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Median sternotomy for synchronous bilateral pulmonary operations
July 1980
Volume 80, Number J
THORACIC AND CARDIOVASCULAR SURGERY The Journal of
J
THORAC CARDIOVASC SURG
80:1-7, 1980
Original Communications
Median sternotomy for synchronous bilateral pulmonary operations Since 1975 10 patiellts at Rush Medical Center have undergone synchronous bilateral pulmonary operations by median sternotomy. Nine had pulmonary metastases and one had bullous emphysema with recurrent spontaneous pneumothorax. Between three and 20 metastases were removed by wedge resection per patient, but right upper lobe anterior segmentectomy and left upper lobectomy were required in one patient, Bilateral bullae resections and plication .I' improved pulmonary function in the patient with emphysema. The average hospital stay was 9 days, and the only complication was one reoperation for postoperative bleeding. Median sternotomy has been advantageous in selected patients with bilateral pulmonary disease because it allows one-stage completion of the required pulmonary procedures with minimal impairment of pulmonary function, shortened hospital Slay, and maximal patient recovery.
Ronald L. Meng, M.D., Robert 1. Jensik, M.D., C. Frederick Kittle, M.D., and L. Penfield Faber, M.D., Chicago, Ill.
T
he increasing interest in attempted salvage from pulmonary metastasis and palliation of bullous emphysema has created a group of surgical candidates with bilateral pulmonary disease. Dissatisfaction with staged bilateral thoracotomies in these patients and the success of median sternotomy for cardiac operations suggested the latter's use for simultaneous exposure of both lungs. The obvious benefit of one operation, the From the Section of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. Received for publication Aug. 29, 1979. Accepted for publication Dec. 14, 1979. Address for reprints: Ronald L. Meng, M.D., Rush-PresbyterianSt. Luke's Medical Center, 1753 W. Congress Parkway, Chicago, III. 60612.
adequacy of exposure for most pulmonary procedures and the minimal post-sternotomy impairment of pulmonary function stimulated our interest in median sternotomy for synchronous bilateral pulmonary operations.
Patients Since 1975 10 patients at Rush-Presbyterian-St. Luke's Medical Center have undergone synchronous bilateral pulmonary operations by median sternotomy (Table I). They ranged in age from 10 to 72 years. Nine were operated upon for suspected metastatic disease, each with controlled primary tumor site and tumordoubling time greater than 40 days. Three to 20 lesions were removed per patient, by wedge resection in eight and by right upper lobe anterior segmentectomy and left upper lobectomy in one. The remaining patient un-
0022-5223/80/070001+07$00.70/0 © 1980 The C. V. Mosby Co.
The Journal of
2 Meng et al .
Thoracic and Cardiovascular Surgery
Patient I died of widespread metastatic embryonal carcinoma, Patient 5 died of metastatic osteosarcoma, and Patient 6 died of doxorubicin-related cardiac failure with recurrent pulmonary metastases. Patient 2 underwent left upper lobectomy via axillary thoracotomy for recurrent metastases 1 year after sternotomy and is currently free of disease . The 48 month survivor, though operated upon for suspected metastatic chondrosarcoma, had only granulomas .
Selected case reports
Fig. 1. Patient 1: The chest x-ray film reveals two pulmonary nodules (arrows).
derwent bilateral bleb resections, bullae plications, and pleurectomies for bullous emphysema complicated by recurrent , persi stent, spontaneous pneumothorax . The average hospital stay of these patients was 9 days , and the only complication was reoperation for postoperative bleeding in one patient. There was no death . All nine patients with suspected metastatic disease were identified by serial chest roentgenography. The plain films showed only unilateral nodules in five patients. Conventional tomography revealed additional nodules and bilateral involvement in all nine patients, but computerized axial tomography revealed still more nodules in each patient studied . When compared with surgical findings, conventional tomography was accurate in only two of the nine patients , whereas computerized axial tomography was accurate in three of four . None of the se nine patients had bronchopulmonary symptoms. Each underwent bronchoscopy with brushings, washings, and postbronchoscopy sputum collections, but only one patient had positive results of cytologic studies . The only other preoperative diagnosis came by transthoracic aspiration in the only patient in whom it was attempted . Resection of pulmonary metastases wa s a brief, intense adjunct to primary , ongoing radiotherapy and /or chemotherapy in each patient. Six of the nine patients are free of disease 18 to 48 months postoperatively.
PAT lEN T 6 . A 16-year-old boy with a left tibial osteogenic sarcom a showed bilateral nodules on the chest x-ray film (Fig. I). Conventional tomography revealed seven additional nodule s, but computerized axial tomography revealed a total of 12 nodule s (Fig . 2) . Intensive treatment by amputation , radiotherapy, and chemotherapy provided control of the primary site and limited regre ssion of the pulmon ary nodule s. Twenty subpleural metastases were then resected via median sternotomy . He reco vered without complication but died I year later with progressive heart failure related to doxorubi cin, Recurrent pulmonary metastases were found at autopsy . PATIENT 4 . A 63-year-old man developed two unilateral pulmonary nodule s and rising levels of carcinoernbryonic antigen (CEA) I year after right hemicolectomy and chemotherapy for Duke 's C colon carcinoma (Fig. 3) . Conventional tomography revealed an additional contralateral nodule (Fig. 4) and computerized axial tomography revealed still another nodule (Fig . 5). After normal bronchoscopic brushings and washing s, transthoracic aspirat ion of the large , central left nodule revealed adenocarcinoma . Exploration via median sternotomy revea led onl y the four known nodule s, but because of their proximity within the hila and the large size of the left upper lobe nodule, right upper lobe anterior segmentectom y and left upper lobectomy were required . The 2 year postoperative chest x-ray film is free of nodule s and the CEA
is normal.
