Search

This article describes the mechanisms by which cardiac disease, when combined with surgery and anesthesia, may tax the respiratory system beyond its capabilities. Techniques of respiratory support aimed at improving oxygenation, ventilation, and the work of breathing are examined.

Progressive scoliosis was seen in eight children after thoracotomy for esophageal atresia. Postoperatively, all had had severe mediastinitis and empyema secondary to dehiscence of the esophageal anastomosis and required reoperation. Healing was accompanied by marked scarring and rib fusion; with growth, a scoliosis developed with the concavity toward the thoracotomy site. Most spinal curvatures appeared years after the thoracotomy and progressed rapidly at the time of adolescent growth spurt. Excision of fused ribs, spinal fusion, and instrumentation led to improvement in four patients.

The therapeutic results and complications of 557 thoracic operations are evaluated. 94.4% of the patients recovered, 2.7% improved and 2.9% died. There appears to be a significant correlation between the therapeutic results, the diagnosis and the type of operation. The 7.0% wound infections were closely related to the age of the patient. The postoperative respiratory complications observed in 11.5% of the cases were in close relation to the diagnosis. The causes leading to respiratory complications and the length of the febrile period are discussed in detail, and the results are assessed in the light of data in the literature.

We have observed soft-tissue calcification of the chest in 4 of 54 patients following thoracotomy in the neonatal period for a Blalock-Taussig or a Blalock-Hanlon procedure. The time of appearance ranged from 2 weeks to 11 months. This calcification is similar to myositis ossificans in having a traumatic origin. In one of the patients, it resolved spontaneously.

The effect of the site of operation on postoperative hypoxemia was studied in 104 patients undergoing thoraco-abdominal, thoracic, upper abdominal, lower abdominal, extra-abdominal and non-thoracic operations. The degree of postoperative hypoxemia was the most extensive in patients undergoing thoraco-abdominal, moderate in thoracic and upper abdominal operations, and minimal in lower abdominal and other operations. On the other hand, the duration of hypoxemia also differed with the surgical procedures. Arterial oxygen tension returned to almost control values by the 3rd postoperative day in cases of lower abdominal and extremity operations and by the 7th postoperative day in those undergoing thoracic and upper abdominal surgery. Postoperative hypoxemia, however, remained throughout the fourteen day study period, in patients undergoing thoraco-abdominal operation. True shunt was measured in 27 patients with thoraco-abdominal, thoracic and upper abdominal operations. An increase in true shunt was evident postoperatively in the entire group of patients. The increase was significantly larger and longer lasting in cases of thoraco-abdominal incision than that in cases of thoracic and upper abdominal incision alone. Differences in postoperative true shunt between cases of thoracic and upper abdominal incisions were nil.

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 +/- 9.2% (standard deviation; p less than 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 +/- 7.5% (p less than 0.05) than in the control group (38.4 +/- 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.

Analysis of 164 percutaneous chest tube thoracostomies performed as a standardized technical procedure in the management of 129 blunt trauma victims demonstrated an overall complication rate of 9.1% (15 of 164). Three complications (1.8%) were related to problems of insertion, and four (2.4%) represented the problem of pneumothorax after chest tube removal. The remaining eight complications (4.9%) were associated with positive bacterial cultures, two (1.2%) of which represented clinical empyema. Both cases of empyema had either prolonged chest tube placement (23 and 15 days) or multiple chest tubes (two and three) on the same side. Percutaneous chest tube thoracostomy remains an important facet in the management of certain types of blunt thoracic trauma. Associated risks can best be minimized with adherence to a standardized technique and management protocol.

The dural sheath may be transected in the course of a posterior thoracic procedure. If air is introduced into the subarachnoid space, a cranial nerve palsy may result. Computed tomographic scanning establishes the diagnosis. The condition resolves without treatment.

