The ability to remove longer segments of airway and to extend resections into the larynx proper has managed to create novel situations that will require attention to postoperative management. This article deals with prophylactic measures to prevent the requirement of assisted ventilation. It, however, also emphasizes various bronchoscopic and intubation techniques, which if required, will help to avoid trauma to the airway anastomosis. In addition, a variety of ventilator modalities are discussed that were developed by the author over many years at the Toronto General Hospital.

Although the influence of lung volume reduction surgery (LVRS) on incremental- and constant-power exercise is important in the evaluation of this procedure for patients with chronic obstructive pulmonary disease (COPD), it is rarely reported even in large randomised controlled trials. This report describes 39 patients with severe COPD ((mean +/- SE) forced expiratory volume in one second 32 +/- 2% pred, functional residual capacity 195 +/- 6% pred) who participated in a randomised controlled trial of LVRS and who completed incremental exercise tests at 6 months as well as endurance tests (constant power of 25 +/- 1 W) at 3, 9 and 12 months. Peak oxygen uptake (V'O2,pk) was similar between the treatment (n = 19) and control groups (n = 20) at baseline. After LVRS, the treatment group had a significantly greater V'O2,pk (mean difference (95% CI) 1.28 (0.07-2.50) mL x kg x min(-1)) and power (13 (6-20) W). The treatment group achieved a significantly greater minute ventilation (7.1 (2.9-11.3) L x min(-1)) with a greater tidal volume (0.16 (0.04-0.28) L). Baseline endurance was similar between groups. After surgery, there were significant between-group differences in endurance time, which were maintained at 12 months (7.3 (3.9-10.8) min). Lung volume reduction surgery is associated with an increase in exercise capacity and endurance, as compared with conventional medical treatment.

Background. This study assesses the risk of bronchogenic carcinoma after solid organ transplantation. Although the overall incidence of malignancy is increased after solid organ transplantation, the risk of bronchogenic carcinoma in the transplant population has not been systematically studied.Methods. Among a cohort of 3,374 patients transplanted in our institution between 1985 and 2000 (1,735 kidney recipients, 930 liver, 313 heart, and 396 lung recipients), 9 patients (0.3%) had a bronchogenic carcinoma develop. Lung carcinoma occurred in 3 kidney recipients, 3 liver recipients, 2 heart recipients, and 1 lung recipient.Results. Time to diagnosis after the transplant procedure ranged from 9 to 126 months (mean, 63 months). Aside from the lung transplant candidate, all recipients had a smoking history. Seven patients underwent thoracotomy and 6 had a complete resection. Tumors were classified as stage IA (n = 1), IB (n = 2), 1113 (n = 2), IIIA (n = 2), IIIB (n = 1), and IV (n = 1). Genotyping demonstrated that the carcinoma arising in the lung transplant recipient originated from the donor and may have been transmitted at the time of transplantation. Two patients were alive without recurrence 21 and 42 months after the operation.Conclusions. The risk of bronchogenic carcinoma is low and occurs mainly in recipients with a smoking history. However, bronchogenic carcinoma can also be transmitted from donor lungs at the time of transplantation. Hence careful examination of chest roentgenograms, and computed tomographic chest scan if available, as well as meticulous assessment of the lung, and biopsy of any suspicious lesions, are important to limit the risk of lung cancer transmission, especially with the liberalization of donor criteria. (C) 2003 by The Society of Thoracic Surgeons.

Background: The clinical value of LVRS has been questioned in the absence of trials comparing it with pulmonary rehabilitation, the prevailing standard of care in COPD. Patients with heterogeneous emphysema are more likely to benefit from volume reduction than those with homogeneous disease. Disease specific quality of life is a responsive interpretable outcome that enables health professionals to identify the magnitude of the effect of an intervention across several domains.Methods: Non-smoking patients aged < 75 years with severe COPD (FEV1 < 40% predicted, FEV1/FVC < 0.7), hyperinflation, and evidence of heterogeneity were randomised to surgical or control groups after pulmonary rehabilitation and monitored at 3 month intervals for 12 months with no crossover between the groups. The primary outcome was disease specific quality of life as measured by the Chronic Respiratory Questionnaire (CRQ). Treatment failure was defined as death or functional decline ( fall of 1 unit in any two domains of the CRQ). Secondary outcomes included pulmonary function and exercise capacity.Results: LVRS resulted in significant between group differences in each domain of the CRQ at 12 months ( change of 0.5 represents a small but important difference): dyspnoea 1.9 (95% confidence interval (CI) 1.3 to 2.6; p< 0.0001); emotional function 1.5 ( 95% CI 0.9 to 2.1; p< 0.0001); fatigue 2.0 ( 95% CI 1.4 to 2.6; p< 0.0001); mastery 1.8 ( 95% CI 1.2 to 2.5; p< 0.0001). In the control group one of 27 patients died and 16 experienced functional decline over 12 months. In the surgical group four of 28 patients died and three experienced functional decline ( hazard ratio = 3.1 ( 95% CI 1.3 to 7.6; p= 0.01). Between group improvements ( p< 0.05) in lung volumes, flow rates, and exercise were sustained at 12 months ( RV - 47% predicted ( 95% CI - 71 to - 23; p= 0.0002); FEV1 0.3 l ( 95% CI 0.1 to 0.5; p= 0.0003); submaximal exercise 7.3 min ( 95% CI 3.9 to 10.8; p< 0.0001); 6 minute walk 66 metres ( 95% CI 32 to 101; p= 0.0002).Conclusions: In COPD patients with heterogeneous emphysema, LVRS resulted in important benefits in disease specific quality of life compared with medical management, which were sustained at 12 months after treatment.

BACKGROUND:The optimal therapy for end-stage Eisenmenger syndrome (ES) is unknown. We analyzed the United Network for Organ Sharing/International Society for Heart and Lung Transplantation Joint Thoracic Registry to determine predictors of survival.METHODS:Univariate analysis was performed using Kaplan-Meier survival curves. Groups were compared using the log-rank test. Multivariate analysis was performed using a proportional hazards model.RESULTS:There were 605 transplants performed between 1988 and 1998. The causes of ES included atrial septal defect (ASD) in 171, ventricular septal defect (VSD) in 164, multiple congenital anomalies (MCA) in 68 and patent ductus arteriosus (PDA) in 32. Procedures included 430 heart-lung (HLT), 106 bilateral lung, and 69 single lung transplants (LT). Survival after HLT was better than after LT on univariate analysis (p = 0.002). For HLT, survival at 30 days and 1 year was 80.7% and 70.1% compared with 68% and 55.2% for LT. Diagnosis was also a significant predictor of survival (p = 0.011), being best for VSD and MCA (1-year survival 71.4% and 77.6%). There was a highly significant benefit of HLT over LT for VSD patients (p = 0.0001). Diagnosis, the combination of diagnosis and procedure, recipient age, recipient gender, donor age, ischemic time and recipient status were significant in a multivariate model. Multivariate analysis confirmed the superior prognosis of patients with VSD or MCA (p = 0.007 and p = 0.022, respectively) and suggested that the adverse effect of LT was predominately in patients with VSD (risk ratio 1.817, p = 0.035).CONCLUSIONS:This analysis suggests that ES recipients are not a homogeneous group. Patients with VSD and MCA have the best prognosis. HLT appears to offer a survival benefit for patients with ES secondary to VSD and should be re-considered as the operation of choice.

