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PubMed2002

Special article: a brief history of pneumonectomy. 1999.

The ineluctable conclusion to be drawn from this article is that thoracic surgery could not develop without endotracheal ventilation. What is astounding is that this technique, known since the 16th century and perfected in the late 19th century, was ignored and in fact rejected by surgeons [4]. The negative effect that Sauerbruch had on the development of thoracic anesthesia was well stated by Comroe: "An impressive piece of hardware, backed by a highly prestigious designer, can hold back progress for decades" [49]. Before the formation of the AATS, there was no forum for the discussion of methods for solving the problems of pulmonary resection and anesthesia. Experience gained in the animal laboratory was largely ignored and not applied to pneumonectomy in humans. Ligation of the pulmonary artery does not initiate the clinical course of massive pulmonary embolism. In the absence of infection, concern about the postpneumonectomy space is groundless. Preresection phrenic nerve crush and pneumothorax are unnecessary, as are attempts to stabilize the postpneumonectomy mediastinum by adjusting intrapleural pressure or by thoracoplasty. It behooves thoracic surgeons to heed Comroe's comment: "Finally, what are we, with our infinite wisdom and magnificent technical advances, doing today that will appear primitive, curious or even stupid 50 years from now?"

History, 19th Century↗
PubMed2001

Intrathoracic free musculocutaneous flap after open-window thoracostomy for chronic empyema.

An 85-year-old man was suffering from right pyothorax caused by methicillin-resistant staphylococcus aureus (MRSA). The empyema cavity was closed by intrathoracic implantation of a free rectus abdominis musculocutaneous (MC) flap using microvascular surgery 2 months after open-window thoracostomy (OWT). Compared with a pedicled MC flap, a free flap has the advantage that it can close a larger empyema cavity since the whole flap can be inserted into the cavity. Although the use of a free MC flap requires a two-stage operation, this method is believed to be more successful for controlling chronic empyema than any other established procedure, including decortication, thoracoplasty or pleuropneumonectomy.

Aged↗
PubMed1997

Unsuccessful omentopexy in thoracic surgery.

Omentopexy has improved the treatment of chronic empyema and postpneumonectomy bronchopleural fistula, which otherwise are difficult to manage. However, omentopexy is not effective in some patients. Four of 17 patients who underwent omentopexy in our institution between January 1978 and March 1994 did not respond to the treatment and died. In two patients, a dead space remained after surgery and there was insufficient sterilization. In one patient, a dead space appeared after surgery and it was impossible to control infection. The fourth patient had dehiscence of the anastomosis triggered by postoperative acute gastritis. All four patients in whom omentopexy was not successful died. When omentopexy is used for empyema, the space should first be sterilized. If sterilization is insufficient, muscle filling and thoracoplasty must be performed and no dead space left.

Adult↗
PubMed1983

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.

Adolescent↗
PubMed2000

Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection.

OBJECTIVE: Successful treatment of postoperative empyema remains a challenge for thoracic surgeons. We report herein our 12-year experience in the management of this condition by means of open window thoracostomy. METHODS: Open window thoracostomy was used in the treatment of 46 patients with empyema complicating pulmonary resection. A bronchopleural fistula was associated in 39 of 46 cases. Previous operations included pneumonectomy (n = 30), bilobectomy (n = 5), lobectomy (n = 9), and wedge resection (n = 2) performed for benign (n = 10) or malignant (n = 36) disease. In 10 patients open window thoracostomy was definitive because of patient death (n = 2), concomitant major illness (n = 2), tumor recurrence (n = 4), spontaneous closure (n = 1), or patient choice (n = 1). In 36 cases intrathoracic flap transposition was eventually performed. Muscular (n = 29), omental (n = 5), or combined muscular and omental (n = 2) flaps were used to obliterate the thoracostomy cavity and to close a possibly associated bronchopleural fistula. In 9 patients with postpneumonectomy cavities too wide to be filled by the available flaps, a limited thoracoplasty represented an intermediate step. RESULTS: Among patients treated with definitive open window thoracostomy, local control of the infection was achieved in all the survivors (8/8). After open window thoracostomy and subsequent flap transposition, success (definitive closure of the thoracostomy and, if present, of the bronchopleural fistula) was achieved in 27 (75. 0%) of 36 patients. Four initial failures could be salvaged by means of reoperation (initial reopening of thoracostomy and subsequent muscular or omental transposition). CONCLUSION: Open window thoracostomy followed by intrathoracic muscle or omental transposition represents a valid therapeutic option in patients with empyema complicating pulmonary resections.

