Unilateral Thoracotomy Research Articles

First 3 Years of the Hungarian Lung Transplantation Program

In this article we summarize the results of the first 3 years after launching the Hungarian Lung Transplantation Program. Patients and MethodsThe first lung transplant in Hungary was carried out on December 12, 2015, with the collaboration of the National Institute of Oncology and the Semmelweis University. Up to December 31, 2018, a total of 62 lung transplants were performed. Data were analyzed retrospectively. Patients were listed for lung transplant after the indication was established by the National Lung Transplantation Committee. Donor lungs were procured from brain-dead donors only. ResultsWithin this period our team was involved in 87 lung procurements, 61 of which resulted in bilateral lung transplant and 1 in single-sided transplant. The operative approach was unilateral thoracotomy (n = 1), bilateral thoracotomy (n = 1), or clamshell incision (n = 60) with venoarterial extracorporeal membrane oxygenation support. The underlying disease of the recipients was obstructive lung disease (n = 30), lung fibrosis (n = 11), cystic fibrosis (n = 18), primary pulmonary hypertension (n = 2), histiocytosis-X syndrome (n = 1), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and retransplant because of bronchiolitis obliterans syndrome (n = 1). The youngest patient was 13 years of age, while the oldest was 65 years. Three patients died in the early postoperative phase. One-year survival was 80%. DiscussionThe number of cases rises steadily in the Hungarian Lung Transplantation Program, which is exceptional compared with the start of other centrums. The incidence of complications and mortality is comparable with those of other experienced centers around the world. Our future goal is to broaden our waiting list, thus increasing the number of lung transplants carried out.

Small dose of naloxone as an adjuvant to bupivacaine in intrapleural infiltration after thoracotomy surgery: a prospective, controlled study.

BackgroundSevere pain always develops after thoracotomy; intrapleural regional analgesia is used as a simple, safe technique to control it. This study was performed to evaluate whether a small dose of naloxone with local anesthetics prolongs sensory blockade.MethodsA prospective, randomized double-blinded controlled study was conducted on 60 patients of American Society of Anesthesiologists statuses I and II, aged 18 to 60 years, scheduled for unilateral thoracotomy surgery. After surgery, patients were randomly divided into two groups: through the intrapleural catheter, group B received 30 ml of 0.5% bupivacaine, while group N received 30 ml of 0.5% bupivacaine with 100 ng of naloxone. Postoperative pain was assessed using the visual analog pain scale (VAS). Time for the first request for rescue analgesia, total amount consumed, and incidence of postoperative complications were also recorded.ResultsThe VAS score significantly decreased in group N, at 6 h and 8 h after operation (P < 0.001 for both). At 12 h after injection, the VAS score increased significantly in group N (P < 0.001). The time for the first request of rescue analgesia was significantly longer in group N compared to group B (P < 0.001). The total amount of morphine consumed was significantly lower in group N than in the bupivacaine group (P < 0.001).ConclusionsAddition of a small dose of naloxone to bupivacaine in intrapleural regional analgesia significantly prolonged pain relief after thoracotomy and delayed the first request for rescue analgesia, without significant adverse effects.

Is Bilateral Staged Muscle-Sparing Thoracotomy Performed within 1 Week for Lung Hydatid Cysts Safe for Pediatric Patients?

Median sternotomy or staged thoracotomies are generally the preferred surgical treatment options for bilateral lung hydatid cysts. According to literature, it is usually recommended to wait from 3 weeks to 3 months between bilateral staged thoracotomies. The aim of this study is to compare postoperative complications, hospitalization days and morbidity and mortality ratios between unilateral thoracotomy and bilateral staged thoracotomy groups and to evaluate the safety of performing bilateral staged thoracotomy within 1 week for lung hydatid cysts in pediatric patients. In total, 112 patients under the age of 16 years who underwent surgery between 2000 and 2016 because of pulmonary hydatid cysts were included in this study. The patients were classified into two groups as Group 1 (unilateral muscle-sparing thoracotomy) and Group 2 (bilateral staged muscle-sparing thoracotomy applied within 1 week). There were 91 patients in Group 1 and 21 patients in Group 2. No statistically significant differences were detected when both groups were compared by age, gender, perforation rates, follow-up period and postoperative complications. To prevent hydatid cysts complications, the elapsed time between two thoracotomies should be not only long enough to evaluate the postoperative complications but also relatively short to prevent possible complications that may develop in the other lung. In our opinion, a patient follow-up of 3-7 days between thoracotomies is sufficient for the assessment of patients' clinical status and possible complications.

