Gordon F. Murray

Elective Pulmonary Lobectomy: Factors Associated with Morbidity and Operative Mortality

Periodic review of clinical results is essential to ensure that high-quality patient care is maintained. To that end, we reviewed the morbidity and operative mortality in a consecutive series of 369 pulmonary lobectomies performed between January 1, 1970, and December 31, 1983. There were 251 male and 118 female patients with a mean age of 50.6 years. The thirty-day operative mortality was 2.2% (8/369), with 6 of these deaths related primarily to respiratory insufficiency. Two hundred twenty-four postoperative management problems occurred in 151 patients and included arrhythmia, air leak, pneumothorax, respiratory difficulties, postoperative bleeding, pleural effusion, wound infection, myocardial infarction, pulmonary embolus, empyema, bronchial stump leak, and lobar gangrene. Multiple factors were related to the occurrence of postoperative morbidity and mortality using both chi-square analysis to examine each individual item and discriminant analysis to evaluate their interaction. Chi-square tabulation showed no difference in the occurrence of major postoperative complications (p greater than 0.05) related to the side of operation, an abnormal preoperative electrocardiogram, a forced vital capacity of 2.8 liters or less, a one-second forced expiratory volume (FEV1) of less than 1.7 liters, an oxygen tension of less than 60 mm Hg, or the seniority of the surgeon (resident versus attending). An increased number of complications (p less than 0.05) was found in male patients, in patients operated on for carcinoma, and in patients older than 60 years. Stepwise discriminant analysis included FEV1 as a significant predictor of postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of Preoperative Pulmonary Function Testing with Clinical Course in Patients after Pneumonectomy

Postoperative morbidity and mortality were correlated with the preoperative results of three widely used tests of pulmonary function in 90 patients who underwent pneumonectomy for carcinoma of the lung. Factors analyzed following operation included thirty-day mortality, the incidence of arrhythmias, the frequency of respiratory complications, and the number of individuals requiring prolonged mechanical ventilation. Fourteen patients had a forced vital capacity (FVC) of 70% or less of predicted normal value. Eleven had a one-second forced expiratory volume (FEV1) of 1.5 liters or less, and 32 had an FEV1 of less than 2 liters. Twenty-six had an FEV1/FVC ratio of 0.6 or less. There were no differences in morbidity or mortality between these individuals and the patients whose test scores exceeded these criteria. As a general rule, decisions regarding operability and extent of resection cannot be made solely on the basis of the three spirometry tests reviewed.

Surgical Management of Left Ventricular–Aortic Discontinuity Complicating Bacterial Endocarditis

Successful hemodynamic repair of left ventricular-aortic discontinuity complicating bacterial endocarditis in 2 patients was achieved using a composite valve-woven Dacron tube graft. The prosthetic valve was sutured without tension into the remaining aortic annulus, ventricular muscle, and base of the aortic leaflet of the mitral valve. Use of the composite graft allows adequate debridement of the abscess, restores ventricular-aortic continuity, excludes the abscess wall from systemic pressure, and does not require saphenous vein coronary bypass. Total exclusion of the aortic root, as described, is a lifesaving alternative repair in the care of desperately ill patients with this condition.

Surgical Management of Symptomatic Pulmonary Aspergilloma

Pulmonary aspergilloma is a potentially life-threatening disease resulting from the colonization of lung cavities by the ubiquitous fungus Aspergillus fumigatus. Complex aspergilloma, characterized by thick-walled cavities with surrounding parenchymal inflammation, is a risk factor for increased morbidity and mortality. Fifteen patients with symptomatic aspergilloma underwent major thoracic procedures at North Carolina Memorial Hospital between January 1, 1972, and December 31, 1983. Twelve of the patients had hemoptysis; in 7 it was recurrent and in 5, life threatening. Tuberculosis and sarcoidosis were the most common underlying causes of lung disease, and more than half of the patients had other coexistent serious medical illness. Eleven of the 15 patients were seen with complex aspergilloma; all of the 4 major complications and the 2 deaths occurred in these patients. Bronchopleural fistula with persistent air space was the most common serious complication, and required thoracoplasty in 3 patients. Nine patients, including 5 with complex aspergilloma, had no postoperative complications, and there were no recurrent symptoms in any of the 13 operative survivors over a mean follow-up of five years. It is concluded that aggressive pulmonary resection can provide effective long-term palliation in critically ill patients with symptomatic pulmonary aspergilloma.

