Biomedical subjects
J G Hentz
Publications and source records attributed to J G Hentz.
Tracheobronchial lacerations after intubation and tracheostomy.
BACKGROUND: Although long-term complications of intubation and tracheostomy are well documented, little has been reported on acute complications of airway access techniques. METHODS: Fourteen patients (1 male and 13 female patients) aged 15 to 80 years presented with tracheobronchial lacerations after single-lumen intubation (n = 9), double-lumen intubation (n = 1), or tracheostomy (n = 4). RESULTS: A left bronchial laceration after double-lumen intubation was discovered and repaired intraoperatively. A tracheal laceration after single-lumen intubation was recognized during induction of anesthesia. The remaining 12 were diagnosed within 6 to 126 hours (median, 24 hours) after injury. All patients had mediastinal and subcutaneous emphysema. At endoscopy, 12 injuries were located in the thoracic trachea and 1 in the cervical trachea. Twelve underwent primary repair through a right thoracotomy (n = 11) or left cervicotomy (n = 1), and 1 was treated conservatively. Two patients with tracheostomy injury died postoperatively. All repairs healed well but one. The latter was performed 5 days after the injury; a dehiscence occurred, but healed spontaneously. CONCLUSIONS: We conclude that prognosis of tracheal lacerations depends both on the general health of the patient and on the rapidity of diagnosis and treatment.
[Do pericardial strips (Peri-Strip) facilitate the follow-up after pulmonary surgery in emphysematous patients?].
The aim of this study was to evaluate the contribution of bovine pericardial strips (Peri-Strip) to achieve aerostasis within emphysematous lungs. A preliminary evaluation included 15 patients (13 men and 2 women, mean age 57 years) with severe emphysema (mean FEV-1: 28.6 +/- 10.2% of predicted, mean RV: 18.4 +/- 41.3% of predicted). Two patients were on ventilator owing to acute respiratory failure. Indication for surgery was elective surgery for emphysema in 9 patients, emergency surgery for emphysema in 2, and resection for bronchogenic cancer in 4 patients. The various procedures included single aerostasis in 1, unilateral bullectomy in 6, bilateral volume reduction in 4, thoracoscopic wedge resection for peripheral cancer in 1 and lobectomy for cancer in 3 (2 of which underwent simultaneous bullectomy) Peri-Strip were used to buttress the staple lines at the base of bullae, on parenchymatous transsection lines, and on the borders of fissures. One patient who underwent emergency thoracotomy for single aerostasis died 8 days post-operatively due to multiple organ failure. Another patient developed pneumonia which resolved under treatment. Mean duration of air leaks was 5.6 days (0-21, median 8). Two patients required tube thoracotomy for residual effusions. Mean hospital stay was 17 days (6-53; median 16). We conclude that use of Peri-Strip offered a real benefit to 12 patients; no evidence of benefit was noted in 3 patients.
Respiratory complications after surgical treatment of esophageal cancer. A study of 309 patients according to the type of resection.
This study analyzes the respiratory complications in a retrospective study of 309 resections for esophageal cancer. We mainly performed two types of resections according to the height of the tumor: the Ivor-Lewis resection for middle thoracic lesions (182 cases), and the Akiyama resection for upper thoracic lesions (127 cases). We compared the respiratory complications occurring after these two procedures. Our overall mortality and morbidity rates were, respectively, 9% and 37%. In our series, the mortality rate was 4 times higher after the Akiyama procedure than after the Ivor-Lewis procedure, and the morbidity was twice as high. Respiratory complications accounted for 64% of the postoperative deaths. The Akiyama procedure yielded more respiratory complications, especially isolated bronchopneumonia and necrosis of the trachea or of the right or left main bronchus. Respiratory complications accounted for 53% of morbidity, mainly recurrent nerve paralysis with false passages and stasis in the transplant. Both are directly related to the surgical act and often result in bronchopneumonia. Rather than the surgical technique or the skill of the surgeon, it seems that local factors, such as the position of the tumor on the esophagus, increased the incidence of recurrent nerve paralysis following the Akiyama procedure. However, the rate of respiratory complications remained high after the Ivor-Lewis procedure. Patient history, which sometimes included a previous ENT cancer, must be taken into account, as well as the gravity of the operation and the duration of the intubation. Frequent false passages and reflux must be fought by intensive physiotherapy and, when necessary, by early tracheotomy before the patient develops postoperative acute respiratory distress syndrome.