Paravertebral block decreases opioid administration without causing hypotension during transapical transcatheter aortic valve implantation.

Paravertebral block (PVB) is feasible for postoperative analgesia in patients who undergo cardiac surgery with unilateral thoracotomy. Postoperative continuous PVB is as effective as thoracic epidural anesthesia and is less likely to cause hypotension. However, the intraoperative utility and safety of PVB remains unclear. Therefore, the present study was conducted to determine the efficacy and hemodynamic influence of intraoperative paravertebral bolus injection during cardiac surgery. We retrospectively compared intraoperative medication use and blood pressure measurements between patients who underwent transapical transcatheter aortic valve implantation (TA-TAVI) with (PVB group, n=46) or without (non-PVB group, n=15) intraoperative PVB. Remifentanil administration was lower by more than 40% in the PVB group compared with that in the non-PVB group (728±319µg vs. 1240±488µg, P<0.001). The average and variability of intraoperative blood pressure showed no significant differences between groups. The duration of hypotension (blood pressure less than 80% of baseline) was 25.1±21.5% and 25.4±18.1% of the entire anesthesia time in the non-PVB and PVB groups, respectively (P=0.74). The use of inotropic and vasopressor agents was comparable between groups. Intraoperative paravertebral bolus injection decreased remifentanil administration without causing hypotension during TA-TAVI in hemodynamically unstable patients. This result suggests the intraoperative utility of PVB in cardiac surgery.

Simultaneous Bilateral Spontaneous Pneumothorax: Report of 6 Adult Patients

Background: Spontaneous pneumothorax (SP) refers to the spontaneous presence of air in the pleural sac(s) without iatrogenic or traumatic factors. The simultaneous bilateral SP (SBSP) is rare yet serious clinical condition which may pose a significant threat to patient’s life. Herein, 6 patients with SBSP managed in Sulaimaniyah Teaching Hospital (STH) over 6-year period (2006-2011) are reported with literature review. Methodology: A prospective clinical study. The diagnosis was made on clinical and radiographic grounds. The initial therapy was a bilateral tube thoracostomy (BTT) followed by chemical pleurodesis. Thoracotomy for excision of subpleural blebs or bullae and pleurectomy was performed for prolonged air leak (lasting >14 days). Results: There were 5 males (83.33%) and 1 female (16.67%) with a mean age of 34.8 years ranging between 20 and 50. All patients had presented with dyspnea and chest pain and were smokers. Three patients (50%) had primary (PSP) whereas the remaining had secondary (SSP) (chronic obstructive pulmonary disease—COPD, n = 2 and pneumonia, n = 1). None of the patients had recurrence. Unilateral thoracotomy was necessary in 5 patients (SSP, n = 3 and PSP, n = 2). Prolonged air leak was observed once postoperatively (16.7%) while mortality was nil. Conclusions: Prompt recognition of this rare yet potentially serious condition is crucial. The clinical diagnosis is straightforward with plain chest radiography being the most helpful workup. The initial therapy is via BTT followed by pleurodesis. Surgery is necessary for prolonged air leak and failure of the lung to expand.

A randomized double-blind study to evaluate efficacy and safety of epidural magnesium sulfate and clonidine as adjuvants to bupivacaine for postthoracotomy pain relief.

Background:The aim of the study was to compare postoperative pain relief in patients undergoing an elective thoracotomy with thoracic epidural analgesia using single shot magnesium and clonidine as adjuvants to bupivacaine.Methods:In a randomized prospective study, 60 patients of American Society of Anesthesiologists physical status I–III of either sex, between 20 and 60 years undergoing elective unilateral thoracotomy, were allocated to three equal groups of 20 patients. Each patient received thoracic epidural analgesia using bupivacaine alone (Group A) or with magnesium (Group B) or clonidine (Group C) at the end of surgery during skin closure. Postoperatively, pain was measured using a visual analog scale (VAS). Rescue analgesia (50 mg tramadol intravenous) was given at a VAS score of ≥4. Duration of analgesia and total dose of rescue analgesic during 24 h was calculated. Postoperative sedation and other side effects if any were recorded.Results:All the groups were homogeneous with respect to their demographics. The 24 h cumulative mean VAS score in Groups A, B, and C was 3.12 ± 0.97, 2.86 ± 0.43, and 1.83 ± 0.59, respectively. The duration of analgesia was prolonged in Group C (165 ± 49.15 min), followed by Group B (138 ± 24.6 min), and Group A (118.5 ± 52.8 min). The duration of analgesia was significantly prolonged in the clonidine group as compared to the control group (P = 0.001). The number of rescue analgesia doses were more in Group A (3.3 ± 1.65) followed by Group B (2.35 ± 0.98) and Group C (1.75 ± 0.71). The sedation scores were significantly higher in Group C. However, shivering was seen in Group A (40%) and Group C (20%) and absent in Group B (P = 0.003).Conclusion:Thoracic epidural analgesia using bupivacaine with clonidine is an efficient therapeutic modality for postthoracotomy pain. Magnesium as an adjuvant provided quality postoperative analgesia decreasing the need for postoperative rescue analgesia and incidence of postoperative shivering without causing sedation.