PAT lEN T 10. A 55-year-old woman who was dyspneic at rest had a second spontaneous pneumothorax. A prolonged air leak complicated tube thora costomy (Fig. 6) . The perfusion scan revealed left upper, left lower, and right upper lobe bullae (Fig . 7) , and her pulmonary function studies revealed severe restrict ive and obstructive impairment and severely decreased diffusion capacity . Bilateral bleb resection s, bullae plications, and pleurectomies were performed via median sternotomy. She was successfully extubated immediately postoperatively and recovered without incident. The 2 year postoperative chest x-ray film is markedl y impro ved (Fig . 8), and she is currently only mildly symptomatic and once again employed .
Discussion The most common indication for bilateral pulmonary operations is pulmonary metastases. ":" Lung metastases occur in approximately one third of patients with cancer and often are the sole metastases, since the lung is a common first metastatic site. 4-6 In patients with succe ssfully controlled primaries and slow-growing
Volume 80
Synchronous bilatera l pulmonary operations
Number 1
3
July , 1980
Fig. 2. Patient I: The example of the conventional tomogram (left) reveals three posterior nodules (arrows) . and the example of the computerized axial tomogram (rig ht) reveals one right and two left pulmonary nodules (arrows) .
Table I. Median sternotomy fo r synchronous bilateral pulmonary operations Method of detection and no . of pulmona ry nodules
Pt. No .
Age, sex
Diagno sis
26,M
Embryonal carcinoma (testicle) Adenocarcinoma (ovary) Adenocarcinoma (breast) Adenocarcinoma (colon) Osteosarcoma Osteosarcoma Osteosarcoma Rhabdomyosarcoma Granulomas (chondrosarcoma) Bullous emphysema
2
59, F
3
47. F
4
M,M
5
30, M 16. M
6 7 8 9
10. F 72. F
10
55. F
56. M
Plain chest x-ray film
2 bilateral
Conventional tomography
Computerized axial tomography
Exploration
Procedure*
Results
2 bilateral
2
Wedge resections
Dead. 20mo
3
3
Wedge resections
Alive.18mo
3 bilateral
4
4
Wedge resections
Alive.19mo
2 unilateral
3 bilateral
4
4
Alive, 30mo
I
3 bilateral 9 3 2 bilateral 4
12
20 4 3 6
RUL anteriorsegmentectomy, LUL lobectomy Wedge resections Wedge resections Wedge resections Wedge resections Wedge resections Bilateral resections. plications. pleurectomies
Alive.26 mo
2 bilateral 2 bilateral I
2 bilateral
3
17
Dead, 9 mo Dead, 12 mo Alive, 26mo Alive,19mo Alive.48mo
Legend. RUL. Right upper lobe. LUL. Left upper lobe.
pulmonary nodules, resection of the metastases has been shown to be a beneficial adjuvant to chemotherapy regardless of the histologic type, number of nodules, or tumor-free interval. 3. 4 Most pulmonary metastases cause no symptoms until late, howev er , and must be diagnosed by serial che st roentgenography. Since plain films do not correctly predict the pre sence or absen ce or extent of pulmonary metastase s in all patients, however, whole-lung tomography is necessary prior to and during majo r therapeutic program s. 7. 8 Conventional tomography may reveal
additional nodules and bilater al involvement in patient s with solitary or unilateral nodules on plain films 7-10 but may not disclo se the preci se number of nodules found at operation , since the most common location of metastases, the subpleural area, is the most difficult area to assess accurately by convent ional tomography . Computerized axia l tomography considerably enha nces the detection of the se nodule s beca use of axial projection and increa sed contrast between nodule, lung tissue, and chest wall. 10 Even computerized axial tomography misses some small nodules, howe ver , and occasionally
The Journal of
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Meng et al.
Thoracic and Cardiovascular Surgery
Fig. 3. Patient 2: The chest x-ray film reveals a large central nodule and a smaller peripheral nodule limited to the left lung (arrows) .