Background. It remains controversial whether transcervical thymectomy offers results equivalent to thymectomy by way of a median sternotomy in the treatment of myasthenia gravis. Furthermore, preoperative prognostic factors have not been clearly defined.Methods. This study is a retrospective chart review and interview of 78 patients completing transcervical thymectomy for myasthenia gravis between 1992 and 1999.Results. There were 24 men and 54 women. Mean age was 40 years (range, 13 to 78 years). Twelve patients were in Osserman class 1, 25 in class 2, 30 in class 3, and 11 in class 4 (mean, 2.5). There was no perioperative mortality and 6 (7.7%) morbidities. Mean length of stay was 1.5 days and mean follow-up, 54.6 months. The crude cumulative complete remission (asymptomatic off medications for 6 months) rate was 39.7% (n = 31). Only 8 patients (10.3%) failed to improve after transcervical thymectomy. Kaplan-Meier estimates of complete remission were 31% and 43% at 2 and 5 years, respectively. Eight patients with thymoma had a 5-year estimated complete remission rate of 75% in contrast to 43% in 38 patients with thymic hyperplasia and 36% in 32 patients with neither thymoma nor hyperplasia (p = 0.01). Twelve patients with ocular myasthenia had a 5-year estimated complete remission rate of 57%, whereas patients with mild-to-moderate (n = 55) or severe (n = 11) generalized symptoms had 5-year complete remission rates of 43% and 30%, respectively (p = 0.21).Conclusions. Overall, extended transcervical thymectomy offers results that are comparable to those published for the transsternal procedure. Patients with milder disease (including isolated ocular disease) and taking no preoperative immunosuppressive agents appear to experience higher remission rates. In contrast to previous studies, we also find that small thymomas predict better responses to thymectomy.

We report two cases of middle mediastinal parathyroid ectopia associated with chronic renal disease. In both patients the diagnosis was delayed and prolonged due to the unusual location of the ectopic parathyroid tissue. The surgical approach was in error in 1 patient and corrected during the second procedure. We describe the surgical technique for exposing and excising parathyroid tissue from this area.

OBJECTIVES We sought to analyze the experience with bronchoplastic procedures over a 7-year period and to determine putative prognostic factors for survival. METHODS From 1991 to 1997, 144 bronchoplastic procedures were performed for non-small cell lung cancer (n = 123), small cell lung cancer (n = 5), carcinoid tumor (n = 10), and metastases of extrathoracic malignant tumors (n = 6). There were 111 sleeve lobectomies, 17 bilobectomies, 4 lobectomies with carinal resection, 8 sleeve pneumonectomies, and 4 bronchotomies without parenchymal resection. Multivariable analysis included risk factors, such as age, sex, type of bronchoplastic procedure (bronchotomy, lobectomy, bilobectomy, or pneumonectomy), additional angioplasty, TNM staging, histology, radicality of resection, respiratory risk (forced expiratory volume in 1 second, percent predicted < 60), cardiovascular risk, and adjuvant therapy. RESULTS Overall 1- and 3-year survival was 72% and 52%, respectively. The overall 30-day mortality was 8.3% (5.4% for single sleeve lobectomies). Multivariable analysis demonstrated 4 risk factors for survival. High tumor stage, type of bronchoplastic procedure, impaired lung function, and presence of cardiovascular risk were associated with a poor outcome. Univariate analysis showed reduced survival in patients with sleeve pneumonectomies (1-year survival, 25%). CONCLUSIONS Bronchoplastic procedures for central tumors and sleeve pneumonectomies are associated with poor survival. Careful selection of these patients, as well as of patients with impaired lung function and cardiovascular risk factors, is mandatory.

The intrusion into the pleural space by surgeons was hindered for several hundred years by the realization that there were major pathophysiological alterations in ventilation and in circulation. The nature of this abnormality, although described very early on in history, went unrecognized until the end of the nineteenth century. The performance of thoracic surgery prior to that time and the development of different modes of ventilatory support are testimony to the intuition and inventiveness of the surgeons of that day. It is hard for the modern thoracic surgeon to fully comprehend the challenges that faced the early surgeon back when there was no such thing as positive pressure ventilation or unilateral lung ventilation. This article traces the origins of ventilation in man and their application to the development of thoracic surgery.

Lung volume reduction surgery for emphysema is evolving rapidly since its re-introduction in 1993. Lung transplantation remains a viable option for others with emphysema. The major difficulty facing surgeons lies in appropriate selection of patients for either procedure. The following paper represents an attempt by review of the literature and personal experience to describe some of the important features involved in patient selection. The current literature on patient selection for lung volume reduction surgery and transplantation for emphysema was reviewed, and the results within the University of Toronto Lung Volume Reduction Program were analyzed. The review suggests that the most reliable predictors of success are heterogeneous distribution of emphysematous change as reflected by the CAT scan and the quantitative ventilation perfusion scan with new emphasis being placed on the ventilation portion of the latter. Poor prognostic indicators are hypercarbia and pulmonary hypertension. It was felt that an algorithm could be established for determination of whether lung volume reduction or transplantation should be offered to patients for emphysema surgery. The algorithm is described.

BACKGROUND:A strategy of mechanical ventilation that limits airway pressure and tidal volume while permitting hypercapnia has been recommended for patients with the acute respiratory distress syndrome. The goal is to reduce lung injury due to overdistention. However, the efficacy of this approach has not been established. METHODS:Within 24 hours of intubation, patients at high risk for the acute respiratory distress syndrome were randomly assigned to either pressure- and volume-limited ventilation (limited-ventilation group), with the peak inspiratory pressure maintained at 30 cm of water or less and the tidal volume at 8 ml per kilogram of body weight or less, or to conventional ventilation (control group), with the peak inspiratory pressure allowed to rise as high as 50 cm of water and the tidal volume at 10 to 15 ml per kilogram. All other ventilatory variables were similar in the two groups. RESULTS:A total of 120 patients with similar clinical features underwent randomization (60 in each group). The patients in the limited-ventilation and control groups were exposed to different mean (+/-SD) tidal volumes (7.2+/-0.8 vs. 10.8+/-1.0 ml per kilogram, respectively; P<0.001) and peak inspiratory pressures (23.6+/-5.8 vs. 34.0+/-11.0 cm of water, P<0.001). Mortality was 50 percent in the limited-ventilation group and 47 percent in the control group (relative risk, 1.07; 95 percent confidence interval, 0.72 to 1.57; P=0.72). In the limited-ventilation group, permissive hypercapnia (arterial carbon dioxide tension, >50 mm Hg) was more common (52 percent vs. 28 percent, P=0.009), more marked (54.4+/-18.8 vs. 45.7+/-9.8 mm Hg, P=0.002), and more prolonged (146+/-265 vs. 25+/-22 hours, P=0.017) than in the control group. The incidence of barotrauma, the highest multiple-organ-dysfunction score, and the number of episodes of organ failure were similar in the two groups; however, the numbers of patients who required paralytic agents (23 vs. 13, P=0.05) and dialysis for renal failure (13 vs. 5, P= 0.04) were greater in the limited-ventilation group than in the control group. CONCLUSIONS:In patients at high risk for the acute respiratory distress syndrome, a strategy of mechanical ventilation that limits peak inspiratory pressure and tidal volume does not appear to reduce mortality and may increase morbidity.

