The Effect of CT-Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

The aim of the study is to investigate the effect of CT-guided artificial pneumothorax combined with a thoracoscopic and central venous catheter on empyema drainage effect and pulmonary function in children. A total of 82 pediatric patients with empyema admitted to our hospital from January 2020 to December 2021 were retrospectively analyzed. The control group was treated with artificial pneumothorax combined with thoracoscopy. The study group was treated with a CT-guided and central venous catheter. The operation time, intraoperative bleeding, surgical field exposure, WBC, C-reactive protein, and pulmonary function were compared between the two groups. The size of effusion and sonographic staging were compared between the two groups. All children underwent spirometry and a maximal incremental cardiopulmonary exercise test. The operation indicators (operation time, intraoperative blood loss, etc.) and adverse reactions were compared between the two groups. The differences in the operation time, intraoperative blood loss, postoperative hospital stay, postoperative drainage volume, and surgical field exposure between the two groups had a statistical significance (P < 0.05); the differences in the body temperature, total peripheral white blood cell count, C-reactive protein, size of effusion, and sonographic staging between the two groups had no statistical significance (P > 0.05); before operation, the differences in the expression levels of FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) and indicators of cardiopulmonary function including VE/VO2, breathing reserve(%), VD/VT(%), and VO2/work between the two groups had no statistical significance, but at 6 months after operation, FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) in the study group were significantly higher than those in the control group (P < 0.05) and VE/VO2 and VD/VT(%) in the study group were obviously lower than those in the control group (P < 0.05); the incidence rate of chest pain, pulmonary edema, and skin infection in the study group was lower than that in the control group (P < 0.05). CT-guided artificial pneumothorax combined with thoracoscopic and central venous catheter drainage of empyema in children is more thorough, with less bleeding, less trauma, rapid recovery of pulmonary function, and is worthy of clinical promotion.

[Thoracoscopic Resection of a Mediastinal Enteric Cyst Assisted with Artificial Pneumothorax in the Prone Position]

Mediastinal enteric cysts are very rare among in adults and usually asymptomatic. A 54-year-old male was referred to our hospital due to an abnormal shadow incidentally found on a chest X-ray at health check. Chest computed tomography scan revealed a cystic mass in the posterior and inferior mediastinum surrounded by diaphragm, inferior vena cava, and esophagus. Based on many reports of thoracoscopic esophagectomy in the prone position in recent years, we chose thoracoscopic resection of the mediastinal tumor in the prone position with artificial pneumothorax. The prone position with artificial pneumothorax provided much better exposure of the operating field and the surgery was performed successfully.

[PECULIARITY OF NATIONAL TUBERCULOSIS PROGRAM, JAPAN--Public-Private Mix from the Very Beginning, and Provision of X-ray Apparatus in Most General Practitioner's Clinics]

Modern National Tuberculosis Program (NTP) of Japan started in 1951 when Tuberculosis (TB) Control Law was legislated, and 3 major components were health examination by tuberculin skin test (TST) and miniature X-ray, BCG vaccination and extensive use of modern TB treatment. As to the treatment program, Japan introduced Public-Private Mix (PPM) from the very beginning, and major reasons why PPM was adopted are (1) TB was then highly prevalent (Table 1), (2) TB sanatoria where many specialists are working are located in remote inconvenient places due to stigma against TB, (3) health centers (HCs) in Japan are working exclusively on prophylactic activities, and minor exceptions are treatment of sexually transmitted diseases and artificial pneumothorax for TB cases, however, as it covers on the average 100,000 population, access is not so easy in rural area, (4) Out-patients clinics mainly operated by general practitioners (GPs) are located throughout Japan, and the access is easy. Methods of TB treatment was developing rapidly in early 1950s, however, in 1952, as shown in Table 2, artificial pneumothorax and peritoneum were still used in many cases, and to fix the dosage of refill air, fluoroscopy was needed. Hence, GPs treating TB under TB Control Law had to be equipped with X-ray apparatus. To maintain the quality of TB treatment, "Criteria for TB treatment" was provided and revised taking into consideration the progress in TB treatment. If applied methods of treatment fit with the above criteria, public support is made for the cost of TB treatment. To discuss the applied treatment, TB Advisory Committee was set in each HC, composing of 5 members, director of HC, 2 TB specialists and 2 doctors recommended by the local medical association. In 1953, the first TB prevalence survey using stratified random sampling method was carried out, and the prevalence of TB requiring treatment was estimated at 3.4%, and only 21% of found cases knew their own disease, and more than half of all TB were found above 30 years of age. Based on these results, mass screening was expanded to cover whole population in 1955, and since 1957, cost of mass screening and BCG vaccination was covered 100% by public fund. Unified TB registration system covering whole Japan was introduced in 1961, and in the same year, national government subsidy for the hospitalization of infectious TB cases was raised from 50% to 80%. Hence, Japan succeeded to organize PPM system in TB care, and with 10% annual decline of TB, in 1975, Japan moved into the TB middle prevalence country.

