Robert J. Jensik

Segmental Resection for Bronchogenic Carcinoma

Segmental resection was performed on 168 patients with peripheral, Stage I bronchogenic carcinoma from 1957 to July 1, 1978. Seventy-four patients (44%) had adenocarcinoma, 58 (34%) had an epidermoid type, 28 (17%) had an unadifferentiated tumor, and 8 (5%) had a bronchoalveolar variety. Ninety-five resections were done on the left lung, the most frequent procedure being removal of the superior division of the left upper lobe (38 patients). On the right side, 73 resections were done. The anterior segment was removed most frequently (19 patients). There were 3 surgical deaths, for a mortality of less than 2%. Complications requiring prolonged hospitalization were associated with air leak in 10 (6%) of the 168 patients. Survival by actuarial curve is 53% at 5 years, 33% at 10 years, and 25% at 15 years. Forty-five patients (27%) died of metastatic carcinoma. Patients with epidermoid lesions have the most favorable prognosis.

Simultaneous Cisplatin Fluorouracil Infusion and Radiation Followed by Surgical Resection in Regionally Localized Stage III, Non–Small Cell Lung Cancer

Sixty-four patients with stage III (M omicron) non-small cell lung cancer were treated with cisplatin fluorouracil infusion chemotherapy and simultaneous radiation therapy for 5 days every other week. A total of 4 cycles (40 Gy) was followed by attempted surgical resection. Clinical response to the preoperative treatment included 5 (8%) complete and 32 (48%) partial responses. Thirty-nine (61%) underwent the planned operation, and in 9 (23%) of these patients the resected specimens were histologically negative. Clinical assessment failed to predict histological response. With 17 months median follow-up (range, 2.4-29 months), estimated 1-year survival was 61% and median survival was 16 months for all patients.

Extrapleural Pneumonectomy for Diffuse, Malignant Mesothelioma

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

Bronchopleural fistula after stapled closure of bronchus

The incidence of bronchopleural fistula after stapling among 2,243 pulmonary resections at the Rush-Presbyterian-St. Lukes Medical Center has been reviewed. There were 35 fistulas in 1,773 stapled and in 470 sutured bronchi (segmentectomy, 2; lobectomy, 1; bilobectomy, 9; and pneumonectomy, 23). We have found that the stapler is expedient and simple to use, and that it produces a hermetic and uniform closure. The stapler is contraindicated when the bronchus is thickened, inflamed, or of insufficient length. The overall incidence of bronchopleural fistula was 1.6%. Approximately two thirds of the patients with bronchopleural fistula had preoperative radiation therapy or chemotherapy or both.

Results of Sleeve Lobectomy for Bronchogenic Carcinoma in 101 Patients

Sleeve lobectomy for bronchogenic carcinoma is an alternative to pneumonectomy. The extent and location of the tumor must be such that a sleeve procedure is feasible. The conservation of lung tissue benefits both compromised and uncompromised patients. From 1961 to 1982, 101 patients underwent sleeve lobectomy for bronchogenic carcinoma of the lung. There were 58 procedures on the right side and 43 on the left. Life-table analysis of 94 of the patients shows a 5-year survival of 30% and a 10-year survival of 22%. Preoperative irradiation was utilized in 51 patients with a 5- and 10-year survival of 25% and 16%, respectively. The sleeve lobectomy group that did not have radiation therapy demonstrated a 5-year survival of 36% and a 10-year survival of 28%. There were 2 operative deaths (2%). Completion pneumonectomy was required in 7 patients because of anastomotic dehiscence in the early postoperative period in 6 and tumor at the margin in 1. Other major complications included empyema and granulation tissue at the anastomosis that were successfully managed by bronchoscopic dilation and suture removal. Tumor recurred locally in the area of the anastomosis in 9 patients. Sleeve lobectomy is a safe procedure and when technically feasible can be considered the procedure of choice for bronchogenic carcinoma.