Fig. 4. Patient 2: Conventional tomogram reveals the presence of an unsuspected right pulmonary nodule (arrow). it reveals nodules which are not metastases.": io Thus neither technique matches the accuracy of surgical exploration . In surgical candidates with metastases documented by plain films , we recommend computerized axial tomography, solely for documentation of bilateral versus unilateral involvement, significantly changing the operative approach. Bilateral pulmonary operations also may be required for complications of chronic obstructive pulmonary disease: bilateral spontaneous pneumothorax and bilateral giant bullous disease. 11-15 Localized bullae which rupture or significantly compress nearby normal tissue can be documented by angiography or perfusion
scan . Their removal or obliteration significantly improves pulmonary function in selected patients. The traditional surgical approach to patients with bilateral pulmonary disease has been staged lateral thoracotomies, 7 to 90 days apart. depending on patient condition and disease progression . Disadvantages include the two required operations with extended hospital stay, increased exposure to morbidity, especially pulmonary complications, and the interval delay . The delay is particularly disadvantageous in patients with metastatic malignancies because postoperative immunosuppression and cessation of radiotherapy and chemotherapy allow unrestrained growth or metastasis of the contralateral, unresected metastases . 16. Ii One study showed that within 2 years, new pulmonary metastases developed in one fourth of those with a 3 month interval but in none with less than a 2 week interval. 1 In patients with emphysema, the capability of synchronous bilateral procedures may actually make the difference between inoperability and operability . Whereas the postoperative ventilatory impairment after unilateral operation may be intolerable in the face of already existing and unimproved contralateral ventilatory impairment, it may be tolerable after simultaneous improvement in the function of both lungs. In addition, some patients with preoperative evidence of only unilateral metastases actually have bilateral involvement,?: 10 and up to one eighth of patients with emphysema who undergo a unilateral operation subsequently require a contralateral operation . I I . 12 On this basis bilateral exploration might be considered even for unilateral nodules or bullae. Thus, in various patients, synchronous bilateral operations may resolve the pulmonary disease more completel y, be tolerated more easily, and avert future operations. Synchronous bilateral operations have been performed through bilateral thoracotomies during one anesthesia and transverse sternotomy with bilateral intercostal extensions, but these methods result in long operating times, severe postoperative pain , and chest wall rigidity-hence, increased pulmonary complications .": 1M Furthermore, these approaches significantly limit exposure. Transverse sternotomy leaves an overhanging rib cage both cephalad and caudad, hindering operation of the apices and posterior bases. The lack of simultaneous bilateral exposure with same-anesthesia bilateral thoracotomies may lead to ventilatory dependence on significantly diminished pulmonary tissue or inability to complete bilateral procedures if a more extensive operation than expected is required on the first lung explored.
Volume 80 Number 1
Synchronous bilateral pulm onary operations
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July. 1980
Fig. 5. Patient 2: Computerized axial tomograms reveal the right nodule, the large and small left nodules, and an additional left nodule posteriorly ( a r ro ws} , In contrast, median sternotomy provides the advantages of synchronous bilateral pulmonary exposure without sacrifice of patient tolerance. It provides adequate exposure for successful completion of most pulmonary procedures.v 19 It provides quick exposure and closure to minimize operating time , and it is associated with an acceptably low complication rate .P?: 2 1 Finally, it causes less derangement of pulmonary volumes , flows, and compliance than lateral thoracotomy , 19. 22 probably because of decreased postoperative pain . This improve s patient recovery and shortens hospital stay, and it is of paramount importance in operations for emphysema. Thus, although originally popularized' " and currently standardized for cardiac operations, median sternotomy has recently been applied enthusiastically to bilateral pulmonary operations." 19 Several principles facilitate successful utilization of this incision for this purpose. Bronchoscopy should be performed preoperatively, not so much for diagnosis as for documentation of en-
dobronchial disease which might change the extent or sequence of resections required. For example, since exposure of the left main-stem bronchus is difficult via median sternotomy, diagnosis of left endobronchial metastases might indicate lateral thoracotomy instead of sternotomy. Double-lumen endotracheal intubation should be utilized to allow unhurried man ipulation of one deflated lung during continued ventilation of the other. Deflation greatly aids in identification of all metastases and resection or plication of bullae. Thorough bilateral exploration should precede dissection in order to plan the extent and sequence of procedure s and to avoid mistaking postresectional artifact or atelectasis for tumor nodules . The upper and right middle lobes are mobile about the hila and easily examined, but adequate exploration of the lower lobes demands division of the inferior pulmonary ligaments . The thorough exploration of the inflated and deflated lung by the operator may reveal preoperatively unsus-
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Thoracic and Cardiovascular Surgery
Fig. 6. Patient 3: The chest x-ray film reveals the right thoracostomy tube and suggests large left upper and lower lobe bullae above markedly flattened hemidiaphragms.