Adult↗
PubMed1982

Timely therapy for empyema: what it constitutes and why.

The incidence and treatment of empyema historically have fluctuated with the introduction of new antibiotics. As resistant strains of bacteria emerge, a return to aggressive surgical therapy becomes necessary. Empyemas are most likely to occur in patients with an underlying factor such as alcoholism, bronchitis, asthma, emphysema, diabetes, tuberculosis, carcinoma, heroin addiction, or steroid therapy. The bacteriology is constantly changing. Recently, the importance of anaerobic organisms--which are now involved in three out of four cases of empyema--has been recognized. Diagnosis is established and antibiotics chosen on the basis of Gram staining and culture of pleural fluid. Surgical procedures include thoracentesis, closed chest tube drainage, open drainage plus rib resection, decortication, thoracoplasty, and excision of the empyema sac with an extrapleural dissection.

Anti-Bacterial Agents↗
PubMedDate not supplied

Spleen rupture after surgery in Marfan syndrome scoliosis.

Spleen rupture occurred in a 14-year-old girl with Marfan syndrome after posterior spinal instrumented fusion and thoracoplasty for scoliosis. Splenectomy successfully treated this unusual complication of spinal surgery. The etiology, diagnosis, and management of spleen rupture following pediatric spinal surgery are discussed.

Adolescent↗
PubMed2000

Reconstruction of irradiated postpneumonectomy empyema cavity with chain-link coupled microsurgical omental and TRAM flaps.

We present the first case of complete hemithoracic reconstruction of an irradiated postpneumonectomy recurrent empyema cavity that was unresponsive to multiple conventional treatments. The procedure described used a chain-link of two coupled free flaps consisting of an omental and TRAM flap. A single abdominal donor site and single operative position are other advantages of this technique that provides sufficient volume to obviate the need for thoracoplasty even in the largest wounds.

Arteries↗
PubMed1987

Rib regeneration area as an indicator of fusion area in adolescent idiopathic scoliosis.

This retrospective study of 24 patients with adolescent idiopathic scoliosis who underwent L-rod instrumentation, posterior thoracoplasty, and rib-bone grafting analyzed the correlation between the quality of rib regeneration and the host response to the rib-bone grafts. A planimetric technique was used to quantitate the coronal plane area of the resected ribs and of an L1-L2 concave fusion area immediately after surgery and at the end of the first postsurgical year. Using computerized regression analysis, these and other variables such as age, Cobb angle, and grafting technique were studied. Rib regeneration correlated with spinal fusion but not with age or Cobb angle. A better host response with strip vs. morseled graft was suggested, but not statistically proven. The data strongly support the belief that systemic biologic factors are a major variable affecting the quality of the fusion procedure.

Adolescent↗
PubMed1996

Spinal shortening in scoliosis surgery, A case with transitory paraplegia.

STUDY DESIGN: A case involving a 16-year-old patient with idiopathic adolescent double-major scoliosis is presented. The curve was so rigid that a shortening surgery was done to reduce neurologic risk. OBJECTIVE: To advise surgeons who are considering this kind of surgical procedure to reduce the neurologic risk involved in correcting scoliosis, may be more dangerous than other, more traditional modes. SUMMARY OF BACKGROUND DATE: The two-stage procedure for anterior resection of a vertebral body followed by posterior resection and fusion by shortening the spine with instrumentation has been reported to be a safe and effective method of correcting deformities and other spinal pathologies. METHODS: Surgical treatment consisted of two anterior approaches, thoracic lumbotomy and thoracofrenolumbotomy, in which all the discs between 75 and L4 and the vertebral body of T8 were resected, followed by a posterior resection. In the third surgery (posterior resection) a full T8 vertebrectomy was completed, and the gap between the adjacent vertebrae was closed. Then a traditional CD configuration with rod rotation was used, and a thoracoplasty of the rib hump was done. RESULTS: During the intraoperative wake-up test, the patient did not move her inferior extremities, and it was necessary to partially reverse the shortening of the gap produced by the vertebrectomy. The preoperative and postoperative curves measured 90 degrees/86 degrees and 25 degrees/27 degrees, respectively. CONCLUSIONS: This procedure appears to be more dangerous than traditional surgery. Partial vertebrectomy as a closing wedge osteotomy of the convexity may be a less risky procedure. The practice of not using bone graft in the intervertebral spaces does not seem to contribute to spinal shortening and increases the pseudoartosis risk.