Progress in Radical Surgery for Malignant Pleural Mesothelioma

Aim: Stages I and II malignant pleural mesothelioma (MPM) can be satisfactorily treated with extended extrapleural pneumonectomy (EPP). We modified our diagnostic methods and surgical techniques to improve outcome. Methods: 74 patients were treated with EPP, 33 from 1988 to May 2000 (first group), and 41 from June 2000 to 2010 (second group) and all underwent thoracoscopy without mediastinoscopy or laparoscopy prior to EPP. We began to make changes in surgical management in group 2 (2000-2010). Staging was improved using 3D CT scan and Standard Uptake Values (SUV) provided by 2-(Fluorine-18)fluro-2-deoxy-D-glucose positron emission tomography (FDG PET) scan. Talc pleurodesis was used preoperatively in 15 cases. Double unilateral thoracotomy, performed on 24 patients, facilitated dissection of the diaphragm and made alterations in the reconstructive phase possible. Polytetrafluoroethylene (PTFE) prostheses were used instead of biological materials. In 10 cases the pericardium was not reconstructed on the left side after the previous negative experience of functional pericardial concretio that needed the prosthesis removal (Table 1). Topical thrombin was used to reduce postoperative complications whereas posterior prosthetic packing was used to prevent paraprosthetic evisceration and reduce postoperative bleeding. Results: Patients of group 2 experienced less morbidity. Fourteen of the 71 patients who survived beyond the immediate postoperative period lived at least 3 years. Potential positive prognostic factors were identified at follow-up. Conclusions: The innovations we adopted, especially the reconstruction procedures, improved the outcome for our series of patients who underwent extended EPP for MPM. Follow-up results suggest that the MIB-1 index, stage 1 disease, prosthetic diaphragmatic replacement, adjuvant radiotherapy and control are important positive prognostic factors.

Pulmonary Resection for Metastatic Adrenocortical Carcinoma: The National Cancer Institute Experience

Adrenocortical carcinoma (ACC) is a rare neoplasm with a high propensity for locoregional recurrences and distant metastases for which there are no effective systemic therapies. This study was undertaken to determine outcomes of patients undergoing pulmonary metastasectomy for ACC. A single-institution retrospective review was performed of patients undergoing pulmonary metastasectomy for ACC from 1979 to 2010. Twenty-six patients underwent 60 pulmonary metastasectomies. Fifteen patients (58%) underwent unilateral thoracotomy, 6 (23%) had staged thoracotomies, and 5 (19%) underwent median sternotomy as the initial thoracic procedure. Median number and size of lesions were 6 and 2 cm, respectively. Twenty-three patients (88%) were rendered free of disease in the lung, and 14 (54%) were rendered completely free of disease. Median overall and 5-year actuarial survivals from initial pulmonary metastasectomy were 40 months and 41%, respectively, with a median potential follow-up of 120 months. Median recurrence-free survival (RFS) and 5-year RFS for ipsilateral thoracic recurrences were 6 months, and 25%, respectively. The median RFS in the contralateral thorax was 5 months. Time to first recurrence after adrenalectomy and T stage of the primary tumor, but not adjuvant or neoadjuvant chemotherapy, were associated with increased overall survival after pulmonary metastasectomy. This study represents the most comprehensive review of outcomes of patients undergoing pulmonary metastasectomy for ACC. Given the lack of effective systemic therapies, pulmonary metastasectomy may be beneficial in properly selected patients.