Fig. 7. Patient 3: The perfusion scan verifies the presence of left upper and lower lobe bullae and reveals in addition a right upper lobe bulla. pected disease and should be repeated by a second examiner, since even more nodules may be found . Each nodule identified should be clearly marked by suture placement. Dissection should proceed with wedge resections and plications prior to major anatomic resections in order to maximize available parenchyma for ventilation. Meti-
Fig. 8. Patient 3: The 2 year postoperative chest x-ray film reveals the effect of right upper lobe bulla plication, diminished volume of the left hemithorax due to resectionof the upper and lower lobe bullae, and good vascular markings bilaterally. culous parenchymal preservation is mandatory in these patients, who are compromised by emphysema or subject to later pulmonary resection for recurrent metastases . Most metastases are subpleural and, therefore , readily excised locally by cautery . Local excision of metastatic nodules deep within the parenchyma, however, may be complicated by troublesome bleeding or prolonged air leak such that anatomic resection is usually preferable . Exposure is adequate for any rightsided segmentectomy or simple or sleeve lobectomy and any left-sided segmentectomy . Although exposure of the distal left main-stem bronchus is tedious because of required retraction of the heart, left upper and lower lobectomies have been successfully performed with the exception of left upper sleeve lobectomy. Right or left pneumonectomy is possible as well, but seldom indicated. Plications and bleb resections are possible throughout both lungs after satisfactory pulmonary mobilization, and pleurectomy is available as an adjunct for those procedures which might be associated with significant air leak. The use of staples greatly simplifies vascular and bronchial control for anatomic resection and parenchymal control for plication and bleb resection . It has been suggested that despite the advantages offered by median sternotomy , prior sternotomy or tho-
Volume 80 Number 1 July, 1980
racotomy and the possibility of left upper sleeve or lower lobectomy are relative contraindications because of increased difficulty of dissection. Those experienced with this approach, however, suggest that these difficulties can be overcome by reporting successful dissection of pleural adhesions and left lower lobectomy. 3. 19 In fact, rather than limiting the applicability of median sternotomy, its proponents are expanding its usage to even unilateral pulmonary operations in patients with borderline pulmonary function or upper lobe disease.
Conclusion Median sternotomy is the best approach for operations in selected cases of bilateral pulmonary disease. When performed with double-lumen endotracheal intubation and liberal pulmonary mobilization, it allows bilateral exploration and performance of nearly any required pulmonary procedure. Furthermore, its complication rate is low and it minimizes postoperative ventilatory impairment. Thus it facilitates definitive, onestage bilateral pulmonary operations with shortened hospital stay and maximal patient recovery.
2
3
4
5
6
7
REFERENCES McConnack PM, Bains MS, Beattie EJ Jr: Pulmonary resection in metastatic carcinoma. Chest 73: 163-166, 1978 Wilkins EW Jr, Head JM, Burke JF: Pulmonary resection for metastatic neoplasms in the lung. Am J Surg 135:480-482, 1978 Takita H, Merrin C. Didolkar MS, et al: The surgical management of multiple lung metastases. Ann Thorac Surg 24:359-364, 1977 Morton DL, Joseph WL, Ketcham AS, et al: Surgical resection and adjuvant immunotherapy for selected patients with multiple pulmonary metastases. Ann Surg 178:360-365, 1973 Holmes EC: The surgical management of pulmonary metastases. Presented at the Meeting on Thoracic Surgery, University of Toronto, June 14, 1979 Mountain CF: Pulmonary metastatic disease-Progress in a neglected area. Int J Radiat Oncol Bioi Phys 1:755-757, 1976 Didolkar MS, Cedennark BJ, Goel JP, et al: Accuracy of roentgenograms of the chest in metastases to the lungs. Surg Gynecol Obstet 144:903-905, 1977
Synchronous bilateral pulmonary operations
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8 Neifeld JP, Michaelis LL, Doppman JL: Suspected pulmonary metastases. Cancer 39:383-387, 1977 9 Schaner EG, Chang AE, Doppman JL, et al: Comparison of computed and conventional whole lung tomography in detection of pulmonary metastases. Am J Radiol 131: 51-54, 1978 10 Muhm JR, Brown LR, Crowe JK: Use of computed tomography in the detection of pulmonary nodules. Mayo Clin Proc 52:345-348, 1977 I I Fitzgerald MX, Keelan PJ, Cugell DW, et al: Long-term results of surgery for bullous emphysema. J THoRAc CARDIOVASC SURG 68:566-586, 1974 12 Mercier C, Page A, Verdant A, et al: Outpatient management of intercostal tube drainage in spontaneous pneumothorax. Ann Thorac Surg 22: 163-165, 1976 13 Delarue NC, Woolf CR, Sanders DE, et al: Surgical treatment for pulmonary emphysema. Can J Surg 20: 222-231, 1977 14 Wesley JR, Macleod WM, Mullard KS: Evaluation and surgery of bullous emphysema. J THoRAc CARDIOVASC SURG 63:945-955, 1972 15 Parker FB Jr: Surgery in chronic lung disease. Surg Clin North Am 54:1193-1202, 1974 16 Tarpley JL, Catalona WJ, Twomey PL, et al: Suppression of cellular immunity by anesthesia and operation. Program of the Tenth Annual Meeting of the Association for Academic Surgery, 1976, p II 17 Ketcham AS, Wexler H, Chretien PB: The metastatic potential of experimental pulmonary metastases. J Surg Res 15:45-52, 1973 18 Julian OC, Dye WS, Javid H, et al: The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery 42:753-761, 1957 19 Cooper JD, Melems JM, Pearson FG: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26:413-418, 1978 20 Sutherland RD, Martinez HE, Guynes WA, et al: Postoperative chest wound infections in patients requiring coronary bypass. J THoRAc CARDIOVASC SURG 73:944947, 1977 21 Culliford AT, Cunningham IN Jr, ZeffRH, et al: Sternal and costochondral infections following open heart surgery. J THoRAc CARDIOVASC SURG 72:714-725, 1976 22 Peters RM, Wellons HA, Htwe TM: Total compliance and work of breathing after thoracotomy. J THoRAc CARDIOVASC SURG 57:348-355, 1969
Volume 80, Number J
THORACIC AND CARDIOVASCULAR SURGERY The Journal of
J
THORAC CARDIOVASC SURG
80:1-7, 1980
Original Communications
Median sternotomy for synchronous bilateral pulmonary operations Since 1975 10 patiellts at Rush Medical Center have undergone synchronous bilateral pulmonary operations by median sternotomy. Nine had pulmonary metastases and one had bullous emphysema with recurrent spontaneous pneumothorax. Between three and 20 metastases were removed by wedge resection per patient, but right upper lobe anterior segmentectomy and left upper lobectomy were required in one patient, Bilateral bullae resections and plication .I' improved pulmonary function in the patient with emphysema. The average hospital stay was 9 days, and the only complication was one reoperation for postoperative bleeding. Median sternotomy has been advantageous in selected patients with bilateral pulmonary disease because it allows one-stage completion of the required pulmonary procedures with minimal impairment of pulmonary function, shortened hospital Slay, and maximal patient recovery.