Objective: To examine the relationship between intensive care unit (ICU) healthcare workers' confidence and their decision to withdraw life support.Design: Cross-sectional survey of Canadian intensivists, ICU housestaff, and bedside nurses. Respondents chose the level of care (from comfort measures only to full aggressive care) for 12 patients described in clinical scenarios, and rated their confidence in their decisions.Setting: Thirty-seven Canadian university-affiliate hospitals.Patients: None.Interventions: We used discrete data analysis models to examine the association between the chosen level of care, confidence in the decisions, the clinical scenario, and healthcare worker group.Measurements and Main Results: The response rate was 1,361 (76%)/1,795; for this analysis, we used data from 1,306 respondents with completed questionnaires. Responses for each scenario varied widely among respondents. The level of care chosen was dependent on the scenario, the healthcare worker group, and the confidence with which the decisions were made (p < .001 for each). Intensivists were less aggressive than the ICU nurses, who were less aggressive than the housestaff, but the magnitude of effect was small. Overall, respondents were very confident about their decisions 34% of the time. After adjustment for clinical scenario and chosen level of care, intensivists were more confident than nurses, who were more confident than housestaff (40% of intensivists, 29% of nurses, and 23% of housestaff were very confident). In general, healthcare workers tended to be more confident when they chose extreme levels of care than when they chose intermediate levels of care. Considerable variability in responses to scenarios remained even when we considered only those responses made with the highest level of confidence.Conclusions: While confidence in decisions about withdrawal of life support increases with seniority and authority, consistency of decisions may not. When given standard information, healthcare workers can make contradictory decisions yet still be very confident about the level of care they would administer.