Adolescent↗
PubMed1997

The role of preoperative pulmonary function tests in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

STUDY DESIGN: A retrospective review of the case records and radiographs of 133 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion and instrumentation between 1986 and 1992. OBJECTIVES: To evaluate the incidence of abnormal results on preoperative pulmonary function tests and their correlation to immediate postoperative pulmonary impairment in patients with adolescent idiopathic scoliosis who had posterior spinal fusion. SUMMARY OF BACKGROUND DATA: It has been stated that preoperative pulmonary function tests are essential to assess surgical risk in a patient with scoliosis because of the possibility of further compromising the pulmonary function. Authors of previous studies have reported on the increased incidence of postoperative pulmonary complications in patients undergoing anterior spinal surgery. METHODS: The case records and radiographs of 133 patients with either a thoracic or a double-major curve, who underwent posterior spinal fusion, were reviewed. The presence of any preoperative or postoperative cardiopulmonary symptoms and increased requirement of postoperative ventilatory support were noted. Results of preoperative pulmonary function tests were classified as normal, restrictive, or obstructive disease. Postoperative chest radiographs were examined to note the presence of atelectasis, infiltrates, pneumothorax, hemothorax, or pneumonia. RESULTS: The majority of patients (72.9%) had normal results on pulmonary function tests. The mean coronal Cobb angle of the thoracic curve was 48 degrees, and the mean angle of kyphosis was 26 degrees. None of the patients had any increased requirement of postoperative ventilatory support. The overall incidence of postoperative pulmonary complications was 2.3%. CONCLUSIONS: Performance of a thoracoplasty was the only risk factor for postoperative pulmonary complications in patients undergoing posterior spinal fusion. There was no correlation between deterioration of preoperative pulmonary function and the risk of postoperative pulmonary complications. It appears that performance of preoperative pulmonary function tests in patients with moderate adolescent idiopathic scoliosis-scheduled for posterior spinal fusion is not necessary.

Adolescent↗
PubMed2004

Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective matched cohort study. OBJECTIVE: To comprehensively compare the 2-year postoperative results of posterior correction and fusion with segmental pedicle screw instrumentation versus those with hook constructs in adolescent idiopathic scoliosis (AIS) treated at a single institution. SUMMARY OF BACKGROUND DATA: Despite the reports of satisfactory correction and maintenance of scoliotic curves by pedicle screw instrumentation compared to hook constructs, few reports on the comprehensive comparison of segmental pedicle screw instrumentation versus hook instrumentation exist. MATERIALS AND METHODS: A total of 52 patients with AIS at a single institution who underwent a posterior spinal fusion with segmental pedicle screw (26) or hook (26) instrumentation were sorted and matched according to four criteria: similar age at surgery (14.8 years in pedicle screw group and 14.2 years in hook group), identical Lenke curve types, same number of fused vertebrae (11.7 in each group), and identical operative methods (18 posterior spinal fusions with thoracoplasty, 4 posterior spinal fusions with iliac crest bone graft, and 4 anterior and posterior spinal fusions in each group). Patients were evaluated before surgery, immediate after surgery, and at the 2-year follow-up according to radiographic changes in curve correction, pulmonary function tests, operative time, intraoperative blood loss, implant costs, and SRS-24 scores. RESULTS: After surgery, the average major curve correction was 76% in the screw group and 50% in the hook group (P < 0.001). At the 2-year follow-up, loss of the major curve correction was less in the screw group (5.4%) compared with the hook group (8.0%) (P = 0.35). Postoperative global coronal and sagittal balance was similar in both groups. An average of 0.8 levels from the distal end vertebra was saved using pedicle screws compared with hook constructs (P = 0.002). Postoperative 2-year proximal junctional change in the sagittal plane (angle between uppermost instrumented vertebra and two vertebral bodies above the uppermost-instrumented vertebra) was 9 degrees in the screw group and 6 degrees in the hook group (P = 0.19). Postoperative 2-year distal junctional change in the sagittal plane was similar in both groups. Operative time averaged 341 minutes in the screw group and 338 minutes in the hook group (P = 0.86), and intraoperative blood loss was similar in both groups (879 mL in screw group vs. 896 mL in hook group) (P = 0.12). Average implant cost in the hook group (11.8 fixation points; 5,816 U.S. dollars) was significantly lower than that of the screw group (17.1 fixation points; 11,508 U.S. dollars) (P < 0.001). Two years following surgery, the screw group demonstrated improved percent predicted pulmonary function values compared with that of the hook group (FVC, 80%--> 79% in screw group vs. 82%--> 74% in hook group, P = 0.0056; FEV-1, 73%--> 76% in screw group vs. 80%--> 79% in hook group, P = 0.017). Postoperative 2-year SRS-24 scores were similar in both groups (screw group [97] vs. hook group [101]) (P = 0.15). There were no neurologic or visceral complications related to hook or pedicle screw instrumentation. CONCLUSION: Pedicle screw instrumentation, although more expensive, offers a significantly better major and minor curve correction without neurologic problems and improved pulmonary function values in the operative treatment of AIS and enables a slightly shorter fusion length than segmental hook instrumentation.

