Junaid H. Khan

Active compression-decompression resuscitation: effects on pulmonary ventilation

This investigation was designed to test the hypothesis that active compression-decompression resuscitation is able to independently provide improved levels of minute ventilation when compared to high-impulse manual cardiopulmonary resuscitation (CPR). Eight adult beagles (10-15 kg) were studied after induction of ventricular fibrillation. Single 1-min CPR trials were performed while arterial blood gases and minute ventilation were monitored. ACD and high-impulse CPR were performed sequentially, in random order at compression rates of 120/min, 1.5- to 2.0-inch compression depth and 50% duty cycle. Minute ventilation averaged 3.6 +/- 0.77 1 during high-impulse CPR and increased to 4.9 +/- 0.88 1 during ACD CPR. No difference was observed in arterial blood pH, PCO2, or PO2 when ACD was compared to high-impulse CPR. We conclude that ACD CPR provides improved levels of minute ventilation when compared to high-impulse manual CPR in this canine model of cardiac arrest. Improved minute ventilation may contribute to the mechanism of improved cardiopulmonary hemodynamics reported in previous investigations of ACD CPR. Further investigation is warranted to determine the effects of ACD CPR on pulmonary ventilation in human subjects after cardiac arrest.

Giant Solitary Fibrous Tumor of the Pleura

Solitary fibrous tumors of the pleura are rare. Approximately 600 cases have been described in the literature. We report a case of a young man with a giant solitary fibrous tumor of the pleura that filled his entire left hemithorax and anterior mediastinum and extended into the right side of his chest. The diagnostic modalities employed, the operation, and the postoperative management resulting in complete resection of the tumor and full lung reexpansion are described.

Thoracic organ donor characteristics associated with successful lung procurement.

Purpose: A shortage of suitable donors is the major impediment to clinical lung transplantation. The rate of lung recovery from potential donors is lower than that for other organs. The purpose of this study was to evaluate what factors could be modified to improve the rate of cadaver lung recovery. 
Methods: We performed a retrospective review of records from all thoracic organ donors procured by the California Transplant Donor Network between 1 January 1995 and 31 May 1997 (251 donors) to determine which donor management factors were associated with an increased likelihood of successful lung procurement. 
Results: There were 88 lung donors (L) and 163 donors from which hearts but no lungs were procured (H). Longer time to donor network referral was associated with a reduced chance for successful lung procurement. Donor age, cause of death, and time of admission were not important factors. Most donors in this study had an acceptable A‐a gradient at admission to the hospital but lung function deteriorated in group H. Corticosteroid usage and initially clear breath sounds were independent predictors of successful procurement by multivariate analysis. 
Conclusions: Early contact with the donor referral network, and corticosteroids may help to improve the lung procurement rate from potential donors.

Pulmonary Metastases of Endocrine Origin : The Role of Surgery

PURPOSE To determine the clinical course and outcome of patients undergoing pulmonary resection for metastatic endocrine tumors. METHODS Retrospective review of 47 patients with known endocrine tumors and pulmonary metastases who were evaluated for surgical resection between 1975 and 1996. RESULTS Tumors evaluated included the following: carcinoid (16), thyroid (12), pancreatic adenocarcinoma (10), adrenocortical carcinoma (6), pheochromocytoma (2), and parathyroid (1). Thirty-three patients were asymptomatic. Hormone secretion was noted in five patients. Twenty-five patients, who had isolated lung metastases, good control of the primary tumor, and no medical contraindication had surgical resection. The number of pulmonary nodules was not a limiting factor as long as all disease could be resected with adequate residual pulmonary function. CT was successful in directing resection in all patients. Twenty-six operations were performed in 25 patients and 22 patients were treated medically. Wedge resection was performed for lesions <2 cm (15), and lobectomy for larger or multiple nodules (10). Four patients had bilateral nodules resected. There was no operative mortality and no major complications. Actuarial 5-year survival was 61% for surgically treated patients. Independent predictors of poor survival included positive mediastinal lymph nodes at time of surgery (p=0.004) and shorter disease-free interval (p=0.01). At a median of 6.7+/-1.2 years, six patients have developed radiographic appearance of a recurrence. A single patient with recurrent Hürthle cell cancer has had a successful reresection. The remaining patients have received chemotherapy. No patient with pancreatic carcinoma or adrenocortical carcinoma was a candidate for resection. All medically treated patients died within 6 months. CONCLUSION Patients with endocrine tumors and pulmonary metastases are usually asymptomatic, their conditions are diagnosed accurately with CT, and they can achieve long-term survival comparable to other tumors (sarcoma) after pulmonary metastasectomy. CLINICAL IMPLICATIONS Patients with carcinoid, thyroid, pheochromocytoma, and parathyroid tumors with pulmonary metastases should undergo surgical resection if there is the following: (1) no evidence of extrathoracic disease; (2) good control of the primary tumor; (3) no medical contraindications for surgery; and (4) pulmonary function that can tolerate resection of all documented disease. The role of adjuvant chemotherapy in patients with positive lymph nodes needs further study.