Hemodilution is an effective treatment for reperfusion edema after lung transplantation.
A 38-year-old patient underwent left single-lung transplantation for end-stage histiocytosis with secondary pulmonary hypertension and polycythemia. Despite use of an optimal lung graft and a total ischemia limited to 250 minutes, major pulmonary edema developed postoperatively. Hemodilution resulted in a quick recovery of lung function. We speculate that blood hyperviscosity was a major factor of pulmonary edema in this patient.
[Results of repeated pulmonary resection in new homolateral neoplastic localization after conservative resection].
From 1978 through 1992, 93 patients with a previous lobectomy for bronchogenic cancer were referred for homolateral cancer recurrence. Forty-six patients were contraindicated for carcinologic reasons (30 stage IIIb and 16 stage IV). Forty-seven patients (50.5%) were resectable, but 17 did not undergo surgery for associated medical problems (n = 11) or refusal (n = 6). The remaining 30 patients form the population of the present study: 29 males and 1 female; mean age of 61 years (range 47-72). The previous cancer was stage I in 26 and stage II in 4. The mean interval between the 2 cancer diagnoses was 30 months (range 6-97). Three patients underwent an exploratory thoracotomy (10%): 2 had mediastinal involvement and 1 had pleural metastases. Twenty-two (73%) underwent a completion pneumonectomy, and 5 had miscellaneous conservative resections. There were 4 operative deaths (13%): one intraoperative bleeding, 1 postoperative bleeding, 1 pulmonary embolism, 1 pneumonia. Four patients had nonfatal surgical complications: 2 clottings (reexploration), 1 empyema (lavage) and 1 bronchopleural fistula (thoracoplasty). Resected patients were staged as follows: 13 stage I, 4 stage II, 10 stage III. Survival following resection including operative mortality at 3 an 5 years was estimated as 52.5% and 44% for the whole series (72% for stage I). We conclude that repeat surgery conveys an increased risk, but may achieve valuable long-term results.
Esophagopleural fistula: an early and long-term complication after pneumonectomy.
Over a 14-year period, we observed eight cases of esophagopleural fistula after pneumonectomy for cancer (n = 7) or infectious lung disease (n = 1). In 2 patients, the fistula was probably related to an intraoperative esophageal injury. Two others had mediastinal cancer recurrence, whereas a fistula developed in 4 without any malignancy. Patients presented with empyema, and a contrast swallow procedure disclosed an esophagopleural fistula. Two patients with recurrent cancer were managed conservatively with chest tube insertion and died within 3 months. A patient with chronic empyema had a delayed diagnosis of esophagopleural fistula 2 years after a presumed intraoperative injury; he was managed with thoracoplasty and feeding gastrostomy and died 12 months later. Five patients had an attempt at curative treatment. A single patient underwent thoracoplasty and bipolar exclusion of the esophagus and had secondary reconstruction with a coloplasty; he died with postoperative peritonitis. Four patients underwent thoracoplasty and muscle flap repair of the esophagus. There was 1 operative death from pulmonary embolism, whereas 3 patients recovered and are well with follow-up of 18 months, 2 years, and 5 years, respectively. We conclude that the prognosis of esophagopleural fistula is ominous when associated with cancer recurrence. A curative approach should combine direct repair of the esophagus with a muscle flap and eradication of the associated empyema with thoracoplasty. This aggressive treatment is addressed to debilitated patients and carries high rates of mortality and morbidity.
Pulmonary distribution of vinorelbine in patients with non-small-cell lung cancer.
