[Lung volume reduction surgery. A new surgical therapeutic possibility for patients with emphysema]

Lung volume reduction surgery is a new surgical procedure for treatment of patients with pulmonary emphysema. At the operation the most peripheral parts of the lung are resected. Only 15-20% of the patients admitted for lung volume reduction surgery are suitable for operation. The preliminary results have demonstrated improvement in lung function in the majority of the patients. Most of the reports comprise small numbers of patients and have a short time of observation. The longest reported period of observation for a larger number of patients is 24 months and shows a continuing improvement in lung function, dyspnoea and six minute walk test. Because of the high incidence of emphysema, lung volume reduction is a procedure that could reach large extension in the future. However, better definition of criteria of inclusion and better evaluation of the operative procedures are needed.

Cardiopulmonary function at rest and during exercise after resection for bronchial carcinoma

BACKGROUND

Measurements of postoperative spirometric values after pneumonectomy and lobectomy vary considerably, and few researchers have studied the changes in exercise capacity during maximal work after lung resection. The purpose of this study was to describe the postoperative alterations in cardiopulmonary function.

METHODS

Ninety-seven consecutive patients with lung malignancy were prospectively examined with maximal exercise test, spirometry, and arterial gas tensions. Fifty-seven patients were reinvestigated 6 months postoperatively.

RESULTS

In patients having lobectomy, forced expiratory volume in 1 second decreased 8%, and exercise capacity, expressed by maximal oxygen uptake and maximal work rate, significantly decreased 13%. In patients having pneumonectomy forced expiratory volume in 1 second significantly decreased 23%, but the loss in lung volume was partly compensated as measured by exercise capacity, which decreased only 16%. Generally patients with the smallest preoperative forced vital capacity had the smallest postoperative deterioration expressed in percentages. We found a weak correlation between alterations in maximal oxygen uptake and lung function after resection.

CONCLUSIONS

Lobectomy is associated with only minor deterioration of lung function and exercise capacity. Pneumonectomy causes a decrease in pulmonary volumes to about 75% of the preoperative values, partly compensated in better oxygen uptake, which postoperatively was about 85% of the preoperative values. Alteration in forced expiratory volume in 1 second is a poor predictor of change in exercise capacity after pulmonary resection.

Exercise testing in the preoperative evaluation of patients with bronchogenic carcinoma

The aim of this study was to evaluate which parameters of preoperative spirometry and cardiopulmonary exercise test are the best predictors of postoperative morbidity and mortality in patients with bronchogenic carcinoma. Ninety seven patients were prospectively and consecutively examined. All patients had preoperative maximal exercise test and dynamic spirometry. Postoperative complications and causes of death were registered. Logistic regression was used and models explaining the relationship between preoperative variables and postoperative complications and deaths were constructed. We found significant differences in preoperative maximal workload and carbon dioxide output between groups, with and without cardiopulmonary-related complications, but not in spirometry variables. Logistic regression showed maximal workload to be the only predictor of cardiopulmonary complications. Maximal oxygen uptake was predictive of cardiopulmonary deaths. Maximal oxygen uptake and forced expiratory volume were predictive of postoperative complications. A maximal oxygen uptake <50% predicted was associated with high risk of death from cardiopulmonary causes. Kaplan-Meier survival curves showed that maximal oxygen uptake was correlated to long-term survival, while spirometric variables were not. Exercise testing can be used in the preoperative evaluation of patients with nonmetastatic bronchogenic carcinoma. A combination of the results of variables from spirometry and exercise testing is proposed to be used as a preoperative criterion for operability.

[Hemothorax and ectopic pregnancy]

Ectopic pregnancy presenting as haemothorax is extremely rare and difficult to handle. A case report concerning this problem is presented and a possible mechanism is discussed. The importance of bearing pregnancy in mind when fertile women present obscure symptoms is emphasized.

The effect of preoperative methylprednisolone on pulmonary function and pain after lung operations

Thirty-six patients undergoing elective thoracotomy with pulmonary resection with the use of combined epidural and general anesthesia were randomized into a double-blind study to receive a single intravenous preoperative dose of methylprednisolone 25 mg/kg body weight or a placebo (saline solution). Postoperative pain relief consisted of epidural morphine 4 mg and paracetamol 1 gm three times a day for 4 days. Postoperative pulmonary function (peak expiratory flow rate, forced expiratory volume in first second, forced vital capacity) was evaluated on days 1, 2, 3, 4, and 7 and after 1 month. The value obtained after 1 month served as the control value. Pain score at rest and during cough was evaluated after 4 and 8 hours and on days 1, 2, 3, and 4. Pulmonary function was reduced after operation to the same degree in the steroid and placebo group: 42% versus 41% for forced expiratory volume in first second and 38% versus 39% for forced vital capacity, compared with control values after 1 month. Pain score was reduced in the steroid group after 4 hours and on day 1 during rest and after 4 and 8 hours and on day 2 during cough, compared with results in the placebo group (p < 0.05). In the steroid group three patients underwent reoperation because of leakage through the chest wall incision. In conclusion, administration of a single preoperative dose of methylprednisolone did not affect the postoperative reduction in pulmonary function after thoracotomy despite attenuated pain response, and the results do not warrant steroid administration before lung operation.