Acupuncture is a feasible treatment for post-thoracotomy pain: results of a prospective pilot trial

BackgroundThoracotomy is associated with severe pain that may persist for years. Acupuncture is a complementary therapy with a proven role in pain control. A randomized trial showed that acupuncture was effective in controlling pain after abdominal surgery, but the efficacy of this technique for the treatment of thoracotomy pain has not been established. We developed a novel technique for convenient application of acupuncture to patients undergoing thoracotomy, and in a Phase II trial evaluated the safety of this intervention and the feasibility of doing a randomized trial.MethodsAdult patients scheduled for unilateral thoracotomy with preoperative epidural catheter placement received acupuncture immediately prior to surgery. Eighteen semi-permanent intradermal needles were inserted on either side of the spine, and four were inserted in the legs and auricles. Needles were removed after four weeks. Using a numerical rating scale, pain was measured on the first five postoperative days. After discharge, pain was assessed using the Brief Pain Inventory at 7, 30, 60 and 90 days.ResultsThirty-six patients were treated with acupuncture. Of these, 25, 23, and 22 patients provided data at 30, 60, and 90 days, respectively. The intervention was well tolerated by patients with only one minor and transient adverse event of skin ulceration.ConclusionThe rate of data completion met our predefined criterion for determining a randomized trial to be feasible (at least 75% of patients tolerated the intervention and provided evaluable data). This novel intervention is acceptable to patients undergoing thoracotomy and does not interfere with standard preoperative care. There was no evidence of important adverse events. We are now testing the hypothesis that acupuncture significantly adds to standard perioperative pain management in a randomized trial.

Continuous Thoracic Paravertebral Block for Pain Management Following Thoracotomy

Background: Continuous thoracic paravertebral block (C-TPVB) produces multidermatomal, ipsilateral, somatic and sympathetic nerve blockade, and is one of the options for pain management following thoracotomy. Herein, our experience of a continuous paravertebral infusion of ropivacaine for pain management following a thoracotomy is reported. Methods: Thirty two patients who underwent a thoracotomy were investigated. TPVB was performed using the Eason and Wyatt's technique at the T3-4 or T4-5 intervertebral space with an 18 G, 8 cm Tuohy needle. An epidural catheter was placed into the TPVS through the 18 G Tuohy needle, and advanced 4 - 5 cm into the TPVS. Eight ml of 1 % mepivacaine was injected into the thoracic paravertebral space (TPVS) and the dermatomal level checked by cold sensation. After the TPVB, general anesthesia was performed. When the visceral pleural had been closed, 8 ml of 0.3% ropivacaine was injected through the catheter, and 4 ml/h of 0.3% ropivacaine 0.3% continuous infused. The postoperative pain visual analog scale (VAS) was checked 2, 8, 24 and 48 hours after the operation in the resting and coughing states. Also, the requirements of the total dose of analgesic drug were recorded. The range of ann motion at the thoracotomy site, the side effects and patients' satisfaction were checked. Results: The mean VAS scores were 3.0 1.1 and 3.2 1.0 in the resting and coughing states, respectively, but there was no significant difference between the two states. The mean degree of ann motion was 1.47 0.5 and the patient satisfaction was good. Conclusions: Our results suggest that continuous thoracic paravertebral block with ropivacaine is an effective method for providing continuous pain relief in patients undergoing a unilateral thoracotomy.

Cost-effective and Time-saving Surgical Treatment of Pulmonary Hydatid Cysts with Multiple Localization

The most frequent anatomic locations of hydatid cysts are the liver and lungs. Because there is no effective medical therapy against this parasitic disease, surgery is the treatment of choice. The aim of this retrospective study was to compare the cost and effect of a one-stage operation with those of two- or three-stage operations in the treatment of lung hydatid cysts with multiple localizations. We evaluated 364 patients who underwent surgical treatment for hydatid cysts, all of whom had multiple localizations. To avoid two- or three-staged operations, we performed median sternotomy, simultaneous bilateral thoracotomy and unilateral thoracotomy with a transdiaphragmatic approach. For the treatment of 460 hydatid cyst localizations in 364 patients, a collective 381 operations were performed. The number of operations and periods of hospitalization were reduced. A one-stage surgical procedure for bilateral lung and liver hydatid cysts is superior to the traditional two- and three-stage operations because it reduces morbidity, hospital stay, and cost.

Lung volume reduction surgery: Lessons learned

The concept of lung volume reduction for generalized emphysema was proposed by Brantigan and associates in 1958 and reintroduced by Cooper and colleagues in 1994. The present study presents lessons learned from an 18-month experience. From August 1, 1994, to August 1, 1995, 53 patients underwent lung volume reduction at Emory University for generalized emphysema. There were 17 women and 36 men ranging in age from 55 to 75 years. The length of stay ranged from 10 to 59 days. At the time of presentation, 47 patients were receiving oxygen and 35 were receiving steroids. Forty-six patients were operated on using a median sternotomy and 7 through a unilateral thoracotomy. All patients underwent preoperative and postoperative pulmonary rehabilitation. There was one early death and four late deaths. Lessons learned from this group of patients are presented. Lung volume reduction surgery remains a sea of relatively uncharted waters, with the future direction yet to be determined.

