Peter J.K. Starek

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 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.

Diagnosis of prosthetic mitral valve malfunction with combined echo-phonocardiography.

Fifty-three patients were studied with combined echo-phonocardiography or phonocardiography alone following prosthetic mitral valve replacement. In sixteen of these patients, clinical deterioration developed, and all subsequently underwent cardiac catheterization and/or surgery. Two patients came to autopsy. Included in this group of sixteen patients were five with obstructed prostheses, six with paravalvular regurgitation, and five with left ventricular dysfunction. Measurements were made of the time interval from the aortic valve closure sound to the peak opening of the mitral prosthesis determined echocardiographically or to the mitral prosthetic opening click (A,-MVO). Echocardiographic studies of left ventricular wall motion were also performed. The A2-MVO interval was significantly shortened (P ⩽ 0.01) with prosthetic valve obstruction (.05 ± .02 sec) and paravalvular regurgitation (.05 ± .01 sec) compared with normally functioning prostheses (Starr-Edwards ball valves .10 ± .02 sec, Lillehei-Kaster tilting disc prostheses .09 ± .01 sec). Shortening of this interval was not specific for these conditions because it was sometimes shortened with left ventricular dysfunction. Echocardiographic studies of left ventricular wall motion were helpful in distinguishing among prosthetic valve obstruction, paravalvular regurgitation and left ventricular dysfunction. The combined echophonocardiographic technique was especially helpful in detecting malfunction of tilting disc prostheses, because the technique enables measurement of the A,-MVO interval in the absence of an audible opening click.

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.

One hundred consecutive thymectomies for myasthenia gravis

BACKGROUND Between June 1997 and November 1993, 100 consecutive thymectomies for myasthenia gravis were performed at University of North Carolina Hospitals in Chapel Hill. METHODS A consistent, planned protocol involving preoperative, intraoperative, and postoperative care was followed. All thymectomies were performed through a median sternotomy with removal of all visible thymus and perithymic fat in the anterior mediastinum. RESULTS There was no perioperative mortality or longterm morbidity. Mean postoperative hospital stay was 6.3 days (range, 3 to 18 days). Ninety-six percent of the patients were extubated the day of the operation, and all patients were extubated within 24 hours. Mean postoperative intensive care unit stay was 1.2 days (range, 1 to 4 days). After a mean follow-up of 65 months (range, 1 to 199 months), 78% of all patients are improved by at least one modified Osserman classification when their current status is compared with their worst preoperative disease severity. In fact, 69% of patients with mild disease preoperatively (class I, II, or III maximal severity) are in pharmacologic remission (asymptomatic without regular medication), whereas 29% of patients with severe disease (class IV or V) are in remission (p = 0.0001). CONCLUSIONS Our programmatic approach to thymectomy through a sternotomy has shown minimal morbidity and mortality. It is beneficial to myasthenics at both ends of the age and severity spectrum.

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.

Echocardiographic and Phonocardiographic Characteristics of the Lillehei-Kaster Mitral Valve Prosthesis

The Lillehei-Kaster (L-K) valve is a tilting disc prosthesis currently in use for heart valve replacement. We report data from phonocardiography (PHONO) and echocardiography (ECHO) in 20 patients with a normally functioning mitral valve prosthesis (MVP). The MVP is well recorded by ECHO, resembling a mitral stenosis pattern with a disc excursion of 7 to 12 mm and a mean opening and closing velocity of 37.7 and 59.8 cm/sec, respectively. Combined PHONO and ECHO show that the opening sound of the MVP is small, related to onset of valve opening and not peak opening. It follows the aortic component of the second sound (A2) by 0.05 to 0.09 sec in normals; it may be absent (12/20). Peak opening follows A2 by 0.08 to 0.12 sec. The closing sound of the MVP, best heard in the mitral area, is always two-fold with a small initial high frequency (HF) component and a second large HF sound separated by no more than 0.03 sec. The first component (A) is related to onset of closure and the second (B) to completion of closure. Systolic and diastolic murmurs were commonly present. These data establish the normal ECHO and PHONO findings for patients with L-K MVP. Two other patients are also reported in whom such data were helpful for the noninvasive evaluation of valve function, indicating in one instance acute mitral regurgitation and in the other an increase in degree of aortic regurgitation.

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.