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

Human Serum Albumin in the Clinical Syndrome of Heart Failure

In 1921 in Holland, Peutz 1 first reported this interesting condition. Later, more elaborate attention was given to the syndrome by Jeghers, 2 and finally, in 1954, Bruwer et al 3 bestowed the title of "Peutz-Jeghers syndrome" on this unusual clinical condition of mucocutaneous melanin pigmentation with coincidental intestinal polyposis. Earlier authors 1,2,4 considered the polyps to be adenomatous, implying a possible precancerous condition. Approximately 20% of the case reports contained descriptions of malignant changes within the polyps. Later, other investigators 5-7 felt that this high incidence of malignancy resulted from misinterpretation of the peculiar nature of these polyps, which they defined as "hamartomas." This interpretation has now gained general acceptance and has been confirmed recently by electron microscopy. 8 Isolated reports of apparent gastrointestinal tract malignancies in patients with the PeutzJeghers syndrome have stimulated further thought on the interpretation of evidence and, therefore, the proper treatment of the patients.

The Peutz-Jeghers Syndrome: Is There a Predisposition to the Development of Intestinal Malignancy?

Results of surgical treatment of thymomas with special reference to the involved organs.

The Lung: Clinical Physiology and Pulmonary Function Tests

We have treated 40 patients with thymoma. All the 18 with benign thymoma were treated with resection alone and none had a tumor recurrence or died from disease-related causes. Postoperative survival in this group ranged from 2 months to 14 years. Of the 22 patients with malignant thymoma, 2 underwent total resection, 10 partial resection and 10 were non-resectable. Fifteen of the 20 patients with non-resectable and partially excised thymomas were given radiotherapy. The cumulative 5- and 10-year survival rate of irradiation treated patients was 45.6%, and 34.4%, respectively. Of 6 non-irradiated patients, only one who underwent complete excision of tumors survived for more than 10 years, and 5 died within 3 years after treatment. Based on our findings we suggest that all patients with malignant thymoma, irrespective of the extent of surgical treatment, should be given postoperative irradiation.

Thymoma: clinicopathologic features, therapy, and prognosis.

The effect of decreased plasma colloid osmotic pressure on the development of pulmonary edema was studied in anesthetized dogs. Lung lymph flow was used aa a sensitive and reliable indicator of fluid filtration rate in the lung. When plasma colloid osmotic pressure alone was reduced by slow infusion of saline, and hydrostatic pressure in the pulmonary vascular bed was maintained at normal level by exsanguination, lung lymph flow increased almost linearly with the reduction in colloid osmotic pressure, but was not increased more than five fold of the control, despite a reduction of 80% in the plasma colloid osmotic pressure. Furthermore, there was no evidence of fluid in the tracheal aspiration and no gross evidence of pulmonary edema. In contrast, both decrease in colloid osmotic pressure and increase in pulmonary capillary hydrostatic pressure produced a marked increase in lung lymph flow. This flow varied linearly with the level of the pulmonary artery wedge-plasma colloid osmotic pressure difference and approached twelve fold of the control, when the plasma colloid osmotic pressure was reduced by 73% and the pulmonary artery wedge pressure was elevated by 20 mmHg from the baseline. Our data indicate that decreased colloid osmotic pressure is not associated with the development of pulmonary edema, when there is no increase in pulmonary vascular hydrostatic pressure.

Effect of decreased plasma colloid osmotic pressure on development of pulmonary edema in dogs.

The effect of the site of operation on postoperative hypoxemia was studied in 104 patients undergoing thoraco-abdominal, thoracic, upper abdominal, lower abdominal, extra-abdominal and non-thoracic operations. The degree of postoperative hypoxemia was the most extensive in patients undergoing thoraco-abdominal, moderate in thoracic and upper abdominal operations, and minimal in lower abdominal and other operations. On the other hand, the duration of hypoxemia also differed with the surgical procedures. Arterial oxygen tension returned to almost control values by the 3rd postoperative day in cases of lower abdominal and extremity operations and by the 7th postoperative day in those undergoing thoracic and upper abdominal surgery. Postoperative hypoxemia, however, remained throughout the fourteen day study period, in patients undergoing thoraco-abdominal operation. True shunt was measured in 27 patients with thoraco-abdominal, thoracic and upper abdominal operations. An increase in true shunt was evident postoperatively in the entire group of patients. The increase was significantly larger and longer lasting in cases of thoraco-abdominal incision than that in cases of thoracic and upper abdominal incision alone. Differences in postoperative true shunt between cases of thoracic and upper abdominal incisions were nil.

Relationship between postoperative hypoxemia and the operative site

A light and electron microscopic study of a case of multiple pulmonary fibro-leiomyomatous hamartoma is described. Like the previous reports, the patient was an old woman with no complaint. The histologic features were characterized by mingling with rich fibroblasts and mesenchymal cells. The definite diagnosis was made by the features which were detected ultrastructurally. In this case, we considered that the fibrous component was more predominant than the leiomyomatous component.

A resected case of pulmonary multiple fibro-leiomyomatous hamartoma--light and electron microscopic study.

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.

Takero Yoshida

Papers

Thymoma: clinicopathologic features, therapy, and prognosis.

Effect of decreased plasma colloid osmotic pressure on development of pulmonary edema in dogs.

Relationship between postoperative hypoxemia and the operative site

A resected case of pulmonary multiple fibro-leiomyomatous hamartoma--light and electron microscopic study.

Evaluation of the Risk of Postoperative Pulmonary Complications