[Lymphadenectomy performed along the left recurrent laryngeal nerve after anterior detachment of the esophagus via thoracoscopic esophagectomy in the prone position under artificial pneumothorax]

Thoracoscopic esophagectomy was performed in the prone position under artificial pneumothorax and did not affect the surgical area during lung ventilation; tracheal mobility was also improved. Lymphadenectomy around the left recurrent laryngeal nerve was performed by separating the left main bronchus and trachea between the esophagus and pericardium before detaching the dorsal side of the esophagus.

Intradiaphragmatic pulmonary sequestration: advantages of the thoracoscopic approach

Pulmonary sequestrations are accessory foregut lesions that are most commonly located within the thorax and occasionally in the abdominal cavity. Sequestrations arising within the diaphragm are exceedingly rare. We describe 2 patients found to have left peridiaphragmatic lesions on prenatal ultrasound and postnatal computed tomography. In the first patient, an initial laparoscopic approach was abandoned in favor of a thoracoscopic approach after no intraabdominal mass was found. The second patient had an uncomplicated thoracoscopic resection of a similar lesion. To our knowledge, these represent the first intradiaphragmatic pulmonary sequestrations to be resected via a minimally invasive approach. The rarity of these lesions makes definitive diagnosis without operative intervention challenging. Thoracoscopy appears to be a reasonable approach for resection of such intradiaphragmatic lesions.

Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation

BACKGROUND AND OBJECTIVE

Medical thoracoscopy (MT) is indicated for the investigation of unexplained pleural exudates. Not all MT units create artificial pneumothoraces because of time. Difficult pleural space access and thick fibrous adhesions may prevent MT and pleurodesis, respectively. The potential role of thoracic ultrasound (TUS) pre-MT has not been fully evaluated. We hypothesized TUS would reduce failure to access the pleural space and enable detection of thick fibrous adhesions.

METHODS

Thirty patients underwent single port MT consecutively for investigation of pleural exudates without pre-MT TUS over a 6-month period. Over the following 6 months, 30 consecutive patients underwent TUS immediately prior to MT. Pleural access rate and thick fibrous adhesion detection at both MT and TUS were recorded.

RESULTS

In the non-TUS cohort, pleural space access failure occurred in 16.7% (leading to five extra procedures), versus no failures in the TUS cohort (P = 0.0522). There were no differences in prevalence of MT fibrous adhesions between cohorts. TUS identified all cases of fibrous septation versus only 12.5% identified by CT in the non-TUS cohort (P = 0.001). All identified cases of thick fibrous septation on TUS did not receive pleurodesis at MT. TUS detected useful ancillary features in 43% of cases.

CONCLUSIONS

A strong trend to reduction in single port MT pleural access failure was noted with pre-MT TUS thus reducing extra procedures and the need for artificial pneumothoraces. Pre-MT TUS also reliably detects thick fibrous adhesions at MT. TUS may also detect useful ancillary features. This study provides a rationale for ultrasound-guided single port MT if a pneumothorax is not created.

[Axonal neuropathy revealing pleural lymphoma as a long-term outcome of therapeutic pneumothorax]

Peripheral neuropathy is a rare presenting feature of malignant lymphoma, and commonly associated with diagnostic delay. We report a patient with axonal neuropathy revealing primary pleural lymphoma as a late outcome of pulmonary tuberculosis. A 72-year-old-man with a past medical history of pulmonary tuberculosis presented with a 5-month history of axonal neuropathy. The patient complained of chest pain, altered general status. Chest computed tomography (CT) showed pleural tumour invading the chest wall and CT-guided pleural biopsy revealed a B-cell lymphoma. Chemotherapy was not started in consideration of the poor performance status of the patient. Despite corticosteroids, the peripheral neuropathy worsened and the patient died 2 months after the diagnosis of lymphoma. To our knowledge, no previous case of peripheral neuropathy revealing pleural lymphoma has been reported. The diagnosis of lymphoma must be entertained in the presence of peripheral neuropathy of unknown aetiology. Neuropathy associated to lymphoma results from various mechanisms and is characterised by clinical polymorphism. Their prognosis depends on the mechanism of the neuropathy and the severity of the lymphoma.

