Document EdM7GBMZB4kNVq6j4Zp2Mbb3x

FILE NAME Kent KNT DATE 1965 Oct 18 DOC KNT160 DOCUMENT DESCRIPTION Journal Article - Pleurectomy - The Journal of The American Medical Association ---- --...-- --,, 1965 VOL 194 NO 3 THE DAVID L. TILDERQUTED MEMORIAL MEDICAL LIBRART OCTOBER 18 1965 THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION ORIGINAL CONTRIBUTIONS PETIT MAL EPILEPSY MD Samuel Livingston MD Numinada Torres L. L. Pauli MD and R. V. Rider ScD Baltimore SURGICAL CURE OF MALIGNANT W. L. Strickler MD Boston HYPERTENSION 227 233 GONOCOCCAL ARTHRITIS IN CHILDREN C. W. Fink MD Dallas 237 SPIROMETRY IN A MEDICAL CLINIC S. W. Rosner MD Sidney Abraham and C. A. Caceres MD Washington DC 239 TRANSIENT OCCLUSION OF MIDDLE CEREBRAL S. A. Holfin MD and Allen Silverstein MD New York ARTERY 243 INACTIVATED MYCOPLASMA PNEUMONIAE VACCINE K. E. Jensen PhD L. B. Senterfit ScD Terre Haute Ind R. M. Chanock MD C. B. Smith MD and R. H. Purcell MD Bethesda Md 248 PRELIMINARY COMMUNICATION PLEURECTOMY John Helwig Jr. MD Rachel Ash MD Sidney Friedman MD T. G. Daughtridge MD and Julian Johnson MD Philadelphia 253 CLINICAL SCIENCE ANTIBODIES AND IMMUNOGLOBULINS II NORMAL DEVELOPMENT AND CHANGES IN DISEASE J. L. Fahey MD Bethesda Md 255 SPORTS CONTRIBUTIONS SPORT PARACHUTING AND SKY DIVING A. J. Ryan MD Madison Wis and C. L. Thomas MD Wilbraham Mass PARACHUTING FOR SPORT Maj F. W. Kiel MC USA Washington DC 259 264 MATHEMATICAL BIOLOGY MODELS AND MATHEMATICS J. T. Apter MD PhD Chicago 269 CURRENT CONCEPTS IN CANCER 8 CANCER OF CERVIX STAGE IV AND RECURRENT Philip Rubin MD Rochester NY Alexander Brunschwig MD and E. W. Munnell MD New York Walter Murphy MD Buffalo and J. C. Bateman MD Washington DC 273 NEGATIVE RESULTS CANCER TREATMENT BY THE METHOD OF REVICI David Lyall MD M. S. Schwartz MD F. P. Herter MD P. B. Hudson MD J. C. Wright MD C. W. Findlay MD New York J. M. Galbraith MD Glen Cove NY A. P. Stout MD and C. D. Haagensen MD New York 279 LEGAL MEDICINE A SURVEY OF THE LAW OF MEDICAL PRACTICE IV NEGLIGENCE IN THE PRACTICE OF MEDICINE Sidney Shindell MD LLB Pittsburgh 281 CONTENTS CONTINUED AND COVER STORY Adv Page 5 a | 683 NW Hin<ng og BACTERIAL IMMUNOFLUORESCENCE DEFENDANT'S DEFENDANT'S EXHIBIT 0078 ATXONE LEON a | 0666 0 9621062h09200092000565 9621062h09200092000565 NO 1.120 j Preliminary Communication Pleurectomy | John Helwig Jr. MD Rachel Ash MD Sidney Friedman MD T. Giffin Daughtridge MD and Julian Johnson MD leurectomy was used to stimulate systemic- pulmonary anastomoses as a palliative treat- ment for patients with cyanotic congenital heart disease with pulmonary hypertension To our knowledge the successful application of this principle suggested to us by Bernice Wedum MD has not heretofore been reported Patients with pulmonary hypertension associated with a right shunt within the heart have systemic hypoxia due to the combination of a decreased effective pulmonary blood flow secondary to the mechanical pulmonary block and the effects of the right shunt itself As a result of pulmonary arteriolar obliterative changes For editorial comment see page 290 the pulmonary resistance is equal to or greater than the systemic resistance In effect multiple peripheral pulmonary stenoses exist In 1949 Barrett and Daley described pleurec- tomy blood heart as a method for increasing the pulmonary flow in patients with cyanotic congenital disease with a decreased pulmonary blood flow and low pulmonary pressures They demonstrated the development of large effective bronchopulmonary anastomoses with considerable clinical improvement in these patients Through the years this method of palliation has been em- ployed in patients in whom Blalock or Pott's shunts could not be performed for technical rea- sons and who were not amenable to heart corrective surgery Liebow and his coworkers have beautifully demonstrated by injection studies the bronchopulmo- nary anastomoses in health and disease We will use the term bronchial arteries to include all systemic arteries that supply or become related to the lungs as does Liebow These precapillary anasto- moses are difficult to demonstrate in health but may become very large in obliterative disease of the lungs or in tetralogy of Fallot with low pul- monary pressures Heath found the bron- From the Cardiovascular Clinical Research Center Hospital of the University of Pennsylvania the Children's Hospital of Philadelphia and the departments of medicine pediatrics radiology and surgery School of Medicine University of Pennsylvania Philadelphia Dr. Helwig is now with the Cardiovascular Section Germantown Dispensary and Hospital Philadelphia Reprint requests to Germantown Hospital Philadelphia 19144 Dr. Helwig widespread tensive pulmonary disease with occlusion of pulmonary arteries These arteries gave rise to walled systemic branches which entered the lung parenchyma The observations