[Function of the lungs and lung surgery; lung angiography].
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Angiography↗
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[Risk assessment of patients before lung surgery].
Lung resection offers the best prospect of long-term survival in patients with nonmetastatic pulmonary neoplasia. In view of the dismal prognosis of unresected bronchial cancer, surgical resection should be encouraged even in patients with reduced cardiopulmonary function. Accurate estimation of the postoperative cardiopulmonary function is therefore desirable to avoid (a) refusal of potentially curative treatment and (b) severe postoperative disability. The origins of post-resection morbidity and mortality are multifactorial. Thus, no single pulmonary function test or hemodynamic measurement can accurately and reliably predict postoperative cardiorespiratory complications. Criteria of functional operability should be based on percent of predicted value, so that patient's age, sex, and height will be taken into consideration. Exercise testing offers the advantage that both pulmonary and cardiac risk can be evaluated simultaneously. The high predictive value of maximal oxygen uptake (VO2max) in assessing postoperative morbidity and mortality is established. The calculation of predicted postoperative lung function (ppo) is of importance. The postoperative values for the forced expiratory volume in one second (FEV1-ppo), the transfer factor (TL,CO-ppo), and VO2max-ppo can be predicted by using the same formula. Patients with nearly normal lung function (FEV1, TL,CO > 75% predicted) and no concomitant cardiac disease can undergo lung resection right up to pneumonectomy without further diagnostic procedures. In the others, FEV1-ppo and TL,CO-ppo should be estimated first by taking into account the number of segments to be resected. Patients with values < 30% predicted are usually regarded as being inoperable, whereas values > 40% predicted qualify for resection without the need for further diagnostics. VO2max < 10 ml/kg/min or < 40% predicted are prohibitive for surgery. If VO2max is > 20 ml/kg/min or > 75% predicted, functional operability without limitation is given. For those cases where diagnostic uncertainty still remains, FEV1-ppo, TL,CO-ppo, and VO2max-ppo can be calculated by means of quantitative lung scans. Patients with either FEV1-ppo and TL,CO-ppo < 30% predicted or VO2max-ppo < 8 ml/kg/min or < 35% predicted are deemed inoperable.
Exercise Test↗
Factors in improving lung surgery; primary lung carcinoma.
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Humans↗
Immunological and hormonal responses to lung surgery during one-lung ventilation.
The effects of lung surgery performed during one-lung ventilation and the associated endocrine stress response on natural killer (NK) cell activity and the distribution of white blood cells in peripheral blood were studied in 10 patients with malignant lung tumours. Patients were anaesthetized with general anaesthesia combined with thoracic epidural anaesthesia. The endocrine response was measured as changes in serum cortisol, plasma adrenaline and noradrenaline. A significant decrease of NK cell activity was found post-operatively accompanied by leucocytosis, neutrophilia and lymphopenia. Significant increases in serum cortisol were demonstrated at the end of operation and throughout the study period. Plasma adrenaline increased significantly during one-lung ventilation with a gradual normalization post-operatively. Plasma noradrenaline increased significantly during the whole post-operative course. In conclusion, lung surgery was accompanied by similar changes in NK cell activity, leucocyte and differential counts, serum cortisol and plasma adrenaline levels as demonstrated after other types of major surgery. The elevated noradrenaline level post-operatively is a new observation that may be specific for lung surgery.
Adult↗
[Current trends in lung surgery. 1. Metastatic lung cancer and pulmonary embolism].
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Adolescent↗
Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery.
BACKGROUND: Lung cancer resection rates are suboptimal in the UK. Pneumonectomy has a higher perioperative mortality risk than lobectomy. To increase resection rates and improve outcomes we have implemented a policy of parenchymal sparing surgery for tumours involving a main stem bronchus. METHODS: In a prospective 4 year study of 119 consecutive patients operated upon by a single surgeon the perioperative course, pathology and survival were compared for 81 patients undergoing pneumonectomy and 38 patients in whom pneumonectomy was avoided by bronchoplastic+/-angioplastic procedures. RESULTS: The rate of pneumonectomy decreased significantly with increasing experience with parenchymal sparing surgery (R(2)=0.98, P<0.001) with 21 of the last 30 patients (70%) avoiding pneumonectomy. There were no significant inter-group differences in patient characteristics, perioperative course or outcome. One-year survival was 64% after pneumonectomy and 73% after sleeve lobectomy. However the perioperative loss of respiratory function was significantly lower in the patients in whom pneumonectomy was avoided (P=0.0003). CONCLUSIONS: Pneumonectomy can be avoided in a large proportion of patients with non-small cell lung cancer of a main stem bronchus without adversely affecting outcome but with preservation of lung function
Adenocarcinoma↗
[Lung surgery in the elderly].
Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.
Age Factors↗
Effects of lung surgery and one-lung ventilation on pulmonary arterial pressure, venous admixture and immediate postoperative lung function.
We studied 17 patients, with unilateral lesions in lung or thoracic wall, during thoracotomy performed in the full lateral position. Balanced anaesthesia was used with pethidine and 50% nitrous oxide, in oxygen. The procedure included a period of one-lung ventilation (OLV). Haemodynamic and gas exchange measurements were performed before and after pleurotomy, during OLV, after re-expansion of the lung and after closure of the thoracic wall. The function of each lung was assessed separately during the first and last stages. Mean venous admixture was 9-12% before and after OLV and 31% during OLV. There was a positive correlation between venous admixture and pulmonary arterial pressure during OLV. End-tidal PCO2, carbon dioxide elimination and compliance of the operated side were reduced significantly at the end of the procedure; this is consistent with reduced blood flow and increased water content in that lung.
Anesthesia, General↗
[Lung neoplasms. Observations on cases of emergency lung surgery and heart-lung function].
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Electrocardiography↗
Glove perforation rate in open lung surgery.
OBJECTIVE: In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS: Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS: One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS: The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.
Equipment Failure↗
Lung surgery: identifying the subgroup at risk for sputum retention.
OBJECTIVES: Sputum retention after lung surgery is a potentially lethal condition, which can progress to atelectasis, pneumonia and respiratory failure requiring ventilatory support. Previous studies have concentrated on the treatment of postoperative respiratory complications but few have studied the risk factors for sputum retention. This prospective study was designed to identify the risk factors which may lead to the development of sputum retention after lung surgery. METHODS: Three hundred sixty-one patients underwent lung surgery between January 1997 and December 1999 in a specialist Thoracic Surgery Unit (pneumonectomy, lobectomy, wedge or segmental resection, bullectomy, etc). Preoperative and intraoperative data collected prospectively included potential risk factors: chronic obstructive airway disease (COAD), forced expiratory volume in 1 s (FEV1)<50%, current smokers, ischaemic heart disease (IHD), cerebrovascular disease (CVA), resection of phrenic or recurrent laryngeal nerve, or absence of regional analgesia. Univariate and multivariate analysis was performed. RESULTS: Sputum related complications occurred in 108 patients (30%). There were 17 deaths of which nine were due to complications related to sputum retention. Univariate analysis confirmed current smokers (n=128), COAD (n=103), IHD (n=41), prior history of CVA (n=16), FEV1<50% (n=48), and absence of regional anaesthesia as significant risk factors (P<0.01). The multivariate analysis confirmed current smokers, IHD and absence of regional anaesthesia as risk factors. CONCLUSIONS: A subgroup of lung surgery patients at high risk for postoperative sputum retention can be predicted by the presence of one of the following criteria: current smokers, history of COAD, CVA, or IHD, and absence of regional analgesia. Prophylactic measures should be considered in this group to reduce the incidence of sputum retention.
Aged↗
Chest re-exploration for complications after lung surgery.
