A 49 year old previously healthy smoker was diagnosed with a giant bulla in his right lung, following a history of dry cough, repeated upper airway infections and increasing dyspnea for several years. Computed tomography (CT) confirmed the presence of a giant bulla in the right inferior lobe and several smaller bullae in the right superior lobe. The giant bulla was 17 cm in diameter, occupying more than half of the right hemithorax. On spirometry a moderate restrictive and a mild obstructive pattern was observed. Lung volume was measured with two different techniques, nitrogen washout and plethysmography, with volume of the bullae estimated at 2.9 L, similar to the 3.2 L determined by CT. The patient underwent thoracotomy, where the giant bulla together with the inferior lobe were removed with lobectomy and the small bullae in the superior lobe with wedge resection. Five months postoperatively the patient is in good health and is back at work. Postoperatively significant improvements in spirometry values and lung volume measurements have been documented. This case demonstrates that giant bullae can be successfully managed with surgical resection and their size can be determined by different techniques, including lung volume measurements and chest CT.
To investigate whether the assessment of resectability of lung cancer can be reliably made on the basis of computed tomography (CT), the thoracic CT scans of 96 lung cancer patients who were operated on, and in whom the tumour was classified to be of stage III at preoperative CT or at thoracotomy, were analysed. Of the patients, 58 underwent complete resection of the tumour, whereas thoracotomy resulted in non-complete resection or exploration only in 38 cases. Overlapping of the CT findings in the groups of complete and non-successful resection was observed. The majority of tumours with apparent growth to the carina, trachea, oesophagus or great vessels at CT were completely resected. Tumours that only bordered on the pleura could not be distinguished from those with pleural invasion. Mediastinal lymph node enlargement did not always mean metastatic spread. We conclude that there is no definite sign that identifies non-resectability of lung tumours, and a certain proportion of non-curative thoracotomies must be accepted.
The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.
Department of Cardiothoracic Anesthesia double daggerDivision of Lung Transplantation, Heart Center Section for Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Denmark. email@example.com
Little is known about persistent postsurgical pain after lung transplantation with the associated intensive and continuous immunosuppressive treatment. Therefore, we investigated the nationwide incidence of chronic pain after lung transplantations.
Detailed questionnaires were sent to all 110 Danish surviving recipients of lung transplantation from September 2002 to September 2007.
Seventy-nine patients fulfilled the inclusion criteria with a mean follow-up time of 39 months. Excluded patients were 1 death during survey, 14 with previous thoracic surgery, and 16 patients who did not respond to an initial mailed questionnaire or a reminder. Fourteen patients (18%) reported persistent pain, whereas only 8 patients (10%) reported pain score >3 (numeric rating scale 0 to 10) and 4 patients (5%) >5 (numeric rating scale 0 to 10). Seventy-one percent of the patients with postsurgical pain also had pain from another part of the body. In patients with persistent postsurgical pain, this was a limiting factor for daily social activities in 29% to 92% dependent on the activity and 54% in pain felt quality of life was compromised due to the pain. Seventy-three percent of persistent postsurgical pain patients (lateral thoracotomy) experienced sensory disturbances compared with 46% of nonpain patients.
Moderate-to-severe persistent postsurgical pain occurred in 5% to 10% of patients after lung transplantation, which is lower than reported after nontransplant thoracotomy. The specific role of the peritransplant immunosuppression on persistent post-thoracotomy pain should be explored further.
