Donald L. Paulson

Long-term survival after resection for bronchogenic carcinoma.

Of 915 resections for bronchogenic carcinoma over a 25-year period (1945–1969), 249 patients survived over 5 years; 127 of the patients eligible survived over 10 years, 61 over 15 years, and 22 over 20 years. The case material was divided into three time periods: 1945–49, 1950–59 and 1960–69, as well as by extent of resection. Lobectomy became the operation of choice, pneumonectomy being reserved for the more extensive lesions. Observed survival rates at 5, 10 and 15 years for 561 patients in the lobectomy series were 35, 22 and 15%, respectively, but strikingly increased to 41, 28 and 19% in the 1960–69 period. Observed rates for 354 patients having pneumonectomies were similar for three time periods, being 16, 8 and 6% at 5, 10 and 15 years, respectively. Relative survival rates for the lobectomy series at 5, 10 and 15 years rose from 33, 28 and 26%, respectively, in the 1950–59 period to 50, 39 and 35% in the last time period, becoming a near horizontal curve segment after 5 years. Dominant factors in survival were extent of the lesion and stage of nodal involvement, histologic type and location being less significant.

Objective Diagnosis (Ulnar Nerve Conduction Velocity) and Current Therapy of the Thoracic Outlet Syndrome

Abstract Analysis of 155 operations in 138 patients with thoracic outlet syndrome demonstrates the validity of resection of the first rib as the optimal method of therapy in patients who are not relieved by conservative management. The ulnar nerve conduction velocity (UNCV) study has provided a reliable, positive, objective method for diagnosis, selection, and evaluation of therapeutic modalities in patients with thoracic outlet syndrome. Median and musculocutaneous nerve compression can be the etiological factor in patients with atypical pain distribution in whom the UNCV is normal. Conduction study of these nerves confirms the diagnosis of thoracic outlet compression. The transaxillary approach allows complete resection of the first rib with decompression of the neurovascular bundle and is associated with a reduced morbidity and hospital stay.

Dual Primary Bronchogenic Carcinoma

Abstract Thirty-four cases of double primary bronchogenic carcinomas, 5 simultaneous and 29 consecutive, were encountered among 2,664 patients treated for bronchogenic carcinoma. Criteria used for establishing the independent nature of these tumors included: (1) the absence of an extrapulmonary primary tumor of a similar histopathology, (2) the presence of bronchial communication, (3) simultaneous appearance of two tumors, and (4) a long interval between consecutive tumors. The interval between two primary tumors ranged from 9 months to 15 years, with the average being 5 years and the highest incidence at the second and fifth years. The tumors in 15 patients were operable; 3 patients are alive at 1 to 4 years and 1 at 5 years. The prognosis in this kind of patient is grave; operation offers the best chance for cure.

Serum 5′-nucleotidase in patients with tumor in the liver

In 11 patients with a histological diagnosis of liver tumor, the 5′‐nucleotidase was elevated in each case. Only 6 of these patients showed an increase of the serum alkaline phosphatase, which was always of a smaller magnitude than the elevation of the 5′‐nucleotidase. In 6 patients with an unequivocal isotope liver scan for metastatic tumor without positive tissue diagnosis 2 patients showed elevations of both enzymes; 2 patients showed slight elevation of the 5′‐nucleotidase with no change in the alkaline phosphatase and 2 patients showed no change in either enzyme. These data suggest that the serum 5′‐nucleotidase shows a greater sensitivity in the detection of primary or metastatic hepatic malignancy in the anicteric patient than does the serum alkaline phosphatase. The authors believe that the apparent increased sensitivity is related to the greater specificity of this enzyme for hepatobiliary disease.

Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina)

Abstract Forty-four patients presenting with chest pain suggesting coronary artery disease had normal exercise stress tests and selective coronary angiography and subsequently were found to have an unsuspected thoracic outlet syndrome. Thirteen additional patients had both significant coronary artery disease and thoracic outlet syndrome. Esophageal and pulmonary disease were ruled out and the diagnosis of brachial plexus compression in the thoracic outlet established by a reduction of the ulnar nerve conduction velocity (UNCV) below normal, the normal value being 72 meters per second. Clinical improvement from thoracic outlet compression resulted either from physical therapy if the UNCVs were above 55 m./sec, or from transaxillary surgical extirpation of the first rib if the UNCVs were below 55 m./sec. Thirteen patients with coronary artery disease and thoracic outlet syndrome required therapy for both problems before improvement ensued. Although the usual symptomatology for thoracic outlet syndrome involves pain and paresthesias of the shoulder, arm, and hand, the chest wall is frequently involved. If the chest pain is predominant with minimal shoulder-hand symptoms, the diagnosis is not suggested clinically and can only be established by the high index of suspicion, positive UNCV reduction, and a normal coronary angiogram. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm.

