Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy

BACKGROUND: We compared the immediate postoperative outcome and cost-effectiveness of using a single chest drain in the midposition to the conventional apical and basal drains after lobectomy. METHODS: Of the 120 consecutive patients who underwent thoracotomy and lobectomy for lung cancer at our center between January 2001 and December 2002, 60 had the conventional 28 French apical and basal drains (group A), whereas the remaining 60 had a single 28 French chest drain placed in the midposition before closure (group B). The assessed outcomes included length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax and pneumothorax, drain reinsertion, patient controlled analgesia duration, maximum pain scores, and analgesic usage. RESULTS: Both groups matched in terms of age (group A vs group B mean, 65 years old vs 66 years old, respectively; p = not significant [NS]) and gender (M:F, 4:1 for group A vs 4:1 for group B). There was no significant difference in the length of stay (mean, 7.7 days for group A vs 7.8 days for group B; p = NS), amount of drainage (mean, 667 mL for group A vs 804 mL for group B; p = NS), duration of drainage (mean, 4 days for group A vs 4.3 days for group B; p = NS), duration of patient controlled analgesia (mean, 3.7 days for group A vs 4.2 days for group B; p = NS) and analgesic combinations used (nonsteroidal antiinflammatory drugs +/- oral opioids +/- paracetamol) between the two groups. There were no clinically significant postdrain removals of hemothorax or pneumothorax in either group. Group A patients had a significantly higher maximum pain score compared with group B patients (mean, 1.4 vs 1.02, respectively; p = 0.02). Cost savings per patient in group B was more than or equal to 55 US dollars, which added up to a total cost savings of approximately more than or equal to 3,300 US dollars. CONCLUSIONS: A single chest drain in the midposition is just as effective, significantly less painful, and much more cost effective than the conventional use of two drains after lobectomy.     

Video-assisted minithoracotomy versus conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas

This study was performed to evaluate the advantages of video-assisted minithoracotomy over conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas. Thirty-two patients with clinical T1N0M0 non-small cell lung carcinoma underwent lobectomy with R2a mediastinal lymphadenectomy. Of these, sixteen patients underwent posterolateral thoracotomy (between April 1994 and November 1995: T group), and sixteen patients underwent video-assisted thoracic surgery (between December 1997 and April 1999: V group). No significant differences were found in the two groups with respect to the total number of mediastinal lymph nodes dissected (T group: 16.9 +/- 8.7. V group: 14.3 +/- 7.2) or operative time (T group: 182.3 +/- 48.8 min, V group: 174.9 +/- 28.8 min). The intraoperative blood loss was significantly less in the V group (T group: 222.3 +/- 107.1 ml, V group: 143.3 +/- 92.6 ml, p < 0.05), and the postoperative max CPK was also less (T group: 1,484 +/- 496, V group: 785 +/- 327, p < 0.0001). Duration of chest tube drainage (T group: 11.3 +/- 3.6 days, V group: 7.9 +/- 2.7 days) and the requirement of epidural analgesia (T group: 6.7 +/- 2.2 days, V group: 5.0 +/- 0.8 days) were less in the V group (p < 0.01), and the length of postoperative hospitalization as also shorter in the V group (T group: 26.3 +/- 8.3 days, V group: 20.6 +/- 4.1 days, p < 0.05). In conclusion, video-assisted minithoracotomy is less invasive than posterolateral thoracotomy for performing lobectomy of lung carcinomas, and has an advantage in that it improves the postoperative quality of life.     