The most common indication for tracheal resection is stenosis secondary to cuff injury from either tracheostomy tube or endotracheal tube or tracheostomy stomal injury. These injuries occur in the upper, middle, or distal trachea and are amenable to resection and reconstruction with excellent results. Techniques have been devised to allow resection of up to one half of the adult trachea. When postintubation stenosis and other inflammatory processes extend from the upper trachea into the subglottic larynx, the problem becomes more complex. If the lesion extends well above the lower border of the cricoid cartilage, circumferential resection is not possible because of the entry location of the recurrent laryngeal nerves into the larynx medial and posterior to the inferior cornua of the thyroid cartilage along the back of the posterior cricoid lamina (Figure I). The stenosis may involve only the anterolateral portion of the cricoid. When circumferential stenosis exists involving the posterior cricoid plate as well, the problem is much more formidable. The closer the stenosis comes to involving the vocal cords, the less suitable it is for resection, reconstruction, and preservation of laryngeal function. Grillo2Grillo HC Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.Ann Thorac Surg. 1982; 33: 3-11Abstract Full Text PDF PubMed Scopus (142) Google Scholar in 1979 devised a radiological classification of upper airway stenosis based on the amount of involvement of the subglottic space (Figure II). Type A is a high tracheal stenosis not involving the cricoid. This lesion is easily treated by segmental resection and tracheotracheal anastomosis. In type B, stenosis reaches the lower border of the cricoid cartilage and involves anastomosis between the trachea and cricoid cartilage. Type C involves inflammation of the anterior portion of the cricoid cartilage. Correction requires resection of the anterior portion of the cricoid cartilage and may require resurfacing of the posterior portion of the cricoid surface if the mucosa is severely scarred. Type D involves inflammation and stenosis of the glottis and has insufficient subglottic space for reconstruction. There currently is no reliable single stage method of reconstruction for stenosis at this level. There is no single factor responsible for subglottic stenosis. The vast majority of subglottic stenoses result from complications of endotracheal or tracheostomy tubes. In our experience, only endotracheal intubation was responsible for the largest number of subglottic stenoses. The point of greatest pressure from oral endotracheal tubes is the posterior cricoid plate (Figure III). The size of the larynx varies from individual to individual. It is recognized that women have a smaller larynx than men, and smaller adults have a proportionately smaller larynx. Larger endotracheal tubes will exert circumferential pressure at the glottic, subglottic, and cricoid levels and, if left in place long enough, may lead to circumferential necrosis at these levels. The aforementioned factors would seem to be responsible for the subglottic stenosis seen in patients that have been intubated with an oral endotracheal tube, as well as for posterior commissure stenosis. Tracheostomy tubes placed through the first tracheal ring or upward pressure by the tube in kyphotic patients may lead to retrograde erosion of the cricoid cartilage. Cricothyroidostomy through the cricothyroid membrane can also result in subglottic stenosis. The next most common cause of subglottic stenosis results from idiopathic stenosis.3Grillo HC Mark EJ Mathisen DJ et al.Idiopathic laryngotracheal stenosis and its management.Ann Thorac Surg. 1993; 56: 80-87Abstract Full Text PDF PubMed Scopus (113) Google Scholar This poorly understood phenomenon occurs predominantly in women and most often involves the subglottic larynx. There is no known cause. Blunt trauma to the upper airway can lead to subglottic stenosis, especially if the cricoid cartilage is damaged.4Mathisen DJ Grillo HC Laryngotracheal trauma.Ann Thorac Surg. 1987; 43: 254-262Abstract Full Text PDF PubMed Scopus (82) Google Scholar Failed attempts at repair or delayed recognition of injuries can result in subglottic stenosis. There are a variety of other inflammatory or infectious problems that are extremely rare but have resulted in subglottic stenosis. Patients determined to have subglottic stenosis should be carefully evaluated by an otolaryngologist to assess glottic function and the need for glottic procedures. In many patients with subglottic laryngeal inflammatory processes, the inflammation extends to just below the vocal cords. If resection is to be carried into the subglottic area, it cannot extend all the way to the vocal cords with hope of uniformly good results. The operation we propose is reserved for patients who on radiological study and direct laryngoscopy have an adequate residual subglottic space (Figures IIA–C). It is particularly important to assess the involvement of mucosa overlying the posterior cricoid plate and the posterior portion of the subglottic larynx. The airway is evaluated radiologically by the usual techniques, and the tracheostomy tube is removed at the time of examination (Figures IVA–B).5Weber A Symposium on the larynx and trachea.Radiol Clin N Am. 1978; Vol 16Google Scholar Vocal cord function is assessed by fluoroscopy of the larynx and by direct examination. Such evaluation is essential not only as a baseline for postoperative conparison of function but also to avoid performing subglotic airway reconstruction in a patient who, in addition has obstruction at the glottic level because of preexising bilateral palsy. Endoscopy with magnifying telescopes are used to evaluate the anatomy in detail (Figure V). It is most important to determine if there is adequate space beneath the glottis for repair because it is often difficult to determine this beforehand. The degree of inflammation in the area where the anastomosis would be carried out is carefully assessed. Inflammation is one of the important factors determining timing of resection and reconstruction. If inflammation does exits, it is best to dilate the stenosis and delay reconstruction. Careful endoscopic measurements should be taken to determine the exact length of involvement and the amount of normal trachea available for reconstruction. Airway management is critical to a successful outcome. It requires close cooperation and patience between the anesthesiologist and surgeon.6Wilson RS Tracheostomy and tracheal reconstruction.in: Kaplan JA Thoracic Anesthesia. Churchill Livingstone, New York, NY1983: 421-445Google Scholar Previous radiologica evaluation is invaluable in understanding the degree and extent of involvement of the airway. The most important aspect to successful management of these difficult airways is the attainment of a deep level of anesthesia with spontaneous ventilation by the patient. A satisfactory level of anesthesia may take 15 to 20 minutes for induction. When this level of anesthesia is reached, the upper airway is evaluated with a laryngoscope, or rigid bronchoscope, and a straight magnifying telescope. The glottis should be inspected very carefully before dilation to properly evaluate the degree of mucosal involvement, especially of the posterior commissure. Active inflammation with friable mucosa may preclude reconstruction at this time. Dilation is initiated by small woven bougies through a large rigid bronchoscope. Subsequent dilations are performed with small pediatric rigid bronchoscopes used as dilators under direct vision. Dilation is performed with gentle forward pressure in a corkscrew fashion under direct vision at all times. If resection is planned, it is only necessary to dilate to a diameter that will allow placement of a no. 6 endotracheal tube. If reconstruction is to be delayed, it should be possible to dilate to the size of a 7 or 8 rigid bronchoscope. This should be satisfactory for days to weeks depending on the origin of the stenosis. Patients should be made aware of this and know to seek medical attention before critical stenosis develops. Because of the complexities involved in reconstruction, tracheostomy is best avoided because it will only complicate subsequent reconstruction. Primary reconstruction or repeat dilation are the best ways to manage patients with subglottic stenosis. A collar incision is usually adequate for exploration. An existing tracheotomy may be included in the incision or separately excised. It is preferable to do a laryngeal release through a short transverse incision over the hyoid bone if exposure is inadequate through the collar incision. The anterior surface of the airway is expose from the thyroid notch to the carina. Dissection is kept close to the airway to avoid injury to the recurrent laryngeal nerves. The nerves are not identified but injury is avoided by staying away from their course. 1(A) The distal end of the lesion is identified first. (B) The trachea is dissected circumferentially at this point, the transection is performed immediately below the lesion.Show full captionThe end of the proximal tracheal segment, which is confluent with the laryngeal portion of the stenosis, is grasped with two toothed clamps, and dissection is carried upward to the cricoid cartilage. Particular care is taken to stay close to the airway when the posterolateral angles of the cricoid lamina are approached. At this point, the recurrent laryngeal nerves are next to the posterior cricoid plate behind the cricothyroid articulations. The airway is entered anteriorly, cutting transversely across at the top of what appears to be obviously diseased tissue. It is always possible to resect additional tissue. Occasionally the decision is difficult and it is preferable to divide the diseased airway vertically in the midline from below upward for a better determination of the level of transection. When it is clear that the anterior cricoid cartilage must indeed be removed, the line of entry is placed deliberately close to the midline of the inferior border of the thyroid cartilage so that there will be a rigid structure for suturing.The line of resection is carried laterally and inferiorly across the cricothyroid membrane on either side until the superior lateral borders of the lateral lamina of the cricoid cartilage are reached. Transection continues to bevel downward and backward, transecting the cricoid cartilage until the inferior border is reached anterior to the posterior cricoid plate itself. Posteriorly, the line of transverse incision lies at the level of the lower border of the cricoid cartilage plate. The mucosa is sharply transected here. The membranous wall of trachea is thus detached. It is critically important in these last maneuvers that the recurrent nerves are not injured. Dissection behind the cricoid plate is never carried more than 1 to 2 mm above the lower most border and often not even this far.Submucosal fibrosis often is found laterally in the subglottic larynx to a degree that seems to be greater than that suggested by preoperative examination or roentgenograms. This is handled in various ways. The oblique line of division of the larynx itself creates a larger subglottic airway than simple horizontal transection. The anterior stenosing process where cricoid has been destroyed by the inflammatory process may pull the lateral laminas of the cricoid cartilage together to produce sharper angulation laterally. In these cases, the lateral laminas of the cricoid are resected further posteriorly so that the anastomosis will not be narrowed by the distortion.(B-D) The distal end of the trachea is inspected to be sure that the cartilage just below the line of transection is of good quality. This cartilage is trimmed back in a gentle curve on either side from full width anteriorly to a sloping angle at the lateral posterior ends of the cartilage. Shaping helps to soften the angulation necessary when direct anastomosis is performed to the beveled transection of larynx.When it is clear that the ends of the airway will approximate by traction on the lateral holding sutures accompanied by cervical flexion, the neck is re-extended and the anastomotic sutures are placed in the usual manner using interrupted 4–0 coated Meryl sutures (Ethicon, Inc, Somerville, NJ). Despite the irregularity of the two ends being anastomosed and their apparently discrepant sizes and shapes, the sutures are placed by eye so that they will generally correspond. The junction points of the tapered tracheal cartilage and the membranous wall on either side are approximated to the angles of the posterior cricoid plate. The midline of the thyroid cartilage is approximated to the midline of the peak of the prow, which has been fashioned in the most proximal cartilage of the trachea. Other sutures are appropriately apportioned. It is not necessary that sutures pass through the full thickness of the cricoid cartilage but, only through the full thickness of the mucosa applied to it and then part way through the cartilaginous portion.