph node metastasis the outcome is poor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cavernous bronchus carcinoma]. / Das kavernisierte Bronchuskarzinom.

In thoracic surgery patients the etiology of cavities has drastically changed in the last 20 years. While at present only very few patients need surgery for cavernous tuberculosis, cavities of cancerous origin are becoming more and more frequent. During the period from 1977 to 1985 24 out of 225 bronchogenic carcinomas treated by resection were found to be cavernous (10.7%). Radiologically the degree of cavitation extended from a small marginal or central air collection to the formation of large, irregular, and thick-walled caverns. The excavation is the result of necrobiotic changes within the tumor. It arises when the tumor masses penetrate into the bronchial tree and are expectorated. However, prognosis of cavitated cancer remains exclusively dependent on the stage of the tumor. The cavitation itself seems not to influence it.

[The value of mediastinoscopy in the diagnosis of hilar and mediastinal lymph node enlargement]. / Die Bedeutung der Mediastinoskopie für die Diagnose hilärer und mediastinaler Lymphknoten-Vergrösserungen.

Of 116 mediastinoscopies performed over a period of 5 years without serious complications, 36 were for diagnosis of obvious or suspected mediastinal and hilar lymphadenopathy. In 34 of these 36 procedures large samples of paratracheal lymph nodes were excised for histological and partially also for bacteriological examination. In 24 patients a definite diagnosis was obtained (mediastinoscopy positive). There were 17 cases of sarcoidosis among them. The investigation was negative in 10 other patients. In 6 of these the negative result was fully explained by the final diagnosis (true negative mediastinoscopy). Only in 4 of the 34 patients a different disease affecting the lymph system was discovered by further investigations (false negative). All four patients had neoplastic disease. In accordance with the results of other investigators, the author's findings show that suspicion of sarcoidosis can be confirmed mediastinoscopically in almost 100% of cases. However, mediastinoscopy was not equally successful in diagnosing Hodgkin's disease and malignant lymphoma. The paratracheal lymph nodes were affected only in approximately half of these patients, although other intrathoracic lymph nodes, e.g. the anterior and/or posterior nodes, were shown to be involved. In these cases diagnosis can be obtained only by thoracotomy and/or staging laparotomy.

[Endobronchial metastases of extrathoracic malignancies]. / Endobronchiale Metastasen von extrathorakalen Malignomen.

The importance of endobronchial metastases originating from extrathoracic malignant tumors is emphasized and illustrated with 11 personally observed cases and with 87 cases from the literature. The primary tumors most frequently found are carcinoma of the breast, hypernephroma, and carcinoma of colon and rectum. 7 of the authors' own 11 patients are still alive at the time of publication, including two women 24 and 12 months respectively after pulmonary resection for endobronchial metastasis from carcinoma of the rectum.

[Massive lung necrosis in klebsiella pneumonia (so-called massive lung gangrene)]. / Ausgedehnte Lungennekrose bei Klebsiellen-Pneumonie (sogenannte massive Gangrän der Lunge).

In the literature only 13 cases of voluminous necrosis of lung tissue, generally referred to as massive pulmonary gangrene, could be found. This disease constitutes an unusual, very severe complication of lobar pneumonia, mostly due to Klebsiella. This type of pneumonia generally affects old or otherwise debilitated persons, quite often chronic alcoholics. It has a high lethality of 20%. Our own observation in a 48-year-old man is presented. He suffered from recurrent massive hemoptysis in relation with a huge cavity of the right lung, filled with necrotic lung tissue. Following right pneumonectomy empyema developed, also due to Klebsiella; it was successfully treated with thoracic fenestration according to Clagett. Knowledge of this severe infrequent complication of pneumonia is necessary since it requires early operative treatment: Out of the 14 patients four were treated medically only and died, while the remaining ten underwent surgery and were all cured.

[Postoperative complications following pulmonary surgery (author's transl)]. / Postoperative Komplikationen nach Lungensperation.

Postoperative complications occurring in a series of 177 patients undergoing lung surgery are discussed in detail according to their pathogenesis. In all, 68 serious complications were observed in 54 patients (30.5 per cent). 9 patients died as a result of these complications (letality rate of 5.1 per cent).