Between March, 1981, and August, 1985, twenty-eight heart-lung transplant operations were done in 27 patients at a single institution. 8 patients died in the perioperative period and adhesions related to previous thoracic surgery proved to be a major risk factor for postoperative haemorrhage. Obliterative bronchiolitis developed in half of the 20 long-term survivors, a mean of 11.2 months (range 2-35 months) after surgery: 4 of these patients died, 3 are functionally limited, 2 were successfully treated with corticosteroids, and the remaining patient was successfully retransplanted. The other 10 long-term survivors returned to a normal life with essentially normal pulmonary function measured at a mean of 22.6 months (range 4-42 months) after transplantation. All the surviving patients have evidence of renal impairment related to cyclosporin nephrotoxicity. The results indicate that, although heart-lung transplantation is compatible with essentially normal long-term pulmonary function, the procedure should not yet be regarded as a routine clinical intervention.

A mediastinal emphysema was seen via x-ray film in 35 of 40 patients after opening of the mediastinum by longitudinal sternotomy. After about a week it was found in approximately every second patient; after 14 days it had been fully absorbed by all patients. Mediastinal emphysema could occur in conjunction with a cutaneous emphysema, and pneumothorax, respectively. Occasionally a pneumopericardium is seen even in the recumbent patient. Safe diagnosis of mediastinal emphysema is possible in the anterior lower mediastinum projected on to the cardiac silhouette if the x-ray film is taken obliquely.

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.

False aneurysm formation is a rare complication of the modified Blalock-Taussig shunt. A patient is described in whom this complication arose 11 months after operation. Death resulted from rupture of the aneurysm into the right lung with associated massive hemoptysis. The onset of hemoptysis in patients with a functioning modified Blalock-Taussig shunt may be the first evidence of a developing false aneurysm.

The present review deals with 63 adult patients having acute nontuberculous empyema treated by early thoracotomy and decortication, during the period from 1955 through 1979. Group I (38 patients) had postpneumonic empyema, but no underlying disease. Group II (25 patients) had acute empyema and one or more serious associated diseases. Positive cultures were present in 45 of 63 patients (71.4%). Most surgeons have customarily recommended conservative management, especially for patients in Group II, because of the supposedly "high risk" involved in decortication. Consequently, the mortality is extremely high. The empyema must be cured; a "well drained" or "controlled" empyema will not suffice. The severely ill patient can better withstand the ordeal of a major operation than the deleterious effects of a lingering empyema. The critically ill patient is best managed by the primary procedure of open thoracotomy and decortication. The author's experience confirms that such patients can expect an outlook (8% mortality) approaching the zero mortality of Group I patients.

A comparative clinical trial was undertaken in 2420 patients undergoing thoracic surgery during a 4-year period (1973-1977); 40% of the patients had bronchial cancer. Random allocation was not considered as being possible by the surgeons and was replaced by allocation according to the time of operation. There were three protocol groups: Protocol A: First morning operations (1007 patients): subcutaneous calcium heparin, 5000 units (Ul) 2 hours and 30 minutes before surgery then every 12 hours for 15 days. Protocol B: Second morning operations (932 patients): same dose and duration of treatment; the first injection took place 24 to 72 hours after the surgical procedure. The doses were increased from the fourth day after surgery in order to obtain a moderately prolonged partial thromboplastin time (difference patient-control: 7 to 14 seconds). Protocol 0: 481 patients received no anticoagulant treatment because of a contraindication or minor surgical procedure. Preliminary results showed and increase of per-operative bleeding (p less than 0.01) in treated patients; this was very well accepted by the surgeons. Among the heparin-treated patients, 11 pulmonary emboli out of 13 were observed in patients with bronchial cancer. Of these 13, 10 were fatal with 9 being verified at autopsy. The pulmonary emboli episodes occurred significantly earlier in protocol B than in protocol A. Fatal pulmonary embolism in patients with bronchial cancer was significantly more frequent in protocol B (7 cases) than in protocol A (1 case); P less than 0.01. These results have shown a low frequency of fatal pulmonary emboli in patients without bronchial cancer receiving twice-daily subcutaneous injections of heparin (2 of 1102 operated subjects). The rate was higher in patients with bronchial cancer and this results supports a recommended thrice-daily dose in such patients. In addition, the pre-operative administration of heparin is useful in preventing early post-operative pulmonary embolism.

