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Cytokine & chemokine response in the lungs, pleural fluid and serum in thoracic surgery using one-lung ventilation
Andreas Breunig, Franco Gambazzi, Beatrice Beck-Schimmer, Michael Tamm, Didier Lardinois, Daniel Oertli, Urs Zingg
Journal of Inflammation , 2011, DOI: 10.1186/1476-9255-8-32
Abstract: Broncho-alveolar lavage (BAL) fluid of both the collapsed, operated and the ventilated, non-operated lung, respectively, pleural space drainage fluid and blood was collected and the concentrations of interleukin (IL)-6, IL-1RA and GROα were determined with enzyme-linked immunosorbent assays in 15 patients.Substantial inter-individual differences in the BAL fluid between patients in cytokine and chemokine levels occurred. In the pleural fluid and the blood these inter-individual differences were less pronounced. Both sides of the lung were affected and showed a significant increase in IL-6 and IL-1RA concentrations over time but not in GROα concentrations. Except for IL-6, which increased more in the collapsed, operated lung, no difference between the collapsed, operated and the ventilated, non-operated lung occurred. In the blood, IL-6 and IL-1RA increased early, already at the end of surgery. GROα was not detectable. In the pleural fluid, both cytokine and chemokine concentrations increased by day one. The increase was significantly higher in the pleural fluid compared to the blood.The inflammatory response of cytokines affects both the collapsed, operated and the ventilated, non-operated lungs. The difference in extent of response underlines the complexity of the inflammatory processes during OLV. In contrast to the cytokines, the chemokine GROα concentrations did not react in the BAL fluid or in the blood. This indicates that GROα might not be useful as marker for the inflammatory reaction in complex surgical procedures.Thoracic surgery such as esophagectomy or lobectomy triggers a more severe systemic inflammatory reaction than intra-abdominal surgery [1]. One possible explanation is the fact that most thoracic procedures mandate a one-lung ventilation (OLV) strategy. The OLV leads to a collapse of the lung that is operated with subsequent shunting of blood and possible hypoxemia. The contralateral lung is ventilated and may suffer from ventilator-induced injury
Lung Physiology and Obesity: Anesthetic Implications for Thoracic Procedures  [PDF]
Alessia Pedoto
Anesthesiology Research and Practice , 2012, DOI: 10.1155/2012/154208
Abstract: Obesity is a worldwide health problem affecting 34% of the American population. As a result, more patients requiring anesthesia for thoracic surgery will be overweight or obese. Changes in static and dynamic respiratory mechanics, upper airway anatomy, as well as multiple preoperative comorbidities and altered drug metabolism, characterize obese patients and affect the anesthetic plan at multiple levels. During the preoperative evaluation, patients should be assessed to identify who is at risk for difficult ventilation and intubation, and postoperative complications. The analgesia plan should be executed starting in the preoperative area, to increase the success of extubation at the end of the case and prevent reintubation. Intraoperative ventilatory settings should be customized to the changes in respiratory mechanics for the specific patient and procedure, to minimize the risk of lung damage. Several non invasive ventilatory modalities are available to increase the success rate of extubation at the end of the case and to prevent reintubation. The goal of this review is to evaluate the physiological and anatomical changes associated with obesity and how they affect the multiple components of the anesthetic management for thoracic procedures. 1. Introduction Obesity is a worldwide health problem. It is estimated that 34% of the North American adult population is obese, of which 5% is morbidly obese [1]. Thus, more patients requiring anesthesia for thoracic surgery will be overweight or obese. Anesthetic goals for thoracic procedures include a smooth induction and intubation, stable hemodynamic parameters during the intraoperative period, optimal lung isolation with adequate minute ventilation and good oxygenation,and optimal analgesia. However, being obese poses a challenge for all the above. The aim of this paper is to evaluate the physiological and anatomical changes associated with obesity and how they affect the anesthetic management for thoracic procedures. 2. Physiological Changes and Comorbidities Associated with Obesity 2.1. Respiratory Mechanics Obesity is associated with restrictive lung disease caused by increased intraabdominal pressure and decreased chest wall compliance [2, 3], resulting in a decrease in static and dynamic lung volumes [4] (Table 1). Low functional residual capacity (FRC) and expiratory reserve volume (ERV) contribute, respectively, to rapid desaturation with apnea or hypoventilation and air trapping with poor lung collapse during one-lung ventilation (OLV). This is more pronounced when ERV approaches or exceeds closing
A Retrospective Study of Chronic Post-Surgical Pain following Thoracic Surgery: Prevalence, Risk Factors, Incidence of Neuropathic Component, and Impact on Qualify of Life  [PDF]