of Liebow and Heath suggested that these systemic pulmonary anastomoses were distal to the pul- monary arteriolar obstruction of these patients with pulmonary hypertension and might be stimu- lated to develop by pleurectomy as has been shown to be effective in patients with pulmonary stenosis Therefore the rationale of the currently proposed procedure is to bring collateral blood flow into the pulmonary circulation at the level of the precapillaries and hence to increase the amount of unsaturated blood flow past the capillary interface Report of a Case A girl born on Jan 13 1947 was admitted to the Children's Hospital of Philadelphia in 1948 and a diagnosis of pseudotruncus arteriosus was made The first Pott's operation done at the Children's Hospital was performed and the anastomosis was made 4 mm in diameter Immediately postoperatively she was pink and did extremely well The marked improvement in clinical status was to portend the progressive development of pulmonary hypertension probably the result of too large a pulmonary anastomosis Because of increasing dyspnea and cyanosis she was admitted to the Hospital of the University of Pennsylvania in September 1964 at which time right and retrograde left cardiac catheterizations were performed The diagnosis of pseudotruncus arteriosus was confirmed by hemodynamic and cineangiocardiographic studies The pulmonary artery was intubated by way of the Pott's anastomosis in a retrograde fashion and both the aortic and pulmonary pressures were found to be 110/70 mm Hg The hemoglobin level was 18.4 100 cc and the hematocrit reading % Both the patient and her mother were most anxious that something be done Pleurectomy on the right side was performed on Sept 28 1964 and the surface of the lung was sprinkled with powdered asbestos The patient had an uneventful postoperative course with a progressive increase in exercise tolerance In March 1965 she was readmitted to the University of Pennsylvania Hospital for reevaluation At this time the patient could 1. Preoperative chest ray film Sept 21 1964. Post- operative chest ray film March 8 1965 was un- changed except for pleural thickening on right side JAMA Oct 18 1965 o Vol 194 139 2. Selective right middle intercostal changer arteriography demonstrates rapid filling of pulmonary veins second after injection upper left 1seconds after injection injection lower lower right upper right 2 seconds after left and 4 seconds after injection climb one flight of stairs without dyspnea whereas prior to surgery a climb of only four steps caused significant dyspnea On physical examination she was considerably less cyanotic and the hemoglobin level was 16.2 100 cc and the hematocrit reading was 56 The chest ray film Fig 1 and electrocardiogram were essentially unchanged Her arterial oxygen pressure Po was 42 mm Hg 78 saturation compared to preoperative Po of 33 mm Hg 64 saturation Selective retrograde intercostal changer arteriography demonstrated significant collateral blood flow from the intercostal and bronchial arteries to the lung with early opacification of the right pulmonary veins Fig 2 Considering that the postoperative study was done only 5months following pleurectomy the degree of collateral circulation was remarkable Comment The clinical course and the angiographic demonstration of significant induced collateral circulation to the right lung of the patient with cyanotic congenital heart disease and pulmonary hypertension strongly suggest that pleurectomy was of real palliative benefit The angiograms demonstrate conclusively that blood now flows from the systemic circulation through the pulmonary parenchyma into the pulmonary veins Although preoperative intercostal arteriograms were not obtained the fact that no significant adhesions between the parietal and visceral pleura were found at surgery excludes the possibility that all the collaterals were due to preexisting bronchial collaterals alone The marked change in systemic oxygen saturation strongly suggests that this collateral blood flow undergoes oxygenation at the alveolar level On the basis of the observations made on this patient we believe a cautious further trial of this procedure is indicated This study was supported in part by Public Health Service grant 06352 and by the John A. Hartford Foundation References 1. Barrett W.R. and Daley R A Method of Increasing the Lung Blood Supply in Cyanotic Congenital Heart Disease Brit Med J 699-702 April 23 1949 2. Liebow A.A Hales M.R and Bloomer of Bronchial to Pulmonary Vascular Tree in Veith I. eds Pulmonary Circulation New Stratton Inc. 1959 pp 79-98 W.E Relation Adams W. and York Grune & 3. Heath D Structural Alterations of Pulmonary Vessels in Response to Pulmonary Hypertension in Adams W. and Veith I. eds Pulmonary Circulation New York Grune & Stratton Inc. 1959 pp 122-125 140 JAMA Oct 18 1965 Vol 194 No 3