Thoracic Surgical Cases Research Articles

A dedicated robotic bedside physician assistant significantly enhances trainee console operating time in general thoracic surgery

ObjectiveAs trainees rotate through thoracic subspecialties within their curricula, a crucial portion of their robotic training consists of actual console operating time. The more time spent on the surgeon console, the greater the development will be through the course of their training. Implementing a physician assistant at the bedside may increase the operative console time for the trainee and develop robotic skills in a more expeditious rate. The objective was to evaluate the impact a designated robotic physician assistant can have on trainee console learning opportunity. MethodsOperating room data collected consisted of all robotic general thoracic surgical cases that trainees participated in with and without a physician assistant present. Metrics regarding case efficiency included anesthesia ready-to-incision, incision-to-console, and raw resident console times. By using PRISM software, a nonparametric t test was used to analyze each averaged data group compared between when a physician assistant was present and not present. ResultsThe mean resident console time without and with a physician assistant assist was 45.8 minutes and 80.9 minutes, respectively (P < .0001). The average portion of a case performed by a trainee similarly without and with a physician assistant present was 28.0% and 77.1%, respectively (P < .0001). Case efficiency metrics between physician assistant presence cohorts showed no difference. ConclusionsThoracic surgical trainees have increased opportunity for robotic skill development within a fellowship or resident program curriculum when a designated robotic physician assistant is present in the operating room. These findings are significant for the improvement of residency and fellowship robotic training models moving forward by incorporating robotic-specialized physician assistants in academic institutions.

Effect of COVID-19 on the delivery of care for thoracic surgical patients

ObjectiveIn this study we aimed to determine the effect of the COVID-19 pandemic on the delivery of care for thoracic surgical patients at an urban medical center. MethodsA retrospective analysis of all thoracic surgical cases from May 1, 2019, to December 31, 2020, was conducted. Demographic characteristics, preoperative surgical indications, procedures, final pathologic diagnoses, and perioperative outcomes were recorded. A census of operative cases, relevant ancillary services, and outpatient thoracic clinics were obtained from our institutional database. ResultsSix hundred nineteen cases were included in this study (329 pre-COVID-19 and 290 COVID-19, representing an 11.8% reduction). There were no differences in type of thoracic procedures or perioperative outcomes among the 2 cohorts. Prolonged reduction of thoracic surgical cases (50% of baseline) during the first half of the COVID-19 period was followed by a resurgence of surgical volumes to 110% of baseline in the second half. A similar incidence of cases were performed for oncologic indications during the first half whereas more benign cases were performed in the second half, coinciding with the launch of our robotic foregut surgery program. After undergoing surgery during the pandemic, none of our patients reported COVID-19 symptoms within 14 days of discharge. ConclusionsDuring the initial surge of COVID-19, while there was temporary closure of operative services, our health care system continued to provide safe care for thoracic surgery patients, particularly those with oncologic indications. Since phased reopening, we have experienced a rebound of surgical volume and case mix, ultimately mitigating the initial negative effect of the pandemic on delivery of thoracic surgical care.

The Effect of COVID-19 Pandemic on the Number and Pattern of Major Thoracic Surgical Cases in Hayatabad Medical Complex, Peshawar

1.1. Introduction: COVID-19 pandemic affected the activities of every department, but most significantly the health department. It is essential to understand and quantify any such effects on the healthcare for better future planning. 1.2. Objective: We used de-identified retrospective data to 1) quantify the prevalence of common surgeries in the thoracic surgery department, 2) investigate the impact of COVID 19 on the patients’ characteristics, and number and proportion of the thoracic surgeries in our department, and 3) search for the possible causes for any such effects. 1.3. Materials and Methods: We used a HIPPA complaint retrospective data of the patients who had surgery in the Thoracic Surgery division of Hayatabad Medical Complex, between December 2018 to July 2021 to work out the effects of the pandemic on the amount and kinds of surgeries in the thoracic department during the pandemic. 1.4. Results: Our data consisted of a total of 242 cases. During the pandemic, the total number of thoracic surgeries increased by 53%. The top five most common thoracic surgeries during the pandemic identified by prevalence were decortication (34.2%), hydatid cystectomy (10.8%), emergency thoracotomy (7%), esophagectomy (5.7%), and feeding jejunostomy (5.7%). During the pandemic, thoracic surgeries were generally more prevalent among males, and among relatively younger patients (age ≤10 years). We saw a significant drop in the proportion of surgeries for oncologic indications. However, no significant change was seen in the baseline characteristics, complications and mortality of the cases. 1.5. Conclusion: Although the pandemic had no significant effect on the baseline characteristics and the safety and efficacy of our procedures, the unplanned diversion of patients from other hospitals resulted in a sudden increased burden on our unit. We recommend a close communication between the different healthcare facilities, under a strict monitoring body, to prevent over burdening of the departments and smooth delivery of care to patients.