单操作孔胸腔镜手术治疗非小细胞肺癌的临床分析

目的探讨单操作孔胸腔镜下行肺叶切除术加系统性淋巴结清扫治疗非小细胞肺癌的可行性和临床应用价值。方法回顾分析2011年3月至2013年3月采用单操作孔胸腔镜行肺叶切除术并且系统性清扫淋巴结治疗的非小细胞肺癌患者42例。手术在腋中线第7或者第8肋间作约1．5cm切口作为观察孔,在腋前线第4或者第5肋间胸大肌外侧缘作4．0—5．0cm切口作为操作孔。结果所有患者均顺利在单操作孔胸腔镜下完成肺叶切除术加系统性淋巴结清扫,无增加第2个操作孔或者中转开胸手术者。行肺叶切除术加系统性淋巴结清扫手术时间90～200min,术中出血量50～400ml,清扫淋巴结数量9～16枚,术后胸腔引流时间5—8d,术后住院6～10d。所有患者均未出现手术并发症,术后恢复良好,顺利出院。结论单操作孔胸腔镜下肺叶切除术加系统性淋巴结清扫治疗非小细胞肺癌,在传统的三孔电视胸腔镜手术基础上进～步减少了手术创伤,具有一定的临床优势,只要病例选择合适,可以作为治疗非小细胞肺癌更微创化的手术方式。     

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy

BACKGROUND: The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy. METHODS: This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS. RESULTS: In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant. CONCLUSIONS: Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.     

Thromboembolism following multiple trauma.

The true incidence of thromboembolic complications following multiple trauma is unknown, and no method of prophylaxis has been shown to be both safe and effective in managing seriously injured patients. In this prospective study, 113 trauma patients were assigned on admission to receive either low-dose heparin (LDH), (5,000 U subcutaneously every 12 hours) or to wear sequential compression devices (SCDs) as prophylaxis against the development of deep venous thrombosis (DVT). Both groups of patients were serially studied with duplex venous ultrasound imaging to detect thrombus in the veins of the thigh. Ventilation-perfusion lung scans and pulmonary angiograms were performed when pulmonary embolism (PE) was suspected clinically. There were 12 patients who had thromboembolic complications, including 9 of 76 in the SCD group (12%) and 3 of 37 in the LDH group (8%). Five patients had DVT only, four had PE without detectable DVT, and three had both DVT and PE. None of the patients with PE died, and there were no major complications associated with either method of prophylaxis. Compared with the patients who did not develop DVT/PE, those with thromboembolic complications were older (49 +/- 23 vs. 36 +/- 17 years, p less than 0.02), spent more hospital days immobilized (24 +/- 15 vs. 10 +/- 13 days, p less than 0.001), received more transfusions (11 +/- 12 vs. 3 +/- 5 U, p less than 0.001) and had clotting abnormalities on admission, as demonstrated by prolonged PTT values (39 +/- 28 vs. 26 +/- 5 seconds, p less than 0.001). It appears that there is an identifiable subgroup of injured patients at highest risk for PE who warrant both prophylaxis and close surveillance for DVT.     

Characteristics and prognosis of resected T3 non-small cell lung cancer

BACKGROUND: T3 tumors can be divided into several subgroups depending on the type of anatomical structure invaded: chest wall, mediastinal pleura, or main bronchus. The aim of this study was to analyze the characteristics and prognosis of each subgroup of T3 tumors. METHODS: The results of surgical treatment were retrospectively analyzed for 261 patients with T3 non-small cell lung cancer invading either the mediastinal pleura or parietal pericardium by direct extension (mediastinal pT3, n = 68), or main bronchus (bronchial pT3, n = 68), or chest wall (chest wall pT3, n = 125) that were operated on between 1984 and 1996. Complete resection including radical mediastinal lymph node dissection was intended in all patients. One patient had segmentectomy, 91 had lobectomy (34.9%), and 169 had pneumonectomy (64.8%). One hundred and fifty-eight patients received adjuvant radiation therapy and 7 patients received both adjuvant chemotherapy and radiation therapy. Actuarial survival curves were drawn using the Kaplan-Meier method and risk factors for late death were identified. RESULTS: In-hospital mortality was 6.1%. Follow-up was 98% complete. Global 5-year survival was 28%, with survival being not significantly different among the three subgroups: 34.9%, 30.6%, and 22.5% (p = 0.19) in the bronchial pT3, mediastinal pT3, and chest wall pT3 subgroups, respectively. Resection margins were microscopically invaded in 33 patients (12.6%). Seventy-four patients had N1 involvement (28.4%) and 78 patients had N2 involvement (29.8%). N0 involvement was more prevalent in the chest wall pT3 subgroup, whereas N1 involvement was more prevalent in the bronchial pT3 subgroup and N2 involvement was more prevalent among patients with mediastinal invasion. Pathologic factors influencing the 5-year survival were tumor size (p = 0.03) and N involvement (p = 0.003). Histology, type of surgical resection (lobectomy versus pneumonectomy), and use of adjuvant therapy did not influence survival significantly. CONCLUSIONS: Five-year survival was not significantly different among the three subgroups of pT3 non-small cell lung cancer, although bronchial pT3 tumors tended to have a better prognosis and chest wall pT3 tumors tended to have a worse prognosis. The pathologic characteristics of each pT3 subgroup seems different. Further research is warranted to explore the pathologic and biological factors influencing prognosis for each pT3 subgroup.     