Ronald L. Meng, M.D., Robert 1. Jensik, M.D., C. Frederick Kittle, M.D., and L. Penfield Faber, M.D., Chicago, Ill.
T
he increasing interest in attempted salvage from pulmonary metastasis and palliation of bullous emphysema has created a group of surgical candidates with bilateral pulmonary disease. Dissatisfaction with staged bilateral thoracotomies in these patients and the success of median sternotomy for cardiac operations suggested the latter's use for simultaneous exposure of both lungs. The obvious benefit of one operation, the From the Section of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. Received for publication Aug. 29, 1979. Accepted for publication Dec. 14, 1979. Address for reprints: Ronald L. Meng, M.D., Rush-PresbyterianSt. Luke's Medical Center, 1753 W. Congress Parkway, Chicago, III. 60612.
adequacy of exposure for most pulmonary procedures and the minimal post-sternotomy impairment of pulmonary function stimulated our interest in median sternotomy for synchronous bilateral pulmonary operations.
Patients Since 1975 10 patients at Rush-Presbyterian-St. Luke's Medical Center have undergone synchronous bilateral pulmonary operations by median sternotomy (Table I). They ranged in age from 10 to 72 years. Nine were operated upon for suspected metastatic disease, each with controlled primary tumor site and tumordoubling time greater than 40 days. Three to 20 lesions were removed per patient, by wedge resection in eight and by right upper lobe anterior segmentectomy and left upper lobectomy in one. The remaining patient un-
0022-5223/80/070001+07$00.70/0 © 1980 The C. V. Mosby Co.
The Journal of
2 Meng et al .
Thoracic and Cardiovascular Surgery
Patient I died of widespread metastatic embryonal carcinoma, Patient 5 died of metastatic osteosarcoma, and Patient 6 died of doxorubicin-related cardiac failure with recurrent pulmonary metastases. Patient 2 underwent left upper lobectomy via axillary thoracotomy for recurrent metastases 1 year after sternotomy and is currently free of disease . The 48 month survivor, though operated upon for suspected metastatic chondrosarcoma, had only granulomas .
Selected case reports
Fig. 1. Patient 1: The chest x-ray film reveals two pulmonary nodules (arrows).
derwent bilateral bleb resections, bullae plications, and pleurectomies for bullous emphysema complicated by recurrent , persi stent, spontaneous pneumothorax . The average hospital stay of these patients was 9 days , and the only complication was reoperation for postoperative bleeding in one patient. There was no death . All nine patients with suspected metastatic disease were identified by serial chest roentgenography. The plain films showed only unilateral nodules in five patients. Conventional tomography revealed additional nodules and bilateral involvement in all nine patients, but computerized axial tomography revealed still more nodules in each patient studied . When compared with surgical findings, conventional tomography was accurate in only two of the nine patients , whereas computerized axial tomography was accurate in three of four . None of the se nine patients had bronchopulmonary symptoms. Each underwent bronchoscopy with brushings, washings, and postbronchoscopy sputum collections, but only one patient had positive results of cytologic studies . The only other preoperative diagnosis came by transthoracic aspiration in the only patient in whom it was attempted . Resection of pulmonary metastases wa s a brief, intense adjunct to primary , ongoing radiotherapy and /or chemotherapy in each patient. Six of the nine patients are free of disease 18 to 48 months postoperatively.
PAT lEN T 6 . A 16-year-old boy with a left tibial osteogenic sarcom a showed bilateral nodules on the chest x-ray film (Fig. I). Conventional tomography revealed seven additional nodule s, but computerized axial tomography revealed a total of 12 nodule s (Fig . 2) . Intensive treatment by amputation , radiotherapy, and chemotherapy provided control of the primary site and limited regre ssion of the pulmon ary nodule s. Twenty subpleural metastases were then resected via median sternotomy . He reco vered without complication but died I year later with progressive heart failure related to doxorubi cin, Recurrent pulmonary metastases were found at autopsy . PATIENT 4 . A 63-year-old man developed two unilateral pulmonary nodule s and rising levels of carcinoernbryonic antigen (CEA) I year after right hemicolectomy and chemotherapy for Duke 's C colon carcinoma (Fig. 3) . Conventional tomography revealed an additional contralateral nodule (Fig. 4) and computerized axial tomography revealed still another nodule (Fig . 5). After normal bronchoscopic brushings and washing s, transthoracic aspirat ion of the large , central left nodule revealed adenocarcinoma . Exploration via median sternotomy revea led onl y the four known nodule s, but because of their proximity within the hila and the large size of the left upper lobe nodule, right upper lobe anterior segmentectom y and left upper lobectomy were required . The 2 year postoperative chest x-ray film is free of nodule s and the CEA
is normal.