Vinorelbine (Navelbine, NVB) is a new semi-synthetic vinca alkaloid that is currently used in the treatment of advanced breast cancer and advanced non-small-cell lung cancer (NSCLC). In this study we investigated the tumoral and healthy pulmonary tissue concentrations of NVB in previously untreated NSCLC patients undergoing surgery. A total of 13 patients (mean age, 60 years; range, 42-70 years) were included and received NVB (20 mg/m2) at 1 h (mean, 1.1 h; SD, 0.2 h; n = 6 patients) and 3 h (mean, 3.0 h; SD, 0.6 h; n = 7 patients) before tumor resection. A tumoral and adjacent healthy lung-tissue specimen as well as simultaneously sampled serum were analyzed for NVB by high-performance liquid chromatography (HPLC). NVB levels were much higher in tissue than in serum (up to 300-fold). The tissue/serum ratio increased between the 1-h sampling time (range, 0.1-100) and the 3-h time point (range, 10-300). In all patients but two, NVB concentrations were lower in tumors than in healthy lung tissue. The tumor/healthy tissue ratio ranged from 0.06 to 1.3 (median, 0.09) at 1 h and from 0.18 to 1.1 (median, 0.55) at 3 h. This ratio increased between the 1-h sampling time and the 3-h time point as a consequence of increasing tumor levels (median, 50.4 ng/g at 1 h and 278 ng/g at 3 h). In four patients, concentrations could be measured in necrotic and peripheral tumor zones, showing lower values in necrotic areas. Thus, these data indicate that NVB is highly distributed in lung tissue, with the disposition rate being slower in tumor tissue than in healthy parenchyma during the first 3 h.
[Organ procurement and transplantation. Ethical reflections from a multicenter study].
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[Postoperative intensive care after thymectomy for myasthenia gravis].
The post-operative management of the myasthenic patient after thymectomy through sternotomy has changed in the last decades. After years of routine preoperative tracheostomies followed by routine prolonged intubation nowadays it is possible to wean the patients from the ventilation and to extubate them early after surgery while reintroducing the acetylcholinesterase inhibitors therapy. A series of 15 patients operated on between 1985 and 1988 for removal of thymic rests or thymoma is presented and confirms this evolution. The clinical and gazometric criteria allowing an early weaning from the ventilator are analyzed. However certain patients with the most severe forms of myasthenic still need prolonged ventilatory support.
The use of intrathecal morphine in thoracic anesthesia.
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[Anesthesia for the surgery of the thoracic and thoraco-abdominal aorta].
Haemodynamic monitoring, anaesthetic technique and perioperative management were reported for a series of 317 consecutive patients who underwent graft replacement of descending thoracic or thoracoabdominal aortic aneurysms at the Baylor College of Medicine, Houston (Texas) between january 1979 and june 1982. The surgical technique used was aortic clamping without shunt. The anaesthetic technique combined high dose fentanyl (50-100 micrograms X kg-1), oxygen ventilation, pancuronium bromide and vascular filing. The patients were monitored by Swan-Ganz catheters. The systemic blood pressure increased by 8% during the clamping of the aorta in spite of the use of sodium nitroprussiate, whereas the systemic vascular resistances did not increase significantly. The cardiac output increased by 19%, whereas the heart rate remained stable. After unclamping, the systemic blood pressure did not decrease significantly, whereas the systemic vascular resistances fell by 20%; the cardiac output increased by 64%, whereas the heart rate remained stable. The 30-day mortality was 10% (32 patients). Four of them died during surgery. The postoperative morbidity included 33 cases of paraplegia and paraparesis, 31 cases of renal insufficiency and 28 cases of postoperative pulmonary complications. The prevention of the consequences of aortic clamping and the management of the hypoxaemia occurring during one lung anaesthesia are discussed.
[A new case of bronchospasm under extracorporeal circulation].
A case of bronchospasm occurring after the termination of cardiopulmonary bypass is reported. The complement fractions C3a, C4a and C5a were measured before and right after CPB. Complement activation is not specific to CPB but may occur in any thoracotomy. The statistically significant increase in complement C3a without any pulmonary symptomatology has been reported by several authors. Complement activation cannot therefore be considered as the explanation of this bronchospasm.