SOME RECENT ADVANCES IN THORACIC SURGERY

In this brief presentation of some recent advances in thoracic surgery a number of miscellaneous topics which deserve consideration at this time are discussed. Among these are acidosis during anesthesia for thoracic operations, the problem of esophagitis in relation to surgery, recent improvements and reorientations in pulmonary operations, and some comments on operations upon the heart and great vessels.     

Bronchiectasis revisited

The writer of this retrospective essay witnessed his first open chest operation during the academic year 1928-29 while an intern in general surgery at Lakeside Hospital, Cleveland, Ohio. The operative procedure was probably the first of its kind to be performed at that teaching hospital, and it involved the excision of a mediastinal tumefaction through a median sternotomy. Now, more than fifty-five years and several thousand thoracic operations later, the author recounts the evolution of pulmonary resection, particularly in relation to the therapy of bronchiectasis. The technical obstacles which delayed too long the achievement of reasonably safe and anatomically complete resections of lung are discussed, and the circuitous route trod by pioneering surgeons in their struggle toward that desired goal is described. In addition, some contributions made along the way by members of the faculty at the Yale University School of Medicine to our present knowledge of bronchiectasis--its pathologic anatomy, pathophysiology, and surgical therapy--are summarized briefly.     

胸部创伤的临床研究进展

虽然胸部创伤的处理方法复杂多样,但随着多层螺旋CT的应用以及低侵入性诊断手段如电视辅助胸腔镜和血管内修复技术的发展,胸部创伤的诊断与治疗正变得相对快捷和详尽。近年来,体外膜肺氧合(ECMO)疗法进一步降低了胸部创伤患者的死亡率。本文将就不同胸部创伤及对机体的影响、相关诊断与处理的临床研究进展进行综述。     

Lung Resection for Tuberculosis in Children

At the Nova Scotia Sanatorium from 1944 to 1959 lung resection for tuberculosis was carried out in 1257 instances. Of these, 44 operations were performed on 41 children from 5 to 15 years of age. Two patients had bilateral surgery, and in two others a second homolateral resection was necessary. Twenty-five per cent of the operations were done for the “middle lobe syndrome”, the remainder for the reinfection type of tuberculosis. Two children died, one in the early postoperative period, of pulmonary edema, and the other six years after a second homolateral resection for progression of her tuberculous disease. Complications occurred in 20% of cases, of which 18% were early and reversible. Thirty-eight of the survivors have fully recovered and the other has improved.Pulmonary resection is required infrequently in children with tuberculosis. When it is indicated, the results are excellent. These young patients withstand major thoracic surgery extremely well.     

Assessment of whether in-hospital mortality for lobectomy is a useful standard for the quality of lung cancer surgery: retrospective study

Objectives To calculate in-hospital mortality after lobectomy for primary lung cancer in the United Kingdom; to explore the validity of using such data to assess the quality of UK thoracic surgeons; and to investigate the relation between in-hospital mortality and the number of procedures performed by surgeons.Design Retrospective study.Setting 36 departments dealing with thoracic surgery in UK hospitals.Participants 4028 patients who had undergone lobectomy for primary lung cancer by one of 102 surgeons.Main outcome measures In-hospital mortality in relation to individual surgeons, among all patients, and among each of five groups of patients defined by the number of operations performed by the surgeon.Results 103 patients (2.6%, 95% confidence interval 2.1% to 3.1%) died after surgery during the same hospital admission. No significant difference was found for in-hospital mortality between the five groups.Conclusions The number of procedures performed by a thoracic surgeon is not related to in-hospital mortality. Reporting data on in-hospital mortality after lobectomy for primary lung cancer is a poor tool for measuring a surgeon''s performance.     