BACKGROUND: Review of the most recent chest re-explorations for lung surgery complications may show methods by which risks can effectively be reduced. METHODS: The data on rethoracotomies following lung surgery over the past 14 years in our department were retrospectively reviewed. The indication, the type of operation, the outcome, and various factors influencing the postoperative mortality were analyzed. From 1983 to 1996, 1960 patients underwent primary thoracotomies for various lung diseases. Among these, 73 (3.7%) patients required re-exploration for various postoperative complications. RESULTS: Mean age was 56.8 years (15-80 years). There were 66 (90.4%) men and 7 (9.6%) women. The most common indication for rethoracotomy was hemorrhage in 38 (52%) patients. The source of bleeding was a mediastinal and/or bronchial blood vessel in 8 patients and an intercostal blood vessel in 6 patients. Six patients had to be reoperated because of hemorrhage from a major artery of the hilus. In 14 cases the postoperative hemothorax occurred without evident surgical origin. Further indications for rethoracotomy were bronchopleural fistula (BPF) in 13 (17.8%) patients, and persistent parenchymal leak in 8 (10.9%) patients. There were 8 additional causes distributed among the remaining 14 (19.3%) patients. The overall mortality rate was 17.8% (13/73), with the highest (38.4%) among BPF patients. CONCLUSIONS: Postoperative complications following lung surgery which require rethoracotomy are rare. The most common complication is postoperative bleeding. This is followed by bronchial stump insufficiency which is associated with the highest mortality and morbidity. Our experience shows that the need for re-exploration can hardly be reduced but the indication for re-exploration should be established as early as possible to avoid late complications.
Adolescent↗
[The clinical features of postoperative ventilator-associated pneumonia after lung surgery].
OBJECTIVE: To investigate the clinical features of postoperative ventilator-associated pneumonia (VAP) after lung surgery. METHODS: Of 104 patients who had undergone lung surgery and been treated with ventilator in our surgical intensive care unit between January 2003 and March 2005, 35 patients met with the criteria of both VAP and postoperative pneumonia (POP), and 41 cases had no evidences of pneumonia. The clinical and laboratory data of all 76 cases were recorded and analyzed by a statistical software package (SPSS). RESULTS: The diagnosis of postoperative VAP was established clinically in 35 patients (46.1%), and etiologically in 33 cases. Compared to the patients without postoperative VAP, the patients with postoperative VAP had a significantly longer mean interval between intubation and operation [(2.7 +/- 2.9) days vs. (1.6 +/- 1.7) days, P = 0.039], a longer duration of mechanical ventilation [(32.2 +/- 37.7) days vs. (4.2 +/- 2.9) days, P < 0.001], and higher morbidity (20.0% vs. 2.4%, P = 0.013). There was a significant difference in mean duration of mechanical ventilation between the 15 cases of early-onset VAP and 20 cases of late-onset VAP (17 +/- 15 days vs. 43 +/- 46 days, P = 0.042). Among the initially detected pathogen, Staphylococcus aureus remains the most common Gram-positive coccus whereas Acinetobacter Baumannii took the place of Pseudomonas aeruginosa as the top Gram-negative rod. CONCLUSION: Postoperative VAP after lung surgery has different clinical features from VAP in medical ICU.
Adult↗
Combined coronary artery bypass grafting and lung surgery.
Combined coronary bypass and lung surgery was performed in 3 patients. Through a median sternotomy or a left thoracotomy, bypass grafting was performed on beating heart or under cardiopulmonary bypass, followed by the lung operation. The lung lesion was diagnosed as carcinoma in 2 patients and hydatid cyst in 1 patient. With few exceptions, beating heart coronary bypass through a median sternotomy can be performed in a combined operation.
Aged↗
[Technical aids by staplers in lung surgery].
Linear stapling devices ensure a safe resection in lung surgery. They are not only convenient for closing the bronchial stump, but also highly efficient for dividing the main pulmonary artery or lobar veins. The superiority of stapling is immediately obvious in the division of fissures and tangential resections of lung parenchyma. Bronchopleural fistulas can be easily avoided. The safe and appropriate use of stapling divices makes a standardized procedure in lung surgery possible.
Anastomosis, Surgical↗
Interatrial right-to-left shunt after lung surgery: diagnostic value of perfusion lung scanning.
A 61-year-old woman presented with platypnea and orthodeoxia after right pneumonectomy for lung cancer. A perfusion lung scan taken after tracer injection in the sitting position showed an extrapulmonary uptake of radioactivity consistent with a right-to-left shunt. Such extrapulmonary uptake was no longer evident when tracer was injected in supine posture. The authors emphasize the value of perfusion lung scanning in the assessment of patients with unexplained dyspnea after thoracic surgery.
Carbon Dioxide↗
Use of an electrothermal bipolar tissue sealing system in lung surgery.
