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Over the past decade, single (SLTx) and bilateral (BLTx) lung transplantation have become accepted therapies for patients with end-stage lung disease. The choice between SLTx and BLTx has been primarily determined by the underlying disease process. Suppurative disorders, such as cystic fibrosis or bronchiectasis, require obligatory replacement of both lungs. Conversely, adequate correction of the physiologic defect in pulmonary fibrosis and pulmonary hypertension has been achieved with SLTx. Emphysema was originally treated with double lung or combined heart-lung transplantation so as to avoid compression of a single lung allograft by the overly compliant contralateral native lung following SLTx. Subsequent experience showed that replacement of a single lung was well tolerated. The persistent shortage of donor organs necessitates the use of single lung allografts in suitable patients to allow organ sharing. However, current data suggest that there is a survival advantage for recipients of bilateral grafts[1] (Chapters 65 and 69). Yet providing an individual patient with two grafts may conflict with the needs of the total recipient population. This issue is particularly acute for patients with chronic obstructive lung disease.

The aim of lung volume reduction surgery is to alleviate the symptoms of severe emphysema and to improve the life quality of the patient. The appropriate candidates (approximately 20% of all emphysematic patients examined in our clinic) had considerable dyspnea, an increased lung capacity, and a heterogenous dissemination of the emphysema with regional destruction of the parenchyma, hyperinflation and poor perfusion. After preoperative physiotherapie with a specified rehabilitation aim, a resection of 20 to 30% of the total lung volume was performed via sternotomy. From January 1993 to February 1996, 150 patients underwent bilateral lung volume reduction (age range = 36 to 77 years). The mean forced expiratory volume in 1 s (FEV1) was preoperatively 25% of the predicted value, the total lung capacity (TLC) 142% and the residual volume (RV) 283%, 94% of these patients necessitated oxygen supply at rest or during exercise. The 90-day mortality was 4%. All patients except 1 were extubated immediately after operation. The median hospital stay was 10 days in the first 100 patients and 7 days in the last 50. An increase of the FEV1 by 51% and a decrease of the RV by 28% was observed 6 months after operation. The mean PaO2 was improved by 8 mm Hg while the percentage of oxygen dependent patients went down from 50 to 16%. In addition a raise of the perseverance capacity, a clear decrease of dyspnea and an improvement of the life quality were achieved. These results persist after 1 (n = 56) and 2 (n = 20) years after operation. Lung volume reduction leads to an improvement of the lung function, symptoms and the quality of life, which is superior to that achieved by maximal clinical intervention.

Lung volume reduction (LVR) for advanced emphysema improves lung function and restores respiratory excursion of chest wall and diaphragm. Between January 1993 and February 1996, bilateral LVR via sternotomy was performed in 150 patients with an early mortality (60 days) of 2% (3/150). In 90 patients, FEV1 rose from 0.7 (24% pred.) preoperatively to 1.1 L (37% pred.) at 6 months (57% increase; p0.001). In the same interval, O2 requirements decreased during exercise from 95 to 46% of patients and from 50 to 16% of patients on continuous O2. After 1 (n = 54) and 2 (n = 15) years, the improvements in FEV1, pO2, 6-min walking distance, and dyspnea, and the reduction of TLC and RV remained stable. In selected patients, bilateral LVR results in marked improvement of emphysema-related disability and offers excellent palliation.

While resection of tracheobronchial segments has become a standard operation in adults, lesions of the carina in children are rare and their treatment is technically more demanding. Since 1980, 8 patients aged 8 to 19 years underwent surgical reconstruction of the carina. The indications were tumors in 5 and non-neoplastic lesions in 3. In 3 patients with tumor (2) and advanced histoplasmosis (1), resection of the carina was combined with parenchymal resection. The principles of operative repair include complete resection, with frozen section confirmation in tumors, particular emphasis on adequate mobilization of the airway in children to reduce anastomotic tension, and use of anesthetic techniques that facilitate early extubation. One patient (12.5%) died after complex airway reconstruction for extensive mediastinal fibrosis. Residual malacia in a patient with postpneumonectomy syndrome required successful re-resection. Seven patients remain free of anastomotic stricture and tumor recurrence during a mean follow-up of 62 months (range 5 to 132 months), with expected preservation of lung function. Late bronchoscopy in 5 patients 6 months to 11 years after operation demonstrated growth of the luminal diameter and patent anastomoses. Carinal reconstruction in children is occasionally required, succeeds in general, and does not result in late problems at the anastomosis.