The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study.

Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Synopsis of cardiovascular and thoracic surgical cases in the University of Port Harcourt Teaching Hospital

Background: The aim of the study was to identify the spectrum of cardiothoracic and vascular surgical cases in the University of Port Harcourt Teaching Hospital (UPTH) and identify the limitations to service delivery and recommend solutions to improve service delivery to patients. Methods: A cross-sectional study of all the cases seen over a 5-year period at UPTH was analyzed. The data were retrieved from theatre records of both elective and emergency cases. All patients were included except those with closed tube thoracostomy drainage inserted in the accident and emergency theaters and patients who were referred out before they could have surgery. The results were tabulated and described using frequencies and percentages. Results: A total of 93 patients had surgeries in the 5-year period with a mean age of 38.5 years and a range of 3–82 years. Fifty-seven (61.3%) were males, with a male-to-female ratio of 3:2. Fourteen (15.1%) patients were children aged 3–16 years, 67 (72.0%) were adults (17–64 years), and 12 (12.9%) were the elderly (65 years and above). Twenty (21.5%) had surgeries on cardiac structures, 46 (49.5%) had surgeries on thoracic structures, and 27 (29.0%) had different vascular surgeries. For the cardiac structures, 8 (40%) had pericardiectomy and tube pericardiostomy while 12 (60%) had pacemaker insertion. Thoracic surgical procedures included 3 (6.5%) diaphragmatic repairs, 7 (15.2%) esophageal surgeries, 22 (47.8%) pleuropulmonary surgeries, 6 (13.0%) chest wall reconstructions, 5 (10.9%) mediastinal tumor excisions, and 3 (6.5%) other surgeries. The vascular surgeries included 26 (96.3%) peripheral vascular repairs and 1 (3.7%) abdominal aortic aneurysm repairs. Conclusion: There are shortcomings with the practice of cardiothoracic surgeries at the hospital as major procedures like open-heart surgeries are not done despite availability of human expertise. Thus, there is an urgent need for measures to ensure that open-heart surgery commences, in addition to the provision of some surgical equipment and improvement on some surgical techniques. Furthermore, more collaboration with the other team members in the hospital needs to be actively encouraged.

Uniportal video-assisted thoracoscopic surgery for the treatment of thoracic emergencies.

While video-assisted thoracoscopic surgery (VATS) is well accepted in the management of thoracic emergencies, uniportal VATS has not yet been studied for this indication. This paper reports the results of the treatment of chest trauma patients by uniportal VATS in a single center with extensive experience in uniportal VATS. In this prospective study all patients who underwent uniportal VATS for thoracic surgical emergency cases, between 06/2012 and 09/2017, were included and the data were reviewed retrospectively. Six hundred forty-two uniportal VATS procedures were performed. Among those, 12 emergency cases could be identified. The indication was a hemothorax with active bleeding in all cases and the uniportal VATS approach was carried out after carefully evaluating all clinical factors and risks related to such a special setting. The location, extent and severity of the injuries were diagnosed and treated intraoperatively. The conversion rate was zero. The mean surgical time was 106.25 minutes [63-240], the chest tube was removed after 6.75 days in average (range, 1-25). All patients were transferred to the post anesthesia care unit (PACU) or intensive care unit (ICU) for at least one night (range, 1-25). The mean postoperative hospital stay was 10.67 days [4-26]. In expert hands, uniportal VATS approach seems to be a safe and feasible procedure for both, the diagnostics and management of emergency cases, such as active thoracic bleeding in cardiopulmonary stable patients.

The Society of Thoracic Surgeons General Thoracic Surgery Database 2018 Update on Outcomes and Quality

For nearly 15 years The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) has provided participating institutions with risk-adjusted feedback reports that allow outcome comparisons relative to national benchmarks. With more than 300 contributing centers across North America, the STS GTSD now includes more than 530,000 cases. In 2017 the STS GTSD Task Force revised the data collection form with the goal of collecting more detailed and accurate information for the most important thoracic surgical cases without increasing the workload of registrars. In addition, the learning curve for thoracoscopic lobectomy was examined, online public reporting was initiated, institutional feedback reports were made more user-friendly, and collaboration with the European Society of Thoracic Surgery continued. The STS GTSD Task Force continues to work to improve the quality of care and support research initiatives in general thoracic surgery. This report summarizes current aggregate national outcomes in general thoracic surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency from the STS GTSD during the past 12 months.