OBJECTIVE: We evaluated the validity of an electrothermal bipolar tissue sealing system (LigaSure, Valleylab Inc., USA) in lung surgery. METHODS: Our study was divided into two phases. EXPERIMENTAL: We performed sutures of pulmonary vessels and bronchi and lung wedge resections by LigaSure in 28 lungs of adult pigs; subsequently, we quantitated the sealing capacity of the system detecting the burst pressure for each anatomical structure. Clinical: LigaSure was used in 36 patients undergoing lung surgery. We performed 23 thoracotomic procedures in 16 patients (19 wedge resections, 2 segmentectomies, and 2 fissure separations), and 20 thoracoscopic procedures (13 wedge resections, 5 bullectomies, and 2 adherence dissections). RESULTS EXPERIMENTAL: Bronchi and vessels were divided into seven groups (diameter: 1-7 mm); 10 burst pressure measurements for each group were performed. A total of 84 wedge resections were performed; lung specimens were divided into seven groups (weight: 0.2-1.4 g). The percentage of bronchial sutures resistant to the pneumatic critical pressure (60 mmHg) was 100% in the 1-mm and 2-mm groups. No bronchi with 6-mm or 7-mm diameter reached the critical pressure. All pulmonary vessel sutures were resistant to the critical hydrostatic pressure (150 mmHg). The average burst pressure of wedge resection margins was higher than the critical pressure, and the percentage of suture margins resistant to the critical pressure decreased from 95% (0.2-g group) to 68% (1.4-g group). Histology confirmed the sealing of vessels, with a mean depth of thermal injury limited to 1.1mm. Clinical: In all patients, hemostasis obtained by LigaSure was effective, with minimal perioperative bleeding. The mean operating time was 77.2 min (range: 60-97) for thoracotomies and 60.3 min (range: 46-80) for thoracoscopies. The mean drainage duration was 3.1 days (range: 1-8). Two patients had prolonged air leaks (>7 days). The mean postoperative stay was 7.3 days (range: 5-13) for thoracotomies and 4.6 days (range: 1-6) for thoracoscopies. CONCLUSIONS: Use of LigaSure in lung surgery appears feasible and easy. It provides satisfactory hemostasis and air-leak prevention; results are comparable to those of stapling devices, but this system seems to have a better benefit/cost ratio. Larger series are needed to confirm these data.
Adult↗
Nosocomial infection after lung surgery: incidence and risk factors.
STUDY OBJECTIVES: To assess the incidence and risk factors for nosocomial infection after lung surgery. DESIGN: Prospective cohort study. SETTING: Service of thoracic surgery of an acute-care teaching hospital in Santander, Spain. PATIENTS: Between June 1, 1999, and January 31, 2001, all consecutive patients undergoing lung surgery were prospectively followed up for 1 month after discharge from the hospital to assess the development of nosocomial infection, the primary outcome of the study. INTERVENTIONS: During the hospitalization period, patients were visited on a daily basis. Postdischarge surveillance was based on visits to the surgeon. MEASUREMENTS AND RESULTS: We studied 295 patients (84% men; mean age, 60.9 years), 89% of whom underwent resection operations. Ninety episodes of nosocomial infection were diagnosed in 76 patients, including pneumonia (n = 10), lower respiratory tract infection (n = 47), wound infection (n = 16; one third were detected after hospital discharge), urinary tract infection (n = 9), and bacteremia (n = 8; three fourths were catheter-related bacteremia). Twenty patients had severe infections (pneumonia or empyema), with a mortality rate of 60%. COPD (adjusted odds ratio [OR], 2.70; 95% confidence interval [CI], 1.52 to 4.84), duration of surgery with an increased risk for each additional minute (Mantel-Haenzel chi(2) test for trend, p = 0.037), and ICU admission (OR, 3.69; 95% CI, 1.94 to 7.06) were independent risk factors for nosocomial infection. The use of an epidural catheter was a protective factor (OR, 0.45; 95% CI, 0.22 to 0.95). There were no differences according to the use of amoxicillin/clavulanate or cefotaxime for surgical prophylaxis. CONCLUSIONS: Nosocomial infections are common after lung surgery. One third of wound infections were detected after hospital discharge. The profile of a high-risk patient includes COPD as underlying disease, prolonged operative time, and postoperative ICU admission.
Bacterial Infections↗