Chest wall resection and reconstruction: a true thoracoscopic approach

We set out to perform resection of a chest wall mass with subsequent reconstruction using a pure thoracoscopic approach. Using video-assisted thoracic surgery via a three-incision approach, we successfully removed an 8.5 × 3.5-cm specimen en bloc. We then reconstructed the chest wall with 2-mm polytetrafluoroethylene. A total thoracoscopic approach to chest wall resection and reconstruction represent an additional option in this area of thoracic surgery. This approach avoids some of the drawbacks of more invasive procedures. This report outlines a totally thoracoscopic approach that we feel represents a safe and viable option for patients requiring chest wall resection and reconstruction.     

Kynurenine metabolism predicts cognitive function in patients following cardiac bypass and thoracic surgery

Cardiac surgery involving extra-corporeal circulation can lead to cognitive dysfunction. As such surgery is associated with signs of inflammation and pro-inflammatory mediators activate tryptophan oxidation to neuroactive kynurenines which modulate NMDA receptor function and oxidative stress, we have measured blood concentrations of kynurenines and inflammatory markers in 28 patients undergoing coronary arterial graft surgery and, for comparison, 28 patients undergoing non-bypass thoracic surgery. A battery of cognitive tests was completed before and after the operations. The results show increased levels of tryptophan with decreased levels of kynurenine, anthranilic acid and 3-hydroxyanthranilic acid associated with bypass, and a later increase in kynurenic acid. Levels of neopterin and lipid peroxidation products rose after surgery in non-bypass patients whereas tumour necrosis factor-α and S100B levels increased after bypass. Changes of neopterin levels were greater after non-bypass surgery. Cognitive testing showed that the levels of tryptophan, kynurenine, kynurenic acid and the kynurenine/tryptophan ratio, correlated with aspects of post-surgery cognitive function, and were significant predictors of cognitive performance in tasks sensitive to frontal executive function and memory. Thus, anaesthesia and major surgery are associated with inflammatory changes and alterations in tryptophan oxidative metabolism which predict, and may play a role in, post-surgical cognitive function.     

Thoracic lymphatic disorders

Thoracic complications of lymphatic disorders can culminate in respiratory failure and death and should be considered in any patient with a lymphatic disease and clinical or radiographic evidence of chest disease. Congenital lymphatic disorders are being increasingly recognized in the adult population. The spectrum of thoracic manifestations of lymphatic disorders ranges from incidental radiographic findings to diffuse lymphatic disease with respiratory failure. This article serves to review some recent advances that allow improved diagnosis and management of thoracic lymphatic disorders. Herein, we describe their anatomical and physiologic effects, the time course of their progression, and the therapies that are currently available. The management of malignant (cancerous) lymphatic disorders of the thorax is beyond the scope of this paper.     

Effects of epidural lidocaine analgesia on labor and delivery: A randomized, prospective, controlled trial

Background

Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems.

Methods

We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles.

Results

Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600).

Conclusion

These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.     

Arthroscopy.

Arthroscopy has reduced the morbidity and period of hospitalisation associated with orthopaedic surgery and has increased the range of procedures that may be performed. From early operations on the knee it has expanded to include procedures for the shoulder, elbow, wrist, hip, ankle, and foot. For some joints the indications for surgery are clear, for others the clinical advantages are still being assessed. This expansion has also led to the recognition of complications, though the incidence is low. Specialist instrumentation has allowed a wide variety of operations previously needing open surgery to be carried out arthroscopically. The repertoire of arthroscopic procedures will undoubtedly continue to expand, and controlled studies are required to validate their efficacy, particularly in the management of degenerative joint diseases.     

Adrenoceptors of the human internal thoracic artery.

Adrenoceptor function in the human internal thoracic artery (ITA) was characterized in vitro using segments of the artery obtained during coronary bypass operations. Specimens were prepared as isolated arterial rings mounted in a tissue bath, and mechanical activity (isometric tension) was measured in response to drugs. The ITA responded to phenylephrine (PE), epinephrine, and norepinephrine with concentration-dependent contractions. The PE-induced contractions were antagonized by phenoxybenzamine, prazosin, and high concentrations of yohimbine. The ITA was not effectively contracted by clonidine in the concentration range normally associated with alpha 2-adrenoceptor stimulation. The beta-adrenoceptor agonist, isoproterenol, had a weak and variable effect on the ITA; samples from 9 out of 12 subjects did not respond to isoproterenol, whereas samples from 3 subjects responded with relaxations of between 33 and 42%. These in vitro studies indicate that the most important adrenoceptors of the human ITA are alpha-adrenoceptors; this may be relevant for the pharmacologic management of patients undergoing coronary bypass surgery using the ITA.     

