Time trend in the surgical management of patients with lung carcinoma

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 surviva

Myocardial revascularization and bilateral lung transplantation without cardiopulmonary bypass

Coronary artery disease is occasionally encountered in lung transplant recipients and is a risk factor for perioperative complications and poor survival. Besides combined heart-lung transplantation, various techniques of myocardial revascularization can be performed before, or at the time of lung transplantation. We report herein a patient with end-stage bronchoemphysema and two-vessel coronary disease who underwent ‘off-pump' coronary artery bypass graft immediately followed by bilateral lung transplantatio

Small size new silastic drains: life-threatening hypovolemic shock after thoracic surgery associated with a non-functioning chest tube

We report a case of a massive haemothorax following bilateral surgical resection of apical bullae. Occult bleeding was not recognized until the onset of a life-threatening circulatory collapse associated with metabolic acidosis and a fall in haemoglobin level. Using a thoracotomy, large amounts of blood were evacuated from the thoracic cavity and bleeding originating from ruptured pleural adhesion was easily controlled. Thrombotic material with talc particles was found to obstruct the 19-French 4-channel Blake drain. Although this new silastic Blake tube has been recommended in cardiac surgical patients, extending its indication in thoracic surgery, particularly when talc pleurodesis is used, should be questioned given the enhanced postoperative prothrombotic state and risk of drain obstruction. In conclusion, caution should be exercised when new small-sized material is introduced in clinical practice, especially after talc pleurodesis following thoracic surger

Impact of intrathecal morphine analgesia on the incidence of pulmonary complications after cardiac surgery: a single center propensity-matched cohort study.

BACKGROUND: Acute pain and systemic opioids may both negatively impact respiratory function after cardiac surgery. This study analyzes the local practice of using intrathecal morphine analgesia (ITMA) with minimal parenteral opioid administration in cardiac surgery, specifically the impact on postoperative pulmonary complications (PPCs). METHODS: Data from adult patients who underwent elective cardiac surgery between January 2002, and December 2013 in a single center were analyzed. Propensity scores estimating the likelihood of receiving ITMA were used to match (1:1) patients with ITMA and patients with intravenous analgesia (IVA). Primary outcome was PPCs, a composite endpoint including pneumonia, adult respiratory distress syndrome, and any type of acute respiratory failure. Secondary outcomes were in-hospital mortality, cardiovascular complications, and length of stay in the intensive care unit (ICU) and hospital. RESULTS: From a total of 1'543 patients, 920 were treated with ITMA and 623 with IVA. No adverse event consequent to the spinal puncture was reported. Propensity score matching created 557 balanced pairs. The occurrence of PPCs in patients with ITMA was 8.1% vs. 12.8% in patients with IVA (odds ratio, 0.6; 95% CI, 0.40-0.89; p = 0.012). Fewer patients with ITMA had a prolonged stay in the ICU (> 4 days; 16.5% vs. 21.2%, p = 0.047) or in the hospital (> 15 days; 25.5% vs. 31.8%. p = 0.024). In-hospital mortality and cardiovascular complications did not differ significantly between the two groups. CONCLUSION: In this study involving cardiac surgical patients, ITMA was safely applied and was associated with fewer PPCs

Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery

INTRODUCTION: In lung cancer surgery, large tidal volume and elevated inspiratory pressure are known risk factors of acute lung (ALI). Mechanical ventilation with low tidal volume has been shown to attenuate lung injuries in critically ill patients. In the current study, we assessed the impact of a protective lung ventilation (PLV) protocol in patients undergoing lung cancer resection. METHODS: We performed a secondary analysis of an observational cohort. Demographic, surgical, clinical and outcome data were prospectively collected over a 10-year period. The PLV protocol consisted of small tidal volume, limiting maximal pressure ventilation and adding end-expiratory positive pressure along with recruitment maneuvers. Multivariate analysis with logistic regression was performed and data were compared before and after implementation of the PLV protocol: from 1998 to 2003 (historical group, n = 533) and from 2003 to 2008 (protocol group, n = 558). RESULTS: Baseline patient characteristics were similar in the two cohorts, except for a higher cardiovascular risk profile in the intervention group. During one-lung ventilation, protocol-managed patients had lower tidal volume (5.3 +/- 1.1 vs. 7.1 +/- 1.2 ml/kg in historical controls, P = 0.013) and higher dynamic compliance (45 +/- 8 vs. 32 +/- 7 ml/cmH2O, P = 0.011). After implementing PLV, there was a decreased incidence of acute lung injury (from 3.7% to 0.9%, P < 0.01) and atelectasis (from 8.8 to 5.0, P = 0.018), fewer admissions to the intensive care unit (from 9.4% vs. 2.5%, P < 0.001) and shorter hospital stay (from 14.5 +/- 3.3 vs. 11.8 +/- 4.1, P < 0.01). When adjusted for baseline characteristics, implementation of the open-lung protocol was associated with a reduced risk of acute lung injury (adjusted odds ratio of 0.34 with 95% confidence interval of 0.23 to 0.75; P = 0.002). CONCLUSIONS: Implementing an intraoperative PLV protocol in patients undergoing lung cancer resection was associated with improved postoperative respiratory outcomes as evidence by significantly reduced incidences of acute lung injury and atelectasis along with reduced utilization of intensive care unit resources

Transoesophageal Doppler Monitoring For Fluid And Hemodynamic Treatment During Lung Surgery

Introduction: Patients undergoing lung resection are vulnerable to fluid overhydration. Recently, goal-directed fluid therapy using transoesophageal Doppler monitoring (TDM) has been shown to improve postoperative clinical outcome. The aim of this study was to assess the feasibility of TDM during open-chest procedures for guiding fluid and hemodynamic treatment. Methods: We performed an observational prospective study including 127 high-risk patients undergoing lung cancer resection. A restrictive fluid strategy was targeted to achieve a stroke volume index (SVI) ≥ 30ml/min/m2. Besides standard hemodynamic measurements, stroke volume index (SVI), corrected flow time (FTc), maximal acceleration (MA) and velocity (PV) were recorded during two-lung ventilation (TLV) and one-lung ventilation (OLV). Results: Doppler flow tracings could not be obtained in 4 patients during TLV (3.1%) and in 6 patients during OLV (4.9%). Preoperatively, 96 pts had SVI ≥ 30ml/min/m2 (N-SVI group) whereas 21 patients had SVI < 30ml/min/m2 (L-SVI group) associated with lower FTc values. After OLV, SVI transiently decreased (−17 ± 9%; P<0.05) in the N-SVI group whereas in the L-SVI group, SVI increased steadily until the end of surgery (+40 ± 12%). Other flow-related parameters as well as heart rate and mean arterial pressure remained unchanged. Surgical and medical characteristics did not differ between the two groups, except that larger volumes of colloids were administered intraoperatively in the L-SVI group (+2.2 ± 0.6ml/min/h compared with N-SVI group, P < 0.05). Conclusion: In thoracic surgical patients, TDM can be used to detect and correct low flow conditions and to guide hemodynamic support during the intraoperative perio

The effects of β1-adrenergic blockade on cardiovascular oxygen flow in normoxic and hypoxic humans at exercise