The effect of partial chest wall resection on subsequent production of spinal deformity was studied in six pediatric patients. The following observations are made: Scoliosis secondary to chest wall resection in the pediatric age group is progressive. The degree of curvature is related to the number of ribs resected. Anterior resection of ribs does not produce significant scoliosis, whereas resection of the posterior aspect of the ribs promptly produces scoliosis. Scoliosis associated with marked pleural thickening secondary to recurrent tumor, irradiation scarring, and underlying pulmonary metastases is always convex toward the normal side. Scoliosis associated with empyema and chest wall osteomyelitis is likewise convex toward the normal side and may respond to removal of this thether in the growing child.

Normal prolactin levels were found in two cases of galactorrhoea following surgical procedures to the chest wall and one was treated successfully with bromocriptine. Studies were then carried out to test the claim that chest-wall injury is one of the common causes of hyperprolactinaemia. Serum prolactin levels were measured before and after thoracotomy in 7 patients, following traumatic rib fractures in 8 patients and after burns to the chest in one patient. No evidence was found to suggest that sustained hyperprolactinaemia follows chest wall surgery or injury, and the role of prolactin in the condition 'chest wall injury' galactorrhoea is discussed.

The contribution of iatrogenic pathology to all pleural diseases was evaluated in a series of 562 cases by studying pleural effusions or pneumothoraxes induced by medical interventions. Iatrogenic pathology accounted for 5.5% of all pleural diseases (effusion 2.5%, pneumothorax 3%). The medical interventions most frequently responsible for pleural effusion were surgical operations performed in the thorax, but also on abdominal organs located close to the diaphragm. Pneumothorax was almost always induced by diagnostic manoeuvres: essentially needle biopsy and, less frequently, transbronchial lung biopsy under fibroscopy. It must be pointed out that iatrogenic pleural lesions are small and usually asymptomatic.

One month following a right upper lobectomy for bronchial carcinoma, a 50-year-old man developed headaches, confusion and a right hemiparesis. Radiographs revealed intraventricular air. This was thought to have originated from air being forced through a dural tear sustained at the time of operation. Both the intraventricular air and the accompanying symptoms and signs subsequently resolved.

The tracing of venous thromboses of the lower limbs by means of iodine 125 marked fibrinogen is possible in thoracic surgery thanks to the calibration of the apparatus on the femoral surface in cases of left thoracotomy or sternotomy. Twelve patients out of 128, i.c. 9.4%, had a positive test: 11 men and 1 woman of whom 11 had a minimum of 2 risk factors of venous thrombosis. These patients had 7 right and 5 left thoracotomies: 6 pneumonectomies (15.4% of pneumonectomies), 5 lobectomies (13% of lobectomies) and one enucleation; 11 positive tests occurred on patients operated on for cancer. There were 5 thrombo-embolic accidents: 2 fatal and 2 non fatal. Mortality was 4.28%: 6 patients of whom 3 died of infectious causes and 3 of pulmonary embolism: 2 after a pneumonectomy, respectively at 2 days and 2 months, and 1 after a lobectomy at 5 days. This examination was useful to known our percentage of isotopic thrombosis of the lower limb after thoracotomy: 9.4% which is small compared with those of the literature. However these results show the importance of instituting more prophylactic procedures to prevent venous thrombosis and thromboembolism by using heparin in all patients operated an for cancer with an exeresis and presenting 2 or more risk factors of venous thrombosis.

Tapia's syndrome, a unilateral paralysis of the muscles of the tongue associated with palsy of the ipsilateral vocal cord, was observed in two patients within a short time of each other, after they had undergone thoracotomy. It can be understood as an extremely localized lesion just at the crossing of the vagal and hypoglossal nerves. Pressure neuropathy of both nerves due to inflation of the cuff within the larynx is an accepted cause. An alternative explanation is that stretch, caused by downward traction of the esophagus, is transferred to both nerves, those being closely connected in many places, and ultimately causing damage to them.

Cardiac arrhythmias are a frequent complication after thoracic operations. The prophylactic value of flecainide administered as a constant-rate, intravenous infusion (0.15 mg/kg/h) after a loading dose (2 mg/kg) was tested in a randomized, placebo-controlled study in 30 patients using Holter monitoring during the first 72 hours after operation. A high incidence of atrial and complex ventricular arrhythmias was observed in the placebo-treated group, with a clear predominance in patients undergoing left thoracotomy. Antiarrhythmic drugs had to be added in 6 patients in the placebo-treated group (n = 16), but in none in the flecainide-treated group (n = 14) (p less than 0.01). The preventive effect of flecainide was observed at serum concentrations in the middle of the therapeutic range (409 ng/mL) without side effects. It is concluded that flecainide administration effectively reduced or prevented cardiac arrhythmias after thoracic operations.