Major Pulmonary Resection for Suspected but Unconfirmed Malignancy

Thoracotomy is not infrequently performed in patients with suspected pulmonary carcinoma but with no histological or cytological confirmation of malignancy. The intraoperative decision to proceed with major pulmonary resection (lobectomy or pneumonectomy) is difficult if a large or central lesion precludes total excisional biopsy. Incisional or needle biopsies violate the principles of good cancer surgery, and the results may be inconclusive if the tumor is missed and areas of associated inflammation or necrosis are sampled. Between January 1, 1970, and December 31, 1980, 303 patients underwent thoracotomy for suspected but unconfirmed malignancy. One hundred twenty-two had a minor resection only, 79 had a major resection (lobectomy or pneumonectomy) after a diagnosis was established by frozen section, and 102 had a major resection without a definitive diagnosis of cancer. Carcinoma subsequently was found in 68% (69) of this group of 102 patients, and benign lesions were identified in the remaining 32% (33), all of whom underwent lobectomy. The diagnoses in these 33 patients included seven granulomas, three hamartomas, nine instances of tuberculosis, and fourteen instances of fibrosis, inflammation, or cystic degeneration. The 2 thirty-day operative deaths in this group of 102 patients occurred among the 69 with malignant disease; 1 died of hemorrhage following pneumonectomy and 1, of respiratory insufficiency after lobectomy. In all 303 patients, there was no difference in operative mortality (p less than 0.01) between lobectomy (2%) and a lesser resection (1.6%). In a patient with a suspicious but inaccessible pulmonary lesion, lobectomy can be performed safely without violating the principles of cancer surgery. This recommendation should probably not be extended to lesions requiring pneumonectomy, because of the increased rates of morbidity and mortality associated with that procedure.

The Assessment of Operability of Esophageal Carcinoma

The extremely poor outlook for patients with esophageal cancer necessitates careful definition of the extent of disease prior to the selection of treatment. Evaluation of regional lymph node involvement may avoid excessive morbidity and identify favorable candidates for aggressive excisional therapy. The role of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid carcinoma of the thoracic esophagus was examined in 30 consecutive candidates for esophageal resection at the North Carolina Memorial Hospital. The prognostic value of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid value in assessing mediastinal extension of carcinoma of the upper thoracic and midthoracic esophagus.

Thoracic Aneurysmectomy Utilizing Direct Left Ventriculofemoral Shunt (TDMAC-Heparin) Bypass

Use of a temporary heparin-coated ventriculofemoral shunt in 2 patients in the successful management of traumatic aneurysms of the descending thoracic aorta is described. Safe and effective bypass protection can be achieved by direct ventriculofemoral diversion when cannulation of the left subclavian artery or ascending aorta is hazardous. The use of a heparinized shunt bypass without systemic anticoagulation considerably simplifies the operation.

The Role of Transbronchial Lung Biopsy in Diffuse Pulmonary Disease

Forty consecutive patients underwent flexible fiberoptic transbronchial lung biopsy for diagnosis of diffuse nodular or infiltrative lung disease. Biplane fluoroscopic examination with image intensification greatly facilitated accurate placement of the biopsy forceps near the pleura; Specimens of lung parenchyma were obtained for culture and histological study in every case. A pathological diagnosis was correctly established in 34 of 40 patients. Transbronchial biopsy was helpful in the clinical management of an additional 4 patients. Biopsy results were not accurate in 2 patients. No significant morbidity was associated with the procedure. Fiberoptic transbronchial lung biopsy is a safe and useful adjunct to the diagnosis of parenchymal lung disease.

Selective Application of Fundoplication in Achalasia

Although esophagomyotomy alone may effectively relieve dysphagia in patients with achalasia, utilization of a complementary fundoplication procedure should be considered for selected patients. Fundoplication is a sensible addition to myotomy in circumstances that suggest high risk for the development of reflux esophagitis. Also, in complicated achalasia, relief of esophageal obstruction by simple myotomy may not be achieved safely. Identification of those pathological features associated with achalasia that merit consideration of fundoplication should improve operative results and reduce morbidity. This paper examines the application of a complementary fundoplication procedure in the operative management of 21 patients with achalasia over a ten-year period.

Bilateral pneumothoraces secondary to latrogenic buffalo chest. An unusual complication of median sternotomy and subclavian vein catheterization.

Pneumothorax following subclavian venipuncture is a well-known risk. Less well recognized is the potential for life-threatening bilateral pneumothoraces occurring at the time of subclavian vein catheterization in patients who have previously undergone median sternotomy. Inadvertent bilateral pleural entry at the time of sternotomy may result in a common pleural space which subsequently places the patient in special jeopardy when the complication of pneumothorax occurs. This report documents the successful management of this important sequence of complications associated with now widely applied therapeutic interventions.