Pulmonary Venoocclusive Disease

Pulmonary venoocclusive disease has been established as a definite clinical entity characterized by congestive cardiac failure with pulmonary arterial hypertension, chronic interstitial pulmonary edema, and normal wedge pressure on cardiac catheterization. This disease was diagnosed and confirmed in a patient during life. A review of the 32 patients reported earlier has been done in an attempt to fine possible etiological agents. Early recognition and treatment with anticoagulants, methylprednisolone, aspirin, and dipyridamole may improve the prognosis.

One-Lung High-Frequency Ventilation for Tracheoplasty and Bronchoplasty: A New Technique

Major airway surgery requires the maintenance of adequate ventilation and oxygenation during the period of resection and reconstruction, as well as an unobstructed surgical field and optimal access to the airways circumference. High-frequency positive-pressure ventilation (HFPPV) at a frequency of 1 Hz (60 breaths/min) or more, along with a small tidal volume (50 to 250 cc), provides adequate ventilation and oxygenation with minimal impairment of pulmonic and systemic circulatory functions. We have used HFPPV of one lung through a 2 mm internal diameter catheter in six patients (three undergoing right sleeve pneumonectomies, two having carinal tumor resections, and one having tracheal resection). High-frequency positive-pressure ventilation of the left lung provided continuous and adequate ventilation and oxygenation during the period of resection and reconstruction of the airways, while the small catheter permitted unimpaired visualization and adequate access to the operative site.

Mucoepidermoid Carcinoma of the Trachea and Bronchus: The Case for Conservative Resection

We report our experience with 5 patients with mucoepidermoid carcinoma treated by conservative resection, and review the literature on the 62 patients previously reported. A visual bronchoscopic diagnosis of adenoma was made in all 5 current patients. Bronchoscopic biopsy was performed in 4 and provided an accurate histological diagnosis in each. Conservative resection was accomplished with bronchoplastic techniques in 4 patients: sleeve lobectomy, 2; lobectomy with plastic bronchial closure, 1; and segmental tracheal resection, 1. The other patient underwent conventional lobectomy. All 5 patients are alive and free from disease 4 to 15 years following operation. The recently demonstrated correlation between histological grading and clinical behavior allows relatively benign variants of mucoepidermoid tumors to be accurately identified by bronchoscopic biopsy prior to thoracotomy. Because these tumors have a propensity to originate centrally in the tracheobronchial tree, bronchoplastic procedures frequently are required in order to accomplish tumor extirpation with limited pulmonary resection.

Surgical Management of Malignant Mesothelioma

The surgical management of 18 patients diagnosed as having malignant mesothelioma is reviewed. Of these patients, 7 received limited treatment--pleurectomy or biopsy. The mean survival was 10 months, and no patient was disease-free at time of death. The other 11 patients were treated by radical extrapleural pneumonectomy. There were 2 long-term, disease-free survivors at 2 and 4 years. Mean survival for the entire group was 15 months, but most patients received good palliation following tumor removal. Surgical procedures for removal of malignant mesothelioma can be accomplished safely and without major morbidity. When possible, radical extrapleural pneumonectomy affords the best palliation and the only opportunity for cure.

One-Lung High-Frequency Positive Pressure Ventilation for Sleeve Pneumonectomy: An Alternative Technique

High-frequency positive pressure ventilation (HFPPV) was originally used in experimental animal studies in 1971 by Jonzon et a1 (I),. and the technique was introduced into clinical anesthesia by Heijman et a1 (2) the following year. HFPPV incorporates the use of a small tidal volume approaching the volume of dead space at a frequency of 1 Hz or more. HFPPV provides adequate ventilation and oxygenation mainly by the generation of eddy flow in the airways, leading to an improvement in the intrapulmonary gas mixture and distribution as well as facilitating gas diffusion. The airway pressure during HFPPV is continuously positive, with low mean and peak pressures, whereas the intrapleural pressure is continuously subatmospheric with minimal effect on the pulmonary and systemic circulation (3).