The clinical effects and financial impact of a change in prescribing habits from routine to occasional use of perioperative bronchodilators, following the presentation of drug information, were assessed retrospectively by comparing the outcomes of patients admitted for major thoracic surgery. Eighteen of 24 (75%) patients in Period A (prior to change) received salbutamol bronchodilator therapy versus 10 of 17 (59%) in Period B (following the change) (p = .448). Of the patients who did receive salbutamol aerosols, the mean dose in grams per patient was greater in Period A than in Period B (6.85 +/- 5.96 vs. 2.64 +/- 4.44 respectively p
The transthoracic and transhiatal resection techniques are compared using the 30-year experience of Oulu University Central Hospital. During the period 1960-1982 we favoured resections trough a transthoracic route, while during the period 1983-1989 a transhiatal route was preferred. This change, and the more enthusiastic attitude adopted towards resection, has lead to an increase in resectability from 23% (46/203) to 62% (43/69) (P less than 0.0001). The difference between radical resections, 50% (23/46) and 37% (16/43) has remained non-significant. Morbidity was higher after transthoracic than transhiatal resections, 57% (26/46) versus 42% (18/43), whereas mortality was nearly the same, 11% (5/46) and 9% (4/43). Postoperative pulmonary complications occurred in 28% (13/46) after transthoracic resection and in 14% (6/43) after transhiatal resection. No significant difference was detected in the development of late anastomotic strictures, 33% (15/46) and 30% (13/43), respectively. We conclude that transhiatal resection is as safe as transthoracic resection and seems to allow more resections to be carried out without any increase in mortality or morbidity, but long-term survival remains poor.
INTRODUCTION: Historically, surgery for SP has been performed with open thoracotomy. Today video-assisted thoracoscopic surgery (VATS) has replaced open surgery for SP in most centers. Long-term results (i.e. recurrent pneumothorax) following VATS have been debated. In Iceland surgery for SP has been performed with both VATS and limited axillary thoracotomy (LAT). The aim of this study was to compare these two approaches, especially reoperations for prolonged airleakage and late recurrences. MATERIAL AND METHODS: This is a retrospective non-randomized study on all patients operated first time for SP at our institution between 1991-2005. Out of 210 patients that underwent 234 procedures (160 males, mean age 29 yrs.), 200 had primary SP (95%) and 10 secondary SP. The cases were divided into two groups; 134 VATS procedures and 100 thoracotomies (LAT). Three surgeons performed a LAT and four performed VATS. RESULTS: Wedge resection was performed in all cases and mechanical pleurodesis was added in 25% of the VATS and 67% of the LAT cases. Median operation time was 20 minutes longer for VATS (p=0.006). Reoperations for late recurrent pneumothorax were 10 vs. 3 in the VATS and LAT group, and reoperations for persistent airleakage 3 vs. 0, respectively (p=0.03). Operative mortality within 30 days from surgery was 0%. Median hospital stay was one day longer after LAT. CONCLUSION: Reoperations following VATS for SP are more common compared to open thoracotomy, explained by a higher rate of both late recurrent pneumothoraces and prolonged early postoperative airleakage. Both approaches are safe and major complications are infrequent. Hospital stay is shorter after VATS, however, VATS takes longer and the higher reoperation rate is a shortcoming and is of concern.
post-thoracotomy pain syndrome (PTPS) and its social consequences have been inconsistently investigated as most studies were either small sized, focused on a limited number of risk factors or included heterogeneous surgical procedures. The current objectives were to obtain detailed information on the consequences of PTPS after thoracotomy and video-assisted thoracic surgery (VATS) from homogenous unselected nationwide data, and to suggest mechanisms for the development of PTPS.
data from 1327 patients were collected using a prospective national database and combined with a detailed questionnaire.
the response rate was 81.5%, resulting in 546 patients without prior thoracic surgery for the final analysis. Follow-up was 22 months (range 12-36). PTPS occurred in 33% thoracotomy patients and 25% VATS patients. Clinically relevant pain was present in 11-18% of the patients and severe pain in 4-12% depending on the level of physical activity. In PTPS patients, 64% also had pain from other locations on the body. Perceived sensory changes in the thoracic area were present in 63% of PTPS patients vs. 25% in pain-free patients (P
The experience of diagnosis and treatment of heart and pericardium wounds in 152 patients are presented. In obecure diagnosis the authors prefer X-ray examination and echocardiography. Total lethality was 23.6%. Its high level is due to injury of coronary arteries and intracardiac structures, other thoracic and abdominal organs. The left anterolaferal thoracotomy is the optimum approach in wounds of the heart and pericardium. The most frequent complication of postoperative period is pericarditis, its echographic symptoms were revealed in 91% examinys. Non-steroid and steroid antiinflammatory drugs are effective for prophylaxis and treatment of pericarditis.