Thoracic Surgery PPT #0

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  • I would like to thank the organizers of this meeting for inviting me to talk to you about the early history of surgical resection for lung cancer. I have always wanted to come to Gdansk to find more information on what I consider to be the first planned elective attempt to treat lung disease with pulmonary resection.
  • H.M. Block was a surgeon, presumably, young, who developed new techniques of pulmonary resection in animals and presented them in this article. He stated his plan to do lung resection in humans and was dissuaded from doing so.
  • We have hearsay evidence of what happened next. Walton wrote home that he had heard that Block had returned to Grdansk and attempted a pulmonary resection on a young relative.l When she died, there was an investigation and Block killed himself.
  • Diagnosis, not available to Block became possible with the effort of Roentgen in 1895 and the introduction of bronshoscopy by Killian in 1898.
  • Heidenhain was the first to resect a lung cancer, in his 1903 case the lung CA was an incidental finding.
  • Davies performed a lobectomy for this cancer in 1912 and the pt. died on the sixth po day. Davies was later badly injured and played little further role in the development of thoracic surgery.
  • Surgeons attempted to give themselves more time by doing pleurodesis as the first stage of a multi-stage technique of lung resection. Here is Mickulykz technique using gauze and rubber sheeting. Bethune described over thirty different technique of pleurodesis. In the first operation the chest was opened and pleurodesis applied. The chest was then closed to allow a few weeks for adhesions to apply. Since there were adhesions holding the lung inflated, respiration would not be catastrophically stopped by opening the chest for the second stage operation.
  • Because of the time factor, anatomical dissection of PA and PV was not possible, and most surgeons used a tourniquet to control the hila so that mass ligatures could be applied
  • It is somewhat surprising that the importance of post-operative underwater seal drainage was not appreciated by the early thoracic surgeons, since Bulau had described the technique in 1873. Sauerbrook continued to lose patients to post-op pneumothorax into the 1920s.
  • as in this early case. Some surgeons just left the tourniquets in place and allowed the lung to become gangrenous and slough out. Bronchopleural fistula and empyema were inevitable consequences of this type of procedure.
  • Samuel Robinson painted this grim portrait of a typical thoracic resection in 1925, obviously distressed by the morbidity and mortality as high as 50% in his patients.
  • Safe effective pulmonary resection developed over the next 50 years with contributions to the seven major components of “modern” technique coming from physicians and surgeons from around the world. The main components of safe modern resection are listed above.
  • Thoracic Surgery PPT #0