The advantages of the tracheal T-tube compared with a regular tracheostomy tube are a physiologic direction of air flow, preservation of laryngeal phonation, and superior patient acceptance. Between 1968 and 1991, 140 patients aged 7 months to 95 years underwent placement of T-, TY- (n = 7), or a modified extended T-tube (n = 4). Primary diagnosis was postintubation stenosis in 86 patients, burn injury in 13 patients, malignant airway tumors in 12 patients, and various disorders in 29 patients. Stenting with a silicone rubber tube was temporary in 31 patients and 14 underwent later operative reconstruction. Definitive permanent insertion was performed in 49 patients. A modified tube was used in 4 patients with left main bronchial stenosis with effective long-term palliation in 3. Postoperative airway obstruction prompted placement in 32 patients. Positioning of the T-tube above the vocal cords in 12 patients for subglottic stenosis was effective in 10. The T-tube was not tolerated in 28 patients (20%) because of obstruction of the upper limb or aspiration. Five of 10 patients under the age of 10 years had airway obstruction necessitating tube removal. Long-term intubation in 112 patients exceeded 1 year in 49 patients and 5 years in 12 patients. Only 5 patients required tube removal for obstructive problems more than 2 months after placement. The tracheal T-tube restores airway patency reliably with excellent long-term results and represents the preferred management of chronic airway obstruction not amenable to surgical reconstruction.

Esophageal replacement remains a challenge. Colon and jejunum provide alternative conduits to replace the lower esophagus when stomach is not suitable. Between 1971 and 1991, 41 patients underwent short-segment interposition of the esophagus with jejunum or colon. Indications were failed antireflux procedures (n = 21), nondilatable stricture (n = 9), achalasia (n = 2), moniliasis (n = 2), Barrett's esophagus with carcinoma in situ (n = 2), hemorrhagic esophagitis after esophagogastrectomy (n = 1), motility disorder (n = 1), instrumental perforation (n = 1), carcinoma (n = 1), and leiomyosarcoma (n = 1). Thirty-one patients (75.6%) had prior surgical procedures. Interposition with colon was performed in 22 patients and with jejunum in 19. Major complications occurred in 45% after colon interposition (10/22) and hospital mortality was 4.5% (1/22). Major complications after jejunal interposition occurred in 31% (6/19) and hospital mortality was 10.5% (2/19). A contained anastomotic leak occurred in 1 patient, perforation of a colon segment in 1, and jejunal graft necrosis in a third. Late functional results in 34 patients with a mean follow-up of 87 months were excellent or good in 26, fair in 5, and poor in 1. Colon interposition failed to improve symptoms in 2 patients with gastrointestinal motility disorders. Six patients underwent manometry and barium food provocation study. Two colon segments and 3 jejunal interpositions were hypoperistaltic or aperistaltic according to manometry. There was 1 case of aperistaltic jejunum with a distended afferent loop. When stomach is not available, successful palliation of swallowing can be accomplished with either jejunum or colon. Surgeons involved in the management of esophageal disease should be familiar with the technical details of both procedures.

Because epidermal growth factor (EGF) is rapidly bound and internalized into rat pancreas, stimulates uptake of tritiated thymidine, and increases pancreatic weight, a cocarcinogenic effect on pancreatic cancer seemed likely. Pancreatic adenocarcinomas were induced in 70 female Syrian hamsters by 19 weekly s.c. injections of N-nitrosobis(2-oxopropyl)amine (BOP) (10 mg/kg). From Wk 5 through Wk 8 of BOP injections, additional s.c. injections of EGF (5 micrograms every 3 days for 10 injections) were given to 45 animals, while 25 received saline solution. An additional group of 10 received EGF alone, and another 10 animals received saline solution alone (controls). Eleven wk later, the mean body weight of EGF-treated animals increased by 29% as compared with that of controls, and their mean pancreatic weight relative to body weight increased by 44% as compared with controls. The mean body weight of EGF + BOP-treated animals increased by 10%, and their pancreatic weight relative to body weight increased by 22% as compared with that of animals treated with BOP alone. The incidence of pancreatic cancer in the EGF + BOP-treated animals was 75% versus 44% in those treated with BOP alone (P = 0.016). No tumors developed in either animals treated with EGF alone or control animals. EGF augments pancreatic carcinogenesis induced by BOP. The incidence of bronchial carcinomas doubles.

Because ulcerative colitis predisposes to colonic cancer, for determination of the effect of colitis on experimental colon carcinogenesis, rectal instillations of peptides that attract and activate neutrophils were used to induce colitis in CD-1 (ICR) BR mice receiving 20 weekly injections of the carcinogen 1,2-dimethylhydrazine [(DMH) CAS: 540-73-8]. From week 4 through week 15 of DMH injections, twice-weekly enemas of formyl-norleucyl-leucyl-phenylalanine were given to DMH-treated mice. The effect of the antioxidant vitamin E in the diet (1,750 IU/kg diet) was studied in another group of mice treated with DMH and having colitis. Four weeks after DMH was discontinued, cancer occurred in 9 of 28 (32%) animals with DMH plus control enemas, in 22 of 29 (76%) animals with DMH plus colitis (P = .001), and in 16 of 28 (57%) animals with DMH plus colitis plus supplemental vitamin E (P = .11 compared with the group with DMH and colitis). Colitis enhances DMH-induced colonic carcinogenesis.