(E-F) With the cervical spine flexed, the lateral traction sutures are tied and then all of the anastomotic sutures are tied from front to back in the usual manner. Traction sutures are not removed. On occasion it is necessary to use one or more 3-Vicryl sutures (Ethicon, Inc) anteriorly in the midline to affect a good approximation of rigid cartilage, particularly if calcification has occurred.(G) In most cases, the thyroid isthmus is rejoined in the midline to cover the anastomosis. If there is any question about the anastomosis and there is sufficient length of trachea available, a small tracheostomy is placed well distal to the anastomosis. It should be at least two complete rings below the anastomosis. If this positions the tube too close to the innominate artery, one of the adjacent strap muscles is sutured carefully to the trachea over the artery to provide buffering.If the trachea has been shortened too much or if the patient's anatomy is such that the tracheotomy would be too close either to the anastomosis or to the artery, a tracheostomy is not performed. The anastomosis is covered, if possible, with thyroid isthmus, and strap muscle or even thymus is placed over the artery, suturing it to the anterior surface of the trachea. A triangular portion of the tracheal wall, which is left bare, is marked with a fine silk suture in the midline at a point where a tracheostomy may be placed in the future, if needed. (Figs 1A–G are reprinted with permission from the Society of Thoracic Surgeons.2Grillo HC Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.Ann Thorac Surg. 1982; 33: 3-11Abstract Full Text PDF PubMed Scopus (142) Google Scholar)View Large Image Figure ViewerDownload (PPT) The end of the proximal tracheal segment, which is confluent with the laryngeal portion of the stenosis, is grasped with two toothed clamps, and dissection is carried upward to the cricoid cartilage. Particular care is taken to stay close to the airway when the posterolateral angles of the cricoid lamina are approached. At this point, the recurrent laryngeal nerves are next to the posterior cricoid plate behind the cricothyroid articulations. The airway is entered anteriorly, cutting transversely across at the top of what appears to be obviously diseased tissue. It is always possible to resect additional tissue. Occasionally the decision is difficult and it is preferable to divide the diseased airway vertically in the midline from below upward for a better determination of the level of transection. When it is clear that the anterior cricoid cartilage must indeed be removed, the line of entry is placed deliberately close to the midline of the inferior border of the thyroid cartilage so that there will be a rigid structure for suturing. The line of resection is carried laterally and inferiorly across the cricothyroid membrane on either side until the superior lateral borders of the lateral lamina of the cricoid cartilage are reached. Transection continues to bevel downward and backward, transecting the cricoid cartilage until the inferior border is reached anterior to the posterior cricoid plate itself. Posteriorly, the line of transverse incision lies at the level of the lower border of the cricoid cartilage plate. The mucosa is sharply transected here. The membranous wall of trachea is thus detached. It is critically important in these last maneuvers that the recurrent nerves are not injured. Dissection behind the cricoid plate is never carried more than 1 to 2 mm above the lower most border and often not even this far. Submucosal fibrosis often is found laterally in the subglottic larynx to a degree that seems to be greater than that suggested by preoperative examination or roentgenograms. This is handled in various ways. The oblique line of division of the larynx itself creates a larger subglottic airway than simple horizontal transection. The anterior stenosing process where cricoid has been destroyed by the inflammatory process may pull the lateral laminas of the cricoid cartilage together to produce sharper angulation laterally. In these cases, the lateral laminas of the cricoid are resected further posteriorly so that the anastomosis will not be narrowed by the distortion. (B-D) The distal end of the trachea is inspected to be sure that the cartilage just below the line of transection is of good quality. This cartilage is trimmed back in a gentle curve on either side from full width anteriorly to a sloping angle at the lateral posterior ends of the cartilage. Shaping helps to soften the angulation necessary when direct anastomosis is performed to the beveled transection of larynx. When it is clear that the ends of the airway will approximate by traction on the lateral holding sutures accompanied by cervical flexion, the neck is re-extended and the anastomotic sutures are placed in the usual manner using interrupted 4–0 coated Meryl sutures (Ethicon, Inc, Somerville, NJ). Despite the irregularity of the two ends being anastomosed and their apparently discrepant sizes and shapes, the sutures are placed by eye so that they will generally correspond. The junction points of the tapered tracheal cartilage and the membranous wall on either side are approximated to the angles of the posterior cricoid plate. The midline of the thyroid cartilage is approximated to the midline of the peak of the prow, which has been fashioned in the most proximal cartilage of the trachea. Other sutures are appropriately apportioned. It is not necessary that sutures pass through the full thickness of the cricoid cartilage but, only through the full thickness of the mucosa applied to it and then part way through the cartilaginous portion. (E-F) With the cervical spine flexed, the lateral traction sutures are tied and then all of the anastomotic sutures are tied from front to back in the usual manner. Traction sutures are not removed. On occasion it is necessary to use one or more 3-Vicryl sutures (Ethicon, Inc) anteriorly in the midline to affect a good approximation of rigid cartilage, particularly if calcification has occurred. (G) In most cases, the thyroid isthmus is rejoined in the midline to cover the anastomosis. If there is any question about the anastomosis and there is sufficient length of trachea available, a small tracheostomy is placed well distal to the anastomosis. It should be at least two complete rings below the anastomosis. If this positions the tube too close to the innominate artery, one of the adjacent strap muscles is sutured carefully to the trachea over the artery to provide buffering. If the trachea has been shortened too much or if the patient's anatomy is such that the tracheotomy would be too close either to the anastomosis or to the artery, a tracheostomy is not performed. The anastomosis is covered, if possible, with thyroid isthmus, and strap muscle or even thymus is placed over the artery, suturing it to the anterior surface of the trachea. A triangular portion of the tracheal wall, which is left bare, is marked with a fine silk suture in the midline at a point where a tracheostomy may be placed in the future, if needed. (Figs 1A–G are reprinted with permission from the Society of Thoracic Surgeons.2Grillo HC Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.Ann Thorac Surg. 1982; 33: 3-11Abstract Full Text PDF PubMed Scopus (142) Google Scholar) 2(A) Operation is modified in those patients in whom stenosis is circumferential, affecting the subglottic area anterior to the cricoid plate in the posterior wall of the larynx. (B) The line of mucosal division is carried up higher on the cricoid plate in order to excise the involved mucosa and submucosa.Show full captionThe posterior cricoid plate itself has not often been found to be involved significantly. Usually the plane between mucosa and cartilage is dissected easily enough with a scalpel or bluntly with a fine dental spatula. One must stop short of the superior border of the cricoid plate, which is immediately below the arytenoid cartilages. No attempt is made to groove or otherwise alter the posterior cricoid cartilage itself. Subperichondrial resection of cartilage is not necessary.Division of the trachea is also carried out differently. The rostrum or bow of the proximal cartilage is shaped as before. Posteriorly, a flap of membranous wall is fashioned. This is gently rounded at each corner so that blood supply will be perfect. (C) When the anastomosis is made, the posterior mucosal sutures pass only through the full thickness of mucosa and submucosa of the posterior wall of the larynx and then through the full thickness of the membranous wall of the trachea.Once again the knots are placed outside of the lumen. This portion of the anastomosis is performed with 4-0 Vicryl sutures (Ethicon, Inc), as previously discussed. Sutures are appropriately tagged to the drapes of the operative field as previously described. (D) Four sutures are placed through the cartilaginous portion of the inferior margin of the cricoid plate and the outer portion of the membranous wall of the trachea below the proximal edge of the flap. Two sutures are led out on either side and are tagged to the drapes. (C-D) These sutures will fix the membranous wall posteriorly to the inferior edge of the cricoid plate and thus help to lay in the mucosal flap, which is replacing the resected laryngeal mucosa.(E) Although this may seem complex, it is a simple technique for replacement of the mucosa. The remainder of the sutures are carefully spaced and placed circumferentially as described before.In those instances when the extent of resection is great such that there would be tension on the anastomosis, laryngeal release is recommended. The suprahyoid release by the technique described by Montgomery7Montgomery WW Suprahyoid release for tracheal stenosis.Arch Otolaryngol. 1974; 99: 255-260Crossref PubMed Scopus (162) Google Scholar is the preferred method. (Figures 2A–B are reprinted with permission from the Society of Thoracic Surgeons2Grillo HC Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.Ann Thorac Surg. 1982; 33: 3-11Abstract Full Text PDF PubMed Scopus (142) Google Scholar; Figures 2C–E are reprinted with permission from the Society of Thoracic Surgeons.8Grillo HC Mathisen DJ Wain JC Laryngotracheal resection and reconstruction for subglottic stenosis.Ann Thorac Surg. 1992; 53: 54-63Abstract Full Text PDF PubMed Scopus (144) Google Scholar)View Large Image Figure ViewerDownload (PPT) The posterior cricoid plate itself has not often been found to be involved significantly. Usually the plane between mucosa and cartilage is dissected easily enough with a scalpel or bluntly with a fine dental spatula. One must stop short of the superior border of the cricoid plate, which is immediately below the arytenoid cartilages. No attempt is made to groove or otherwise alter the posterior cricoid cartilage itself. Subperichondrial resection of cartilage is not necessary. Division of the trachea is also carried out differently. The rostrum or bow of the proximal cartilage is shaped as before. Posteriorly, a flap of membranous wall is fashioned. This is gently rounded at each corner so that blood supply will be perfect. (C) When the anastomosis is made, the posterior mucosal sutures pass only through the full thickness of mucosa and submucosa of the posterior wall of the larynx and then through the full thickness of the membranous wall of the trachea. Once again the knots are placed outside of the lumen. This portion of the anastomosis is performed with 4-0 Vicryl sutures (Ethicon, Inc), as previously discussed. Sutures are appropriately tagged to the drapes of the operative field as previously described. (D) Four sutures are placed through the cartilaginous portion of the inferior margin of the cricoid plate and the outer portion of the membranous wall of the trachea below the proximal edge of the flap. Two sutures are led out on either side and are tagged to the drapes. (C-D) These sutures will fix the membranous wall posteriorly to the inferior edge of the cricoid plate and thus help to lay in the mucosal flap, which is replacing the resected laryngeal mucosa. (E) Although this may seem complex, it is a simple technique for replacement of the mucosa. The remainder of the sutures are carefully spaced and placed circumferentially as described before. In those instances when the extent of resection is great such that there would be tension on the anastomosis, laryngeal release is recommended. The suprahyoid release by the technique described by Montgomery7Montgomery WW Suprahyoid release for tracheal stenosis.Arch Otolaryngol. 