Pulmonary metastases—Principles principles and strategies of surgical treatment

Surgical therapy of pulmonary metastases has become an established concept in tumor treatment as therapeutic alternatives are often missing and risks are acceptably low. Reviewing literature and analysing own experience the challenge for an oncological surgeon pursuing a multimodal concept in the treatment of pulmonary metastases is demonstrated. Between August 1989 and December 1993 155 patients had been operated on pulmonary metastases from extrapulmonary malignomas, with 125 of them having a carcinoma as primary malignanyy. Among them most had colorectal cancer (n=37), cancer of the kidney (n=32), the testicles (n=17) and the breast (n=14). In the 209 operations performed the mortality is zero. In case of multiple and/or centrally sited metastases unilateral thoracotomy one by the other seems an appropriate operative management. Prognosis after surgical resection of lung metastases is in general better for carcinoma than for sarcoma patients. Within the group of carcinomas patients with testicular carcinoma show a good prognosis (all our 17 patients are still alive). Important prognostic factors are completeness of surgery and hilar lymph nodes free of tumor in colorectal and kidney cancer metastases of the lung. Median survival time in patients with metastases of colorectal-, kidney-and breast carcinoma is 48 months, 51 months respectively 61 months. Surgical resection is the importance of a curative therapeutic attempt in the treatment of pulmonary metastases. To value the importance of the several therapeutic approaches in a multimodal treatment concept and to adapt them to the different tumor classes, prospective trials with a sufficiently large number of cases are required. With this it might be possible to derive tumor dependent concepts for a multimodal therapy, like the ones which already exist for the treatment of pulmonary metastases of germ cell tumors.

CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery.

Postthoracotomy atrophy of chest wall muscles results from nerve injury during surgery. After encountering patients with different patterns of chest wall muscular atrophy postthoracotomy, we performed this study to determine the relationship between type of thoracotomy and atrophic muscles as seen on CT scans. CT scans of 58 patients who had previously undergone unilateral thoracotomy were reviewed. Forty patients had a posterolateral thoracotomy, and 18 had an anterolateral thoracotomy. In two cases, the incision extended posteriorly. Atrophy seen on CT scans was defined as a marked decrease in size or thickness of a muscle compared with the muscle on the other side. Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle was detected on CT scans in 40 patients. No atrophy was found in 16 patients. The remaining two displayed atrophy only in the serratus anterior muscle. Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle developed in all patients who had a posterolateral thoracotomy. Atrophy developed in only two of the 18 patients who had an anterolateral thoracotomy, and in these two, the incision had been extended posteriorly. A direct correlation was found between type of thoracotomy and site of atrophy of the chest wall muscles seen on CT scans. This finding may account for different CT appearances of the thoracic wall in patients who have had thoracic surgery.

Surgical and medical management of patients with pulmonary metastasis from parathyroid carcinoma.

The aim of this study was to characterize patients with pulmonary metastasis of parathyroid carcinoma and to evaluate the long-term effect of surgical and medical therapy. Seven patients with pulmonary metastasis of parathyroid carcinoma were treated between 1980 and 1992. Six patients underwent resection of pulmonary metastases, and one patient has had long-term bisphosphonate therapy alone. Bisphosphonate was also given before or after operation to three patients. Two patients underwent a unilateral thoracotomy for a single pulmonary lesion, and four other patients with multiple lesions underwent staged bilateral thoracotomies. The postoperative serum calcium level returned to normal after each thoracotomy in three patients who were alive and well 3, 8, and 12 years after the first thoracotomy. Hypercalcemia persisted in the other three patients. In two of the patients, bisphosphonate therapy was also unable to control hypercalcemia. In one patient the serum calcium level has been maintained in the 13 mg/dl range by bimonthly bisphosphonate therapy alone for 3 years. The aggressive surgical approach to pulmonary metastasis of parathyroid carcinoma was shown to be effective for palliation in selected patients. Bisphosphonate therapy is an alternative to resection but has only a temporary calcium-lowering effect.