PAT lEN T 10. A 55-year-old woman who was dyspneic at rest had a second spontaneous pneumothorax. A prolonged air leak complicated tube thora costomy (Fig. 6) . The perfusion scan revealed left upper, left lower, and right upper lobe bullae (Fig . 7) , and her pulmonary function studies revealed severe restrict ive and obstructive impairment and severely decreased diffusion capacity . Bilateral bleb resection s, bullae plications, and pleurectomies were performed via median sternotomy. She was successfully extubated immediately postoperatively and recovered without incident. The 2 year postoperative chest x-ray film is markedl y impro ved (Fig . 8), and she is currently only mildly symptomatic and once again employed .
Discussion The most common indication for bilateral pulmonary operations is pulmonary metastases. ":" Lung metastases occur in approximately one third of patients with cancer and often are the sole metastases, since the lung is a common first metastatic site. 4-6 In patients with succe ssfully controlled primaries and slow-growing
Volume 80
Synchronous bilatera l pulmonary operations
Number 1
3
July , 1980
Fig. 2. Patient I: The example of the conventional tomogram (left) reveals three posterior nodules (arrows) . and the example of the computerized axial tomogram (rig ht) reveals one right and two left pulmonary nodules (arrows) .
Table I. Median sternotomy fo r synchronous bilateral pulmonary operations Method of detection and no . of pulmona ry nodules
Pt. No .
Age, sex
Diagno sis
26,M
Embryonal carcinoma (testicle) Adenocarcinoma (ovary) Adenocarcinoma (breast) Adenocarcinoma (colon) Osteosarcoma Osteosarcoma Osteosarcoma Rhabdomyosarcoma Granulomas (chondrosarcoma) Bullous emphysema
2
59, F
3
47. F
4
M,M
5
30, M 16. M
6 7 8 9
10. F 72. F
10
55. F
56. M
Plain chest x-ray film
2 bilateral
Conventional tomography
Computerized axial tomography
Exploration
Procedure*
Results
2 bilateral
2
Wedge resections
Dead. 20mo
3
3
Wedge resections
Alive.18mo
3 bilateral
4
4
Wedge resections
Alive.19mo
2 unilateral
3 bilateral
4
4
Alive, 30mo
I
3 bilateral 9 3 2 bilateral 4
12
20 4 3 6
RUL anteriorsegmentectomy, LUL lobectomy Wedge resections Wedge resections Wedge resections Wedge resections Wedge resections Bilateral resections. plications. pleurectomies
Alive.26 mo
2 bilateral 2 bilateral I
2 bilateral
3
17
Dead, 9 mo Dead, 12 mo Alive, 26mo Alive,19mo Alive.48mo
Legend. RUL. Right upper lobe. LUL. Left upper lobe.
pulmonary nodules, resection of the metastases has been shown to be a beneficial adjuvant to chemotherapy regardless of the histologic type, number of nodules, or tumor-free interval. 3. 4 Most pulmonary metastases cause no symptoms until late, howev er , and must be diagnosed by serial che st roentgenography. Since plain films do not correctly predict the pre sence or absen ce or extent of pulmonary metastase s in all patients, however, whole-lung tomography is necessary prior to and during majo r therapeutic program s. 7. 8 Conventional tomography may reveal
additional nodules and bilater al involvement in patient s with solitary or unilateral nodules on plain films 7-10 but may not disclo se the preci se number of nodules found at operation , since the most common location of metastases, the subpleural area, is the most difficult area to assess accurately by convent ional tomography . Computerized axia l tomography considerably enha nces the detection of the se nodule s beca use of axial projection and increa sed contrast between nodule, lung tissue, and chest wall. 10 Even computerized axial tomography misses some small nodules, howe ver , and occasionally
The Journal of
4
Meng et al.
Thoracic and Cardiovascular Surgery
Fig. 3. Patient 2: The chest x-ray film reveals a large central nodule and a smaller peripheral nodule limited to the left lung (arrows) .