At exercise steady state, the lower the arterial oxygen saturation (SaO2), the lower the O2 return (\ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2}). A linear relationship between these variables was demonstrated. Our conjecture is that this relationship describes a condition of predominant sympathetic activation, from which it is hypothesized that selective β1-adrenergic blockade (BB) would reduce O2 delivery (\ifmmode\expandafter\dot\else\expandafter\.\fi{Q}{\text{aO}}_{2} ) and \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} . To test this hypothesis, we studied the effects of BB on \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}{\text{aO}}_{2} and \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} in exercising humans in normoxia and hypoxia. O2 consumption (\ifmmode\expandafter\dot\else\expandafter\.\fi{V}{\text{O}}_{2} ), cardiac output (\ifmmode\expandafter\dot\else\expandafter\.\fi{Q}, CO_{2}\; \hbox{rebreathing}), heart rate, SaO2 and haemoglobin concentration were measured on six subjects (age 25.5±2.4years, mass 78.1±9.0kg) in normoxia and hypoxia (inspired O2 fraction of 0.11) at rest and steady-state exercises of 50, 100, and 150W without (C) and with BB with metoprolol. Arterial O2 concentration (CaO2), \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}{\text{aO}}_{2}, and \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} were then computed. Heart rate, higher in hypoxia than in normoxia, decreased with BB. At each \ifmmode\expandafter\dot\else\expandafter\.\fi{V}{\text{O}}_{2} , \ifmmode\expandafter\dot\else\expandafter\.\fi{Q} was higher in hypoxia than in normoxia. With BB, it decreased during intense exercise in normoxia, at rest, and during light exercise in hypoxia. SaO2 and CaO2 were unaffected by BB. The \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}{\text{aO}}_{2} changes under BB were parallel to those in \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}. \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} was unaffected by exercise in normoxia. In hypoxia the slope of the relationship between \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}{\text{aO}}_{2} and \ifmmode\expandafter\dot\else\expandafter\.\fi{V}{\text{O}}_{2} was lower than 1, indicating a reduction of \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} with increasing workload. \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} was a linear function of SaO2 both in C and in BB. The line for BB was flatter than and below that for C. The resting \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} in normoxia, lower than the corresponding exercise values, lied on the BB line. These results agree with the tested hypothesis. The two observed relationships between \ifmmode\expandafter\dot\else\expandafter\.\fi{Q}\bar{{\text{v}}} {\text{O}}_{2} and SaO2 apply to conditions of predominant sympathetic or vagal activation, respectively. Moving from one line to the other implies resetting of the cardiovascular regulatio

Incidence, risk factors and prognosis of changes in serum creatinine early after aortic abdominal surgery

Objective: To determine the incidence, risk factors, and prognostic implications of serum creatinine changes following major vascular surgery. Design: Observational study. Settings: University hospital. Patients: Cohort of 599 consecutive patients undergoing elective abdominal aortic surgery. Interventions: Review of prospectively collected data from 1993 to 2004. Measurements and results: The receiver-operator characteristic (ROC) curve analysis was used to detect the best threshold for postoperative elevation in serum creatinine (Δ Creat) in relation to major complications. Acut-off value of +0.5 mg/dl was selected to define renal dysfunction (RD0.5 group, n = 91; no RD0.5, n = 508) that was associated with higher mortality (7.7% in RD0.5 group vs 1.4% in no RD0.5 group, P  40 min; OR, 3.8, 95% CI, 1.9-7.2), blood transfusion (> 5 units; OR, 1.9, 95% CI 1.2-6.1), and rhabdomyolysis (OR, 3.6, 95% CI 1.7-7.9). Conclusions: Postoperative RD0.5 (Δ Creat  > 0.5 mg/dl) occurs in 15% of vascular patients and carries abad prognosis. Preoperative renal insufficiency and factors related to the complexity of surgery are the main predictors of renal dysfunctio

Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis

INTRODUCTION: Left ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis. METHODS: Perioperative data were prospectively collected in 108 surgical candidates with an expected operative mortality ≥ 9%. All anesthetic and surgical techniques were standardized. Reduced LV systolic function was defined by an ejection fraction <40%. Diastolic function of the LV was assessed using standard Doppler-derived parameters, tissue Doppler Imaging (TDI) and transmitral flow propagation velocity (Vp). RESULTS: Doppler-derived pulmonary flow indices and TDI could not be obtained in 14 patients. In the remaining 94 patients, poor systolic LV was documented in 14% (n = 12) and diastolic dysfunction in 84% of patients (n = 89), all of whom had Vp <50 cm/s. During weaning from CPB, 38 patients (40%) required inotropic and/or mechanical circulatory support. By multivariate regression analysis, we identified three independent predictors of LV systolic dysfunction: age (Odds ratio [OR] = 1.11; 95% confidence interval (CI), 1.01 to 1.22), aortic clamping time (OR = 1.04; 95% CI, 1.00 to 1.08) and Vp (OR = 0.65; 95% CI, 0.52 to 0.81). Among echocardiographic measurements, Vp was found to be superior in terms of prognostic value and reliability. The best cut-off value for Vp to predict LV dysfunction was 40 cm/s (sensitivity of 72% and specificity 94%). Patients who experienced LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6% in patients without LV dysfunction, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001). CONCLUSIONS: This study provides the first evidence that, besides advanced age and prolonged myocardial ischemic time, LV diastolic dysfunction characterized by Vp ≤ 40 cm/sec identifies patients who will require cardiovascular support following valve replacement for aortic stenosis