A 5-year experience with surgical repair of atrial septal defect employing limited exposure

BACKGROUND There has been a trend in recent years towards less invasive therapy for many congenital cardiac malformations. For the past 5 years, we have employed a technique of limited surgical exposure when repairing atrial defects within the oval fossa. METHODS Over the 5-year period from July 1992 to August 1997, 115 consecutive patients underwent surgical repair of an isolated atrial septal defect in the region of the oval fossa by a single surgeon. The patients had a limited midline skin incision starting at the line of the nipples and extending inferiorly across 2 to 3 intercostal spaces. A partial sternotomy was performed, sparing the manubrium. Standard instruments and cannulation techniques were used for cardiopulmonary bypass and fibrillatory arrest. RESULTS There were no deaths and no major complications. The median time to extubation after leaving the operating room was 3 hours (30 minutes to 8 days). Mediastinal drains were removed the morning after surgery. The median stay in the intensive care unit was 7 hours (3 hours to 10 days), and patients were discharged from the hospital a median of 4 days postoperatively (2 to 23 days). CONCLUSIONS This approach using limited exposure can be applied safely without any new instruments and without peripheral incisions or sites of vascular access, while providing a comfortable exposure for the surgeon and achieving a cosmetically superior result for the patient.

Clinical Investigations: Resecting MetastasesPulmonary Metastases of Endocrine Origin: The Role of Surgery

PURPOSE To determine the clinical course and outcome of patients undergoing pulmonary resection for metastatic endocrine tumors. METHODS Retrospective review of 47 patients with known endocrine tumors and pulmonary metastases who were evaluated for surgical resection between 1975 and 1996. RESULTS Tumors evaluated included the following: carcinoid (16), thyroid (12), pancreatic adenocarcinoma (10), adrenocortical carcinoma (6), pheochromocytoma (2), and parathyroid (1). Thirty-three patients were asymptomatic. Hormone secretion was noted in five patients. Twenty-five patients, who had isolated lung metastases, good control of the primary tumor, and no medical contraindication had surgical resection. The number of pulmonary nodules was not a limiting factor as long as all disease could be resected with adequate residual pulmonary function. CT was successful in directing resection in all patients. Twenty-six operations were performed in 25 patients and 22 patients were treated medically. Wedge resection was performed for lesions <2 cm (15), and lobectomy for larger or multiple nodules (10). Four patients had bilateral nodules resected. There was no operative mortality and no major complications. Actuarial 5-year survival was 61% for surgically treated patients. Independent predictors of poor survival included positive mediastinal lymph nodes at time of surgery (p=0.004) and shorter disease-free interval (p=0.01). At a median of 6.7+/-1.2 years, six patients have developed radiographic appearance of a recurrence. A single patient with recurrent Hürthle cell cancer has had a successful reresection. The remaining patients have received chemotherapy. No patient with pancreatic carcinoma or adrenocortical carcinoma was a candidate for resection. All medically treated patients died within 6 months. CONCLUSION Patients with endocrine tumors and pulmonary metastases are usually asymptomatic, their conditions are diagnosed accurately with CT, and they can achieve long-term survival comparable to other tumors (sarcoma) after pulmonary metastasectomy. CLINICAL IMPLICATIONS Patients with carcinoid, thyroid, pheochromocytoma, and parathyroid tumors with pulmonary metastases should undergo surgical resection if there is the following: (1) no evidence of extrathoracic disease; (2) good control of the primary tumor; (3) no medical contraindications for surgery; and (4) pulmonary function that can tolerate resection of all documented disease. The role of adjuvant chemotherapy in patients with positive lymph nodes needs further study.

Repair of secundum atrial septal defect: limiting the incision without sacrificing exposure

A simple and effective technique for repair of secundum atrial septal defect is described. The heart is exposed through a limited midline skin incision and partial sternotomy, and the atrial septal defect is closed through a right atriotomy with ascending aortic and dual venous cannulation. This approach achieves a cosmetically superior result with standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions.

Management Strategies for Complex Bronchopleural Fistula

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.