Donald P. Jones

Significance of Metastatic Disease in Subaortic Lymph Nodes

Thirty-five patients underwent resection of primary bronchogenic carcinoma of the left upper lobe or left main bronchus in the presence of metastatic disease in subaortic lymph nodes. No patient had metastatic disease in other mediastinal node stations. There was 1 postoperative death. Complete follow-up is available on 34 patients. Three-year and five-year actuarial survival for the entire group is 44% and 28%, respectively. For 23 patients undergoing complete resection, five-year actuarial survival is 42%. Resection of primary bronchogenic carcinoma in the presence of subaortic nodal metastases is associated with improved survival relative to reports of survival following resection of metastatic disease in other mediastinal node stations. Resection should be undertaken in these patients especially when it is judged that the resection is likely to be complete.

The role of central haemodynamic monitoring in abdominal aortic surgery. A prospective randomised study

To test the hypothesis that central haemodynamic monitoring is not necessary in all patients undergoing abdominal aortic surgery, a prospective randomised study in 40 consecutive patients undergoing elective abdominal aortic surgery was carried out. Patients with unstable angina, recent myocardial infarction (less than or equal to 6 months), and left ventricular ejection fraction (LVEF) less than 0.50 were excluded. Twenty-one patients had perioperative central haemodynamic monitoring while 19 patients had central venous pressure monitoring alone. Parameters studied included, perioperative haemodynamics and fluid balance, perioperative cardiac drug administration, operation time and clamp time, postoperative renal function, incidence of postoperative ventilation and line complications, duration of hospital and ICU stay, and 30 day postoperative outcome. Results obtained were compared with a high risk group of patients (LVEF less than 0.50) undergoing similar surgery. Statistical analysis failed to show any difference in outcome for any variable measured in either low risk group. All serious postoperative cardiac complications occurred in patients with LVEF less than 0.50 (P less than 0.0001). These data suggest that patients with LVEF greater than or equal to 0.50 are at low risk of developing postoperative cardiac complications and can be successfully managed perioperatively without the added potential risks and costs of central haemodynamic monitoring.

Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach

Thirteen patients with postpneumonectomy bronchopleural fistula occurring 4 months to 10 years after the initial operation have been treated with a transsternal transpericardial approach after the associated empyema had been treated by either tube thoracostomy or open-window thoracostomy. In 10 patients, there were contraindications to using an ipsilateral transthoracic approach. In 10 of the 13 patients, the procedure was successful. Three fistulas recurred; two were quite small, one of them closing spontaneously within 6 months. There were no deaths or clinically significant morbidity related to the transsternal approach. We have found this technique to be most applicable in those patients in whom other procedures have failed to resolve the problem. The technique is relatively simple and safe.

Gelfoam Occlusion of Peripheral Bronchopleural Fistulas

A technique for occlusion of peripheral bronchopleural fistulas using Gelfoam as a temporary endobronchial blocker is described.

Computed tomographic diagnosis of pulmonary sequestration

Two cases of pulmonary sequestration demonstrated by CT scans of the chest are described. In one, CT demonstrated the anomalous artery. This finding may obviate the need for angiography when surgery is not contemplated.

A computed tomographic study of the dog lung during hemorrhagic shock and after resuscitation

A shock model was used to explore the capability of computed tomography (CT) to detect changes in lung density during hypovolemia and after resuscitation. The same level of the lower thorax was scanned repeatedly during base-line, shock (aortic pressure 60 mmHg), and after resuscitation with shed blood. The average baseline CT number (+/- SEM) for 5 areas of interest for four prone dogs was -754 +/- 16 (air = -1000, water = 0). This decreased 7.4% to -810 +/- 15 (P less than .05) during shock. After resuscitation CT density was -773 +/- 17 or 2.5% less than baseline (P greater than .1). A dorsal to ventral gradient of increasing CT density during baseline was maintained in all five areas during shock and post-resuscitation. From baseline to shock there were also significant changes in heart rate, mean aortic pressure, cardiac output, and vascular volume. Extravascular lung volume after resuscitation was equal to baseline volume. We conclude that CT is sufficiently sensitive to detect rapid physiological changes leading to increased or decreased lung density.

Diagnostic Work-Up of Chest Disease

The most important aids available to the thoracic surgeon for the evaluation of pulmonary disease are history, physical examination, and chest x-ray. Proper use of these modalities will allow a diagnosis to be made quickly with a minimum of hardship and risk to the patient and hence permit a reasonable and logical approach to therapy to be instituted. In addition, the various ancillary tests that are occasionally indicated in the work-up of patients with pulmonary disease have been reviewed, and the indications for each have been outlined.

Preoperative Dynamic Assessment of Cardiac Reserve in Patients Following Abdominal Aortic Surgery. A Probability Analysis

In order to estimate cardiac reserve preoperatively the authors studied 33 con secutive patients aged forty-four to eighty-one years (mean ± SD, 67.2 ± 7.3) scheduled for elective infrarenal abdominal aortic surgery. All patients had pul monary artery catheters inserted on the morning of surgery and had Starling curves constructed by plotting of the rate of change in cardiac output against the rate of change in pulmonary artery wedge pressure (PAWP) with a specific volume loading protocol. The slope of the curve and the PAWP, which cor responded to the maximum cardiac output (PAWPmax), were carefully noted in each patient. A deliberate effort was made perioperatively to maintain each patient on the upslope of the curve and not to exceed their estimated PAWP max. Four patients developed a major postoperative cardiac complication and 1 patient died. All complications occurred in patients with a Starling slope of < 0.035 (p = 0.0003). By utilization of this slope in a derived probability model the authors could accurately and quantitatively predict which patients were at greatest risk of developing a postoperative cardiac complication following ab dominal aortic surgery.