The incidence of deep-vein thrombosis (DVT) verified by fibrinogen test was studied in 44 high-risk patients after major non-cardiovascular thoracic surgery. In eight patients (18%) a total of ten DVT appeared within the first postoperative week. Four thrombi were located at or above knee level. More extensive surgery was associated with higher DVT incidence than lesser operations (32% v. 8%). In patients belonging to blood groups B and AB, DVT was more common than in other blood groups. Five of the six unilateral DVT were detected on the same side as the thoracotomy. The findings suggest that DVT incidence after this kind of surgery may be of the same order as after major general surgery, indicating a need for thromboprophylactic measures.

The role of antibiotics in the therapeutical result and in the postoperative complications was studied after 557 thoracic operations. It was found that antibiotics have no decisive role in the therapeutic result and there was no difference in the incidence of wound infections between the groups treated with different antibiotics. The principles and practice of treatment of would infections and pyothorax are discussed in detail. No relationship was found between the incidence of postoperative respiratory complications and the various drug treatments. Prevention and treatment of postoperative respiratory complications are discussed. The length of the febrile period was independent of the antibiotics applied. Their time of application, the problem of changing drugs and their side-effects after thoracic operations are analyzed.

Painful scars after thoracic or abdominal surgery were treated in 37 patients with various methods, including analgesic block, transcutaneous nerve stimulation (TNS), neurotomy, scar resection, epidural spinal electrical stimulation and thermocoagulation. At follow-up, three patients were free from pain and three experienced significantly less pain as a result of the treatment. In two other patients the pain had spontaneously diminished. The results indicate that surgery on peripheral structures is not effective, which suggests that the source of the pain is to be found in central structures. The authors advocate conservative measures such as blockade, TNS and physiotherapy in combination with psychologic support.

The high incidence (50-60%) of deep venous thrombosis of the legs (DVT) after major thoracic surgery is reduced only by about half with routine low-dose heparin prophylaxis. The present study compared the efficacy of a higher dose of heparin (7500 U twice daily) with the commonly used dose of 5000 U twice daily in preventing scan-detected DVT in 100 consecutive patients having thoracotomy for carcinoma of the lung or oesophagus. After the higher dose of heparin, postoperative DVT was not significantly less frequent (22% compared with 33% for total DVT) but was significantly less extensive (8% and 14%, respectively, for bilateral calf DVT, and 0% and 4% for popliteal DVT). Despite prophylaxis, DVT was especially common after oesophagogastrectomy (41% total DVT, 30% extensive DVT). No excessive postoperative bleeding was noted in either group. It is concluded that an increased dose of heparin safely offers increased prophylaxis against DVT in patients undergoing major thoracic surgery for cancer.

Catheter aspiration for simple pneumothorax (CASP) was evaluated prospectively in the outpatient management of simple traumatic pneumothorax in 17 patients and compared to conventional tube thoracostomy (CTT) in 17 matched control patients. In 16 of the 17 consecutive study patients CASP maintained lung reexpansion without complications. Pneumothorax was due to needle puncture for drug abuse in 11 patients, stab wounds in five patients, and blunt trauma in one patient. The CASP patients were not hospitalized, whereas the control CTT patients averaged 4.9 days' hospitalization. CTT was associated with complications in two patients versus none for CASP. Parenteral analgesics were utilized for greater than 48 hours in CTT patients but were not needed for CASP patients. Costs averaged +310 for CASP compared to +3,030 for CTT. This ongoing pilot study data indicates that CASP is a reasonable alternative to CTT in selected patients with simple traumatic pneumothorax.

Spontaneous pneumothorax is not uncommon and can be potentially dangerous, especially in older people. A series of 201 patients is presented. Conservative treatment with tube thoracostomy had a 19% failure rate. It seems nevertheless to be the treatment of choice, though with risk of serious complications. Among the 60 patients who underwent lateral thoracotomy, 30% had recurrence of pneumothorax or other complications. Reoperation because of inadequate pulmonary expansion was necessary in four cases.