Biomedical subjects
Publications and source records attributed to M Licker.
There is some evidence that complete resection of both primary and metastatic sites of non-small cell lung carcinoma has more influence on survival than the locoregional stage of the lung cancer. We describe prolonged survival (>5 years) after complete surgical resection of a bronchogenic carcinoma (T3N0M1) and solitary adrenal metastasis.
We report the use of transmyocardial laser revascularization in combination with partial left ventriculectomy for treatment of end-stage dilated ischemic cardiomyopathy. The disappearance of the reversible perfusion defects in the treated left ventricular territories and improvement of the systolic function led us to believe that the simultaneous use of these two techniques was complementary in our patient.
OBJECTIVES: To define the place of lung volume reduction surgery (LVRS) for non-bullous emphysema, to discuss the mechanisms of postoperative functional improvement and to suggest guidelines for perioperative medical management. DATA SOURCES AND EXTRACTION: The Medline data base was searched for any article (original papers, editorials, comments, reviews) published in English, French or German, from 1980 to April 1998. The key words were: lung volume reduction surgery, emphysema, respiratory failure, anaesthesia, lung transplantation. The data have been analysed to explain the physiological mechanisms underlying the postoperative improvements and to assess the risk-benefit ratio associated with LVRS. Finally, proposals are suggested for selection criteria and perioperative medical strategies. DATA SYNTHESIS: Besides pharmacological treatment and lung transplantation, LVRS is considered as an alternative treatment for patients with end-stage pulmonary emphysema. Perioperative management includes selective lung ventilation, continuous peridural analgesia and a general anaesthetic technique that can be easily reversed. Care should be taken to detect and rapidly correct dynamic hyperinflation, pneumothorax, tube malpositioning and major air leaks. In a majority of selected patients (70-80%), resection of 20-30% of lung volume produces significant clinical and physiological improvement (dyspnoea, exercise capacity, FEV1, VO2max), as well as of the quality of life that has been attributed to greater elastic recoil, reduced respiratory workload and better diaphragmatic and right ventricular function. The most common complication is prolonged air leaks. In-hospital mortality varies widely (0-20%, with a median value at 4%), depending in part on the experience of the surgical team and on the selection criteria. Several factors may predict an unfavourable outcome: advanced age, hypercapnia, diffuse emphysema, predominant airway disease and previous thoracic surgery. CONCLUSIONS: According to the favourable preliminary results and an acceptable incidence of perioperative complications, LVRS is presently considered as a new therapeutic option for some patients with respiratory failure. Future clinical studies should be focused on appropriate selection criteria, operative techniques and long term outcome data.
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OBJECTIVES: A database of patients operated of lung cancer was analyzed to evaluate the predictive risk factors of operative deaths and life-threatening cardiopulmonary complications. METHODS: From 1990 to 1997, data were collected concerning 634 consecutive patients undergoing lung resection for non-small cell carcinoma in an academic medical centre and a regional hospital. Operations were managed by a team of experienced surgeons, anaesthesiologists and chest physicians. Operative mortality was defined as death within 30 days of operation and/or intra-hospital death. Respiratory failure, myocardial infarct, heart failure, pulmonary embolism and stroke were considered as major non-fatal complications. Preoperative risk factors, extent of surgery, pTNM staging, perioperative mortality and major cardiopulmonary complications were recorded and evaluated using chi-square statistics and multivariate logistic regression. RESULTS: Complete data were obtained in 621 cases. The overall operative mortality was 3.2% (n = 19). Cardiovascular complications (n = 10), haemorrhage (n = 4) and sepsis or acute lung injury (n = 5) were incriminated as the main causative factors. In addition, there were 13 life-threatening complications (2.1%) consisting in strokes (n = 4), myocardial infarcts (n = 5), pulmonary embolisms (n = 1), acute lung injury (n = 1) and respiratory failure (n = 2). Four independent predictors of operative death were identified: pneumonectomy, evidence of coronary artery disease (CAD), ASA class 3 or 4 and period 1990-93. In addition, the risk of major complications was increased in hypertensive patients and in those belonging to ASA class 3 or 4. A trend towards improved outcome was observed during the second period, from 1994 to 97. CONCLUSION: Our data demonstrate that perioperative mortality is mainly dependent on the extent of surgery, the presence of CAD and provision of adequate medical and nursing care. Preoperative testing and interventions to reduce the cardiovascular risk factors may help to further improve perioperative outcome.