Fig. 4. Patient 2: Conventional tomogram reveals the presence of an unsuspected right pulmonary nodule (arrow). it reveals nodules which are not metastases.": io Thus neither technique matches the accuracy of surgical exploration . In surgical candidates with metastases documented by plain films , we recommend computerized axial tomography, solely for documentation of bilateral versus unilateral involvement, significantly changing the operative approach. Bilateral pulmonary operations also may be required for complications of chronic obstructive pulmonary disease: bilateral spontaneous pneumothorax and bilateral giant bullous disease. 11-15 Localized bullae which rupture or significantly compress nearby normal tissue can be documented by angiography or perfusion
scan . Their removal or obliteration significantly improves pulmonary function in selected patients. The traditional surgical approach to patients with bilateral pulmonary disease has been staged lateral thoracotomies, 7 to 90 days apart. depending on patient condition and disease progression . Disadvantages include the two required operations with extended hospital stay, increased exposure to morbidity, especially pulmonary complications, and the interval delay . The delay is particularly disadvantageous in patients with metastatic malignancies because postoperative immunosuppression and cessation of radiotherapy and chemotherapy allow unrestrained growth or metastasis of the contralateral, unresected metastases . 16. Ii One study showed that within 2 years, new pulmonary metastases developed in one fourth of those with a 3 month interval but in none with less than a 2 week interval. 1 In patients with emphysema, the capability of synchronous bilateral procedures may actually make the difference between inoperability and operability . Whereas the postoperative ventilatory impairment after unilateral operation may be intolerable in the face of already existing and unimproved contralateral ventilatory impairment, it may be tolerable after simultaneous improvement in the function of both lungs. In addition, some patients with preoperative evidence of only unilateral metastases actually have bilateral involvement,?: 10 and up to one eighth of patients with emphysema who undergo a unilateral operation subsequently require a contralateral operation . I I . 12 On this basis bilateral exploration might be considered even for unilateral nodules or bullae. Thus, in various patients, synchronous bilateral operations may resolve the pulmonary disease more completel y, be tolerated more easily, and avert future operations. Synchronous bilateral operations have been performed through bilateral thoracotomies during one anesthesia and transverse sternotomy with bilateral intercostal extensions, but these methods result in long operating times, severe postoperative pain , and chest wall rigidity-hence, increased pulmonary complications .": 1M Furthermore, these approaches significantly limit exposure. Transverse sternotomy leaves an overhanging rib cage both cephalad and caudad, hindering operation of the apices and posterior bases. The lack of simultaneous bilateral exposure with same-anesthesia bilateral thoracotomies may lead to ventilatory dependence on significantly diminished pulmonary tissue or inability to complete bilateral procedures if a more extensive operation than expected is required on the first lung explored.
Volume 80 Number 1
Synchronous bilateral pulm onary operations
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Fig. 5. Patient 2: Computerized axial tomograms reveal the right nodule, the large and small left nodules, and an additional left nodule posteriorly ( a r ro ws} , In contrast, median sternotomy provides the advantages of synchronous bilateral pulmonary exposure without sacrifice of patient tolerance. It provides adequate exposure for successful completion of most pulmonary procedures.v 19 It provides quick exposure and closure to minimize operating time , and it is associated with an acceptably low complication rate .P?: 2 1 Finally, it causes less derangement of pulmonary volumes , flows, and compliance than lateral thoracotomy , 19. 22 probably because of decreased postoperative pain . This improve s patient recovery and shortens hospital stay, and it is of paramount importance in operations for emphysema. Thus, although originally popularized' " and currently standardized for cardiac operations, median sternotomy has recently been applied enthusiastically to bilateral pulmonary operations." 19 Several principles facilitate successful utilization of this incision for this purpose. Bronchoscopy should be performed preoperatively, not so much for diagnosis as for documentation of en-
dobronchial disease which might change the extent or sequence of resections required. For example, since exposure of the left main-stem bronchus is difficult via median sternotomy, diagnosis of left endobronchial metastases might indicate lateral thoracotomy instead of sternotomy. Double-lumen endotracheal intubation should be utilized to allow unhurried man ipulation of one deflated lung during continued ventilation of the other. Deflation greatly aids in identification of all metastases and resection or plication of bullae. Thorough bilateral exploration should precede dissection in order to plan the extent and sequence of procedure s and to avoid mistaking postresectional artifact or atelectasis for tumor nodules . The upper and right middle lobes are mobile about the hila and easily examined, but adequate exploration of the lower lobes demands division of the inferior pulmonary ligaments . The thorough exploration of the inflated and deflated lung by the operator may reveal preoperatively unsus-
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Fig. 6. Patient 3: The chest x-ray film reveals the right thoracostomy tube and suggests large left upper and lower lobe bullae above markedly flattened hemidiaphragms.