A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients

BACKGROUND: Optimal antimicrobial prophylaxis for the pediatric cardiac surgical patient is unknown. We have reviewed our experience with more than 4,000 pediatric cardiac surgical patients at the University of Michigan to evaluate antibiotic prophylaxis regimens. METHODS: Three antibiotic prophylaxis protocols were serially used during a 6-year period: Protocol 1 (n = 786): cefazolin was administered before operation and continued as long as thoracostomy tubes or central venous catheters were present; Protocol 2 (n = 1095): cefazolin was discontinued 48 hours postoperatively, regardless of the presence of tubes or catheters; Protocol 3 (n = 2039): cefazolin was continued as long as thoracostomy tubes were present, but not for central venous catheters. Patients with an open chest postoperatively received vancomycin and gentamicin until chest closure. This was identical during all three protocols. We retrospectively determined the rate of surgical site infections and unrelated bloodstream infections (the latter for both cardiac medical and surgical patients) for the three protocols. RESULTS: Surgical site infections per 100 operations for protocols 1, 2, and 3 was 2.04, 6.58, and 1.67, respectively (p < 0.05 for protocol 2 versus protocols 1 and 3). The mean age of patients with a surgical site infection ranged from 12 to 15.4 months. Patients with an open chest had a higher rate of surgical site infection (18.8% for protocol 2 and 9.3% for protocol 3). Bloodstream infections per 1,000 patient days for protocols 1, 2, and 3 were 2.18, 6.51, and 5.02, respectively (p < 0.05 protocol 1 versus protocols 2 and 3). CONCLUSIONS: These data suggest that pediatric cardiac surgical patients may benefit from prophylactic antibiotics as long as thoracostomy tubes are in place.     

Blood loss in elective coronary artery surgery: a comparison of centrifugal versus roller pump heads during cardiopulmonary bypass

OBJECTIVES: To compare the effects of centrifugal pumps versus roller pumps for cardiopulmonary bypass (CPB) in routine cardiac surgery on hematologic parameters in the context of modern practice. DESIGN: Prospective, randomized, partially blinded. SETTING: University teaching hospital. PARTICIPANTS: Elective coronary artery surgery patients (n = 113) INTERVENTION: Patients were randomized to be perfused with either a roller head (group R, n = 56) or a centrifugal head (group C, n = 57) pump. Patients received epsilon-aminocaproic acid before and during CPB. Core body temperatures were allowed to drift down to approximately 32 degrees C. MEASUREMENTS AND MAIN RESULTS: Postoperative chest tube blood loss, blood product requirements, hemoglobin, and platelet counts were assessed. There were no significant differences in preoperative or intraoperative parameters, including CPB time, complexity of procedure, and minimum core temperature. There were the expected reductions in hemoglobin and platelet levels post-CPB in both groups to a similar extent. Chest tubes remained in situ for similar durations, and the final volume of drainage was not significantly different (group C, 1300 +/- 92 mL; group R 1117 +/- 83 mL; p = 0.14). Allogeneic blood was given to 23% of patients in group C and 18% in group R (p = 0.63). Aspirin was associated with an increase in early chest tube drainage. CONCLUSIONS: In this surgical and perfusion environment, the authors were unable to show an advantage, from the hematologic point of view, in the routine use of a centrifugal pump head in elective coronary artery surgical patients. The use of antifibrinolytic agents and mild hypothermia may have effects on hemostasis that overshadow the influence of pump head design in this type of surgery.     