OBJECTIVE: The goal of the study was to analyze the histological and clinical trends in lung carcinoma and their influence upon the preoperative evaluation, surgical procedures and survival. METHODS: We retrospectively reviewed the charts of 1079 consecutive patients who underwent surgery for primary lung carcinoma between 1977 and 1996 in our institution. Patients were divided into five equal 4-year periods according to the year of surgery (1977-1980; 1981-1984; 1985-1988; 1989-1992; 1993-1996). RESULTS: Between 1977-1980 and 1993-1996, the incidence of squamous cell carcinoma significantly declined, whereas the incidence of adenocarcinoma and bronchioloalveolar carcinoma increased. During the same period, the proportion of squamous cell carcinoma visualized at bronchoscopy and the rate of preoperative histological diagnosis significantly decreased. An increasing proportion of lobectomy and less extended resection was associated with an increasing number of patients with stage I carcinoma. Meanwhile, the operative mortality significantly declined from 9 to 4% and the 5-year survival improved from 25 up to 40%. CONCLUSION: Over the last two decades, the shift in histological distribution was associated with an increasing proportion of patients with stage I disease, a lower operative mortality and a better 5-year survival.
The proportion of elderly patients presenting with bronchogenic carcinoma is increasing. To study the impact of age on clinical presentation, management and outcome of patients, the authors have reviewed their clinical experience over the last 20 yrs. Between 1977 and 1996, 1,079 patients underwent thoracotomy for primary lung carcinoma in the authors' institution. Patients were grouped by age at the time of surgery as <60 yrs, 60-69 yrs and > or =70 yrs. Although the mode of clinical presentation was similar between all age groups, patients <60 yrs were more prone to have advanced stage carcinoma at the time of diagnosis. The rates of exploratory thoracotomy and pneumonectomy were higher in patients <70 yrs, whereas lobectomies and lesser resections largely predominated in patients > or =70 yrs. The mortality rate following lobectomy and lesser resection increased from 1.3% in patients <60 yrs to 5.5% in patients > or =60 yrs (p=0.04) and the mortality rate following pneumonectomy increased from 6.5% in patients <60 yrs to 13.7% in patients > or =70 yrs (p=0.24). The specific long-term survival, which included only the patients who died from primary lung carcinoma, was similar in all age groups. Operative mortality and survival rates are acceptable in patients > or =70 yrs. Therefore, age in itself should not constitute a contraindication to surgical lung resection for primary lung carcinoma as long as a careful preoperative assessment is performed to appropriately select surgical candidates.
Postpneumonectomy bronchopleural fistula (BPF) remains a serious and often life-threatening complication. Over a seven-year period, seven cases of BPF occurred in a series of 100 consecutive pneumonectomies performed for lung carcinoma by the same surgical team. The incidence increased from 3% (1/33) prior to 1993 to 9% (6/67) thereafter. The presence of tumour within the main stem bronchus and the need for postoperative mechanical ventilation correlated significantly with the occurrence of BPF. However, it is likely that other risk factors, such as the introduction of systematic mediastinal lymph nodes dissection since 1992 and bronchial stapling since 1993, were involved. In four patients, closure of BPF was achieved by transposition of pedicled latissimus dorsi (LD) muscle flap and closed-chest irrigaiton of the pleural cavity. Patients were discharged after a median stay of 19 d; fistula recurred in one case and was successfully treated with an omental flap. No complications related to the LD division were observed. In conclusion, mediastinal lymph node dissection may increase the risk of post-pneumonectomy BPF. Systematic bronchial stapling should be used cautiously, especially if the tumour is present within the main stem bronchus. Treatment with predicted LD muscle flap or omental flap associated with closed-chest irrigation proved to be simple, time-saving and efficient.
