Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis

BACKGROUND

The effectiveness of lung volume reduction for the treatment of patients with emphysema is well established, but data about the surgical approach, the postoperative management, and complications are limited. We report a comparison of patients undergoing bilateral lung volume reduction (BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on hospital course and complications.

METHODS

All patients undergoing BLVRS at Hospital of University of Pennsylvania were analyzed for mortality and morbidity, using a combination of prospective data analysis and retrospective chart review.

RESULTS

Patients undergoing BLVRS via median sternotomy were older than those undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9+/-6.89 vs 59.3+/-9.4 years, p = 0.005). Operating time was longer for the VATS procedure (147 versus 129 minutes, p = 0.006) while estimated blood less was greater for median sternotomy (209 versus 82 L, p = 0.0000017). Significant differences were found in intensive care unit stay, days intubated, life-threatening complications, respiratory complications, requirement for tracheostomy, and death that favored VATS BLVRS. When only later cohorts of patients were compared, more life-threatening complications and deaths were found in patients undergoing BLVRS by median sternotomy. There were no differences between early and late median sternotomy BLVRS patients. Twenty-six percent of the lethal complications in median sternotomy BLVRS patients were bowel perforations, equally divided between duodenal ulcers and colons.

CONCLUSIONS

Managing patients after BLVRS remains complex. Bilateral video-assisted volume reduction offers equivalent functional outcome with potentially decreased morbidity and mortality. Gastrointestinal perforations can complicate the management of these patients.

Analysis of Epstein-Barr virus-associated posttransplantation lymphoproliferative disorder after lung transplantation

BACKGROUND

Epstein-Barr virus (EBV)-associated posttransplantation lymphoproliferative disorder (PTLD) is a serious complication of lung transplantation. Besides immunosuppression the risk factors for PTLD development are largely unknown.

METHODS

The incidence of PTLD was ascertained in a lung transplant population consisting of 45 patients. Nine patients (20%) experienced PTLD. The clinical, histologic, and human leukocyte antigen (HLA) data were collected on all patients. The incidence of EBV infection in lymphoid tissue taken at the time of engraftment was studied by using EBV in situ hybridization.

RESULTS

All patients with PTLD had polymorphous lymphoproliferations, seven of which were polymorphous B-cell hyperplasias and two of which were polymorphous B-cell lymphomas. EBV was identified in all lesions. All patients with polymorphous B-cell hyperplasias had clinically unsuspected disease, five of which were identified at autopsy. The two polymorphous B-cell lymphoma lesions were monoclonal and regressed with immunosuppression reduction. EBV in situ hybridization on donor or recipient lymph nodes obtained at engraftment from the 45 transplant recipients showed no difference in the number of EBV positive cells in patients with and without PTLD. Cyclosporine and PTLD and azathioprine dosages and cyclosporine levels were similar between patients with and without PTLD. PTLD was seen in patients with high cumulative doses of antilymphocyte globulin. Analysis of HLA status showed a predominance of HLA A2 and DR7 in the donors of the patients with PTLD, whereas donor HLA B7 was more common in patients without PTLD>

CONCLUSIONS

Detailed studies are necessary to further elucidate the risk factors for PTLD development in the lung transplant population.

Surgical critical care for cancer patients

Progress in cancer surgery and changes in philosophy have resulted in greater numbers of critically ill surgical oncology patients. The effects of cancer and prior exposure to cancer therapies increase the risks for postsurgical problems. Life-threatening cardiopulmonary sequela and patients undergoing liver resections and transplantation are examples of problems that require the knowledge and skill of critical care nurses. Critical care surgical nurses face new challenges by merging their surgical nursing expertise with principles of cancer care.

Cell surface distribution of endogenous and effects of exogenous gangliosides on neuronal survival, cell shape and growth in vitro

In vitro immunostaining of neurons from spinal cord or brain of embryonic chicken by means of monoclonal anti-ganglioside antibodies (Q211, D21b) revealed a fluorescence-labeling of c-polysialogangliosides and GD1b evenly distributed over the entire neuronal surface including filopodia at the growth cones. On electronmicroscopical level the gold-stained ganglioside-antigens were found more or less densely packed in small adjacent areas suggesting a concentration in local "domains". Survival in serum-free or serum-containing medium of embryonic spinal cord motoneurons, which normally died if not cultivated in muscle conditioned medium or in contact to myotubes, was remarkably improved in the presence of a ganglioside mixture (10 microM) from bovine brain. If embryonic neurons from optic lobes were cultivated at low Ca(2+)-concentration (< 20 microM) they developed flat, broad cell bodies with many filopodia and only a few flat-shaped short processes. A very weak cytoskeleton-staining by means of rhodamine-linked phalloidine indicated that polymerization of actin was impaired in these neurons. At the same low Ca(2+)-concentration of < 20 microM but in the presence of ganglioside GM1 (up to 100 microM) most of the neurons developed a "normal" cell shape with rounded perikarya and thin neurites with "normal" shaped growth cones. In this case rhodamine-linked phalloidine revealed a much more intense staining mainly concentrated within the growing tips. The morphology and growth of the ganglioside-treated neurons resembled that of neurons cultivated at a higher Ca(2+)-concentration of at least 600 microM.