1974; 99: 255-260Crossref PubMed Scopus (162) Google Scholar is the preferred method. (Figures 2A–B are reprinted with permission from the Society of Thoracic Surgeons2Grillo HC Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.Ann Thorac Surg. 1982; 33: 3-11Abstract Full Text PDF PubMed Scopus (142) Google Scholar; Figures 2C–E are reprinted with permission from the Society of Thoracic Surgeons.8Grillo HC Mathisen DJ Wain JC Laryngotracheal resection and reconstruction for subglottic stenosis.Ann Thorac Surg. 1992; 53: 54-63Abstract Full Text PDF PubMed Scopus (144) Google Scholar) Although these anastomoses have proved to be surprisingly competent initially, they may achieve only a percentage of a normal cross-sectional airway area because of the amount of disease involvement that is present submucosally even at the immediate subglottic level. In some patients, it is judicious to use a small tracheostomy temporarily as an alternative airway. It may also be necessary to leave this airway in place for some time until the edema subsides sufficiently to permit extubation. For some patients, it is impossible to place such a tracheostomy tube without endangering either the anastomosis or the innominate artery. In these patients, an area should be walled off and marked as noted. Such patients should be extubated in the operating room. If the airway is adequate, they are allowed to breathe on their own and are watched carefully for the next few days. If they do not breathe adequately or if they develop trouble in the immediate postoperative period, a small endotracheal tube is gently inserted between the vocal cords into the trachea. Ventilation is not usually required because there is no insult to the pulmonary parenchyma. If required, a cuff may be placed well below the anastomotic area with safety. The endotracheal tube is left in place for a number of days. It is usually withdrawn in the operating room. If the patient does not breathe adequately, it is replaced, the wound is reopened, and a tracheostomy tube is placed at the premarked position. By this time the anastomosis and the innominate artery are walled off. In some patients where there is no room for a safe tracheostomy, the endotracheal tube can again be placed until the patient can be extubated. If a tracheostomy tube is placed too close to the anastomosis, erosion may lead to recurrent subglottic stenosis, which probably will not be reparable. We have not found it necessary to splint the anastomosis with an inlaying T-tube or other type of tube. When a tracheostomy tube is placed at the original operation, the anastomosis and innominate artery are walled off by local strap muscles. Figure VI shows the radiographic appearance after surgical correction of the subglottic stenosis seen in Figure IVA. We have treated 80 patients in whom the subglottic larynx was partially resected with trachea for inflammatory stenotic processes and in whom primary reconstruction was performed.8Grillo HC Mathisen DJ Wain JC Laryngotracheal resection and reconstruction for subglottic stenosis.Ann Thorac Surg. 1992; 53: 54-63Abstract Full Text PDF PubMed Scopus (144) Google Scholar The anterior cricoid arch was resected in all patients. This series excludes patients with primary and secondary tumors because this is a much different problem than inflammatory stenosis. In inflammatory disease, the process frequently extends above the stenosis in the subglottic larynx, nearly to the vocal cords. Resection, therefore, cannot be carried proximally to include all of the inflammation. For tumors, once the excision of tumor has been accomplished, the line of anastomosis lies in normal tissue. Fifty of the 80 patients had lesions that resulted from intubation done for ventilatory support. (Table 1). Thirty-one of these had endotracheal tubes only; in 16, the lesion was believed to result from stomal erosion of the cricoid cartilage, and in three the originating trauma was an elective cricothyroidostomy for ventilatory support. In five patients, the stenosis was of traumatic origin. In four of these it was because of blunt trauma, usually with separation of larynx and trachea and with injury to the lower larynx, and in one it was because of gouging of the anterior laryngotracheal wall by a flying object. A patient suffering from an inhalation burn was the first treated in this series. One patient was referred from another institution with a postoperative stenosis after an attempt at a complex laryngotracheal repair with a hyoid graft, performed to correct deformity because of a goiter.TABLE 1Results of Surgical Treatment of Subglottic StenosisResultsNo. of PatientsExcellent18Good48Satisfactory8Failure2Death1Uncertain3Total80Mortality (%)1.3 Open table in a new tab Of the 23 remaining patients, 19 had idiopathic laryngotracheal stenosis. We have now seen over 60 patients with idiopathic subglottic stenosis and operated on over 50 (unpublished data, April 1998). Five patients had tracheoesohageal fistulas when first seen. In two, the fistula had resulted from blunt trauma and in three, from intubation and ventilation with tracheoesophageal erosion. In 16 patients, paralysis or paresis of one or both vocal cords was identified preoperatively. In numerous others there was malfunction of one or both vocal cords. In those patients in whom the stenotic process involved only the anterior portion of the subglottic larynx (49 out of 80), resection of this portion of the cricoid arch in an arcuate line extending up to a point just short of the midline of the thyroid cartilage anteriorly sufficed. The posterior margin of resection was along the lower border of the cricoid cartilage. In patients in whom the subglottic process was circumferential, extending in front of the posterior plate of the cricoid, the line of posterior mucosal resection was incised above the level of stenosis, approaching the arytenoid cartilages. All involved mucosa and scar tissue was excised from the front of the posterior cricoid plate, leaving the cartilage intact posteriorly, to be surfaced by a broad-based flap of membranous trachea advanced from below. The margin of the anterior defect in the subglottic larynx was sutured in both types of resection to a prow-shaped segment of one distal tracheal ring, shaped to fit. The posterior membranous flap of tracheal wall was required for resurfacing of the bared cricoid in 31 of 80 patients. In 49 patients, it was possible to perform an anastomosis without resecting the tissues overlying the posterior cricoid plate. In the five patients with tracheoesophageal fistula, including one with three adjacent fistulas, the esophagus was closed in two layers with inverting sutures, and a pedicled flap of strap muscle was interposed between the esophageal closure and the laryngotracheal anastomosis anteriorly.9Mathisen DJ, Grillo HC, Wain JC, et al: Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg (in press)Google Scholar In the first 20 patients, tracheostomy was used in 14 at the time of the original operation and an endotracheal tube in one. In the subsequent 60 patients, tracheostomy was used only nine times. This represented a drop in use of protective airway devices from 75% to 15%. There was only a single postoperative mortality in 80 patients. This was related to a fatal myocardial infarction. Two patients suffered early and long-term failure of treatment. One was the only man who was retrospectively classified as having idiopathic laryngotracheal stenosis. The other patient had had a tracheostomy in infancy and had undergone multiple reconstructions and T-tube splinting before attempted repair here. In classifying the results obtained (Table 1), we have deemed as excellent the patient with a normal voice and without any limitation of respiration at rest or on exercise. Patients were considered to have a good result if they suffered only slight lessening of maximum volume of voice, slight hoarseness that did not impede vocal use, slight weakness of voice after prolonged use, diminished ability to sing, and if their breathing was adequate for all normal activities. Patients labeled as having a satisfactory results were those with a hoarse voice, and either slight wheezing or shortness of breath on exercise not sufficient to impair usual activities. Eighteen patients achieved an excellent result, 48 a good result, and eight were classified as satisfactory. As noted, there were two failures and one immediate postoperative death. Three are listed as uncertain despite initial good results, because their follow-up was for less than 6 months. Forty-nine patients were contacted in late 1990 in follow-up from 6 months to 12 years. In 13 additional patients, follow-up was available between 2 to 10 years after operation, and in four between 1 to 2 years. In three, follow-up data was available at between 6 months and 1 year, and in three less than 6 months. The fact that no patient who achieved an excellent or good status was found to deteriorate in subsequent months or years should be noted. In contrast, an apparent failure improved over 3 years, as noted earlier, and most who required tracheostomies eventually were successfully decannulated. It may be concluded that, if anything, the long-term results represent a minimum statement. Early complications, in addition to the need for prolonged intubation because of glottic edema or anastomotic edema, included superficial wound infection in one patient that required drainage, suture granuloma in the incision of a second patient that required removal of the suture, and re-exploration for air leak in one patient. A pinhole leak was closed with a local muscle flap and healed promptly. Eight patients had difficulty with deglutition or with aspiration postoperatively. All had undergone extensive resection, and four of them had suprahyoid laryngeal release performed. One required a gastrostomy tube for nutrition and two others had such tubes placed at the time of surgery in anticipation of difficulty, especially because one of these two had also undergone reclosure of a recurrent tracheoesophageal fistula. With time and retraining in swallowing, it was possible to remove all gastrostomy tubes. Tracheal granulations were removed bronchoscopically in two patients who had anastomoses performed with Tevdek (Dernatel, Inc, Fall River, MA) and in five who had anastomoses performed with Vicryl (Ethicon, Inc). One of these patients restenosed. A polyp of the vocal cord was lasered in one patient. The patient with leukemia required a prolonged period for healing of the tracheal stoma, which had been made at the time of reconstruction. Twenty-two patients had a persistent hoarse voice in varying degree and 16 had weakness of the voice when attempting to project their speech. In four cases, these were expected consequences of bilateral vocal cord paralyses because of trauma and, in some others, of unilateral paralyses that was preexisting. Eight complained of an alteration of singing voice. Otolaryngological literature is filled with descriptions of multiple modes of treatment of non-neoplastic stenosis involving subglottic larynx and upper trachea. Conservative measures include dilatation, intubation, stenting, steroid injection, cryotherapy, electrocoagulation and laser therapy. Operative procedures, often complex, include scar excision, incision of cricoid anteriorly or posteriorly, grafts of buccal mucosa or skin, free cartilage inserts, pedicled hyoid grafts, and creation of cutaneous gutters variously supported; all are often stented for a prolonged period and are usually accompanied by tracheostomy. More procedures than encouraging results have been recorded. Pearson et al10Pearson FG Cooper JD Nelems JM et al.Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves.J Thorac Cardiovasc Surg. 1975; 70: 806-816PubMed Google Scholar described a single-stage repair using partial subperichondrial resection of the posterior cricoid to remove posterior stenotic scar, narrowing of the trachea by suturing the ends of cartilage together and intusussception of the trachea into the groove created by the subperichondrial resection. A follow-up report1Maddaus M Pearson FG Subglottic resection.in: Pearson FG Deslauriers J Ginsburg RJ Thoracic Surgery. Churchill Livingstone, New York, NY1995: 322Google Scholar in 1986 of 28 patients with non-neoplastic stenosis (postintubation, traumatic, burn, and idiopathic) and seven with neoplasm so treated, produced a good airway in 26 and a limitation in two. A T-tube was used postoperatively in 10, and 13 had laryngeal release. Couraud et al12Couraud L Brichon PY Velly JF The surgical treatment of inflammatory and fibrous laryngotracheal stenosis.Eur J Cardiothorac Surg. 1988; 2: 410-415Crossref PubMed Scopus (31) Google Scholar updated their experience between 1978 and 1988 with laryngotracheal resection for stenosis resulting from intubation or trauma, including 27 patients who had a Pearson-type procedure (F.G. Pearson, MD, Toronto, Canada)10Pearson FG Cooper JD Nelems JM et al.Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves.J Thorac Cardiovasc Surg. 1975; 70: 806-816PubMed Google Scholar, 11Pearson FG Brito-Filomeno L Cooper JD Experience with partial cricoid resection and thyrotracheal anastomosis.Ann Otol Rhinol Laryngol. 1986; 95: 582-585PubMed Google Scholar and seven who had total or subtotal cricoid plate resection with stenting. All had good results. The similar and generally good results obtained in this difficult group, of patients by units employing similar single-stage operations suggest that many complex procedures still used might well be abandoned. However, diagnostic precision is essential, operative timing must be carefully judged, operative technique is exacting, and postoperative care early and late must be meticulous. These are not operations to be done occasionally.

