Role of physiological lung exclusion in difficult lung resections for massive hemoptysis and other problems

Broncho-esophageal fistula: When surgery and endoscopy fail, consider physiological lung exclusion

We discuss the case of an esophageal cancer patient treated by chemo and radiotherapy complicated by an esophageal stenosis and an iatrogenic broncho-esophageal fistula. This latter was managed with multiple palliative stenting procedures and colonic surgical bypass. Despite a long disease free survival but decreased quality of life and frailty, we came to the proposal of an extremely unusual form of treatment - physiological lung exclusion, with clinical benefit and so far without any drawbacks related to the procedure.

Physiological Lung Exclusion in Tetralogy of Fallot Without Left Pulmonary Artery With Aspergilloma

Tetralogy of Fallot with unilateral absence of the pulmonary artery is a rare congenital cardiac disorder that makes the ipsilateral lung susceptible to opportunistic infections. This disorder adds to the complexity of the case and tests the surgical and decision-making skills of the surgeon. We present an adult male patient with tetralogy of Fallot and absent left pulmonary artery who underwent physiologic exclusion of the left lung for aspergilloma along with intracardiac repair as a single stage procedure.

Management of severe hemoptysis

INTRODUCTION

Though rare, severe hemoptysis (SH) is associated with a mortality rate exceeding 50% when not managed properly. Areas covered: This paper reviews the recent epidemiological data regarding SH, the role of multidetector computed tomography angiography (MDCTA), and fiberoptic bronchoscopy (FOB) in its management, as well as the value of current treatments. Expert commentary: MDCTA is becoming an essential modality, since it allows determining the location, etiology, and mechanism of the bleeding. FOB can be delayed, except when local control of bleeding is required. Emergency treatment relies on interventional radiology. Both bronchial and non-bronchial arteries should be explored during bronchial arteriography. Surgery must be considered in all operable patients if the cause of hemoptysis persists.

Extracorporeal membranous oxygenation (ECMO) in polytrauma: what the radiologist needs to know

The purpose of this article is to review the spectrum of severe traumatic injuries treatable with ECMO and their imaging features, considerations for cannula placement, and complications that may arise in polytraumatized patients on extracorporeal life support. Recent major advances in miniaturization and biocompatibility of ECMO devices have dramatically increased their safety profile and expanded the application of ECMO to patients with severe polytrauma.

Massive hemoptysis controlled with transection of a pulmonary vein and bronchus--a case report

Massive hemoptysis caused by bronchiectasis in which bronchial artery embolization does not control the bleeding is not rare. Traditional surgical intervention is anatomical lung resection. We present a case of a patient with bronchiectasis and massive hemoptysis in which the bleeding was controlled with transection of a pulmonary vein and bronchus with preservation of the pulmonary artery.

Challenges in the management of massive haemoptysis in a resource-scarce facility

Massive hemoptysis is a life-threatening condition requiring multidisciplinary management not often available in resource-deprived countries with a limited range of therapeutic options. Prognosis is poor when salvage surgery is offered during active bleeding.

Surgical lung resection for severe hemoptysis

BACKGROUND

The role of surgical lung resection in the management of severe hemoptysis has evolved after advances in interventional radiology. We sought to describe the indications for surgical lung resection in such patients and to identify predictive factors of postoperative complications.

METHODS

This study is a retrospective analysis (May 1995 to July 2006) of consecutive patients referred to the intensive care unit of a tertiary hospital for severe hemoptysis who underwent surgical lung resection.

RESULTS

Among 813 patients referred for severe hemoptysis, 111 underwent surgical lung resection. Interventional radiology had been first attempted in 87 patients (78%); 68 underwent surgery because of a failed procedure (n = 28) or bleeding persistence or recurrence within 72 hours despite a completed procedure (n = 40); 19 patients underwent surgery after bleeding control. The remaining 24 patients (22%) were directly referred to the surgeon (5 for emergency surgery). Overall, surgery was performed in emergency (n = 48), scheduled after bleeding control (n = 48), or planned after discharge (n = 15). The main indications for surgery were mycetoma, cancer, bronchiectasis, and active tuberculosis. Surgery for mycetoma (odds ratio, 9.4; 95% confidence interval, 2.8 to 32), emergency surgery (odds ratio, 5.3; 95% confidence interval, 1.8 to 16), and pneumonectomy (odds ratio, 4.7; 95% confidence interval, 1.2 to 18) independently predicted complications. Fifteen patients died in the intensive care unit, of whom 14 underwent emergency surgery. Chronic alcoholism (odds ratio, 4.6; 95% confidence interval, 1.1 to 19), the need for mechanical ventilation or vasoactive drugs on admission (odds ratio, 8.2; 95% confidence interval, 1.9 to 35), and blood transfusion before surgery (odds ratio, 8; 95% confidence interval, 1.5 to 42) predicted mortality.

CONCLUSIONS

Attempting at controlling bleeding with first-line nonsurgical approaches appears necessary to optimize the operative conditions and improve outcome of patients with severe hemoptysis.

L’hémoptysie massive : prise en charge et traitement Quelle est la place de la chirurgie ?

OBJECTIVE

To define the role of interventional radiology and surgery respectively, in the treatment of massive haemoptysis. GENERAL CONSIDERATIONS: For the management of massive haemoptysis in non-terminal pathologies an intensive care facility and a multi-disciplinary team are necessary. It is of paramount importance to identify rapidly the pulmonary or bronchial source of the bleeding. CT scanning and bronchoscopy are essential to localise the bleeding and determine its cause. Initial management. An attempt to control the initial bleeding to allow localisation of its origin and determine the treatment.

TREATMENT

Bronchial or systemic embolisation and surgery are the only effective medium and long-term treatments. Embolisation achieves excellent results in bleeding from bronchial or parietal systemic arteries prior to surgery and may be the only technique possible in the presence of major co-morbidity. Surgery is necessary in the case of failure, in certain specific conditions, and in the case pulmonary artery haemorrhage from a proximal lesion. Various surgical techniques are available depending on the type of lesion encountered and the facilities for post-operative care. Emergency surgery carries a high risk and deferred surgery gives better results.

CONCLUSION

The management of massive haemoptysis should be multi-disciplinary. Intensive care, respiratory and radiological diagnosis, Surgical management and interventional radiology should be combined to improve the prognosis of this grave condition. Pulmonary arterial haemorrhage from a necrotic tumour constitutes a surgical emergency and should be operated on without delay.

Surgical management of tuberculosis-related hemoptysis

BACKGROUND

Tuberculosis is a disease that is often treated with chemotherapy. However, medical treatment usually fails in the management of tuberculosis-related hemoptysis. In this paper, we review our experience in the surgical treatment of tuberculosis-related hemoptysis.

METHODS

Fifty-nine patients with tuberculosis-related hemoptysis (46 men, 13 women) who underwent surgical treatment were enrolled in this study. A thoracotomy was performed urgently in 21 patients with massive (>600 mL daily) hemoptysis, and within the first 2 days in 24 with major (200 to 600 mL daily) hemoptysis, and within the first 4 days in 14 with persistent minor (<200 mL daily) hemoptysis.

RESULTS

A chest roentgenogram showed cavitary lesion in all of the patients with massive hemoptysis (21 patients), in 22 of 24 patients with major hemoptysis, and in 3 of 14 patients with persistent minor hemoptysis. Pneumonectomy was performed in 4 patients, lobectomy in 39 patients, and segmentectomy or wedge resection in 16 patients. The average hospitalization period was 13 days. The mortality rate was 6.8% perioperatively. Of the patients deceased, 3 were intubated with a single-lumen endotracheal tube and 1 with a double-lumen endotracheal tube. During the postoperative period, empyema and bronchopleural fistula developed in 3 patients, and no other severe complications occurred. The average postoperative follow-up period was 3 years. The number of thoracotomies for tuberculosis performed in the years from 1995 to 2003 was significantly decreased, compared with the years between 1985 to 1994 (p = 0.042).

CONCLUSIONS

In tuberculosis-related hemoptysis, thoracotomy with double-lumen endotracheal intubation and resection of the cavity may be curative and lifesaving.