Effect of routine fibrin glue use on the duration of air leaks after lobectomy

The effectiveness of fibrin glue as a sealant to reduce postoperative air leaks after pulmonary lobectomy was evaluated in 28 consecutive patients between November 1988 and May 1989. A fibrin glue spray was used in 14 patients, and 14 patients served as controls. Assignment of either group was made before thoracotomy. Nine male and 5 female patients with a mean age of 63.8 years were in the fibrin glue experimental group, and 8 male and 6 female patients with a mean age of 59 years, in the control group. An equal number of complete and incomplete fissures were in each group. All fissures were handled in the same way (stapled). Two milliliters of fibrin glue was applied through a double-syringe delivery system and sprayed on the staple line and any cut surface of the inflated lung just before thoracotomy closure. The fibrin glue-treated group had a mean air leak duration of 2.3 +/- 3.7 days, chest tube drains for 6 +/- 4.1 days, and a postoperative hospitalization of 9.8 +/- 3.1 days. The control group had a mean air leak duration of 3.3 +/- 3.3 days (p = 0.94), chest tube drains for 5.9 +/- 3.9 days (p = 0.95), and a postoperative hospitalization of 11.5 +/- 3.9 days (p = 0.21). We conclude that the routine use of a fixed quantity of fibrin glue is not effective in reducing the duration of air leaks, chest tube drainage, or hospitalization after uncomplicated pulmonary lobectomy.     

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

BACKGROUND: Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done. METHODS: Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected. RESULTS: A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients. CONCLUSIONS: There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.     

A sheep model for thoracic aortic surgery in the presence of systemic coagulopathy.

Surgical repair of aneurysms, traumatic injuries, or congenital anomalies of the thoracic aorta are associated with high morbidity and mortality mainly as a result of excessive and uncontrollable hemorrhage from diffuse coagulopathy. We developed a model in sheep that simulates this coagulopathic state for experimentation with thoracic aorta surgery. This experimental animal model involves administering a 600-mg aspirin suppository once a day for the 2 days preceding surgery and a final dose on-call to surgery. Prior to cross-clamping the aorta, an intravenous (i.v.) bolus of heparin (400 IU/kg) was administered. Thirty minutes later, the i.v. heparin bolus was repeated. Pre- and intraoperative activated clotting time was 101 +/- 10 s and >1500 s (p < .0001); prothrombin time, 21 +/- 1 s and >100 s (p < .0001); and activated partial thromboplastin time, 20 +/- 1 s and >50 s (p < .0001), respectively. We utilized a partial cross-clamp-and-sew technique to anastomose a woven, gelatin-impregnated, 16-mm tube graft end-to-side to the descending thoracic aorta. Mean total blood loss was 1367 +/- 282 mL, which included mean blood loss from time of release of aortic cross-clamp to close (422 +/- 135 mL) and mean total blood output from chest tube drain (945 +/- 203 mL). The mean time to achieve hemostasis at suture lines after aortic cross-clamp release was 15.5 +/- 6.6 min. In conclusion, a sheep model with induced coagulation defects was successfully developed and reproducible for experimentation involving thoracic aortic surgery.     

Efficacy of Blake drains for mediastinal and pleural drainage following cardiac operations

BACKGROUND: Mediastinal and pleural drainage following cardiac operations has traditionally been achieved with large bore, semirigid chest tubes. The purpose of this study was to evaluate the safety and efficacy of drainage by means of small, soft, and flexible 19 F Blake drains. METHODS: This is a review of all patients who underwent heart surgery over a 3-year period at a single institution. Chest tubes and Blake drains were removed on postoperative day 1 to 5 depending on patient's condition, amount of drainage, and surgeon's preference. The criteria for drain removal did not vary with type of drain. RESULTS: There was no significant difference in the amount of drainage between both groups. Postoperative mediastinal exploration occurred in 3.47% of patients (12/346) in the chest tube group and in 2.08% of patients (8/385) in the Blake group (p = 0.27). Significant pleural effusions requiring a subsequent drainage procedure occurred in 9.54% of patients (33/346) in the chest tube group and in 9.87% of patients (38/385) in the Blake group. CONCLUSIONS: No significant differences were noted in the number of mediastinal explorations in patients drained with conventional chest tubes as compared to Blake drains during cardiac operations. Though not statistically significant, there may actually be an advantage of Blake drains over conventional chest tubes in this regard. There was also no significant difference in the incidence of postoperative pleural effusions. Blake drains appear to be at least as effective and safe as conventional chest tubes in draining the mediastinum and pleural spaces following cardiac surgery.     

