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Thoracic surgery is performed in dogs and cats for many reasons. Because it is performed less frequently than surgery on other body regions, and because the pathophysiologic effects of thoracotomy are life threatening, a good understanding of the principles of thoracic surgery is essential to success.
Thoracic epidural fentanyl has been used successfully for postoperative analgesia in patients undergoing thoracic surgery. Prior investigators have suggested that increasing the administered dosage and volume of lumbar epidural fentanyl may increase the spread of analgesia. The feasibility of injecting a high volume (20 mL) of fentanyl into the lumbar epidural space for post-thoracic surgery analgesia was studied in 17 patients undergoing elective thoracotomy or sternotomy. All patients had a lumbar epidural catheter placed before induction of general anesthesia. No narcotic was administered during surgery. Thirty minutes before the conclusion of anesthesia, 200 micrograms of fentanyl in 16 mL of 0.9% saline was administered via the epidural route. In the intensive care unit (ICU), additional fentanyl in the same dosage and volume was injected when the patient complained of pain. Pain was scored on a linear analog scale pre-injection and 30 minutes post-injection. Arterial blood gases were obtained simultaneously. All patients experienced pain relief within 15 minutes of injection. No significant respiratory depression or hypercarbia was noted. Lumbar epidural fentanyl is a safe and practical alternative to thoracic epidural analgesia in the post-thoracic surgical patient.
Studies published in the English-language literature on the use of prophylactic systemic antibiotics in vascular surgery, noncardiovascular thoracic surgery, mastectomy, and herniorrhaphy were reviewed. The effectiveness of antibiotic prophylaxis in preventing deep and superficial wound infections in peripheral vascular surgery appears to be well documented, especially if prophylaxis is directed against Staphylococcus aureus. In clean thoracic surgery the evidence is equivocal, and no studies have sufficient statistical power to eliminate the possibility even of a 50% reduction in incidence. In herniorrhaphy and mastectomy some evidence from a much more powerful study suggests that antibiotic prophylaxis may result in a decrease of up to 50% in wound infections, but whether these data can be generalized uncritically to all clean wounds is still a matter of debate. Accordingly, only guarded recommendations can be made regarding the use of prophylactic antibiotics in procedures associated with a very low risk of serious infection.
Responding to a survey about their practice in 1985, 2,969 (70%) Board-certified thoracic surgeons provided data that were compared with data from manpower surveys in 1980 and 1976. (table; see text) Thoracic surgeons were most active between ages 35 and 54 years when they accomplished 61% of all general thoracic and 85% of cardiac operations. Surgeons older than 50 years performed significantly more general thoracic operations than younger surgeons, and the younger group performed significantly more cardiac operations than their older counterparts. Solo practice continued to decline. In smaller referral areas, the number of general thoracic procedures per surgeon increased, but the number of cardiac operations have decreased compared with 1980. Overall, general thoracic and cardiac operations increased, but peripheral vascular procedures and pacemaker insertions decreased in almost all nine census regions. Fewer general thoracic and cardiac operations were performed per thoracic surgeon in the western United States than in central and eastern regions. In response to questions about work load, 55% believed that their clinical activity was satisfactory, 42% operated too little, and 3% operated too much. The 363 non-Thoracic Board-certified surgeons who responded performed 14% of general thoracic and 8% of cardiac surgery in 1985. During the first half of the 1980s, our specialty certified an average of 134 thoracic surgeons annually, which is higher than the 120 surgeons per year estimated to meet the projected demand.
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Twelve patients undergoing elective thoracic surgery because of lung cancer, have been studied. The anesthetic management included: continuous epidural anesthesia with bupivacaine (T6-T7), continuous infusion of propofol and vecuronium, mechanical ventilation with an oxygen/air mixture. We evaluated the perioperative analgesia and the cardiovascular side effects of two groups of patients differing for the position (supine or lateral) selected to administer the local anesthetic. We also analysed the most important characteristics of the recovery from anesthesia (degree of analgesia and consciousness, respiratory function and cooperation with physiotherapeutic manoeuvres). The authors conclude that, although the number of patients studied is limited, there are no significant differences between the two groups for intraoperative analgesia and hemodynamic imbalance; the anesthetic technique employed is a reliable alternative to classic balanced anesthesia, because seems to reply very well to the mayor purposes of thoracic surgery. Moreover it makes the operative room free from pollution caused by volatile anesthetics.
Modern thoracic surgery was born at about the time the Swiss Surgical Society was founded. Tuffier, Rehn, Lilienthal, Thorek were some of the pioneers. Today the important developments are esophagectomy without thoracotomy, the routine performance of cardiac transplantation and the emergence of lung transplantation. The past, present and future of these developments are outlined.