电视胸腔镜与开胸手术治疗重症肌无力的疗效及安全性分析

目的:探讨电视胸腔镜与开胸手术治疗重症肌无力的疗效及安全性。方法:选取60例重症肌无力患者,按随机数字表法分为两组,观察组(32例)采用电视胸腔镜手术治疗,对照组(28例)采用开胸手术治疗,观察并记录两组围手术期指标,两组术前、术后3个月、6个月QMG评分及随访6个月期间并发症的发生情况。结果:围手术期间,两组手术时间相比差异无统计学意义(P0.05),观察组术中出血量少于对照组,术中引流时间、住院时间及切口长度均短于对照组(P0.05)。术前,两组QMG评分比较无统计学差异(P0.05),术后3个月、6个月,两组QMG评分均较治疗前显著降低,且观察组QMG评分均低于对照组(P0.05)。随访6个月期间,观察组并发症7例,对照组并发症17例,主要并发症为肺部感染,观察组并发症发生率显著低于对照组(P0.05)。结论:采用电视胸腔镜手术治疗重症肌无力具有手术切口小、患者术后恢复快,手术安全性较高的优点。     

经胸腔镜与开胸手术治疗胸腺瘤合并重症肌无力的临床疗效比较

目的:观察和比较经胸腔镜与开胸胸腺瘤扩大切除术治疗胸腺瘤伴重症肌无力(MG)患者的临床疗效和安全性。方法:回顾性分析2010年1月至2015年12月在新疆医科大学附属第一医院胸外科接受胸腔镜手术与开胸手术(本研究指胸骨正中劈开胸腺瘤扩大切除术)共120例胸腺瘤伴MG患者的临床资料,比较两组的手术时间、术后并发症、术后WHO病理分型、Masaoka分期、术后MGFA分级、远期随访总缓解率、术中出血量、术后拔管时间、术后住院天数和术后VAS疼痛评分。结果:两组手术时间、术后并发症、术后WHO病理分型、Masaoka分期、术后MGFA分级及远期随访总缓解率比较差异均无统计学意义(P0.05);开胸组肿瘤直径明显大于胸腔镜组,胸腔镜组术中出血量、术后拔管时间、术后住院天数和术后VAS疼痛评分明显短于或低于开胸组,差异均有统计学意义(P0.05)。结论:经胸腔镜与开胸胸腺瘤扩大切除术治疗MG的远期疗效相当,但胸腔镜手术创伤更小,有利于减少术后疼痛并加快患者恢复。     

Minimally invasive surgery. Future developments.

The rapid development of minimally invasive surgery means that there will be fundamental changes in interventional treatment. Technological advances will allow new minimally invasive procedures to be developed. Application of robotics will allow some procedures to be done automatically, and coupling of slave robotic instruments with virtual reality images will allow surgeons to perform operations by remote control. Miniature motors and instruments designed by microengineering could be introduced into body cavities to perform operations that are currently impossible. New materials will allow changes in instrument construction, such as use of memory metals to make heat activated scissors or forceps. With the reduced trauma associated with minimally invasive surgery, fewer operations will require long hospital stays. Traditional surgical wards will become largely redundant, and hospitals will need to cope with increased through-put of patients. Operating theatres will have to be equipped with complex high technology equipment, and hospital staff will need to be trained to manage it. Conventional nursing care will be carried out more in the community. Many traditional specialties will be merged, and surgical training will need fundamental revision to ensure that surgeons are competent to carry out the new procedures.     