    1. 1. Thoracic Surgery Frederic W. Grannis Jr. MD A lecture to students at the Western University of Health Sciences Pomona CA December 17, 2002
    2. 2. Thoracic Surgery <ul><li>Cardiac Surgery </li></ul><ul><ul><li>Acquired </li></ul></ul><ul><ul><li>Congenital </li></ul></ul><ul><li>Vascular Surgery </li></ul><ul><ul><li>aneurysms </li></ul></ul><ul><ul><li>aortic dissection </li></ul></ul><ul><li>Esophageal Surgery </li></ul><ul><li>General Thoracic Surgery </li></ul><ul><ul><li>Pulmonary </li></ul></ul><ul><ul><li>Chest Wall </li></ul></ul><ul><ul><li>Mediastinal </li></ul></ul><ul><ul><li>Pleural </li></ul></ul><ul><ul><li>Pericardial </li></ul></ul><ul><ul><li>Neural </li></ul></ul>
    3. 3. Thoracic Surgery: Pulmonary Surgery <ul><li>Infections </li></ul><ul><ul><li>TB </li></ul></ul><ul><ul><li>Lung Abscess </li></ul></ul><ul><ul><li>Bronchiectasis </li></ul></ul><ul><ul><li>Fungi </li></ul></ul><ul><ul><li>Parasitic </li></ul></ul><ul><li>Trauma </li></ul><ul><ul><li>blunt vs. penetrating </li></ul></ul><ul><li>Congenital </li></ul><ul><ul><li>cystic fibrosis </li></ul></ul><ul><li>Emphysema </li></ul><ul><li>Neoplasms </li></ul><ul><ul><li>Bronchogenic CA </li></ul></ul><ul><ul><li>Other malignant tumors </li></ul></ul><ul><ul><li>Lung Metastasis </li></ul></ul><ul><ul><li>Benign tumors </li></ul></ul><ul><li>Palliative </li></ul><ul><ul><li>pleural-pericardial effusion </li></ul></ul><ul><ul><li>airway obstruction </li></ul></ul>
    4. 4. Stop at the Pleura! A Brief History of Thoracic Surgery Frederic W. Grannis Jr. MD City of Hope National Medical Center, Duarte, California
    5. 5. H. M. Block <ul><li>Experimenteles zur Lungenresection </li></ul><ul><li>von Dr. Block (Danzig) </li></ul><ul><li>Deutsche Medizinische Wochenschrift </li></ul><ul><li>7:634-6, 1881 </li></ul>
    6. 6. Letter from Berlin: Resection of the Lung as Proposed by Dr. Block G.L. Walton. Boston Medical and Surgical Journal, Vol CVII:261-262. February 23, 1883
    7. 7. Bronchoscopy <ul><li>Gustav Killian </li></ul>1898
    8. 8. Physiology of the Open Chest <ul><li>1898 J. B. Murphy </li></ul><ul><li>1918 Evarts Graham </li></ul><ul><li>Because of the rapidly deteriorating condition of the patient with an open chest, the most important factor in early surgical cases was time . </li></ul>
    9. 9. Ludolph Breuer <ul><li>Uberdruck </li></ul>1904
    10. 10. Ferdinand Sauerbruch Unterdruck 1904
    11. 11. Chausier Ribemont Gairal Early Endotracheal Tubes Geudel 1928
    12. 12. Endotracheal Intubation Whelan Doyen
    13. 13. Fell+O’Dwyer 1898
    14. 14. Meltzer and Auer New York 1909
    15. 15. History of Lung Cancer <ul><li>The most salient point in the history of lung cancer is that it was almost non-existent before the twentieth century. </li></ul><ul><li>Adler reported 221 collected cases to 1900 and 374 to 1912. </li></ul><ul><li>Cigarette smoking as etiology first suspected by Soemmerling. </li></ul>
    16. 16. Evarts Graham Pneumonectomy 1932 Cautery Pneumectomy
    17. 17. Lothar Heidenhain First resection of a lung cancer 1903 (incidental in lobectomy for bronchiectasis)
    18. 18. Davies First anatomic dissection c. 1912
    19. 19. Pleurodesis v. Mickulykz
    20. 20. Tourniquets Shenstone Roberts
    21. 21. Bulau 1873
    22. 22. Pulmonary Resection circa 1930
    23. 23. <ul><li>“ There is bleeding and infectious leakage from the lung, and bleeding from the diaphragm. Tight closure of the chest without drainage seems inadvisable under such conditions, and yet necessary to avoid the ills of postoperative pneumothorax. Suddenly, it is obviously time to return the patient to his bed. Not much has been accomplished...And, after all, the greatest dangers occur after the operation.” </li></ul>Samuel Robinson 1925
    24. 24. “ Modern” Pulmonary Resection <ul><li>Developed from an international collaborative effort on the part of a number of surgeons and anesthesiologists over a period of approximately 50 years. </li></ul><ul><li>By 1940 thoracic surgeons were prepared to face the new epidemic of lung cancer. </li></ul>
    25. 25. Components of “Modern” Thoracic Surgery <ul><li>Anatomic-Pathologic Diagnosis </li></ul><ul><li>Endotracheal intubation and positive pressure ventilation </li></ul><ul><li>Anatomic dissection and individual ligation </li></ul><ul><li>Secure bronchial closure </li></ul><ul><li>Closed pleural suction drainage </li></ul><ul><li>Respiratory therapy and ventilatory support </li></ul><ul><li>Antibiotic therapy </li></ul>

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