Introduction This randomized controlled study evaluated the clinical benefit and physiological effects of prophylactic chest physiotherapy in open major abdominal surgery.

Methods A group of 174 patients received chest physiotherapy including breathing with pursed lips, huffing and coughing, and information about the importance of early mobilization. In addition high-risk patients were given resistance training on inspiration and expiration with a mask. The resistance used during inspiration was −5 cmH2O and that during expiration +10 cmH2O. The control group (194 patients) received no information or treatment unless a pulmonary complication occurred.

Results Oxygen saturation on postoperative days 1–3 was significantly greater in the treatment group. Treated patients were mobilized significantly earlier. No difference was noted in peak expiratory flow rate or forced vital capacity. Postoperative pulmonary complications occurred in 6 per cent of patients in the treatment group and in 27 per cent of controls (P<0·001). In high-risk patients the numbers with pulmonary complications were six of 40 and 20 of 39 respectively. Pulmonary complications were particularly common in patients with morbid obesity.

Conclusion Preoperative chest physiotherapy reduced the incidence of postoperative pulmonary complications and improved mobilization and oxygen saturation after major abdominal surgery.

Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery

• Preoperative spirometry is commonly ordered before abdominal surgery, with the goal of predicting and preventing postoperative pulmonary complications. We assessed the evidence for this practice with a systematic literature search and critical appraisal of published studies. The search identified 135 clinical articles, of which 22 (16%) were actual investigations of the use and predictive value of preoperative spirometry. All 22 studies had important methodological flaws that preclude valid conclusions about the value of screening preoperative spirometry. The available evidence indicates that spirometry's predictive value is unproved. Unanswered questions involve (1) the yield of spirometry, in addition to history and physical examination, in patients with clinically apparent lung disease; (2) spirometry's yield in detecting surgically important occult disease; and (3) its utility, or beneficial effect on patient outcome. Spirometry's full potential for risk assessment in the individual patient has not yet been realized. (Arch intern Med1989;149:280-285)

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Preoperative Spirometry Before Abdominal Operations: A Critical Appraisal of Its Predictive Value

P. TOSI,' P. LUZI,' L. LEONCINI,' C. MIRACCO,' M. GAMBACORTA,t AND A. GROSSI* The survival rates of 90 patients who underwent operation for bronchogenic carcinoma were analyzed statistically according to sex. age, tumor stage and histologic type, types of surgical procedures (lobectomy or pneumonectomy), and to immunomorphologic parameters of inimunologic activity in perihronchial and hilar lymph nodes. The Stage I group survived significantly longer than did the Stage 11 and 111 groups, the lobectomized patients survived significantly longer than the pneumonectomized patients. The absence 3r presence of lymph node metastases was one of the niajor determinants of survival. lhe mean values (percent of total node cut surface) of lymph node sinus hystiorytosis and of paracortical area could he correlated directly to survival in each of the histologic tumor-type groups. while the development of follicular cortex and germinal centers correlated inversely with survival. Increased survival might he associated with changes concomitant with immune reactirity in lymph node T-cell areas and with the sinus histiocytosis pattern, the latter representing probably a tumor-host reaction of the delayed hypersensitivity type. By contrast, increased activity of lymph node B-cell areas tended to correlate with poor prognosis of lung cancer patients. Moreover, patterns showing germinal center hyperplasia were statistically associated with lymph node neoplastic invasion, while the pattern with sinus histiocytosis and expanded paracortical areas was statistically associated with tumor-free lymph nodes. Cancer 48:2288-2295, 1981.

Bronchogenic carcinoma: survival after surgical treatment according to stage, histologic type and immunomorphologic changes in regional lymph nodes.

In patients 70 years or older, pulmonary function tests were performed before and after abdominal surgery to correlated the results with the development of postoperative pulmonary complications which developed in 48% of these patients, compared to 15% in the control group. To predict the development of PPC, preoperative analysis of the flow-volume curve is useful and
 
$$4\left( {\dot V_{50} - \dot V_{25} } \right)/forced$$

 vital capacity is a valuable parameter for the analysis of the flow-volume curve. Postoperatively, pulmonary function was reduced and there was a delay in the restoration of pulmonary function in cases with postoperative pulmonary complications. The administration of appropriate analgesics may be useful to improve postoperative ventilatory disturbances.

Pulmonary function before and after abdominal surgery in the aged

One of the most popular areas of clinical investigation has been the determination of immune status of cancer patients. Almost every issue of cancer oriented journals and of clinical immunology oriented journals contains at least one article in which some immunologic parameter is defined for a population of cancer patients. Of course, such studies are not confined to malignant disease as an extraordinary volume of literature has accumulated on the measurement of the immune parameters in a whole spectrum of pathological conditions. It is not the intent of this review to catalogue all such studies. In contrast, it is our intention to critically review the usefulness and methodology for the assessment of immunocompetence in cancer patients. Therefore, we have tended to concentrate in this review on studies with reasonable numbers of patients, where appropriate statistical analysis was included, and where reproducible methodology was employed. Even so, we have undoubtedly failed to include a large number of completely respectable scientific efforts.

Immunocompetence in Cancer Patients

Ten of 40 patients who underwent major thoracic or abdominal operations developed postoperative pulmonary complications, consisting of six massive atelectasis, three pneumonias and one edema. They were mostly thoracotomy cases and cigarette smokers. Many of these complications would have been prevented, if reliable pulmonary function tests are available to predict preoperatively such occurrence. Flow-volume curve tracing and closing volume measurement were evaluated in this respect. Both flow at the point of functional residual capacity on flow-volume curve, and the closing capacity subtracted from functional residual capacity were found to be well correlated with the occurrence of postoperative complications and can be used to evaluate the risk of pulmonary complications developing in postoperative period.

Naoto Katayama

Papers

Evaluation of the Risk of Postoperative Pulmonary Complications

Changes in T cell population in patients with bronchogenic carcinoma.