Postoperative pain management and respiratory depression after thoracotomy: A comparison of intramuscular piritramide and intravenous patient-controlled analgesia using fentanyl or buprenorphine

Study Objective: To compare the analgesic efficacy of fentanyl, buprenorphine, and piritramide and to define the respiratory risk during conventional postoperative pain management and patient-controlled analgesia (PCA). Design: Randomized, single-blind study. Setting: Department of anesthesiology of an urban hospital. Patients: Sixty patients (ASA physical status II and III) recovering from unilateral thoracotomy performed under standardized general anesthesia including intercostal blockade. Interventions: Patients were treated with intramuscular (IM) piritramide (7.5 to 15 mg as needed) or intravenous (IV) PCA with fentanyl (demand dose 34 μg) or buprenorphine (demand dose 80 μg) during the early postoperative period, using the On-Demand Analgesia Computer (ODAC, Janssen Scientific Instruments, Beerse, Belgium). Measurements and Main Results: The mean postoperative observation period was 24 to 25 hours. During this time, patients requested 55.8 ± 23.2 mg of piritramide, 1.04 ± 0.54 mg of fentanyl, or 1.81 ± 0.78 mg of buprenorphine. Analgesia in all groups was judged mostly good to excellent, with a preference for PCA. Side effects were only of minor intensity in all groups; euphoria or dysphoria occurred only with buprenorphine. Two patients using PCA and five patients having IM analgesia developed short periods of respiratory depression (respiratory rate ⩽8 breaths/minute and/or oxygen (O 2) desaturation ⩽90%), which promptly responded to commands to breathe deeply. Respiration rates did not differ, and frequent arterial blood sampling showed normal mean partial pressures of oxygen (PO 2) and carbon dioxide (PCO 2) and arterial oxygen saturation (SaO 2) in all subgroups. Conclusions: Opiod-induced respiratory depression occurred infrequently during postoperative pain management whether by conventional means or using PCA, even though high doses of opioid analgesics were required intermittently for adequate postoperative pain relief by either technique.

Technique of Pulmonary Thromboendarterectomy for Chronic Pulmonary Embolism

Pulmonary embolism infrequently results in severe chronic pulmonary arterial obstruction. However, when it does, affected patients are significantly symptomatic and have shortened survival. Medical management has proven ineffective. In the majority of surgical reports, unilateral thoracotomy with distal pulmonary arteriotomies has been emphasized. The average operative mortality was 22%. In this article, we discuss various preoperative considerations and describe in detail a surgical approach using median sternotomy for bilateral pulmonary thromboendarterectomy with cardiopulmonary bypass, deep hypothermia and circulatory arrest. With this standardized approach in 103 consecutive patients from October 1, 1984, to September 20, 1988, the hospital mortality (death within 30 days or during hospitalization) has been 11.7%.

Regional lung function in the presence of pleural symphysis.

We studied 4 men who had undergone unilateral thoracotomy for pleurodesis 2 to 9 years previously; all had normal over-all lung function. Regional lung function was measured with 'Xe, and the results on the operated side were compared with those from the unoperated side. At residual volume (RV), regional volumes and the distribution of inhaled boluses were normal, and no side-to-side differences were seen. In 2 subjects, at both functional residual capacity (FRC) and greater lung volumes, regional volumes on the operated side were slightly larger than on the other; this was most evident in the lower lung regions where there appeared to be a decrease in the apex-to-base volume gradient on the side with pleurodesis. In all subjects, boluses inhaled slowly at FRC were distributed more to the apex and less to the base on the operated side than on the unoperated side, and this was particularly marked in the 2 subjects with side-to­ side differences in regional volumes. All subjects showed a decrease in flow dependence of the distribu­ tion of boluses inhaled at FRC; the distribution of boluses at high flow rates was more similar to that of slowly inhaled boluses on the side with pleurodesis than it was on the side without. These findings sug­ gested that during maneuvers initiated at FRC, an abnormal pattern of forces was applied to the)ung with pleurodesis. Regional washouts were normal and showed no side-to-side differences, indicating that abnormalities noted during other maneuvers were probably not of clinical significance.

About unilateral free thoracotomy

Abstracts. Surgery. About unilateral free thoracotomy. T. Ohsawa (Zntrlbl. F. Chir. 1930, no. 40) describes Professor K. Torikata's method of unilateral opening of the chest without the use of pressure apparatus. After resection of the VII and VIII or VIII and IX ribs at the costal angle, the pleural cavity is opened in the VII or VIII intercostal space. The lung collapses and, if necessary, is retracted to the side. N. phrenicus intersects near the diaphragm.