[Malignant mesothelioma of the pleura with an unusual course]

An unusual case of malignant mesothelioma of the pleura in a man aged 73 years is described. Four years after debut of symptoms a tumour emerged at the site of a previous pleural drainage and grew during the next two years to the size of a man's head. After removal of the tumour, the histological diagnosis was reviewed and confirmed. Six and a half years after the first diagnosis, the patient is still alive and in a reasonable condition in spite of bilateral pleural involvement.

[Thoracic Ewing's sarcoma]

The case history of a girl aged 16 years with Ewing's sarcoma of a rib is presented. The symptomatology was typical and consisted mostly of moderate and intermittent pain in the thorax. The time elapsing between the first symptoms and the diagnosis was about 18 months and the consequent therapeutic delay was obvious. The importance of early diagnosis in cases of this type is emphasized.

Predictability of esophagus- and cardiatumor resectability by preoperative computed tomography

Prior to operation, 32 patients with a tumor in the esophagus or in the cardia region were examined with computed tomography (CT), to evaluate the predictability of tumor resectability by CT. Twenty patients had the tumor operatively resected, in 2 patients the bulk of tumor could only be partly resected, and 10 patients were non-resectable due to invasion into the surrounding structures. The tumor resectability evaluated by preoperative CT resulted in positive/negative predictive values of 91 and 90%, respectively. This indicates that CT is a valuable method in planning the therapeutic strategy in cases of carcinoma of the oesophagus and the cardia region. The predictability of lymph-node involvement in the mediastinum and abdomen was less convincing.

Computed tomography and the TNM classification of lung cancer

Computed tomography (CT) of the thorax and upper abdomen was prospectively evaluated in 84 patients with potentially operable lung cancer. Invasion into the thoracic wall and the mediastinal structures was not accurately demonstrated by CT. For metastatic mediastinal lymph nodes, the sensitivity and specificity of CT were, respectively, 86% and 61% and the positive and negative predictive indices 49% and 91%. For T1, T2 and T3 tumours the negative indices were 100%, 96% and 71%. Positive predictive index did not differ between squamous cell carcinoma and adenocarcinoma. Adrenal metastases were CT-suspected in 17 cases and liver metastases in eight, but were verified by ultrasonography in only one and four cases. CT should be used in preoperative investigation of lung cancer, irrespective of stage. Demonstration of thoracic-wall or mediastinal invasion need not exclude tumour resection. Preoperative mediastinoscopy is indicated if CT shows nodal metastases or if there are signs of tumour invasion, but not in CT-negative T1 or T2 tumour. Abdominal metastases indicated by CT should be investigated with CT-guided needle biopsy.

Transhiatal esophagectomy without thoracotomy

Twenty patients with cancer of the esophagus and/or cardia underwent transmediastinal esophagectomy by blunt dissection without thoracotomy. Resection and reconstruction with gastroesophageal anastomosis was performed in a single stage in 13 cases. The tumor was nonresectable in seven cases, and instead a substernal bypass was performed. The technical maneuvers are described, and the results and possible advantages and disadvantages of the transhiatal method are discussed.

Symptoms and signs predictive of the voiding pattern after acute urinary retention in men

Over a 9-month period 228 men were admitted for acute urinary retention to six different casualty wards in the Copenhagen area. The patients were followed in the corresponding urological departments for one year. Twenty-seven variables were registered for each patient. The cumulative rate of recurrent retention was 56% after one week and 68% after one year. Factors predictive of preserved voiding ability were a retained volume less than 500 ml, a known event provocative of acute retention, and a maximum flow rate of more than 5 ml/s after the retention. The maximum flow rate measured within the first week after the retention was reliable within the follow-up period if the voided volume was 150 ml or more. The etiology of the acute retention was infravesical obstruction in 90% of the patients, and 85% required subsequent surgical treatment. Predictive of surgical treatment for infravesical obstruction were recurrent urinary retention within one week, a volume of retention of more than 500 ml, the absence of a provocative situation prior to the retention episode and nocturia twice or more.

Acute urinary retention in women: a prospective study of 18 consecutive cases

Over a 9 month period 18 women were admitted for acute urinary retention to six different Copenhagen hospitals, serving a population of approximately 700,000 people. Urodynamically 9 patients had underactive detrusor function, 2 had infravesical obstruction and 3 had both underactive detrusor function and infravesical obstruction. In 4 patients bladder and urethral function were not classified. In 10 patients a provocative event preceded the retention episode. Eleven patients developed recurrent retention within 3 months and 7 patients had persistent severe obstructive voiding problems. Best prognosis was found for patients with correctable infravesical obstruction and for patients with minimal symptoms prior to the retention episode.