Zhiyou Peng, Huiling Li, Chong Zhang, Xiang Qian, Zhiying Feng, Shengmei Zhu
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0090014
Abstract: Background Thoracic surgeries including thoracotomy and VATS are some of the highest risk procedures that often lead to CPSP, with or without a neuropathic component. This retrospective study aims to determine retrospectively the prevalence of CPSP following thoracic surgery, its predicting risk factors, the incidence of neuropathic component, and its impact on quality of life. Methods Patients who underwent thoracic surgeries including thoracotomy and VATS between 01/2010 and 12/2011 at the First Affiliated Hospital, School of Medicine, Zhejiang University were first contacted and screened for CPSP following thoracic surgery via phone interview. Patients who developed CPSP were then mailed with a battery of questionnaires, including a questionnaire referenced to Maguire's research, a validated Chinese version of the ID pain questionnaire, and a SF-36 Health Survey. Logistic regression analyses were subsequently performed to identify risk factors for CPSP following thoracic surgery and its neuropathic component. Results The point prevalence of CPSP following thoracic surgery was 24.9% (320/1284 patients), and the point prevalence of neuropathic component of CPSP was 32.5% (86/265 patients). CPSP following thoracic surgery did not improve significantly with time. Multiple predictive factors were identified for CPSP following thoracic surgery, including age<60 years old, female gender, prolonged duration of post-operative chest tube drainage (≥4 days), options of post-operative pain management, and pre-existing hypertension. Furthermore, patients who experienced CPSP following thoracic surgery were found to have significantly decreased physical function and worse quality of life, especially those with neuropathic component. Conclusions Our study demonstrated that nearly 1 out of 4 patients underwent thoracic surgery might develop CPSP, and one third of them accompanied with a neuropathic component. Early prevention as well as aggressive treatment is important for patients with CPSP following thoracic surgery to achieve a high quality of life.
Revista del Instituto Nacional de Enfermedades Respiratorias , 2004,
Abstract: sixty years after the birth of thoracic surgery at the national institute of respiratory diseases, its evolution can be associated to significant events in the field of medicine in mexico and the world. when the tuberculosis bacillus was discovered, one of the best alternatives for treatment was surgery. at the beginning of the century, the news in mexico talked about the consequences of tuberculosis. at the same time, the mexican revolution had started. thoracic surgery emerged together with these events. at that time, tlalpan was a war field for zapatistas and constitutionalists. in 1930, general lázaro cárdenas decreed the construction of a tuberculosis sanatorium, which was concluded in 1935. the thoracic surgery service was inaugurated on january 11, 1944. along the twentieth century the medicine that involved thoracic surgery progressed notoriously. the first bronchoscopy was performed in 1933, and the first lobectomy in 1943. the first intracardiac angiocardiography was made in 1946 as well as the first arterial closure. meanwhile, the structure of the country changed significantly. the first heart transplant was done in 1967, and survived 18 days. various types of surgery were developed, some of which have presently been abandoned, like extra pleural pneumothorax, pulmonary collapse surgery and fistulectomies, and other procedures have been improved, like open lung biopsy and pleural decortication. a total of 17,083 surgical procedures were recorded in the first 50 years of the service. during the last 20 years we have practiced the most innovative techniques of surgery such as video surgery, mediastinostomy, extended mediastinoscopy, use of laser in the airway and auto suture techniques, as long as unilateral lung transplant, tromboendarterectomy, tracheal surgery and lung volume reduction surgery. the new and universal profile of thoracic surgeons has been integrated to the service as human resources formation with institutional representation in several s
Goal-Directed Fluid Therapy Using Stroke Volume Variation Does Not Result in Pulmonary Fluid Overload in Thoracic Surgery Requiring One-Lung Ventilation  [PDF]
Sebastian Haas,Volker Eichhorn,Ted Hasbach,Constantin Trepte,Asad Kutup,Alwin E. Goetz,Daniel A. Reuter
Critical Care Research and Practice , 2012, DOI: 10.1155/2012/687018