Adolescent↗
PubMed2006

Allograft versus no graft with a posterior multisegmented hook system for the treatment of idiopathic scoliosis.

STUDY DESIGN: A prospective, randomized study. OBJECTIVE: To compare the clinical results of posterior spinal fusion (PSF) with allograft augmentation versus no graft for patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The use of allograft has become a standard means of augmenting a PSF. Many studies have shown equal rates of fusion when comparing allograft with autogenous iliac crest. There have been no studies to directly compare the results obtained with allograft with those achieved without the use of any bone graft at all. METHODS: Ninety-one patients with AIS were randomized into two treatment groups. Seventy-six patients had greater than 2-year follow-up and are included in this review. The Allograft Group consisted of 37 patients who underwent a standard PSF using a multisegmented hook-screw and rod system with the use of corticocancellous allograft for augmentation. The No Graft Group included 39 patients with AIS who underwent the same procedure without any bone graft. All autogenous bone resulting from a thoracoplasty and any local bone (for example, that removed from spinous processes) was discarded in both groups. Patients with at least 2 years of radiographic and clinical follow-up were evaluated using established criteria for possible or definite pseudarthrosis. Treatment groups were similar with respect to age, preoperative deformity, and correction obtained. RESULTS: The overall definitive pseudarthrosis rate for this study was 1.3% (1 of 76 patients). The 1 patient with pseudarthrosis was in the Allograft Group (1 of 37, or 2.7%, P = 0.98 as defined by our criteria), versus none of 39 in the No Graft Group. Two patients in each group (5.4% in the Allograft Group and 5.1% in the No Graft Group) met the radiographic criteria for possible pseudarthrosis. This establishes a P value of 0.65 comparing risk of possible pseudarthrosis in the two groups. CONCLUSION: Our results suggest that a PSF using newer-generation multisegmented hook-screw and rod systems can be successful with allograft and/or local bonegraft without the use of supplemental autogenous bone graft (from the iliac crest or ribs) in patients with AIS.

Adolescent↗
PubMed1987

Combined unilateral high frequency jet ventilation and contralateral intermittent positive pressure ventilation.

The anaesthetic management of a patient who required right lower lobectomy for bronchial carcinoma associated with emphysema, pneumoconiosis and a previous thoracoplasty for pulmonary tuberculosis, is described. A technique of unilateral high frequency jet ventilation plus conventional intermittent positive pressure ventilation to the contralateral lung was used.

Anesthesia, General↗
PubMed1996

Results of surgical treatment of 107 patients with complications of pulmonary tuberculosis.