We report our experience with 2 cases of simultaneous single-lung transplantation and lung volume reduction for emphysema. The lung volume reduction was undertaken electively in an attempt to improve overall lung function above that to be expected from single-lung transplantation alone. There were no postoperative problems related to the addition of lung volume reduction. The pulmonary function at 3 months was greater than that seen in a retrospective group of bilateral lung transplants previously reported from our institution.

The surgical management of pulmonary metastases remains controversial, as no randomized trials have compared surgical excision with nonoperative treatment (to our knowledge). A Medline-generated review of the literature was undertaken to determine the factors influencing survival following metastasectomy in published trials. In the absence of randomized comparative trials, data must remain inferential and circumstantial. However, the literature does support the anecdotal observation that patients with metastatic disease can achieve long-term survival following surgical excision, irrespective of the source of the primary neoplasm, if there is no demonstrable extrathoracic disease and complete excision of the pulmonary disease is possible. Other factors noted as influencing survival appear to be anecdotal and variable from report to report. Pulmonary metastasectomy should be considered in patients with sufficient pulmonary reserve when the lung is the only site of metastatic disease and the lesions can be totally excised. An algorithm is proposed for a logical approach to the problem.

Background. We sought to determine whether low diffiusion capacity of the lung to carbon monoxide (DLCO) is a predictor of high postoperative mortality and morbidity after major pulmonary resection and whether major pulmonary resection in patients with low DLCO results in substantial long-term morbidity.Methods. Sixty-two major pulmonary resections were performed in 61 patients with low DLCO (DLCO less than or equal to 60% predicted for pneumonectomy or bilobectomy; less than or equal to 50% predicted for lobectomy). Contemporaneously, 262 other patients underwent 263 major pulmonary resections (group II). Long-term morbidity was assessed in subsets of patients with low (n = 24) and high (n = 22; DLCO >60% predicted) DLCO.Results. The hospital mortality rates were equivalent (4.8% low DLCO versus 4.9% group II), whereas respiratory complications were more frequent in patients with low DLCO (18% versus 9.5%; p = 0.05). In the subgroup analyses, patients with low DLCO had more hospitalizations for respiratory compromise and worse median dyspnea scores. Analysis of patients with substantial dyspnea revealed an association with extended pulmonary resection and postoperative radiation therapy in patients with low DLCO.Conclusions. Patients with low DLCO underwent major pulmonary resection with a low mortality rate and an acceptable, but increased, respiratory complication rate. Long-term respiratory morbidity was increased in patients with low DLCO; however, the extent of pulmonary resection and the use of postoperative radiation therapy may have contributed to the development of dyspnea in these patients.