20 patients undergoing thoracic surgery were studied. Before anaesthesia either a catheter was placed in the intercostal space, at the same level as the thoracotomy (16 patients) or an epidural catheter was inserted if there was a contraindication of intercostal blockade (4 patients). Marcaine 0.5--was injected. Anaesthesia was induced with propofol 2.5 mg.kg-1, vecuronium 0.1 mg.kg-1, dextromoramide 50 mcg.kg-1. It was maintained with propofol 9 mg.kg-1.h-1 for 30 mn, then 4.5 mg.kg-1.h-1 for following hours (by a syringe pump) and vecuronium 0.1 mg.kg-1.h-1. Cardio vascular effects were studied only in the 16 patients with intercostal blockade: during induction bradycardia in 3 patients, and systolic arterial pressure (S.A.P.) decrease of 30% in 8 patients were observed. After the incision, heart rate and S.A.P. became steady. The average duration of anaesthesia was 214 min +/- 74. The time from the end of propofol infusion to the moment of extubation was 15.4 min +/- 33 and the time to recover all mental faculties was 46 mn +/- 11. 30 min after the end of anaesthesia the maxima minute ventilation was equal to the post operative value at 48 H. Propofol anaesthesia allows a fast awakening, without cumulative effects.
One hundred patients undergoing elective thoracic surgery were anesthetized with propofol as a continuous intravenous infusion. In 60 patients, nitrous oxide was used for supplementation. The technique proved satisfactory, but induction of anesthesia was associated with significant decreases in blood pressure. The use of nitrous oxide markedly reduced the propofol requirements, and prolonged the time to the first spontaneous breath during recovery. The mean infusion rate of propofol was 7.2 +/- 2.72 mg/kg/h with air-oxygen, and 5.7 +/- 1.97 mg/kg/min with nitrous oxide-oxygen (P less than 0.01). This technique seems to be a satisfactory alternative for patients primarily requiring an intravenous anesthetic during thoracic surgery.
In the 1970s and 1980s the measures for providing the inhabitants of the FRG with regionally distributed facilities in thoracic and cardiovascular surgery took almost only heart surgery into account. In the field of thoracic surgery, by contrast, several centers were closed or used for other purposes. This development was due to the decline in tuberculosis, but also partly to the lack of exact statistics concerning thoracic surgery. The result has been a considerable deficit in the provision of specialized care for the population and stagnation in research. A nationwide questionnaire in 1989 showed that in 78.4% of the surgery departments asked general thoracic surgery was undertaken only occasionally (less than 100 interventions a year); 42.8% of the operations were undertaken by non-specialized surgeons. Malignant diseases dominated the case-load. Because of the lack of sufficient thoracic surgery departments with appropriate specialized knowledge, it must be assumed that many patients with cancer of the thoracic organs are receiving either no, inefficient, or too late a treatment of their disease. Reorganisation of general thoracic surgery is necessary in order to provide the population with adequate facilities in this field. The existing thoracic surgery centers should be enlarged and attached to the universities in order to ensure research and teaching. Specialized treatment of thoracic surgical diseases can be achieved by reorganizing general surgery departments in the regional hospitals which already undertake thoracic interventions and by establishing additional thoracic surgery departments under qualified leadership.
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The amazing development of thoracic surgery was due to the extraordinary number of operations necessary in the treatment of diseases of epidemic proportions: tuberculosis, rheumatic heart disease and coronary disease. From 1939 onwards, the young chest surgeons were confronted with war wounds of the heart and great vessels. Back in civilian practice, they became the pioneers of an initially primitive, blind cardiac surgery. In the course of 40 years this surgery developed to become the highly specialized interdisciplinary specialty of today's cardiovascular surgery, the crowning of which is the routine heart transplantation of 1990.
In Sweden thoracic surgery is a surgical specialty. Treatment is organized by 5 hospitals for thoracic surgery. In 3 clinics there is although open heart surgery. From 1969 to 1977 the number of interventions on the lung, mediastinum and chest wall rose by 35%, the reason is the increasing number of patients with bronchogenic cancer. Vascular surgery (peripheral vessels) is mostly performed by general surgeons, pacemaker surgery in district hospitals. From a prospective study there is no reason to change the organization of thoracic surgery in Sweden during the next years.
Twenty-two elective thoracic surgeries were performed under epidural high dose fentanyl anesthesia. These included 11 mastectomies, 3 lung lobectomies, and 8 operations for esophageal carcinoma. Through an epidural catheter, 10 micrograms.kg-1 fentanyl with [E (+)] or without [E (-)] epinephrine (1: 100,000) was given. N2O (66%) and enflurane (0.2-0.8%) were also administered, and muscle relaxants were given as needed. The onset and duration of the action were approximately 20 minutes and 3 hours, respectively. Anesthesia was maintained with enflurane (up to 0.4%) in 17 patients (77.3%). There were no differences between the E (+) group and the E (-) group. Systolic pressure, diastolic pressure and heart rate during operations were about 30% lower than those observed before the operations. Patients recovered from anesthesia rapidly. Naloxone was administered intravenously in 6 patients after mastectomies or lung lobectomies (42.9%), whose respiratory rate was below 10.min-1. The patients with short operating time (shorter than 2 hours) needed more naloxone. Troubles did not occur either in the recovery room or in the ward with both naloxone and non-naloxone groups.