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Modified Euro-Collins (EC) solution, a crystalloid intracellular-type solution, has been commonly used for pulmonary preservation. Several experimental studies have shown the advantages of using extracellular colloid-based solutions. The aim of this study was to compare the quality of preservation of two extracellular colloid solutions, leukocyte-depleted blood (BL) and low-potassium dextran (LPD) solutions, with that of EC solution. Lungs of 22 domestic pigs were flushed and preserved with EC (n = 8), BL (n = 7), or LPD (n = 7) solution. After harvesting, one of the lungs was reperfused immediately in an ex vivo circuit (control lungs), whereas the contralateral lung was reperfused after 8 h of cold (4 degrees C) storage (preserved lungs). Besides the lung function parameters (gas exchange, pulmonary hemodynamics and mechanics), the permeability of the endothelial-epithelial barrier was assessed by determining the transferrin leak index (TLI) using a double radioisotopic method, by measuring the alveolar/arterial protein concentration ratio, and by analyzing histopathologic changes. The functional quality (oxygenation, airway resistance, dynamic compliance [CL, dyn]) of both BL and LPD lungs was slightly but significantly superior to that of EC lungs. However, pulmonary vascular resistance was lower in BL-preserved than in EC- or LPD-preserved lungs. The TLI was increased in EC control and preserved lungs, whereas it was low in BL and LPD control lungs and did not increase after preservation. The alveolar/arterial protein concentration ratio was not different between control groups, but was increased fourfold in EC-preserved compared with BL- or LPD-preserved lungs. Finally, EC-preserved lungs presented a weight gain about twice that of BL- and LPD-preserved lungs. Morphologic analysis confirmed these results, because in the EC-preserved lungs, rupture of alveolar septa and severe alveolar edema and hemorrhage were observed, whereas BL- and LPD-preserved lungs showed a relatively well-preserved structure. The results demonstrate that both BL and LPD flush solutions preserve the endothelial-epithelial barrier better than does EC solution. Although the quality of preservation is similar, pulmonary vascular resistance is higher in LPD-preserved than in BL-preserved lungs.
INTRODUCTION: Although the treatment of Pancoast tumours usually combines radiotherapy and surgery, poor prognosis has been reported. The influence of clinical signs and extension of surgical resection on long-term survival has not yet been systematically investigated. METHODS: Between 1977 and 1997, among 1129 patients operated consecutively in our institution for a bronchogenic carcinoma, 14 (1.2%) presented a Pancoast tumour. Delay between the onset of symptoms and definite diagnosis ranged from 1 to 14 months (median 7 months). A complete surgical resection was performed in 7 patients, 6 of whom did not have mediastinal lymph node metastasis. Radiotherapy or radiochemotherapy was performed in all patients. RESULTS: Overall 5-year survival rate is 36%. However, 5-year survival rate increases up to 60% if the diagnosis is established within 6 months after the onset of symptoms, and up to 67% if the tumour has been removed without mediastinal lymph node metastasis. In contrast, the 5-year survival rate decreases to 20% or 0% respectively, if symptoms last more than 6 months, or if tumoral resection is incomplete. CONCLUSIONS: The incidence of Pancoast tumours compared to other bronchogenic carcinomas is low. An early diagnosis allows complete resection of the tumour and contributes to improve survival.
In recent years, lung transplantation (LT) and volume reduction surgery (LVRS) have been proposed for selected patients with end-stage pulmonary emphysema. Retrospectively, we analyzed the perioperative time course of 30 patients with emphysema who underwent either LVRS (n = 17) or LT (n = 13). In the LVRS group, patients were significantly older, presented less severe functional disability and all but one could be extubated at the end of surgery. In contrast, patients undergoing LT required postoperative mechanical ventilation (19 +/- 11 hrs) and had a prolonged hospital stay (37 [25-60] days vs 19 [11-42] days in LVRS patients) due to reperfusion lung edema, infection, hemorrhage and acute rejection. Six months postoperatively, forced expiratory volume in 1 second was improved and was significantly larger after LT compared with LVRS (+200% vs +63%). Our preliminary results suggest that, although LT produces greater functional improvement, LVRS is associated with lower surgical risk and is an alternative therapy in selected patients with severe emphysema.