Results of Bronchoplastic Procedures for Bronchogenic Carcinoma

Results of Bronchoplastic Procedures for Bronchogenic Carcinoma* Donald Paulson;Robert Shaw; Annals Of Surgery

Surgical Advantages of Selective Unilateral Ventilation

Abstract Two hundred major thoracic operations have been performed using controlled selective unilateral pulmonary ventilation with no morbidity or mortality related to this technique. A group of 20 patients ventilated selectively with a double-lumen endotracheal tube and 5 additional patients ventilated with a single-lumen tube were studied to determine the physiological effects of each technique. Blood gases and physiological shunt determinations showed better values with selective ventilation, whereas some derangement was noticed in the group ventilated with a single-lumen tube. The physiological and technical advantages provided by the double-lumen endobronchial tube make selective ventilation safer and more practical.

PRESURGICAL IRRADIATION IN BRONCHOGENIC CARCINOMA, SUPERIOR SULCUS TYPE.

Shaw, Paulson, and Kee (6) in 1961 reported that a review of the survival rates of patients with bronchogenic carcinoma of the superior sulcus type revealed only one five-year survival without disease. In addition, they quoted Pancoast (4) and Walker (7) as stating that this tumor was radioresistant and that irradiation was of no avail. Our experience with bronchogenic carcinoma, superior sulcus type, prior to 1956 was rather discouraging. The average survival following various forms of surgery, irradiation, and combinations of both, ranged from ten to fourteen months, with the longest time being twenty-seven months. These frustrating results stimulated us to explore avenues of therapy other than the conventional ones and led to a program both theoretical and empirical in concept and design. We have previously reported the results of this approach (5, 6). In the 24 proved cases reported in April 1962 (5) resection was done prior to September 1961 and a full two-year evaluation can therefore be made at thi...

Preservation of lung tissue by means of bronchoplastic procedures

Abstract 1. 1. Bronchoplastic procedures are feasible and are indicated under certain conditions to preserve healthy lung tissue. A traumatic, inflammatory, or neoplastic lesion of the bronchus does not always require resection of all of the lung tissue supplied by the bronchus. 2. 2. The authors have used a variety of procedures to restore bronchial continuity in eighteen patients. The bronchial lesions so treated include traumatic occlusion, acute traumatic rupture, tuberculous stenosis, adenoma and carcinoma. 3. 3. The indications for the use of bronchoplastic procedures with resection for bronchogenic carcinoma in nine patients were inadequate pulmonary reserve in three, to extend operability in two, and deliberately for small centrally located lesions in four patients. One operative mortality occurred due to inadequate pulmonary function following resection of an entire lung, coryna and trachea. Three patients died of carcinoma within one year of the operation. The remaining five patients, in four of whom the operation was performed deliberately, are alive and well one, five, fourteen, sixteen and twenty-one months, respectively.

An Improved Surgical Technique for the Complicated Hiatal Hernia with Gastroesophageal Reflux

Abstract Although so-called valve reconstruction procedures at the gastroesophageal junction provide marked relief for most patients with gastroesophageal reflux and hiatal hernia, there is a recurrence rate of 10 to 15%. Many of the recurrences are in patients with obesity, severe pulmonary disease, or stricture, or in patients who have developed a recurrence from other previous types of surgical therapy. Since the primary cause of failure in hiatal hernia repair is tension on the distal esophagus, which is created as a result of securing an adequate length of intraabdominal esophagus, the Collis gastroplasty, which lengthens the esophagus by construction of a tube of the lesser curvature of the stomach, combined with a Belsey reconstruction of the gastroesophageal angle and dilation in cases of stricture, has been successfully employed over the past three years in patients with factors that predispose to recurrence. This technique provides adequate length without tension, and in more than 39 such patients there has been no evidence of reflux or recurrence of hernia by clinical symptoms or cine esophagogram. No mortality or significant morbidity has been observed.