[Clinical analysis of eight cases with pyothorax-associated lymphoma]

We retrospectively reviewed the medical records of eight patients (five males and three females, median age: 75.6) with pyothorax-associated lymphoma (PAL) from 1993 to 2007. All cases were histopathologically identified as diffuse large-B-cell lymphoma and had a history of artificial pneumothorax for the treatment of pulmonary tuberculosis. Chest and/or dorsal pain was the most common symptom followed by bloody sputum. Ten needle biopsies and five surgical biopsies were performed, and diagnostic rates were 30% and 60% respectively. More than two biopsies were needed in four out of eight patients. Nine months in median were necessary to confirm a diagnosis of PAL. We evaluated gallium scintigraphy in five and 18FDG-PET in two patients. High uptake was observed only at the tumor site, not in the pleural cavities of all examined patients. While all five male patients died of their tumors, the three female patients were all alive after intensive therapy. We conclude that gallium scintigraphy, and 18FDG-PET are useful for discriminating tumor from pyothorax. It is also necessary to further understand the uncertainty of biopsy results and the need for repeat examinations for early diagnosis of PAL.

[Toxic effect of radiotherapy on metastatic lesions of the lung]

The study was concerned with identifying toxic effect of certain methods of radiotherapy of metastatic lesions of the lung. Leukocyte index intoxication (Kalf-Kalif), paramecin test and mean molecule level determination were used. The worst endogenous intoxication was found to be caused by irradiating four consecutive fields of the mediastinum. The least damage was caused in combination with artificial pneumothorax. Use of smaller-size fields of irradiation was followed by a significant drop in adverse side-effects.

Clinicopathological features of pyothorax-associated lymphoma; a retrospective survey involving 98 patients

To investigate clinicopathological features of pyothorax-associated lymphoma (PAL), we examined medical records of 98 patients (88 males and 10 females) with PAL at a median age of 70 years (range 51-86). Seventy-nine patients had a history of artificial pneumothorax. Median interval between diagnosis and artificial pneumothorax was 43 years (range 19-64). At diagnosis, performance status (PS) was 0-1 (n=56) and 2-4 (n=42). Clinical stages were I (n=42), II (n=26), III (n=8) and IV (n=22). Pathological diagnosis comprised diffuse large-B-cell (n=78) and peripheral T-cell lymphoma (n=1). Seventeen were treated supportively. The other 81 received aggressive treatments; chemotherapy (n=52), radiotherapy (n=7), surgery (n=4) and combination (n=18). Five-year overall survival (OS) was 0.35 (95% confidence interval, 24% to 45%). Causes of deaths were PAL (n=39), respiratory failure (n=13) and others (n=12). Multivariate analysis identified prognostic factors for OS; lactate dehydrogenase levels [hazard ratio (HR)=2.36; P=0.013], sex (female versus male) (HR=0.15; P=0.01), PS (2-4 versus 0-1) (HR=2.20; P=0.02), clinical stages (III/IV versus I/II) (HR=1.95; P=0.037) and chemotherapy (HR=0.31; P=0.01). Most patients with PAL are elderly and have comorbidities, while some of them achieve durable remission with appropriate treatments. These findings prompt us to establish an optimal treatment strategy on the basis of risk stratification of individual patients.

PRE- AND POSTTHORACENTESIS CHEST RADIOGRAPHIC FINDINGS DO NOT PREDICT ABNORMAL PLEURAL ELASTANCE

STUDY OBJECTIVES

Pneumothorax following ultrasound-guided thoracentesis is rare. Our goal was to explain the mechanisms of pneumothorax following ultrasound-guided thoracentesis in a setting where pleural manometry is routinely used.

METHODS

We reviewed the patient records and procedure reports of 401 patients who underwent ultrasound-guided thoracentesis. When manometry was performed, pleural space elastance was determined. A model assuming dependence of the pleural space elastic properties on respiratory system elastic properties was used to isolate cases with presumed normal pleural space elastance. Elastance outside mean +/- SD x 2 of the isolated sample was considered abnormal. Four radiographic criteria of unexpandable lung were used: visceral pleural peel, lobar atelectasis, basilar pneumothorax, and pneumothorax with ipsilateral shift.

RESULTS

There were 102 diagnostic thoracenteses, 192 therapeutic thoracenteses with pleural manometry, and 73 therapeutic thoracenteses without manometry. There was one pneumothorax that occurred from lung puncture and eight unintentional pneumothoraces, all of which showed radiographic evidence of unexpandable lung. Four of eight unintentional pneumothoraces had abnormal elastance; none had excessively negative pleural pressure (< -25 cm H(2)O).

CONCLUSIONS

Unintentional pneumothoraces cannot be prevented by monitoring for symptoms or excessively negative pressure. These pneumothoraces were drainage related rather than due to penetrating lung trauma or external air introduction. We speculate that unintentional pneumothoraces are caused by transient, parenchymal-pleural fistulae caused by nonuniform stress distribution over the visceral pleura that develop during large-volume drainage if the lung cannot conform to the shape of the thoracic cavity in some patients with unexpandable lung. These fistulae appear to be pressure dependent, and the resulting pneumothoraces rarely require treatment. Drainage-related pneumothorax is an unavoidable complication of ultrasound-guided thoracentesis and appears to account for the vast majority of pneumothoraces occurring in a procedure service.

Reviving an old idea: can artificial pneumothorax play a role in the modern management of tuberculosis?

OBJECTIVE

To determine the usefulness of artificial pneumothorax (AP) in the management of pulmonary tuberculosis (PTB) patients when anti-tuberculosis treatment is ineffective.

DESIGN

We evaluated the outcome of therapy in 214 patients with cavitary PTB bacteriologically confirmed by culture treated during 1998-2004, 78.9% of whom had multidrug resistance. AP was applied in 109 patients (56 newly diagnosed TB and 53 retreatment cases). A control group consisted of 105 patients (respectively 55 and 50) treated without AP. The average period of AP application was 4.5 months for newly diagnosed patients and 9 months in retreatment cases. Anti-tuberculosis treatment regimens in both groups were based on drug susceptibility test results.

RESULTS

Culture negativity was achieved in patients treated with AP in all new cases and in 81.1% of retreatment cases. Cavity closure occurred in 94.6% and 67.9% respectively. In the control group, culture negativity was achieved in respectively 70.9% and 40.0%, and cavity closure occurred in respectively 56.3% and 24.0%.

CONCLUSION

AP considerably improved the treatment outcome in both newly diagnosed and retreatment patients. This procedure can be considered a useful addition in managing certain patients with cavitary TB, particularly those with drug resistance.

Thoracoscopic repair of congenital diaphragmatic hernia by inflation-assisted bowel reduction, in a resuscitated neonate: a better access?

Elective endoscopic diaphragmatic hernia repairs have been reported. But endoscopic surgery was regarded unsuitable for emergency repair of diaphragmatic hernia in ventilated newborn children in bad general condition. We report a new method for inflation-assisted reduction and thoracoscopic repair of congenital diaphragmatic hernia diaphragmatic in a vitally endangered neonate. From three 2.7 mm to 5 mm accesses warmed low-pressure, low-volume CO2 was inflated into the thorax at 100 ml/min and 2 mm mercury. This allowed spontaneous reduction of the thoracic viscera into the abdomen and diaphragmatic suture with minimal handling. The 65-min procedure was tolerated well without perioperative deterioration. The baby was weaned off the respirator and breast-fed within 2 days, mediastinal shift normalized in 6 days. In suitable infants thoracoscopic repair and inflation-assisted reduction of thoracic contents is a more physiological access to congenital diaphragmatic hernia than laparoscopy or laparotomy.

Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization

An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach.

Protective Pneumothorax for Needle Biopsy of Mediastinum and Pulmonary Hilum

The risk of performing CT-guided transthoracic needle biopsy of some mediastinal and pulmonary hilar masses is increased by the presence of intervening lung. A series of patients is presented in whom a protective pneumothorax provided access for biopsy of masses in the mediastinum and pulmonary hilum. Review of Interventional Radiology records revealed 24 patients who had biopsies of mediastinum or pulmonary hilum, in whom protective pneumothorax was used, or attempted, to provide percutaneous access for biopsy. Characteristics of these patients and their procedures were reviewed. Percutaneous access to the pleural space was gained in 21/24 (88%) of patients. A protective pneumothorax was established in 19 (79%); 2 patients had pleural adhesions that prevented the lung from being displaced. The process of creating the protective pneumothorax added a mean time of 17 minutes to the procedure (range 6-30 minutes). All patients had biopsy using coaxial technique, with either a 20-gauge or 18-gauge core biopsy instrument, in addition to needle aspiration. Air leak requiring tube drainage occurred in 1/19 (5%) of patients who had a protective pneumothorax, and in 2/5 (40%) of patients in whom protective pneumothorax was not established. Percutaneous creation of a protective pneumothorax is a safe method that provides access for needle biopsy of deep lesions in the chest without traversing aerated lung.

Chest Tube Suction-Associated Unilateral Negative Pressure Pulmonary Edema in a Lung Transplant Patient

We describe a 29-yr-old male, status post-bilateral lung transplant, who developed unilateral negative pressure pulmonary edema induced by chest tube suction in association with bilateral bronchial anastomotic strictures. We conclude that negative pressure pulmonary edema may occur secondary to high levels of negative pressure applied to the intrapleural space via chest tubes in the presence of partial large airway obstruction. Post-lung transplant patients may be especially at risk because of compromised lymphatic drainage.

Artificially induced pneumothorax for percutaneous transthoracic radiofrequency ablation of tumors in the hepatic dome: initial experience

After institutional review board approval, informed consent was obtained from six patients (four men and two women, aged 47-74 years) with a total of six tumors of the liver dome. These patients were treated by means of radiofrequency (RF) ablation with computed tomographic (CT) guidance and a transthoracic approach. With use of general anesthesia, a right pneumothorax was induced by means of manual injection of air until the route allowing access to the tumor was cleared of all lung parenchyma. Then RF ablation was performed with transthoracic extrapulmonary transdiaphragmatic access. After retrieval of the RF electrode, the pneumothorax was fully aspirated. All procedures were successfully performed without complications. Artificially induced pneumothorax appears useful and safe for CT-guided RF ablation of liver dome tumors, although this experience was minimal, with only six patients treated.

Percutaneous Transthoracic Radiofrequency Ablation of Renal Tumors Using an Iatrogenic Pneumothorax

OBJECTIVE

We report on a new technique for percutaneous radiofrequency ablation of tumors in the upper pole of kidneys in the presence of intervening lung parenchyma.

CONCLUSION

Percutaneous radiofrequency ablation of tumors in the upper pole of kidneys with intervening lung parenchyma can be accomplished successfully using a transthoracic approach through an iatrogenic pneumothorax. This technique allows for precise placement and repositioning of the radiofrequency electrode under CT guidance without repeated puncture of the visceral pleura.

Conscious off pump coronary artery bypass surgery--an audit of our first 151 cases

PURPOSE

An audit of our first 151 cases of conscious off pump coronary artery bypass (COPCAB) surgery with epidural anesthesia as sole anesthetic.

METHODS

Patients underwent conscious off pump coronary artery bypass (OPCAB) surgery using high thoracic epidural anesthesia. The epidural catheter was inserted on the day before the surgery.

RESULTS

There were 118 male and 33 female patients. The incision was via midsternotomy except in 3 patients. Single graft was performed in 25 patients, double in 61, triple in 46, quadruple in 19. Twenty-nine patients developed pneumothorax. Three patients required conversion to general anesthesia. In one patient cardiopulmonary bypass (CPB) was instituted. There was no mortality in the group.

CONCLUSION

Our experience shows that conscious OPCAB surgery can be performed safely in selected patients.

Thoracoscopic diaphragmatic procedures under artificial pneumothorax

Diaphragmatic plication is technically simple using a conventional operative technique, but it requires a large skin incision and rib injury. We present an alternative technique for thoracoscopic plication of the diaphragm and evaluate the advantages of the procedure. Six patients (five with diaphragmatic eventration and one with diaphragmatic hernia with a sac) ranging in age from 8 to 20 months were treated by this method. Three of the six cases were right-sided, and three were left-sided. The operation was performed under artificial pneumothorax using carbon dioxide gas at 4 mmHg. Three trocars for laparoscopy were inserted at the 4th and 5th intercostal spaces. An adequate operative view was obtained by pressing the diaphragm throughout the operation. The eventrated diaphragm was plicated with several rows of nonabsorbable sutures in the anterolateral-to-posterolateral direction to prevent injury to the main phrenic nerve. A tight diaphragm was confirmed by decompressing the artificial pneumothorax. The technique was successfully performed in all cases, and the patients' postoperative courses were uneventful. During the operation, the hemodynamic effects of carbon dioxide gas at 4 mmHg were minimal. Over a mean follow-up period of 3.1 years (range, 1-6 years), no recurrence of diaphragmatic eventration was seen. Judging from the satisfactory postoperative course, this procedure is suitable for children with all forms of diaphragmatic eventration.

Allelic distribution of human leucocyte antigen in historical and recently diagnosed tuberculosis patients in Southern Italy

This study addresses the analysis of the human leucocyte antigen (HLA) allele distribution in 54 historical and in 68 recently diagnosed tuberculosis (TB) patients. The historical cohort was characterized by the presence of large fibrocavernous lesions effectively treated with therapeutic pneumothorax during the period 1950-55. Patients and healthy controls enrolled in the study were from the Campania region of southern Italy. No significant association between HLA alleles and TB in the population of recently diagnosed TB patients was observed. On the contrary, among the historical TB patients there was a strong association with an increased frequency of the HLA-DR4 allele alone and/or in the presence of the HLA-B14 allele (P = 0.000004; Pc = 0.0008), as well as with a decreased frequency of the HLA-A2+,-B14-,DR4- allele association (P = 0.00005; Pc = 0.01). In order to exclude any interference from age-related factors, these results were confirmed by comparing the historical cohort of TB patients with an age-matched healthy control population of the same ethnic origin (P = 0.00004; Pc = 0.008; and P = 0.0001; and Pc = 0.02, respectively).

[Adult pulmonary Langerhans' cell histiocytosis]

INTRODUCTION

Adult pulmonary Langerhans'cell histiocytosis, also referred to as histiocytosis X, is a disorder of unknown etiology which affects preferentially young smokers. The disease is characterized by granulomatous lesions which progressively invade and destroy distal airways, leading to the formation of characteristic cicatricial kystic lesions. Florid granulomas contain numerous Langerhans'cells, antigen-presenting cells of the dendritic cell lineage, associated with T lymphocytes and eosinophils. The diagnosis rests on the combination of clinical and radiologic data, and particularly on high-resolution CT scan findings showing a typical association of nodular and cystic changes, predominantly in the upper and middle lobes. Further evaluation with surgical lung biopsy is indicated in less typical situations.

CURRENT KNOWLEDGE AND KEY POINTS

The pathogenesis of Langerhans'cell histiocytosis is not fully understood, but several arguments suggest that the disease results from an abnormal immune reaction initiated by Langerhans'cells and directed against the bronchial epithelium. Other arguments suggest the presence of genetic abnormalities susceptible, for example, to increase the sensitivity of these cells to cytokines (GM-CSF, or others) known to influence their survival and maturation.

FUTURE PROSPECTS AND PROJECTS

These recent advances in the pathogenesis of Langerhans'cell histiocytosis could promote the development of new therapeutic strategies designed to regulate the number and activated state of Langerhans'cells in specific lesions.

Thoracoscopic lobectomy for prenatally diagnosed lung lesions

PURPOSE

The aim of this report is to assess the technique and outcome of thoracoscopic lobectomy for asymptomatic prenatally diagnosed lung lesions.

METHODS

From June 1999 to March 2002, 14 consecutive asymptomatic patients with a prenatal diagnosis of congenital cystic adenomatoid malformation or pulmonary sequestration, ages 3 to 15 months, underwent postnatal thoracoscopic lobectomy. Single-lung ventilation and controlled pneumothorax with low pressure (4 torr) and low flow (1.0 L/min) were used in all. Follow-up ranged from 4 to 35 months.

RESULTS

All procedures were completed successfully using 3 ports. Rather than using stapling devices or clips, pulmonary vessels were sealed and the fissure completed (when necessary) with the Ligasure thermal energy device. Eleven lesions were on the left (10 lower lobe), and 3 were in the right lower lobe. The mean operating time was 110 minutes. The average hospital stay was 38 hours. There were no intraoperative or postoperative complications.

CONCLUSIONS

This is the first report of a completely thoracoscopic technique for pulmonary lobectomy in small children. Thoracoscopic lobectomy is a relatively quick and safe procedure, and the cosmetic result is excellent. Early resection obviates the risk of infection in these lesions.

[Life-threatening displacement of a tracheostomy tube in a patient with severe angiotensin-converting enzyme inhibitor-induced angioedema]

Angioedema of the lips and the tongue with pharyngeal and laryngeal involvement caused by angiotensin-converting enzyme inhibitors (ACEI) is rare but can cause severe airway compromise and even death due to suffocation. We present the case of a 83-year-old woman with a life-threatening displacement of a tracheostomy tube followed by tension pneumothorax after initial successful treatment of such an airway obstruction by emergency tracheostomy. This case highlights the hazards of tracheostomy tube displacement and is a reminder that where concern of tube dislodgement exists and especially when the possibility of orotracheal intubation is lacking due to upper airway obstruction or difficult airway, permanent epithelized tracheostomy should be performed early to ensure safe and fast tube replacement at any time.

[Efficacy of ofloxacin (zanocin) in the treatment of multidrug resistant pulmonary tuberculosis]

Data concerning chemotherapy of patients with multiresistant tuberculosis of the lungs by reserve antituberculous agents in combination with ofloxacin are presented. It was shown that the ofloxacin-including chemotherapy regimen applied to patients with multiresistant destructive tuberculosis of the lungs provided by the end of the 6-month treatment course elimination of multidrug resistant tubercle bacilli isolation at least in 80% of the patients and closure of the lung caverns after artificial pneumothorax and routine surgical interventions in more than half of the patients. For all this, side effects that could not be eliminated were stated merely in 8.5% of the patients.

Myocardial revascularization surgery with regional anesthesia without an endotracheal tube in conscious patients

OBJECTIVE

To report initial experience with myocardial revascularization surgery (MRS) performed on patients who were totally awake and without an endotracheal tube.

METHODS

Between January 1994 and May 2001, 272 patients underwent MRS without extracorporeal circulation. In 24, the operations were performed without the use of an endotracheal tube and with the patients totally awake and breathing normally. The age ranged from 51-75 years with the predominant male sex. Epidural thoracic administrations of the anesthesia was performed. Surgery was performed through a habitual anterolateral thoracotomy. During the entire procedure, the left lung remained partially collapsed.

RESULTS

The 24 patients progressed well through the surgery. Pneumothorax time ranged from 70-190 minutes. No electrocardiographic, echocardiographic, or enzymatic alterations occurred that characterized pre- and postoperative infarcts. Twenty-three patients were stable enough to be released after 24 hours.

CONCLUSION

This technique could be performed on an large number of selected patients. However, more experience is necessary.

Segmental wall motion abnormalities during telerobotic totally endoscopic coronary artery bypass grafting

In addition to single-lung ventilation (SLV), intrathoracic CO2 insufflation is mandatory for adequate exposure during totally endoscopic coronary artery bypass grafting. With transesophageal echocardiography, we investigated biventricular myocardial wall motion in 25 patients with isolated disease of the left anterior descending coronary artery who underwent totally endoscopic coronary artery bypass grafting with the "Da Vinci" robotic surgical system. At distinct time points during the operation, a cine loop of both ventricles was registered from a transgastric mid-short-axis view. Myocardial wall motion analysis was performed according to an established segmentation model of the left ventricle and to an established five-point scale for wall motion (1, normal; 5, dyskinesia). Significant alterations from preoperative baseline wall motion were visible in the septal, inferior, and anterior segments of the left ventricle at some time during the prebypass period, combined with a markedly decreased PaO2 under SLV and increased intrathoracic pressure. The same findings applied to the right ventricle; however, wall motion abnormalities were more pronounced here. After myocardial revascularization, weaning from cardiopulmonary bypass, CO2 deflation, and return to double-lung ventilation, myocardial wall motion recovered to baseline values. Clinically significant hemodynamic instability did not occur. The data suggest that robot-assisted coronary artery bypass grafting leads to significant prebypass alterations of biventricular segmental wall motion. On the basis of our data, it cannot be definitively stated whether the observed results were due to reduced oxygenation during SLV and thus "real" myocardial ischemia, intrathoracic CO2 insufflation with positive pressure leading to mechanical compromise of the heart, absolute or relative hypovolemia, or a combination of these factors. However, in this cohort, which consisted of patients with single-vessel disease and good ventricular function, these changes were of limited clinical relevance.

IMPLICATIONS

Segmental myocardial wall motion was evaluated with transesophageal echocardiography during robot-assisted totally endoscopic coronary artery bypass grafting. Significant biventricular segmental wall motion abnormalities occurred before cardiopulmonary bypass under single-lung ventilation and carbon dioxide insufflation. The changes in myocardial wall motion were of limited clinical relevance.

[Surgical treatment of pulmonary tuberculosis: experience and prospects]

The author's experience accumulated over 40 years shows that two major forms of surgical pulmonary tuberculosis (restrictive and disseminated) should be distinguished. The treatment of the former patients is highly effective and safe. To treat patients with progressive disseminated tuberculosis, especially in those who isolate Mycobacteria resistant to previously used drugs is difficult and expensive, which requires non only new generation antituberculous drugs, but comprehensive complex preparation for surgery. The author prefers collapse surgical interventions, but, if necessary, resorts even to pulmonectomy and application of an artificial pneumothorax contralaterally. Lobectomy is a major type of resection of the lung. Thus, surgery as a constituent of ensures recovery (stabilization of the process) in the most critically ill patients with pulmonary tuberculosis.

[Efficacy of treatment for pulmonary tuberculosis with multidrug mycobacterial resistance]

The efficiency of treatment was studied in 149 patients with pulmonary tuberculosis who isolated multidrug resistance of Mycobacteria tuberculosis (MBT). The multidrug resistance of MTB, to at least isoniazid and rifampicin can be associated with both the resistance to other essential (streptomycin, ethambutol) and that to reserve drugs. With this, patients with MBT resistance to a combination of essential and reserve drugs more frequently showed a chronic course of the disease with severe clinical manifestations and more disseminated infiltrative-and-destructive lesions in the lung. Drug treatment regimens using a combination of reserve drug were effective only in patients with MBT resistance to essential drugs while they were little effective in those with resistance to essential and reserve agents. The use of artificial pneumothorax in patients with MBT resistance to essential and reserve agents could cease bacterial isolation in 77.8% of the patients even by ingesting a small number of the drugs. Clinically, the occurrence of MBT resistance to reserve drugs is justified to determine a radically new status in patients in the context of chemotherapy and the whole further treatment in this group of patients. A clinical classification of MBT multidrug resistance is proposed, which identifies two categories of patients with pulmonary tuberculosis: those resistant to essential drugs and those resistant to a combination of essential and reserve drugs.

Late complications of collapse therapy for pulmonary tuberculosis

STUDY OBJECTIVES

Collapse therapy for pulmonary tuberculosis involved placement of various materials to occupy space and keep the lung collapsed. Complications are encountered decades later.

PATIENTS AND METHODS

Between 1980 and 1997, we treated 31 patients with a history of pulmonary tuberculosis in whom collapse therapy had been used and who later developed complications related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable pneumothorax was present in 1 patient, and migration of a foreign body with formation of subcutaneous mass occurred in 3 patients. All patients with empyema were treated with antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted.

RESULTS

Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and 1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap remained closed. Following extraction of paraffin blocks, infection developed in one patient. During the follow-up period, three patients died, all of unrelated causes.

CONCLUSIONS

Delayed complications of collapse therapy for tuberculosis should be treated without delay. Pressure on adjacent structures or their erosion presents danger and mandates immediate extraction; however, there is no need for routine removal of every residual plombe. Further increase in the number of multiple-drug resistant strains may force the return of collapse therapy.

[Primary pleural lymphoma: a rare complication of tuberculosis pleural sequelae]

We report two cases of malignant lymphoma of B phenotype occurring after therapeutic pneumothorax for tuberculosis. In both cases, outcome was fatal without time for specific treatment. Mainly reported in Japan, this pathology seems to be less frequent in western countries. As for B phenotype lymphoma associated with immunodeficiency, association with Epstein Barr virus is reported. Definite diagnosis is difficult and requires surgical biopsy. Prognosis remains poor with a survival ranging from 3 to 6 month.

Primitive squamous-cell carcinoma after extrapleural pneumothorax for active tuberculosis

Squamous-cell carcinoma into an extrapleural pneumothorax for active tuberculosis was incorrectly diagnosed as late tubercular empyema. Right axillary thoracostomy was carried out to drain large dense effusion decompressing the brachial plexus and the sympathetic chain with symptomatic release. Surgical biopsy of the extrapleural sac allowed to identify two different tissues: normal epithelium similar to epidermis and nodular fragments composed of well-differentiated squamous carcinoma. The cause of this tumour is not clear: probably the carcinoma arose from normal epidermis carried in the extrapleural cavity during multiple air-refills to maintain the therapeutic pneumothorax.

[Morphometric assessment of rat lungs insufflated with liquid fixative at different pressures close to total lung capacity]

INTRODUCTION

Liquid lung fixing through the trachea to a pressure of 25 cmH2O is currently accepted to be ideal. However, some studies do not seem to confirm that assumption.

MATERIAL AND METHODS

The lungs of Fischer rats were filled with fixing liquid to four different pressures: 20 cm, 25 cm, 30 cm and 35 cmH2O. The fixed lungs were processed for inspection under a light microscope for morphometric study. The following variables were recorded: lung volume, tissue volume, air volume, internal alveolar surface (IAS), alveolar chord to measure the size of the distal air space, and the number of alveoli. Statistical comparisons were performed.

RESULTS

Lung volume increased with insufflation pressure, with significant differences related to pressure increases from 20 cm to 25 cm and from 30 cm to 35 cmH2O. Air volume did not change, although tissue volume changed when pressure increased from 20 cm to 30 cmH2O and from 30 cm to 35 cmH2O. The increase of tissue volume was related to extravasation of interstitial fixer. The number of alveoli increased with pressure from 20 to 30 cm and from 30 to 35 cmH2O. IAS increased with pressure from 20 cm and all the other pressures. Alveolar chord, which is related to size of alveoli, decreased significantly as pressure increased from 20 cm to 25 cm.

CONCLUSION

A pressure of 25 cmH2O is ideal for liquid fixing of lung volumes. With lower pressures the lung is partially distended and with higher pressures the fluid can pass into the interstitial space.