Enhanced recovery after thoracic surgery reduces discharge on highly dependent narcotics

There is large prescription drug epidemic in United States. We want to determine if ERATS (enhanced recovery after thoracic surgery) program can reduce discharge on highly dependent narcotics. We performed a retrospective analysis of prospectively collected data on patients who underwent lung resection and foregut procedures on thoracic surgery service over an 8-month time period. Patients underwent preoperative conditioning instructions, multimodal non-narcotic pharmaceutical usage, total intravenous anesthesia (TIVA) and minimizing highly addictive narcotics during the post-operative period. We gathered information on demographics, indication and type of surgery, morbidity, mortality and length of stay. We also recorded the type of pain medication patients were given as a prescription based on the Drug Enforcement Agency's classification schedule. Fifty-two patients underwent lung resection and 54 patients underwent foregut surgery. There were no mortalities in either group. Ten percent of patients after lung surgery and 6% after foregut surgery had a greater than grade II complication. The median length of stay after lung resection was 2 days and foregut surgery was 1 day. Only 10% of patients went home after lung resection and 2% after foregut surgery with a prescription for schedule II narcotics. We found that patients who were on schedule II narcotics prior to surgery all went home with schedule II narcotics. We found that ERATS program for thoracic surgical cases can reduce the number of patients going home with highly dependent narcotics. This strategy will decrease the availability of highly addictive prescription drugs in the community.

Asian perspective in surgery: thoracic surgery in Turkey.

Turkey with a population of 78 million is located between Asia and Europe geographically and culturally. There are 577 active pure thoracic surgeon and 37 thoracic surgery teaching units. Thoracic surgeons usually deal with lung cancer patients due to relatively higher rate of tobacco usage as well as inflammatory diseases such as pulmonary hydatid disease, bronchiectasis and empyema. Minimally invasive thoracic surgery has been a new approach which is being adapted by increasingly more surgeons. There are a number of reasons to predict that the number of thoracic surgical cases will be increased and new generation of thoracic surgeons will be operating more minimally invasive resectional surgeries for most lung cancer in future.

Measuring Surgical Quality: Comparison of Postoperative Adverse Events with the American College of Surgeons NSQIP and the Thoracic Morbidity and Mortality Classification System

Monitoring surgical outcomes is critical to quality improvement; however, different data-collection methodologies can provide divergent evaluations of surgical outcomes. We compared postoperative adverse event reporting on the same patients using 2 classification systems: the retrospectively recorded American College of Surgeons (ACS) NSQIP and the prospectively collected Thoracic Morbidity and Mortality (TM&M) system. Using the TM&M system, complications and deaths were documented daily by fellows and reviewed weekly by staff for all thoracic surgical cases conducted at our institution (April 1, 2010 to December 31, 2011). The ACS NSQIP recording was performed 30 to 120 days after index surgery by trained surgical clinical reviewers on a systemic sampling of major cases during the same time period. Univariate analyses of the data were performed. During the study period, 1,788 thoracic procedures were performed (1,091 were designated "major," as per ACS NSQIP inclusion criteria). The ACS NSQIP evaluated 182 of these procedures, representing 21.1% and 16.7% of patients and procedures, respectively. Mortality rates were 1.4% in TM&M vs 2.2% in ACS NSQIP (p = 0.42). Total patients and procedures with complications reported were 24.4% and 31.1% by TM&M vs 20.2% and 39.0% by ACS NSQIP (p = 0.23 and 0.03), respectively. Rates of reported cardiac complications were higher in TM&M vs ACS NSQIP (5.8% vs 1.1%; p = 0.01), and wound complications were lower (2.5% vs 6.0%; p = 0.01). Although overall rates were similar, significant differences in collection, definitions, and classification of postoperative adverse events were observed when comparing TM&M and ACS NSQIP. Although both systems offer complementary value, harmonization of definitions and severity classification would enhance quality-improvement programs.