Background. Nitric oxide is believed to play a critical role in the maintenance of vascular integrity through its interaction with neutrophils, platelets, and cellular components of the vessel wall. It has been reported that endogenous nitric oxide level was depressed after ischemia, reperfusion, or both. Furthermore, exogenous as well as endogenous nitric oxide decreases reperfusion-induced vascular dysfunction. We hypothesized that nitroprusside, a potent nitric oxide donor, might enhance lung preservation and reduce posttransplantation lung allograft dysfunction.Methods. Ten dogs underwent left lung allotransplantation. Donor lungs were flushed with modified Euro-Collins solution and stored for 21 hours at 1 degrees C. Immediately after transplantation, the contralateral right main pulmonary artery and bronchus were ligated to assess isolated allograft function. Hemodynamics and arterial blood gas analysis (inspired oxygen fraction, 1.0) were assessed for 6 hours before sacrifice. Allograft myeloperoxidase activity and wet-to-dry weight ratio were assessed. Group 1 (n = 5) animals received no nitroprusside. In group 2 (n = 5), the donor lung received nitroprusside in the flush solution (10 mg/L) and recipient animals received 0.2 mg/kg just before reperfusion as well as a continuous infusion (0.11 +/- 0.01 mg . kg(-1) h(-1)) during the assessment period.Results. Superior gas exchange and hemodynamics were noted in lungs receiving nitroprusside. Although allograft myeloperoxidase activity and the total amount of fluid suctioned from the allograft were significantly reduced in group 2, protein levels in bronchoalveolar lavage fluid were not statistically different.Conclusions. Nitroprusside administration in the flush solution and during reperfusion improves lung allograft function and blood flow, and reduces pulmonary vascular resistance and myeloperoxidase activity in the transplanted lung. Nitroprusside reduces lung allograft reperfusion injury.

To avoid the laborious task of investigating the cerebrovascular circulation in the midst of a trachea-innominate artery fistula, we strongly recommend preoperative cerebrovascular investigations in all patients about to undergo mediastinal tracheostomy. Paramount to this dictum remains the possibility of asymptomatic cerebrovascular disease. Inadequate preoperative cerebrovascular assessment may result in, as described in this report, the possibility of significant postoperative neurologic morbidity or mortality. Angiography should assist the surgeon in deciding which method of cerebral arterial reconstruction is best suited to the individual circumstance. We recommend the avoidance of innominate artery reconstruction even with the interposition of autologous tissues, as the operative field remains grossly infected.

BACKGROUND:Previous reports have described bronchial obstruction after left pneumonectomy (so-called post-pneumonectomy syndrome) in the presence of a right aortic arch with the bronchus being compressed between the ascending aorta and thoracic spine. This study reports on 4 patients with left postpneumonectomy syndrome in the presence of a normally located left aortic arch and ascending thoracic aorta.METHODS:The case histories of 4 patients with this syndrome were reviewed and several features common to all 4 were noted. In each case, the obstruction was thought to be due to a clockwise rotation of the mediastinum with bronchial compression occurring between the right main pulmonary artery and thoracic spine.RESULTS:Three patients were treated by repositioning of the mediastinum, and all 3 obtained relief of their dyspnea. In these cases, permanent repositioning was ensured by the insertion of a prosthesis filled with saline solution. The fourth patient was successfully treated by resection of a portion of the adjacent thoracic vertebra.CONCLUSIONS:Postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms.