Pulmonary thromboembolism after surgery for esophageal cancer: Its features and prophylaxis

(Received for publication on Jan. 22, 1999; accepted on Nov. 11, 1999)     

Perfusatory Recovery of the Grafted Lung During Convalescence from Acute Rejection

(Received for publication on Nov. 2, 1998; accepted on July 13, 1999)     

Effectiveness of an inferior vena caval filter as a preventive measure against pulmonary thromboembolism after abdominal surgery

(Received for publication on Aug. 3, 1998; accepted on Jan. 7, 1999)     

Late pleuropulmonary aspergillosis after the treatment of pneumothorax: Report of three cases

(Received for publication on June 19, 1998; accepted on Mar. 11, 1999)     

An Experimental Study of Atrial Natriuretic Peptide Levels and the Effect of Inhaled Nitric Oxide After Pneumonectomy

(Received for publication on Feb. 24, 1999; accepted on Nov. 11, 1999)     

Pulmonary thromboembolism after spinal instrumentation surgery

A 57-year-old woman was hospitalized because of gait disturbance and dysuria. Close examination revealed a cauda equina tumor at the level of L2 and L3. Tumor resection was performed, with posterolateral fusion and spinal instrumentation. On the eleventh day after the surgery, she experienced dyspnea and chest pain during standing and walking exercise. Pulmonary thromboembolism was diagnosed, based on: (1) blood gas analysis findings of hypoxemia and (2) defective images in both of the upper lobes on urgent pulmonary blood flow scintigram. Her clinical status improved with urgent thrombolytic therapy (with tisokinase and urokinase) and anticoagulation therapy (with heparin and warfarin), and her life was saved. When pulmonary thromboembolism occurs, early diagnosis by pulmonary blood flow scintigram and early thrombolytic and anticoagulative therapies are necessary. Special attention should be paid to symptoms of pulmonary thromboembolism in patients after spinal surgery. Received for publication on Sept. 30, 1998; accepted on March 5, 1999     

Complete resection of non-small-cell lung cancer and oligo-metastatic brain disease

BACKGROUND: Non-small-cell lung cancer is a leading cause of cancer morbidity and mortality in Australia. Brain metastases are common, and rapidly fatal if untreated. Optimal management consists of resection and whole brain irradiation. However, there is a paucity of local data documenting survival after such treatment. METHODS: Medical records for all patients who underwent complete resection of non-small-cell lung cancer at one institution between January 1999 and December 2003 were reviewed in order to determine survival after initial surgery. The survival of all patients was compared with patients who underwent resection of synchronous or metachronous brain metastases and whole brain irradiation as part of their lung cancer management. RESULTS: Between 1 January 1999 and 31 December 2003, 170 patients underwent complete resection of non-small-cell lung cancer by a thoracic surgeon. Resection of synchronous or metachronous brain metastases followed by whole brain irradiation was also carried out on 15 of these patients. Complete cerebral resection was achieved in 12 cases. The overall 5-year survival after attempted curative resection of brain metastases and successful complete resection was 60% and 70%, respectively. The survival of patients with both cerebral metastasectomy and lung cancer resection approximated that of the cohort of patients that only required complete resection of their lung cancer. CONCLUSIONS: Control of local disease at each site and long-term survival after lung resection and resection of either synchronous or metachronous brain METASTASIS and whole brain irradiation is readily achievable. We believe this should continue as the standard of care for this presentation.     

The effects of circulating interleukin-8 and adhesion molecules on pulmonary dysfunction in pediatric orthotopic liver transplantation

2 /FIO₂ showed a significant inversed corre-lation with the peak IL-8 concentration, after the exclusion of two patients, one of whom died and one of whom rejected the transplanted liver, no correlation was able to be found between the PaO₂/FIO₂ ratio and the maximum IL-8 concen-tration. Furthermore, there was no correlation between the adhesion moleclues and PaO₂/FIO₂. These results suggest that IL-8 exerts only a slight effect on respiratory function following successful pediatric liver transplantation, and that circulating adhesion molecules do not affect perioperative lung function. (Received for publication on May 6, 1998; accepted on May 27, 1999)     

Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease

Objective: The purpose of this study was to investigate the impact of pulmonary rehabilitation on surgical morbidity and lung function in lung cancer patients with chronic obstructive pulmonary disease (COPD). Methods: Prospectively, 22 lung cancer patients with COPD who underwent lobectomy between 2000 and 2003 were enrolled for this study as a rehabilitation group (Rehab. Group). The criteria of COPD were preoperative forced expiratory volume in 1 second (FEVl)/forced vital capacity (FVC) ≦70% and more than 50% of low attenuation area in a computed tomography. Preoperatively patients performed aggressive pulmonary exercise for two weeks and received chest physiotherapy postoperatively. As a historical control, 60 patients with lung cancer who fulfilled the same criteria but did not receive rehabilitation between 1995 and 1999 (control group) were entered in this study. Results: Patient backgrounds were all equivalent between the two groups. However, FEV1 and FEV1/FVC were significantly lower in the Rehab. Group (p<0.05). Prolonged oxygen supplement and tracheostomy tended to be more frequent in the control group. The ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the Rehab. Group (p=0.047). Furthermore, postoperative hospital stay was significantly longer in the control group (p=0.0003). Conclusion: Despite lower FEV1 and FEV1/FVC in the Rehab. Group, postoperative pulmonary complications and long hospital stay could be effectively prevented and FEV1 was well preserved by rehabilitation and physiotherapy.     

Reexpansion Pulmonary Edema Due to High-Frequency Jet Ventilation: Report of a Case

Barotrauma is well known to be a relatively common complication of high-frequency jet ventilation (HFJV); however, the occurrence of reexpansion pulmonary edema (REPE) is extremely rare. We report herein a case of REPE caused by difficulties encountered with anesthesia using HFJV during video-assisted thoracic surgery (VATS) for a spontaneous pneumothorax. We believe the rapid increase in pressure in the lung after degassing for VATS resulted in REPE as well as typical barotrauma. Received: August 27, 1999 / Accepted: July 25, 2000     

Surgical Treatment for Chronic Pulmonary Thromboembolism Under Cardiopulmonary Bypass with Selective Cerebral Perfusion

The median sternotomy approach for the treatment of chronic pulmonary thromboembolism was recently improved by Daily, Jamieson, and coworkers who adopted it for use under cardiopulmonary bypass with intermittent circulatory arrest; however, we have sometimes found that the circulatory arrest time was too short to complete thromboendarterectomy. Therefore, we attempted to perform a selective cerebral perfusion technique to extend the endarterectomy time. Although we noted slight back-bleeding from the bronchial arteries, we were able to extend the endarterectomy time without causing any postoperative delirium. We conclude that the median sternotomy approach using cardiopulmonary bypass with selective cerebral perfusion may be the best option for extending the thromboendarterectomy time. Received: August 13, 1999 / Accepted: September 26, 2000     

Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery

Background: Whether and how pulmonary hypertension (PH) impacts perioperativeoutcome in non-cardiac surgery is incompletely understood. Methods: From November 1999, all patients undergoing non-cardiac, non-localanaesthetic surgery and ever examined by echocardiography within30 days before surgery were screened. Those having echocardiographicpulmonary artery systolic pressure >70 mm Hg were enrolledprovided they were not already intubated. Case-matched peerswith normal pulmonary pressures served as controls. Perioperativeoutcomes were compared between the two groups, and predictorsof adverse perioperative outcomes were investigated by multivariatelogistic regression analysis. Results: From November 1999 to August 2004, a total of 62 patients (male38, mean age 67 yr) with PH were found. Compared with the case-matchedcontrols, patients with PH experienced equivalently smooth operativecourses, but significantly more frequent postoperative heartfailure (9.7 vs 0%, P = 0.028), delayed tracheal extubation(21 vs 3%, P = 0.004), and in-hospital deaths (9.7 vs 0%, P= 0.028). Multivariate regression analysis identified emergencysurgery [odds ratio (OR), 44.738; P = 0.028], coronary arterydisease (CAD; OR, 9.933; P = 0.042), and systolic pulmonaryartery pressure (OR, 1.101; P = 0.026) as independent predictorsof postoperative mortality and surgery-specific cardiac risklevel (OR, 6.791; P = 0.033) and CAD (OR 6.546, P = 0.017) aspredictors of morbidity. Conclusion: PH is an important predictor of adverse cardiopulmonary outcomein non-cardiac surgery as reflected by markedly increased postoperativecomplications, especially in patients with coexistent high-riskclinical and surgical characteristics.     

Significance of non-calcified pulmonary nodules in patients with extrapulmonary cancers

BACKGROUND: This study sought to determine the rate and patterns of malignancy in patients with extrapulmonary cancers and non-calcified pulmonary nodules, and to develop a statistical model to guide clinicians regarding choice of patients for diagnostic biopsy. METHOD: The medical records of 151 patients evaluated at the Memorial Sloan-Kettering Cancer Center between January 1999 and December 2001 for non-calcified pulmonary nodules were reviewed. Nodules were considered malignant based on the results of a diagnostic biopsy, and were considered benign if their appearance remained stable 2 years after the initial study, if they resolved, or if a biopsy showed a non-malignant condition. RESULTS: Sixty four of 151 patients (42%) were diagnosed with malignant nodules; 32 had newly diagnosed lung cancers, 28 had metastatic spread of their primary cancers, and four had lesions that were either new cancers or of undetermined aetiology. On univariate analysis the likelihood of malignancy increased with nodule size, tobacco exposure, and the finding of a solitary nodule. On multivariable analysis only nodule size and tobacco exposure were predictive of malignancy. The model had good predictive accuracy (area under the curve 0.751) but had insufficient discrimination for use as a clinical tool to determine which patients should undergo diagnostic biopsy. CONCLUSION: Nearly half the non-calcified pulmonary nodules identified in this series were malignant. Lung cancer was more common than metastatic disease. These findings support the need for close interval follow up and a low threshold for diagnostic biopsy in patients with extrapulmonary cancers and non-calcified pulmonary nodules. In smokers, such lesions should raise concern for lung cancer.     

Improved outcome of pulmonary aspergillosis in heart transplant recipients with early diagnosis and itraconazole treatment

Pulmonary aspergillosis is a severe complication in heart transplant recipients. The drug of choice for this infection is amphotericin B, but its use is limited because of its side effects. We observed six cases of pulmonary aspergillosis in a group of 200 patients who had received heart transplants from January 1988 to January 1999. Predisposing factors such as previous rejection, neutropenia and/or cytomegalovirus reactivation were present in all patients. The clinical presentation was characterized by fever and a non-productive cough. X-rays showed monolateral or diffuse infiltrate with or without nodular lesions. The median interval between symptoms and diagnosis was 5 d (range 4–7). Diagnosis was made by culturing trans-tracheal aspirate samples. Aspergillus fumigatus was isolated in 3 patients and A. niger in the other 3. All patients were treated with itraconazole at 200–400 mg/day for 20–60 d and all recovered. One patient treated with the lowest dosage for the shortest term had a recurrence after 1 month and needed a second 30-day course of itraconazole at a higher dosage. No significant side effects were registered. Itraconazole is effective in the therapy of pulmonary aspergillosis, particularly when an early diagnosis is made.     

Resection of Invasive Pulmonary Aspergillosis in Immunocompromised Patients

Background: Immunocompromised patients are prone to develop invasive pulmonary aspergillosis (IPA). Relapse and high mortality rates are seen in those patients who receive subsequent immunotoxic therapy. Standard antifungal regimens often fail to completely eradicate IPA, which then warrants an aggressive surgical approach.Methods: We performed a retrospective chart review of 13 immunocompromised patients who were considered to have IPA and who underwent surgery between 1988 and 1998.Results: Twelve patients had a hematological malignancy and one patient had breast cancer. The diagnosis of IPA was based on a chest computed tomographic scan in all patients. A preoperative diagnosis of aspergillosis was made in three patients, and mucormycosis in one patient, by bronchoalveolar lavage. Before surgery, seven patients received chemotherapy, one patient underwent bone marrow transplantation, and five patients received a combination of chemotherapy and bone marrow transplantation. Symptoms included cough (54%), fever (54%), hemoptysis (30%), and shortness of breath (8%). Three patients (23%) were asymptomatic. The mean preoperative absolute neutrophil count was 4881 cells/ml. Seventeen thoracic operations were performed, i.e., 12 wedge resections, 4 lobectomies, and 1 pneumonectomy. One patient also underwent nephrectomy for invasive aspergillosis and one patient underwent craniotomy to resect an aspergillus brain mass. Surgical pathology revealed IPA in 13 (76%), invasive mucormycosis in 2 (15%), aspergilloma in 1, and diffuse alveolar hemorrhage in 1. Postoperative complications included the following: operative bleeding requiring transfusion, three patients; prolonged air leak, two patients; death because of hepatic/renal failure, one patient; and death because of overwhelming multisystem aspergillosis, one patient. Seven (54%) patients underwent further immunotoxic treatment with no aspergillosis recurrence. After a mean follow-up of 12 months, five (38%) patients are alive and seven (54%) have died without evidence of aspergillosis and/or mucormycosis.Conclusions: Surgical resection, in combination with antifungal agents, is a safe and effective form of therapy for invasive mycoses. It prevents recurrence and allows for subsequent cytotoxic therapies.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

电视胸腔镜手术在肺硬化性血管瘤诊断和治疗中的应用

目的探讨电视胸腔镜手术在以孤立性肺结节（solitary pulmonary nodule,SPN）为表现的肺硬化性血管瘤（pulmonary sclerosing hemangioma,PSH）诊断和治疗中的价值。方法回顾性分析1999年2月-2008年10月,11例术前经胸片、胸部CT发现的周围型SPN（咳嗽2例,咳血1例,胸痛1例,无症状7例）,术后病理确诊为肺硬化性血管瘤的临床资料。全胸腔镜或胸腔镜辅助小切口肺楔形切除7例,肺段切除3例,肿瘤切除术1例。结果 11例均成功完成电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）。术中快速冰冻病理示PSH7例,2例肺良性病变,2例恶性肿瘤待排除;术后病理确诊为PSH。平均手术时间57 min（45-70 min）,平均出血量85 ml（50-120 ml）;术后无并发症和手术死亡。11例术后随访22-63个月,平均31个月,无复发。结论 PSH术前诊断困难,电视胸腔镜不仅是PSH的诊断手段,也是目前最有效的治疗方法。     

Correlation of unilateral thoracoscopic lung volume reduction with improvement in lung function and exercise performance in patients with severe pulmonary emphysema

1 ), forced vital capacity, static compliance, and maximal oxygen uptake. The functional residual capacity as measured by the gas dilution method (FRC_gas), was unchanged; however, it was found to be decreased significantly when measured by body plethysmograph (FRC_box). Positive correlations existed between the reduction in FRC_box and the increase in FEV₁ (r = 0.586, P = 0.0042) and maximal oxygen uptake (r = 0.550, P = 0.018). Pulmonary ventilation and exercise ability in patients with pulmonary emphysema were improved in a volume-dependent manner by thoracoscopic lung volume reduction. These findings indicate that patients with a preoperative trapped gas volume level exceeding 1 l would be ideal candidates for thoracoscopic lung volume reduction. (Received for publication on Mar. 4, 1998; accepted on Jan. 7, 1999)     

Pulmonary Carcinoid Found in a Patient who Presented with Initial Symptoms of Brain Metastasis: Report of a Case

Although atypical pulmonary carcinoids frequently metastasize to regional lymph nodes, they rarely metastasize to the brain. We describe herein an extremely unusual case of a 52-year-old woman who presented with the symptoms of brain metastasis as the initial manifestation of an atypical pulmonary carcinoid. After control of the multiple metastatic brain lesions had been achieved by tumorectomy and stereotactic radiosurgery, a middle lobectomy of the right lung was performed to completely resect the primary pulmonary carcinoid. This aggressive surgical approach was successful in that it prolonged the survival of the patient and enhanced her quality of life. Received: November 25, 1999 / Accepted: January 9, 2001     

肺动脉及分支量化分析在法洛四联症根治术中的意义

目的：对法洛四联症患者的肺动脉（PA）,左肺动脉（LPA）和右肺动脉（RPA）分支进行量化分析,探讨其临床意义。方法：术前测量236例法洛四联症患者PA及其分支直径,计算PA与主动脉（AO）直径比值（PA／AO＿,PA与体表面积（BSA）比值（PA／BSA）,PA与正常肺动脉面积（NPA）比值（PA／NPA）,（LPA＋RPA）／AO,（LPA＋＿RPA）／PA,（LPA＋RPA）／BSA等,测量术后右心室与左心室收缩压比值（PRV／LV）,分析存活者与死亡者这些指标判别意义。结果（LPA＋RPA）／AO＜0．5时,手术危险性显著增加,PA／BSA大于等于2．0时,（LPA＋RPA）／BSA大于等于2．4及PA／NPA大于等于0．6时,其手术安全性是显著增加,是否需跨肺动脉瓣环补片主要与PA／SBA,PVA／BSA,PA／NPA有关;术后PRV／LV比值与PA及其分支发育情况无关,而主要受术中右心室流出道和PA疏通情况的影响。结论：PA及其分支发育情况虽然对手术结果有影响,但更重要的是手术过程对右心室流出道及肺动脉狭窄的纠正情况／     

Benefit of surgical resection of invasive pulmonary aspergillosis in pediatric patients undergoing treatment for malignancies and immunodeficiency syndromes

Purpose: The aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed.Methods: The authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection.Results: Among the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P < .001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA.Conclusions: The overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.