Don't Forget the Heart When Looking at the Risk of Postoperative Pulmonary Complications

We read with great interest the recent study by Canet et al. 1In this investigation, based on 2,464 surgical patients, the incidence of postoperative pulmonary complications (PPCs) was 5%, with a related mortality rate at Day 30 of 19.5% (95% CI, 12.5–26.5%).Predicting risk factors for PPCs is a cornerstone of better patient management. However, reliable knowledge of PPC incidence in a broad, heterogeneous surgical population remains difficult because of nonrepresentative samples and statistical flaws. Furthermore, definitions of PPC are often not explicit and differ among studies. The recent study of Canet et al. 1has similarities with that of McAlister et al. 2Both investigations were built with a strong statistical methodology and included a large representative surgical population. Yet, the 5% incidence of PPC reported by Canet et al. 1is almost double the 2.7% reported by McAlister et al. 2This higher rate of complications observed by Canet et al. 1could be explained, in part, by the inclusion of emergency cases (14.2%), whereas McAlister et al. 2included only scheduled cases. The risk of PPC increases significantly in emergency cases.3In addition, Canet et al. 1included some thoracic surgical cases. Another major difference is related to the use of different PPC definitions. The diagnostic criteria used by McAlister et al. 2were stricter, including supplementary therapeutic action, such as mechanical ventilation for respiratory failure, percutaneous intervention for treatment of pleural effusion, and bronchoscopic intervention for atelectasis.2Nevertheless, the most striking result reported by Canet et al. 1is not the high incidence of PPC per se but the high percentage of mortality (19.5%) associated with these cases. It seems difficult to conceive that PPC alone can explain this finding. A previous study by Lawrence et al. 4showed that, in a cohort of patients undergoing major abdominal surgery, 33% who developed PPC also had cardiovascular complications. This result suggests that a significant proportion of patients studied by Canet et al. 1also had cardiovascular complications that were not evaluated and that these complications may have been the cause of death in these patients.In conclusion, further studies are necessary to examine prospectively comparative incidence, outcomes, and predictors of both types of complications.*Hôpital Foch, Suresnes, France. m.fischler@hopital-foch.org

Sepsis and Therapeutic Hypercapnia

Sepsis and Therapeutic Hypercapnia

Changing Pattern of Thoracic Diseases in Korea over the Last 25 Years

Current medical practice is a reflection of disease patterns and of recent advances in medical knowledge and technology. Gradual or abrupt changes in disease patterns have infl uenced our practices in the cardiothoracic surgical fi elds. These changes can also redistribute human and material resources according to the requirements of the medical fi eld. For example, the decrease in birth rate in Korea is no longer a new topic; the number of newborns in 2005 was approximately 430,000, which was about two-thirds of the 630,000 newborns in 2000. The nationwide decrease in the number of newborns has infl uenced the practices of many medical departments in addition to obstetrics and pediatrics. In cardiothoracic surgery, the decrease in the number of newborns has affected congenital cardiac surgery, so decreases in the surgical volume and number of new positions in congenital cardiac surgery were inevitable. Advances in medical knowledge and technology have also infl uenced medical practice. The drug-eluting stent was introduced several years ago in Korea. Now, it is the most powerful alternative to coronary artery bypass surgery. The increase in the use of drug-eluting stents has slowed the rate of increase of bypass operations in Korea for the past 5 years, as bypass grafting is no longer the only option for treatment of multivessel coronary artery disease. In the fi eld of general thoracic surgery, abrupt changes have not occurred until recently. However, the changes that did occur have continued, and our practices have adapted accordingly. In an earlier period of thoracic surgery, infl ammatory disease was the most common condition encountered by the thoracic surgeon: most frequently, empyema, bronchiectasis, and tuberculosis. Drainage, thoracoplasty, and resection of the infected pleural space and lung parenchyme were major surgical procedures in the late 1800s and early 1900s. However, the introduction of antibiotic therapy in the 1920s and 1930s gradually decreased the prevalence of complicated infl ammatory disease. During the last 50 years, like many other surgical departments, thoracic surgery has changed from surgery for infl ammatory disease to oncologic surgery. In our hospital, the number of general thoracic surgical cases was approximately 200 in the early 1980s. Only 10% of cases were resections for lung cancer, while infl ammatory disease constituted 36%. In recent years, the surgical volume has increased to 1,000 cases annually, and the proportion of lung cancer resections has increased to 36%, whereas infl ammatory disease has decreased to 8%. Changes have also occurred in the profi le of lung cancer. In the early 1980s, squamous cell carcinoma was the predominant cell type and constituted 65% of all lung cancers, while adenocarcinomas accounted for only 18% of the surgical cases in our hospital. Since the start of the new millennium, the proportion of adenocarcinomas vs squamous cell carcinomas has changed to 48% vs 35%. Together with the increase in the number of adenocarcinomas, early lung cancer has become the major indication in lung cancer surgery. The proportion of stage I lung cancers has risen from 29% in the early 1980s to 56% in the 2000s.