Refinement of intrathymic injection in mice

Direct intrathymic injection is a common procedure used in several types of experimental protocols in the mouse. Currently available approaches involve major surgical procedures that expose the thoracic cavity, resulting in an increased risk of poor recovery and postsurgical complications. The authors sought to refine this surgery to reduce animal pain and distress without compromising overall efficiency of the technique. Using a minimally invasive method that does not expose the thoracic cavity, the authors gave accurately placed intrathymic injections, as confirmed by analyses with a reporter dye. They describe this new approach for intrathymic injection in mice that reduces complications associated with lengthy periods of anesthesia and thoracic cavity exposure.     

Acute hepatitis B in patients in Britain related to previous operations and dental treatment.

The frequency of transmission of hepatitis B virus infection from health service staff to patients was assessed from reports of confirmed cases of acute clinical hepatitis in 1980-3. During the four years 4505 reports (91% of the total) included replies to a question about recent operations; 153 patients (3.4%) had this history. Transfused blood or blood products were considered the source for 27 cases (0.06%). Eleven patients (0.02%) were infected in two clusters, both in cardiac surgery units; six were caused by a perfusion technician, who was a symptomless carrier, and five by a surgical registrar during the incubation period of an acute hepatitis B infection. The estimated average annual risk of a patient developing acute hepatitis B as part of a cluster caused by staff during surgical procedures was one in a million operations. For another 11 patients blood transfusion could not be excluded as a source. Where no association between surgery and hepatitis was found the incidence of a history, lay between 2.3 and 2.6%. The Hospital In-Patient Enquiry data showed that about 2.4% of the population had had operations in a six month period. These findings suggest that transmission of hepatitis B infection from staff to patients is rare in Britain and that the small risk could be eliminated by attention to measures to preserve asepsis and by immunising staff at risk.     

CT and radiographic analysis of sagittal profile changes following thoracoscopic anterior scoliosis surgery

ABSTRACT: BACKGROUND: Previous studies report an increase in thoracic kyphosis after anterior approaches and a flattening of sagittal contours following posterior approaches. Difficulties with measuring sagittal parameters on radiographs are avoided with reformatted sagittal CT reconstructions due to the superior endplate clarity afforded by this imaging modality. METHODS: A prospective study of 30 Lenke 1 adolescent idiopathic scoliosis (AIS) patients receiving selective thoracoscopic anterior spinal fusion (TASF) was performed. Participants had ethically approved low dose CT scans at minimum 24 months after surgery in addition to their standard care following surgery. The change in sagittal contours on supine CT was compared to standing radiographic measurements of the same patients and with previous studies. Inter-observer variability was assessed as well as whether hypokyphotic and normokyphotic patient groups responded differently to the thoracoscopic anterior approach. RESULTS: Mean T5-12 kyphosis Cobb angle increased by 11.8 degrees and lumbar lordosis increased by 5.9 degrees on standing radiographs two years after surgery. By comparison, CT measurements of kyphosis and lordosis increased by 12.3 degrees and 7.0 degrees respectively. 95% confidence intervals for inter-observer variability of sagittal contour measurements on supine CT ranged between 5-8 degrees. TASF had a slightly greater corrective effect on patients who were hypokyphotic before surgery compared with those who were normokyphotic. CONCLUSIONS: Restoration of sagittal profile is an important goal of scoliosis surgery, but reliable measurement with radiographs suffers from poor endplate clarity. TASF significantly improves thoracic kyphosis and lumbar lordosis while preserving proximal and distal junctional alignment in thoracic AIS patients. Supine CT allows greater endplate clarity for sagittal Cobb measurements and linear relationships were found between supine CT and standing radiographic measurements. In this study, improvements in sagittal kyphosis and lordosis following surgery were in agreement with prior anterior surgery studies, and add to the current evidence suggesting that anterior correction is more capable than posterior approaches of addressing the sagittal component of both the instrumented and adjacent non instrumented segments following surgical correction of progressive Lenke 1 idiopathic scoliosis.