The objective of this study was to evaluate the results of surgical intervention performed on 107 patients with pulmonary tuberculosis complications. Between September 1988 and December 1995, 107 patients underwent a total of 126 operations for major complications of pulmonary tuberculosis. One hundred and twenty-six operations consisted of lobectomies only or plus other lung resections performed in 55 cases, pneumonectomies in 20 cases, segmentectomies in 18 cases, wedge resections in two cases, tracheobronchoplasties in four cases, decortications in two cases, cavernostomies with concomitant muscle transpositions in seven cases, thoracoplasties reserved for the previously failed operations or to be a supplement for pulmonary resections in 18 cases. The operative mortality rate was of 1.8%, and the major complication rate was of 16.8%. Twenty-eight (26.1%) patients with tuberculosis bacilli in sputum before operation have converted except one diabetic patient. In conclusion, surgery is indicated in pulmonary tuberculosis complications that are life-threatening or unresponsive to chemotherapy. Pulmonary resection is the procedure of choice for most cases that require surgery.

Adolescent↗
PubMed2005

Optimization of rib surgery parameters for the correction of scoliotic deformities using approximation models.

BACKGROUND: As opposed to thoracoplasty (a cosmetic surgical intervention used to reduce the rib hump associated with scoliosis), experimental scoliosis has been produced or reversed on animals by rib shortening or lengthening. In a prior work (J. Orthop. Res., 20, pp. 1121-1128), a finite element modeling (FEM) of rib surgeries was developed to study the biomechanics of their correction mechanisms. Our aims in the present study were to investigate the influence of the rib surgery parameters and to identify optimal configurations. Hence, a specific objective of this study was to develop a method to find surgical parameters maximizing the correction by addressing the issue of high computational cost associated with FEM. METHOD OF APPROACH: Different configurations of rib shortening or lengthening were simulated using a FEM of the complete torso adapted to the geometry of six patients. Each configuration was assessed using objective functions that represent different correction objectives. Their value was evaluated using the rib surgery simulation for sample locations in the design space specified by an experimental design. Dual kriging (interpolation technique) was used to fit the data from the computer experiment. The resulting approximation model was used to locate parameters minimizing the objective function. RESULTS: The overall coverage of the design space and the use of an approximation model ensured that the optimization algorithm had not found a local minimum but a global optimal correction. The interventions generally produced slight immediate modifications with final geometry presenting between 95-120% of the initial deformation in about 50% of the tested cases. But in optimal cases, important loads (500-2000 N mm) were generated on vertebral endplates in the apical region, which could potentially produce the long-term correction of vertebral wedging by modulating growth. Optimal parameters varied among patients and for different correction objectives. CONCLUSIONS: Approximation models make it possible to study and find optimal rib surgery parameters while reducing computational cost.

Adolescent↗
PubMed1992

[A case of Candida albicans endocarditis with impaired lung function].

A 53-year-old male was admitted to the hospital because of Candida albicans endocarditis. He had had a thoracoplasty due to pulmonary tuberculosis and showed severe restructive lung function. In 1987 and '89, trachiostomy was made because of respiratory failure. The patient was well until nine months earlier, when he consulted a physician because of fever. The investigations failed in finding the cause of the fever. He was administered antituberculosis agents and antiinflammatory drugs but had a fever every day. Two months before admission, a cardiac ultrasonographic study showed evident vegetations with mitral regurgitation. From the above course and examinations, a diagnosis of Candida albicans endocarditis was made. Infusions of CEZ, TOB, PIPC and miconazole for more than one month was ineffective. In November, 1990, he was referred to our medical center for the purpose of operation. A blood culture proved Candida albicans infection. An intravenous administration of fluconazole 400 mg/day was begun. However, there was pulmonary bleeding probably due to heparin used for prevention of atrial thrombosis and he developed fever, hypoexemia, ventricular tachycardia, and hyponatremia. He underwent mitral-valve replacement with a SJM valve. Culture of the vegetated mitral valve again proved Candida albicans. After operation, hypoexemia, ventricular tachycardia, hyponatremia were improved gradually. However he had an eosinophilia, eruption, and dyspnea. We suspected a drug eruption of fluconazole. Lymphocyte stimulating test of fluconazole proved positive. After the episode, he had no symptoms and was discharged.

Candidiasis↗