Abstract: Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as stroke volume variation (SVV), seems to optimize hemodynamics and possibly improves clinical outcome. However, this strategy is believed to be rather fluid aggressive, and, furthermore, during surgery requiring thoracotomy, the ability of SVV to predict volume responsiveness has raised some controversy. So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation (OLV). Therefore, we assessed the perioperative course of extravascular lung water index (EVLWI) and -ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload. Methods. A total of 27 patients (group T) were enrolled in this prospective study with 11 patients undergoing lung surgery (group L) and 16 patients undergoing esophagectomy (group E). Goal-directed fluid management was guided by SVV (SVV < 10%). Measurements were performed directly after induction of anesthesia (baseline—BL), 15 minutes after implementation OLV (OLVimpl15), and 15 minutes after termination of OLV (OLVterm15). In addition, postoperative measurements were performed at 6 (6postop), 12 (12postop), and 24 (24postop) hours after surgery. EVLWI was measured at all predefined steps. The -ratio was determined at each point during mechanical ventilation (group L: BL-OLVterm15; group E: BL-24postop). Results. In all patients (group T), there was no significant change in EVLWI during the observation period (BL: 7.8 ± 2.5, 24postop: 8.1 ± 2.4?mL/kg). A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI. The -ratio decreased significantly during the observation period (group L: BL: 462 ± 140, OLVterm15: 338 ± 112?mmHg; group E: BL: 389 ± 101, 24postop: 303 ± 74?mmHg) but remained >300?mmHg except during OLV. Conclusions. SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload. Although oxygenation was reduced, pulmonary function remained within a clinically acceptable range. 1. Introduction Early, preemptive strategies of hemodynamic optimization are an important factor for sufficient organ microcirculation and are considered to be associated with reduced morbidity and mortality [1]. Within this context, improvement of intravascular volume status seems essential. After central
The Clinical Application of Video Mediastinoscopy and CT in the N Staging of Preoperative Lung Cancer  [PDF]
Zhiheng WANG,Weibo QI,Yong ZHU,Ruobai LIN
Chinese Journal of Lung Cancer , 2009,
Abstract: Background and objective Preoperative lung cancer with mediastinal lymph nodes metastasis can be diagnosed by vedio mediastinoscopy (VM) and CT. This study was to explore the value of VM and CT in the diagnosis of N staging of preoperative lung cancer, and to discuss the difference between the 2 methods. Methods 48 cases diagnosed of lung cancer by CT or PET-CT were examined by VM. The sensitivity, specificity, validity, positive predictive value and negative predictive value of VM and CT were speculated according to the postoperative pathological reports, and the difference between VM and CT in the diagnosis of lung cancer with mediastinal lymph nodes metastasis was discussed. Results ①Under the examination of VM, 31 patients with the negative outcome received the direct operation, 14 patients with N2 received 2 courses of neoadjuvant chemotherapy before operation, 3 patients with N3 received chemotherapy and/or radiotherapy. ②Forty-one cases with final diagnosis of lung cancer were used as samples to speculate the sensitivity, specificity, validity, positive predictive value and negative predictive value of VM. They were 93.3%, 100%, 97.6%, 100%, 96.3%, which of CT were 66.7%, 53.8%, 58.5%, 45.5%, 73.7% (χ2=4.083, P=0.039), the difference between VM and CT was statistically significant. ③In this group, the complications of VM incidence rate is 2.08% (1/48), the case is pneumothorax. Conclusion VM is superior to CT in the diagnosis of N staging of preoperative lung cancer, it is safe and effective, and there will be a wide perspective for VM in thoracic surgery.
Necessity Of Anatomical Knowledge In Thoracic Surgery.  [PDF]
Arribalzaga, Eduardo B.
Revista Argentina de Anatomia Online , 2011,
Abstract: The necessity of anatomical knowledge was fundamental issue for medical practice since prehistoric times and with the passing of centuries, that knowledge was improved very slowly. So in mid-1535 Vesalius began to study the human body by dissecting cadavers and warned that the dissection was the most important means by direct observation as the only reliable source. Through his work set aside age-old classic mistakes to discover that Galen's investigations were based on the dissection of animals, not of humans. His contemporary highlighted the anatomical knowledge as essential to the practice of surgery, shared this view with Vesalius. He was the initiator of the regional anatomy describing topographic anatomical areas and regional levels. Through the centuries, the anatomical knowledge was updated to facilitate the incorporation of techniques and technologies that emerged every day. Alejandro Posadas in Argentina who opened the thoracic surgery endocavitary insisted on a clear notion of the thoracic anatomy to aid in surgical practice. Later Avelino Gutierrez and Eugenio A. Galli highlighted a reasoned interpretation and a new nomenclature for the cardiac chambers according to their topographic reality. Jose Luis Martinez finally gave a distinctive character to Argentinian thoracic surgery by highlighting a detailed anatomical knowledge and begin to dissect the pulmonary hilum neglecting mass ligation of the pedicle. The acquisition of new Biostructural knowledge allows therapeutic approaches by new routes such as video-assisted surgical procedures and new diagnostic imaging such as magnetic resonance angiography. There is talk of a new disease for lack of anatomical basics notions. Its integration with the semiologic knowledges allows the combination of the basic notions that provide adequate medical care.
