Adel Naamee

Vocal cord dysfunction after left lung resection for cancer

OBJECTIVES To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction (VCD) after left lung resection for cancer. METHODS From February 1996 to April 1999, a review of prospectively gathered data was performed on 99 consecutive patients who underwent a pneumonectomy (n=50) or a lobectomy (n=49) with a mediastinal lymph node dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in patients with symptom(s) or sign(s) of VCD or respiratory complications. RESULTS Thirty-one patients (31%) had a postoperative VCD (group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD (P=0.13). Group VCD patients developed more pulmonary complications (P=0.014) and cardiac complications (P<0.001) compared to group non-VCD patients. A higher rate of reintubation (P=0.005), pneumonia (P=0.06), arrhythmia (P=0.002), cardiac failure (P<0.001) was noticeable in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy (P=0.001) and pneumonectomy (P=0.008) were predictive of postoperative VCD. Hospital stay was 22+/-16 days in group VCD and 13+/-9 days in group non-VCD (P<0.002). CONCLUSION VCD is a frequent event that can lead to dramatic pulmonary complications. We would recommend to track it and to treat it as early as possible.

Prediction of hypoxemia and mechanical ventilation after lung resection for cancer

BACKGROUND Hypoxemia usually occurs after thoracotomy, and respiratory failure represents a major complication. METHODS To define predictive factors of postoperative hypoxemia and mechanical ventilation (MV), we prospectively studied 48 patients who had undergone lung resection. Preoperative data included, age, lung volume, force expiratory volume in one second (FEV1), predictive postoperative FEV1 (FEV1ppo), blood gases, diffusing capacity, and number of resected subsegments. RESULTS On postoperative day 1 or 2, hypoxemia was assessed by measurement of PaO2 and alveolar-arterial oxygen tension difference (A-aDO2) in 35 nonventilated patients breathing room air. The other patients (5 lobectomies, 9 pneumonectomies) required MV for pulmonary or nonpulmonary complications. Using simple and multiple regression analysis, the best predictors of postoperative hypoxemia were FEV1ppo (r = 0.74, p < 0.001) in lobectomy and tidal volume (r = 0.67, p < 0.01) in pneumonectomy. Using discriminant analysis, FEV1ppo in lobectomy and tidal volume in pneumonectomy were also considered as the best predictive factors of MV for pulmonary complications. CONCLUSIONS These results suggest that the degree of chronic obstructive pulmonary disease in lobectomy and impairment of preoperative breathing pattern in pneumonectomy are the main factors of respiratory failure after lung resection.

Intrathoracic blood supply of the left vagus and recurrent laryngeal nerves.

Abstract The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.

Tracheoplasty With Use of an Intercostal Muscle Flap for Caustic Necrosis

We report a case of intercostal muscle flap used in tracheobronchial reconstruction for extensive necrosis after burn lesions of the posterior wall. A 32-year-old man attempted suicide by ingestion of caustic material. He underwent emergency total esogastrectomy, tracheostomy, and feeding jejunostomy. Ten days later, endoscopy showed complete destruction of the membranous trachea, extending from the tracheostomy to the carina. Reconstruction was conducted with the patient under venovenous extracorporeal membrane oxygenation by use of a pedicled intercostal muscle flap. The patient was weaned from respiratory support on the 14th postoperative day. Examination of a biopsy specimen from the flap 7 months after tracheoplasty showed ciliated neoepithelium.