单向式全胸腔镜肺癌根治术探讨

目的探讨单向式胸腔镜肺叶切除术治疗非小细胞肺癌安全性、有效性和可行性。方法回顾性分析82例非小细胞肺癌患者施行单向式全胸腔镜肺叶切除术的临床资料。结果成功完成单向式全胸腔镜肺癌根治术79例;3例因胸腔镜下难以控制出血,增加10 cm辅助小切口。术中清扫淋巴结数量为7～22枚,手术时间80～210 min,术中出血量50～600 ml。术后胸管引流时间3～8 d,术后住院时间4～9 d10无围手术期死亡,无肺动脉栓塞等严重并发症。结论单向式全胸腔镜肺叶切除术具有创伤小、恢复快、疼痛轻、住院时间短等优点,淋巴结清扫彻底,是一种安全有效的手术方式,是治疗早期肺癌的可靠方法。尤其对初学者易操作、易掌握。     

Surgical treatment of malignant mediastinal neurogenic tumors in children.

INTRODUCTION: The aim of this study was to identify the role of surgical resection in the treatment of malignant mediastinal neurogenic tumors in children. MATERIALS AND METHODS: Thirty-eight consecutive children, who underwent surgical resection of a malignant mediastinal neurogenic tumor between 1986 and 2004, were included in this study. The tumor cell types were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for curative resection in localized tumors and salvage resection of residual mediastinal masses after chemotherapy in stage IV tumors. Of the 16 patients (42.1%) who underwent salvage resection, 14 had neuroblastoma and 2 ganglioneuroblastoma. RESULTS: Mean patient age was 3.4+/-3.0 years (1 month-13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in eight patients (21.1%), invasion of chest wall in four, heart and vena cava in two, lung in one, and chest wall and lung in one. Complete gross resection was possible in 30 patients (78.9%) and there was no surgical mortality. Surgical morbidity occurred in 10 patients (26.3%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 95.2% for a localized tumor and 52.5% for a stage IV tumor (p=0.004). The significant risk factors of long-term survival were adjacent structure invasion (p=0.002) and a stage IV tumor (p=0.002) by multivariate Cox regression analysis. CONCLUSIONS: Surgical resection of localized malignant mediastinal neurogenic tumor in children showed good long-term survival, and salvage operations after chemotherapy showed acceptable long-term survival.     

Comparison of three different chest drainages after coronary artery bypass surgery--a randomised trial in 150 patients.

OBJECTIVE: Drainage of blood from the mediastinum and pleura following open cardiac procedures is usually carried out using one or more large-bore plastic chest tubes. Recently small diameter siliastic drains have been reported to evacuate blood with a better patient comfort. The efficacy and safety of different chest tubes have not yet been fully evaluated. METHODS: One hundred fifty patients undergoing coronary artery bypass surgery were randomised to have either Blake) 24F (Ethicon, Inc, Somerville, NJ), Argyle 32F plastic (Tyco Healthcare, Tullamore, UK) or Jostra 32F silastic (Maquet Cardiopulmonary AG, Hirrlingen, Germany) drains inserted for evacuation of postoperative bleeding. Bleeding rate per hour, total blood loss, patient discomfort during drain removal, residual pleural fluid at chest X-ray 3 days and 3 weeks after the operation were recorded. Results: Bleeding pattern and total bleeding did not differ significantly in the three groups. Median blood loss was 615 ml (quartile range 390-820 ml) in the Blake-group, 750 ml (quartile range 430-870 ml) in the Jostra-group and 580 ml (quartile range 450-750 ml) in the Argyle-group, respectively (p=0.17). Pain at removal the day after the operation was similar in the three groups. Residual fluid in the left pleura did not differ significantly at 3 days (p=0.41) or at 3 weeks postoperatively (p=0.42). Conclusions: None of the three chest tubes was superior to drain postoperative bleeding or considering pain at removal. Local clinical routines and cost aspects should be the guide in choosing drainage system for open cardiac operations.     

Combined thoracoscopic and open chest approach of lobectomy with inferior chest wall resection for advanced lung cancer

Patients with advanced non-small cell lung cancer invading a chest wall are surgical candidates if complete resection is possible. When a primary tumor locating the lower lobe invades an inferior chest wall, either a wide skin incision or double skin incisions to secure surgical views both for dissection of hilum and mediastinum and for inferior chest wall resection is necessary. Wider incision causes higher rate of wound necrosis and infection. We describe a combined approach of thoracoscopic and open chest surgery for lobectomy and inferior chest wall resection, respectively. Patient was a 68-year-old man with an advanced non-small cell lung cancer. Video-assisted thoracoscopic middle and lower lobectomies and mediastinal nodal dissection was completed via 5 ports. Chest wall resection including the posterior portion of the 9th and 10th ribs and the transverse process followed inferior postero-lateral thoracotomy. Postoperative course was uneventful. The present surgical approach can avoid a wide thoracotomy for an advanced lung cancer invading an inferior chest wall.     

Management of the irradiated bronchus after lobectomy for lung cancer

BACKGROUND: Radiation effects make operative dissection difficult, impair subsequent healing, and increase morbidity. This study evaluates tissue reinforcement of the irradiated bronchus as a modality to reduce morbidity after lobectomy for lung cancer. METHODS: We retrospectively reviewed all patients who had preoperative radiotherapy before lobectomy for lung cancer between May 1977 and June 2000. RESULTS: There were 56 patients (33 men and 23 women) who ranged in age from 42 to 80 years (median, 59 years). Bronchial stump reinforcement included no coverage in 24 patients (42.8%), mediastinal tissue (parietal pleura, pericardial fat, or azygos vein) in 16 (28.6%), and muscle (serratus anterior) in 16 (28.6%). Median preoperative radiation dose was 4,600 cGy (range, 3,000 to 9,810 cGy) and did not differ between the groups. There were three deaths (13%) in the no coverage group, one (6%) in the mediastinal tissue group, and one (6%) in the muscle group (NS). Pulmonary complication rate was 67% in the no coverage group, 44% in the mediastinal group, and 25% in the muscle group (p = 0.03). Median duration of chest tube drainage was 8 days in the no coverage group, 6 days in the mediastinal group, and 5 days in the muscle group (p = 0.006). Median hospital stay was 13 days in the no coverage group, 9 days in the mediastinal group, and 7 days in the muscle group (p = 0.02). Patients in the muscle group had reduced hospital stay, duration of chest tube drainage, and pulmonary complications compared with the other two groups (p < 0.05). Subjectively, presence and magnitude of postoperative pain, range of motion, and strength of the upper extremity of the muscle flap side were not different between the groups (p = NS). Follow-up was complete and ranged from 4 to 147 months (median, 17 months). CONCLUSIONS: Tissue reinforcement of the irradiated bronchus after lobectomy reduces postoperative morbidity and hospitalization. Transposition muscle flap may be preferred.     

Perfadex for clinical lung procurement: is it an advance?

BACKGROUND: Extensive laboratory experience suggested that low potassium dextran lung preservation solution (Perfadex; Medisan, Uppsala, Sweden) is superior to Euro-Collins (EC; Frusen, Hamburg, Germany), the clinical standard. The purpose of this study was to evaluate Perfadex in clinical lung transplantation. METHODS: A retrospective analysis of the outcome of 69 consecutive lung allografts retrieved and used for transplantation was made. Donor lungs were flushed with EC in 37 patients and Perfadex in 32 patients. The evaluation measurements were quantitative chest roentgenogram score (grade 0 to 4), graft oxygenation, duration of mechanical ventilation, length of intensive care treatment, and survival. RESULTS: The mean chest roentgenogram score was 1.55 and 1.81 for the EC group compared with 1.18 and 2.09 for the Perfadex group at 1 and 48 hours, respectively (p = 0.1 and 0.8, respectively). Arterial alveolar oxygen tension ratio was similar at 12 and 24 hours (0.61 vs 0.67; p = 0.8; and 0.64 vs 0.53; p = 0.3, respectively). The mean ventilation time was 71.2 +/- 32.3 hours versus 81.9 +/- 43.6 hours for the EC and Perfadex groups, respectively (p = 0.4). The mean intensive therapy unit stay was 3.1 +/- 2.6 days for the EC group compared with 4.1 +/- 3.9 days for the Perfadex group (p = 0.4). Death caused by primary organ failure was 5.1% for the EC group compared with 3.1% for the Perfadex group (p = 0.8). CONCLUSIONS: There was no difference between Perfadex and EC in clinical lung preservation. This may reflect the difference between controlled laboratory environment and the real world of brain death lung injury. Further studies are required to investigate the impact of Perfadex in the long-term outcome of lung transplantation.     

Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures

From January, 1979, to December, 1984, at the Cardiac Surgery Department of the University of Torino Medical School, major sternal wound infections developed in 48 (1.86%) of 2,579 consecutive patients. These patients underwent open-heart procedures through a midline sternotomy and survived long enough for infection to appear. Possible risk factors were evaluated by means of a multivariate analysis. For the group of patients, we considered age, sex, hospital environment (different locations of our surgical facilities over the years), interval between hospital admission and operation, antibiotic prophylaxis, type of surgical procedure, elective or emergency surgical procedure, reoperation, duration of surgical procedures, duration of cardiopulmonary bypass, amount of blood transfused, postoperative blood loss, chest reexploration, rewiring of a sterile sternal dehiscence, duration of mechanical ventilation, and days of treatment in the intensive care unit. Univariate analysis indicated that age, sex, type and mode of surgical procedure, antibiotic prophylaxis, and duration of mechanical ventilation were not significantly associated with wound infection. For all other predisposing factors, a p value of less than .05 was demonstrated. These variables were entered in a multiple stepwise logistic regression. Six emerged as significant: hospital environment (p = .0001), interval between admission and surgery (p = .041), reoperation (p less than .0001), blood transfusions (p = .031), early chest reexploration (p less than .0001), and sternal rewiring (p less than .0001). Contamination of patients may occur before, during, and after operation, and any kind of reintervention may predispose to wound infection.     

Wound problems following hip arthroplasty before and after the introduction of a direct thrombin inhibitor for thromboprophylaxis

In the United Kingdom, national guidelines have stated that patients undergoing elective hip surgery are at increased risk for venous thromboembolic events (VTE) following surgery and have recommended thromboprophylaxis for 28-35 days (1, 2). Studies of direct thrombin inhibitors have hitherto concentrated on major bleeding. We prospectively assessed wound discharge in patients who underwent hip arthroplasty and who received oral dabigatran postoperatively between March 2010 and April 2010 (n=56). We compared these results to a retrospective matched group of patients who underwent similar operations six months earlier, at which time all patients were given subcutaneous dalteparin routinely postoperatively until discharge, and then discharged home on 150 mg aspirin daily for 6 weeks (n=67). Wound discharge after 5 days was significantly higher in the patients taking dabigatran (32% dabigatran n=18, 10% dalteparin n=17, p=0.003) and our rate of delayed discharges due to wound discharge significantly increased from 7% in the dalteparin group (n=5) to 27% for dabigatran (n=15, p=0.004). Patients who received dabigatran were more than five times as likely to return to theatre with a wound complication compared with those who received dalteparin (7% dabigatran n=4, vs. 1% dalteparin n=1), but this was not statistically significant (p=0.18). We now administer dalteparin until the wound is dry and then start dabigatran. Our study demonstrates the need for further clinical studies regarding wound discharge and direct thrombin inhibitors.