Endoscopic Transforaminal Thoracic Foraminotomy and Discectomy for the Treatment of Thoracic Disc Herniation  [PDF]
Hong-Fei Nie,Kai-Xuan Liu
Minimally Invasive Surgery , 2013, DOI: 10.1155/2013/264105
Abstract: Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery. 1. Introduction Thoracic disc herniation is an uncommon condition. Although conservative treatment works well for many patients with thoracic disc herniation, surgical treatment is needed for patients suffering from myelopathy and/or neurological deficit caused by thoracic disc herniation. In the past decade, quite a few surgical procedures have been reported in the literature, and each of them has its own advantages and disadvantages [1–14]. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Minimally invasive spine surgery has proven safe and effective in treating lumbar and cervical herniations [15–24]. The advantages of minimally invasive techniques have compelled many physicians to explore the feasibility of using minimally invasive techniques in treating thoracic disc herniation, and a number of authors have reported encouraging primary results [14, 25–28]. Based on our extensive experience with treating lumbar and cervical disc herniation using minimally invasive techniques, we have developed an endoscopic transforaminal foraminotomy and discectomy technique for treating thoracic disc herniation. The purposes of this paper are to describe the
Immunomodulatory Effects of Anesthetics during Thoracic Surgery  [PDF]
Khaled Mahmoud,Amany Ammar
Anesthesiology Research and Practice , 2011, DOI: 10.1155/2011/317410
Abstract: Background. One-lung ventilation (OLV) during thoracic surgery may induce alveolar cell damage and release of proinflammatory mediators. The current trial was planned to evaluate effect of propofol versus isoflurane anesthesia on alveolar and systemic immune modulation during thoracic surgery. Methods. Fifty adult patients undergoing open thoracic surgery were randomly assigned to receive propofol or isoflurane anesthesia. The primary outcome measures included alveolar and plasma concentrations of interleukin-8(IL-8) and tumour necrosis factor-α (TNF-α), whereas secondary outcome measures were alveolar and plasma concentrations of malondialdehyde (MDA), superoxide dismutase (SOD), and changes in alveolar albumin concentrations and cell numbers. Results. Alveolar and plasma concentrations of IL-8 and TNF-α were significantly lower in the isoflurane group, whereas alveolar and plasma concentrations of MDA were significantly lower in the propofol group. Alveolar and plasma SOD levels increased significantly in the propofol group whereas they showed no significant change in the isoflurane group. Furthermore, the isoflurane group patients developed significantly lower alveolar albumin concentrations and cell numbers. Conclusion. Isoflurane decreased the inflammatory response associated with OLV during thoracic surgery and may be preferable over propofol in patients with expected high levels of proinflammatory cytokines like cancer patients. 1. Introduction One-lung ventilation (OLV) during thoracic surgery may trigger alveolar cell damage and release of proinflammatory mediators that might lead to lung injury and infection in the postoperative period [1]. A series of clinical and experimental studies on mechanical ventilation reported alteration of alveolar and systemic immunity during surgery and anesthesia [2–4]. Different factors have been implicated that include preoperative smoking or drugs, degree of surgical trauma, preexisting lung or systemic diseases, in addition to type and duration of anesthesia [5, 6]. Propofol has been suggested to suppress pathologic changes associated with acute lung injury during endotoxemia in rabbits [7]. Other experimental studies have reported that volatile anesthetics may alter cytotoxic or phagocytic activity of alveolar macrophages. [8] Both sevoflurane and desflurane have shown ant-inflammatory effect during thoracic surgery [9, 10]. The aim of this prospective, randomized, blinded clinical trial was to assess effect of propofol versus isoflurane anesthesia on alveolar and systemic immune modulation during thoracic
Clinical variables of preoperative risk in thoracic surgery
Saad, Ivete Alonso Bredda;De Capitani, Eduardo Mello;Toro, Ivan Felizardo Contrera;Zambon, Lair;
Sao Paulo Medical Journal , 2003, DOI: 10.1590/S1516-31802003000300004
Abstract: context: pulmonary complications are the most common forms of postoperative morbidity in thoracic surgery, especially atelectasis and pneumonia. the first step in avoiding these complications during the postoperative period is to detect the patients that may develop them. objective: to identify risk variables leading to early postoperative pulmonary complications in thoracic surgery. design: prospective study. setting: hospital das clínicas, faculdade de ciências médicas, universidade estadual de campinas. patients: 145 patients submitted to elective surgery were classified as low, moderate and high risk for postoperative pulmonary complications using a risk assessment scale. procedures: the patients were followed up for 72 hours after the operation. postoperative pulmonary complications were defined as atelectasis, pneumonia, tracheobronchitis, wheezing, prolonged intubation and/or prolonged mechanical ventilation. main measurements: univariate analysis was applied in order to study these independent variables: age, nutritional status, body mass index, respiratory disease, smoking habit, spirometry and surgery duration. multivariate logistic regression analysis was performed in order to evaluate the relationship between independent and dependent variables. results: the incidence of postoperative complications was 18.6%. multivariate logistic regression analysis showed that the variables increasing the chances of postoperative pulmonary complications were wheezing (odds ratio, or = 6.2), body mass index (or = 1.15), smoking (or = 1.04) and surgery duration (or = 1.007). conclusion: wheezing, body mass index, smoking and surgery duration increase the chances of postoperative pulmonary complications in thoracic surgery
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