Bilateral lung volume reduction produces significant clinical and physiologic improvement in selected patients with end-stage emphysema. Current surgical approaches consist of median sternotomy and video-assisted thoracoscopy. This report describes an alternate technique of single-stage, bilateral lung volume reduction using muscle-sparing anterior thoracotomy in 18 patients with severe lung emphysema.
Separation of the lungs with a double-lumen endobronchial tube facilitates the surgical approach and protects the bronchial system from contamination by pus or blood from the operated lung. We report a case of a 49-year-old man who suffered a gram-negative pneumonia requiring mechanical ventilatory support and prolonged hospitalization after pulmonary resection. Contamination of the ventilated-dependent lung was documented intraoperatively. Current information on postoperative infectious complications and preventive measures are discussed.
We reported an unusual case of symptomatic diaphragmatic paralysis in an elderly patient with progressive respiratory-dependent limitation of her daily activities. Surgical plication of the affected hemidiaphragm resulted in early clinical and physiological improvements.
To investigate the contribution of nitric oxide in the regulation of regional blood flow and metabolism in vivo, we administered incremental doses of N omega-L-arginine-methyl ester (L-NAME 1, 3, 10, 30 and 100 mg kg-1, intravenously) in isoflurane anaesthetized pigs. The pulmonary vascular bed exhibited a greater sensitivity to the L-NAME-induced pressor effects compared with the systemic arterial bed as the slope of the dose-response curve was steeper (42.9 +/- 4.3 vs. 24.3 +/- 3.6, P < 0.05) and the dose of L-NAME required to induce a 25% pressure increase was lower (PD25 of 6.2 +/- 2.5 vs. 22.8 +/- 5.2 mg kg-1, P < 0.05). L-NAME infusion produced a dose-dependent reduction in cardiac output that was evenly distributed among the mesenteric, femoral, hepatic and carotid arterial circulation as demonstrated by unchanged regional blood flows-to-cardiac output ratios, except in the kidney where the L-NAME-induced vasoconstriction was most pronounced (renal blood flow/cardiac output decreased from 6.2 +/- 0.6 to 3.7 +/- 0.7% after 100 mg kg-1 of L-NAME, P < 0.05). After the administration of L-NAME 30 mg kg-1, intestinal O2 uptake (Vo2) increased (+39 +/- 3%, P < 0.05) whereas renal Vo2 tended to decrease (-19 +/- 4%, P = 0.07) and whole body Vo2 remained unchanged. Plasma noradrenaline and adrenaline concentrations did not change significantly with L-NAME infusion. These data demonstrate that in anaesthetized pigs, endogenous nitric oxide is most important for the regulation of pulmonary and renal blood flows and in spite of unchanged global metabolic demand, nitric oxide inhibition leads to an increase in intestinal Vo2 associated with enhanced gut motility without rise in circulating lactate levels.
We have investigated patients undergoing cardiac surgery with hypothermic bypass to see if the addition of skin surface warming during systemic rewarming on bypass (heated group, n = 43) would improve perioperative thermal balance compared with conventional management without skin warming (control group, n = 43) in an open, randomized, controlled study. Intraoperative skin warming with a water mattress and forced warm air over the face, neck and shoulders attenuated the afterdrop in nasopharyngeal temperature after weaning from bypass (2.3 (1.2) degrees C and 1.3 (0.5) degrees C in the control and heated groups, respectively) (P < 0.05) and resulted in higher rectal temperature 4 h after surgery. Despite similar standard coagulation tests, heated patients had lower blood loss via the chest tubes (600 (264) ml vs 956 (448) ml in control patients) (P < 0.05) and less requirements for i.v. colloid infusion (1662 (404) ml vs 1994 (389) ml) (P < 0.05). There was a significant inverse correlation between rectal temperature on arrival in the ICU and postoperative blood loss (r = 0.57, P < 0.001). These data suggest that additional skin surface warming with a water mattress and forced warm air helped to preserve perioperative thermal balance and may contribute to reduced bleeding after cardiac surgery.