A comparison of two types of new bronchial blockers, Uniblocker™ and Coopdech endotracheal blocker tube, for one-lung ventilation during thoracoscopy

The purpose of this study was to compare the use of a wire-guided bronchial blocker, Uniblocker™ (Fuji Systems Corporation, Tokyo, Japan), with a spread type of bronchial blocker, Coopdech endotracheal blocker tube (Daiken Medical Corporation, Osaka, Japan), for lung isolation during elective thoracic surgical cases.

A comparison of the double-lumen tube with the torque control blocker univent tube

单肺通气可通过双腔支气管导管(double-lumentube,DLT)技术和支气管阻塞技术来实现.DLT在临床上使用最普遍,但DLT的有效管腔小、病人术后不易耐受而常需换管、声门暴露不佳者插管困难及没有小儿的型号等缺点,使其使用范围受到限制.带扭力控制阻塞装置(torque control blocker)的univent管、即TCB univent管(TCBU)是支气管阻塞器的一种,可弥补DLT的上述缺陷,但因近几年才开始使用,临床应用及报道较少.本研究采取随机对照的方法,在择期胸科手术需单肺通气的病人中,通过比较DLT和TCBU的插管定位时间、盲插成功率、气道峰压增加率、移位次数、需行纤支镜检查的次数、术野暴露情况、术后咽痛声嘶发生率等指标,来评价何者更优。

The effectiveness of high dependency unit in the management of high risk thoracic surgical cases.

To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk cases with favourable outcome. It provides excellent pain control facilities, detects complications early and avoids unnecessary ITU admissions. It also provides an excellent training opportunity for both medical and nursing staff.

Risk Factors for Early Mortality and Major Complications Following Pneumonectomy for Non-small Cell Carcinoma of the Lung

To assess the mortality rate and the incidence of cardiopulmonary complications after pneumonectomy for non-small cell lung carcinoma (NSCLC) and to identify possible associated risk factors. Observational study of patients who underwent pneumonectomy. Potential risk factors were analyzed from a local database including all thoracic surgical cases. A university hospital and a chest medical center. From January 1, 1990, to April 30, 2000, 193 consecutive pneumonectomies were performed for NSCLC in two affiliated institutions. The following information was recorded: demographic, clinical, functional, and surgical variables; as well as intraoperative and postoperative events. The risk of mortality and cardiopulmonary complications was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). After undergoing pneumonectomy, all patients were successfully extubated in the operating room and then transferred to a postanesthesia care unit (126 patients) or ICU (67 patients). The 30-day mortality rate was 9.3%, and cardiovascular and/or pulmonary complications occurred in 47% of cases. Coronary artery disease (CAD) was a predictor of 30-day mortality (OR, 2.9; 95% CI, 1.1 to 8.9). Cardiac morbidity (mainly arrhythmias) was significantly related to advanced age (OR, 3.7; 95% CI, 1.6 to 8.6) and pathologic stages III/IV (OR, 1.4; 95% CI, 1.1 to 4.7), whereas continuous epidural analgesia was associated with a reduced incidence of respiratory complications (OR, 0.2; 95% CI, 0.1 to 0.6). Pneumonectomy for lung cancer is a high-risk procedure, the risk for which is significantly related to the presence of CAD and advanced pathologic stages. Importantly, the provision of epidural analgesia contributes to lower the risk of respiratory complications.

Con: The univent tube is not the best method of providing one-lung ventilation

The Univent tube is a new form of bronchial blocker and is an addition to the armamentarium of the anesthesiologist for managing thoracic surgical cases. As with any new equipment/technique it will require time until the exact indications for its use become clear. The preference of anesthesiologists has oscillated between bronchial blockers and DLTs for the past 50 years, and no overall "best" method of providing OLV has yet been found. Anesthesiologists will continue to use, and to need to know how to use, DLTs for the foreseeable future.

THE VALUE OF ROUTINE PULMONARY FUNCTION STUDIES IN THORACIC SURGICAL CASES: Results in 212 Cases

THE VALUE OF ROUTINE PULMONARY FUNCTION STUDIES IN THORACIC SURGICAL CASES: Results in 212 Cases

The Technique of Administering Epidural Anesthesia in Thoracic Surgery

The important anatomical and physiological factors of the epidural space are discussed. The advantages and disadvantages of epidural anesthesia are presented. A brief history of epidural anesthesia is given. A detailed presentation is given of the technique of administering epidural anesthesia as was used in 617 thoracic surgical cases at the Missouri State Sanatorium at Mount Vernon, Missouri from October 30, 1945 to August 24, 1949.