George Stirling

Lung volume reduction surgery in emphysema: a systematic review

The aim of this study was to systematically review the literature regarding the safety and efficacy of lung volume reduction surgery (LVRS) in patients with emphysema. Studies on LVRS to August 2000 were identified using MEDLINE, Embase, Current Contents, and the Cochrane Library. Human studies of patients with upper, lower or diffuse distributions of emphysema were included. All types of bullous emphysema were excluded. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. When LVRS was compared with medical management, at 2 years LVRS was associated with a higher FEV1 and at least equivalent survival. The use of staple excision of selected areas of lung appeared to be more efficacious than laser ablation. There is insufficient evidence to show preference for median sternotomy or videoscopically assisted thoracotomy, as the more safe and efficacious procedure. In highly selected patients with emphysema LVRS is deemed an acceptable treatment. To fully evaluate the safety and efficacy of LVRS, outcomes beyond 2 years must be included. The results of prospective randomized trials between medical management and LVRS, now in progress, are essential before a final assessment can be made.

Stress inoculation for acute pain: a clinical trial

The study attempted a clinical evaluation of the efficacy of stress inoculation training for postoperative pain control using patients undergoing coronary artery graft surgery. A treatment group receiving stress inoculation training was compared to attention-education and no-treatment control groups. No differences were found between the groups on two pain rating measures, analgesic intake, or measures of state anxiety and depression. The ineffectiveness of stress inoculation in this study may be due to the difference between experimental and clinical pain, the multiple demands of the preoperative period, possible memory difficulties which some patients may have experienced, or the possibility that the procedure is not sufficiently potent for the intensity of this type of pain.

A Recirculating Cooling System for Improved Topical Cardiac Hypothermia

A simple system is described that recirculates cooling fluid for topical cardiac hypothermia. This disposable system can produce a flow of 1,500 ml/min at 2 degrees to 4 degrees C. The recirculating cooler produced significantly lower myocardial temperatures than a conventional fluid-discard system in 22 patients having coronary operation. This system has been used as part of the technique of hypothermic cardioplegia in more than 600 patients. During various cardiac procedures, septal temperatures were maintained well below 20 degrees C for 60 minutes or more without the need to reinfuse the cardioplegic solution.

Left ventricular aneurysmectomy: A comparison of linear and circular repairs

Abstract Aim: To review the long-term results of left ventricular aneurysmectomy in the Alfred Hospital, and to compare the results of circular versus linear repair. Method: The hospital records of 94 patients who were referred for left ventricular aneurysmectomy between July 1984 and June 1994 were reviewed. Seven patients did not have an aneurysm at operation and were excluded. Eighty-seven remaining patients were divided into 2 groups: circular plasty repair and linear repair. The 2 groups were matched for age, sex, functional class, and indications for operation. A standard ventriculographic grading system for left ventricular function was used for all patients. Follow-up studies conducted until August 1995 and a standard questionnaire was completed for each patient. Results: The mean age of patients was 59.35 years. Twenty patients (23%) had symptoms specific to the aneurysm (heart failure, thromboembolism, arrhythmia). Sixty-three patients (72.4%) were in New York Heart Association (NYHA) class III and IV. Left ventricular function was recorded as grade II and III in 48 (67.6%) and IV in 22 (31%) patients. Circular repair was used in 41 (47.1%) patients and linear repair in the others. Coronary artery bypass was deemed unnecessary in 11 patients. Postoperative gated blood pool scan in 12 patients showed improvement in ejection fraction in 7 patients (58.3%). Early mortality was 5.7%. Mean follow-up was 52.8 months with a range of 4–121 months. Seventeen patients (77.2%) in the circular and 13 patients (43.3%) in the linear repair group were in NYHA class I and II at latest follow-up. Actuarial 5 and 10-year survivals were 75% and 58%, respectively. Survival figures for linear repair versus circular repair with or without coronary artery bypass did not show any significant difference. Conclusion: Our data show good short-term and long-term results, with patients undergoing circular repair experiencing significantly better improvement in exercise tolerance.

Pulmonary embolectomy in the management of massive pulmonary embolism

Abstract This paper reports the Alfred Hospital experience with pulmonary embolectomy in the management of 61 patients with massive pulmonary embolism over a 26-year period. All operations were performed on cardiopulmonary bypass. Mortality was 16% in patients who had not sustained a cardiac arrest preoperatively (n=44), and 59% in those who had arrested (n=17). Pulmonary embolectomy for massive pulmonary embolism can be performed safely and may be the treatment of choice in the patient with circulatory instability. In the patient who has sustained a cardiac arrest from pulmonary embolism, embolectomy offers the only hope in a desperate situation.