Fig. 7. Patient 3: The perfusion scan verifies the presence of left upper and lower lobe bullae and reveals in addition a right upper lobe bulla. pected disease and should be repeated by a second examiner, since even more nodules may be found . Each nodule identified should be clearly marked by suture placement. Dissection should proceed with wedge resections and plications prior to major anatomic resections in order to maximize available parenchyma for ventilation. Meti-
Fig. 8. Patient 3: The 2 year postoperative chest x-ray film reveals the effect of right upper lobe bulla plication, diminished volume of the left hemithorax due to resectionof the upper and lower lobe bullae, and good vascular markings bilaterally. culous parenchymal preservation is mandatory in these patients, who are compromised by emphysema or subject to later pulmonary resection for recurrent metastases . Most metastases are subpleural and, therefore , readily excised locally by cautery . Local excision of metastatic nodules deep within the parenchyma, however, may be complicated by troublesome bleeding or prolonged air leak such that anatomic resection is usually preferable . Exposure is adequate for any rightsided segmentectomy or simple or sleeve lobectomy and any left-sided segmentectomy . Although exposure of the distal left main-stem bronchus is tedious because of required retraction of the heart, left upper and lower lobectomies have been successfully performed with the exception of left upper sleeve lobectomy. Right or left pneumonectomy is possible as well, but seldom indicated. Plications and bleb resections are possible throughout both lungs after satisfactory pulmonary mobilization, and pleurectomy is available as an adjunct for those procedures which might be associated with significant air leak. The use of staples greatly simplifies vascular and bronchial control for anatomic resection and parenchymal control for plication and bleb resection . It has been suggested that despite the advantages offered by median sternotomy , prior sternotomy or tho-
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racotomy and the possibility of left upper sleeve or lower lobectomy are relative contraindications because of increased difficulty of dissection. Those experienced with this approach, however, suggest that these difficulties can be overcome by reporting successful dissection of pleural adhesions and left lower lobectomy. 3. 19 In fact, rather than limiting the applicability of median sternotomy, its proponents are expanding its usage to even unilateral pulmonary operations in patients with borderline pulmonary function or upper lobe disease.
Conclusion Median sternotomy is the best approach for operations in selected cases of bilateral pulmonary disease. When performed with double-lumen endotracheal intubation and liberal pulmonary mobilization, it allows bilateral exploration and performance of nearly any required pulmonary procedure. Furthermore, its complication rate is low and it minimizes postoperative ventilatory impairment. Thus it facilitates definitive, onestage bilateral pulmonary operations with shortened hospital stay and maximal patient recovery.
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REFERENCES McConnack PM, Bains MS, Beattie EJ Jr: Pulmonary resection in metastatic carcinoma. Chest 73: 163-166, 1978 Wilkins EW Jr, Head JM, Burke JF: Pulmonary resection for metastatic neoplasms in the lung. Am J Surg 135:480-482, 1978 Takita H, Merrin C. Didolkar MS, et al: The surgical management of multiple lung metastases. Ann Thorac Surg 24:359-364, 1977 Morton DL, Joseph WL, Ketcham AS, et al: Surgical resection and adjuvant immunotherapy for selected patients with multiple pulmonary metastases. Ann Surg 178:360-365, 1973 Holmes EC: The surgical management of pulmonary metastases. Presented at the Meeting on Thoracic Surgery, University of Toronto, June 14, 1979 Mountain CF: Pulmonary metastatic disease-Progress in a neglected area. Int J Radiat Oncol Bioi Phys 1:755-757, 1976 Didolkar MS, Cedennark BJ, Goel JP, et al: Accuracy of roentgenograms of the chest in metastases to the lungs. Surg Gynecol Obstet 144:903-905, 1977
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8 Neifeld JP, Michaelis LL, Doppman JL: Suspected pulmonary metastases. Cancer 39:383-387, 1977 9 Schaner EG, Chang AE, Doppman JL, et al: Comparison of computed and conventional whole lung tomography in detection of pulmonary metastases. Am J Radiol 131: 51-54, 1978 10 Muhm JR, Brown LR, Crowe JK: Use of computed tomography in the detection of pulmonary nodules. Mayo Clin Proc 52:345-348, 1977 I I Fitzgerald MX, Keelan PJ, Cugell DW, et al: Long-term results of surgery for bullous emphysema. J THoRAc CARDIOVASC SURG 68:566-586, 1974 12 Mercier C, Page A, Verdant A, et al: Outpatient management of intercostal tube drainage in spontaneous pneumothorax. Ann Thorac Surg 22: 163-165, 1976 13 Delarue NC, Woolf CR, Sanders DE, et al: Surgical treatment for pulmonary emphysema. Can J Surg 20: 222-231, 1977 14 Wesley JR, Macleod WM, Mullard KS: Evaluation and surgery of bullous emphysema. J THoRAc CARDIOVASC SURG 63:945-955, 1972 15 Parker FB Jr: Surgery in chronic lung disease. Surg Clin North Am 54:1193-1202, 1974 16 Tarpley JL, Catalona WJ, Twomey PL, et al: Suppression of cellular immunity by anesthesia and operation. Program of the Tenth Annual Meeting of the Association for Academic Surgery, 1976, p II 17 Ketcham AS, Wexler H, Chretien PB: The metastatic potential of experimental pulmonary metastases. J Surg Res 15:45-52, 1973 18 Julian OC, Dye WS, Javid H, et al: The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery 42:753-761, 1957 19 Cooper JD, Melems JM, Pearson FG: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26:413-418, 1978 20 Sutherland RD, Martinez HE, Guynes WA, et al: Postoperative chest wound infections in patients requiring coronary bypass. J THoRAc CARDIOVASC SURG 73:944947, 1977 21 Culliford AT, Cunningham IN Jr, ZeffRH, et al: Sternal and costochondral infections following open heart surgery. J THoRAc CARDIOVASC SURG 72:714-725, 1976 22 Peters RM, Wellons HA, Htwe TM: Total compliance and work of breathing after thoracotomy. J THoRAc CARDIOVASC SURG 57:348-355, 1969