CO2 artificial pneumothorax on coagulation and fibrinolysis during thoracoscopic esophagectomy

BACKGROUND

CO2 artificial pneumothorax creates a sufficient operative field for thoracoscopic esophagectomy. However, it has potential complications and continuous CO2 insufflation may impede coagulation and fibrinolysis. We sought to compare the effects of CO2 artificial pneumothorax on perioperative coagulation and fibrinolysis during thoracoscopic esophagectomy.

METHODS

We investigated patients who underwent thoracoscopic esophagectomy with (group P, n = 24) or without CO2 artificial pneumothorax (group N, n = 24). The following parameters of coagulation-fibrinolysis function: intraoperative bleeding volume; serum levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), thromboelastogram (TEG), D-Dimer; and arterial blood gas levels were compared with two groups.

RESULTS

Group P showed higher levels of PaCO2, reaction time (R) value and kinetics (K) value, but significantly lower pH value, alpha (α) angle and Maximum Amplitude (MA) value at 60 minutes after the initiation of CO2 artificial pneumothorax than group N ((P < .05, all). The t-PA level after CO2 insufflation for 60 minutes was significantly higher in group P than in group N (P < .05), but preoperative levels were gradually restored on cessation of CO2 insufflation for 30 min (P > .05). There was no significant difference in D-dimer.

CONCLUSION

CO2 artificial pneumothorax during thoracoscopic esophagectomy had a substantial impact on coagulation and fibrinolysis, inducing significant derangements in pH and PaCO2.

TRIAL REGISTRATION

The study was registered at the Chinese clinical trial registry (ChiCTR1800019004).

Lung Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: A Series Contribution to a Debated Procedure

Introduction: Transbronchial cryobiopsy is an alternative to surgical biopsy for the diagnosis of fibrosing interstitial lung diseases, although the role of this relatively new method is rather controversial. Aim of this study is to evaluate the diagnostic performance and the safety of transbronchial cryobiopsy in patients with fibrosing interstitial lung disease. Materials and methods: The population in this study included patients with interstitial lung diseases who underwent cryobiopsy from May 2015 to May 2018 at the Division of Pneumology of San Giuseppe Hospital in Milan and who were retrospectively studied. All cryobiopsy procedures were performed under fluoroscopic guidance using a flexible video bronchoscope and an endobronchial blocking system in the operating room with patients under general anaesthesia. The diagnostic performance and safety of the procedure were assessed. The main complications evaluated were endobronchial bleeding and pneumothorax. All cases were studied with a multidisciplinary approach, before and after cryobiopsy. Results: Seventy-three patients were admitted to this study. A specific diagnosis was reached in 64 cases, with a diagnostic sensitivity of 88%; 5 cases (7%) were considered inadequate, 4 cases (5%) were found to be non-diagnostic. Only one major bleeding event occurred (1.4%), while 14 patients (19%) experienced mild/moderate bleeding events while undergoing bronchoscopy; 8 cases of pneumothorax (10.9%) were reported, of which 2 (2.7%) required surgical drainage. Conclusions: When performed under safe conditions and in an experienced center, cryobiopsy is a procedure with limited complications having a high diagnostic yield in fibrotic interstitial lung disease.

A Case of Massive Cerebral Arterial Air Embolism Induced by Artificial Pneumothorax and Its Analysis

OBJECTIVE

This study aimed to investigate the characteristics of cerebral arterial air embolism.

CLINICAL PRESENTATION AND INTERVENTION

The clinical data of a patient with cerebral arterial air embolism induced during artificial pneumothorax were retrospectively analyzed. The patient needed the induction of artificial pneumothorax for medical thoracoscopy but developed hemiplegia and disturbance of consciousness during the induction. Cerebral arterial air embolism was detected by head computed tomography.

CONCLUSION

Artificial pneumothorax may induce cerebral arterial air embolism.

Bolshevik disease and Stalinist terror: on the historical casuistry of artificial pneumothorax

From its initial development by Carlo Forlanini at the end of the nineteenth century until the advent of antibiotics in the 1940s, artificial pneumothorax was one of the most widely used treatments for pulmonary tuberculosis. However, there were strongly held reservations about this therapy because of its risks and side effects. In the Soviet Union under Stalin, such uncertainties became instruments of political denunciation. The leading Soviet pulmonary physician Volf S. Kholtsman (1886-1941) was alleged to have used the so-called 'aristocratic therapy' of artificial pneumothorax to kill prominent Bolsheviks. Drawing on documents from Stalin's personal Secretariat, this historical study of the pneumothorax scandal contributes to the cultural history of tuberculosis, showing how it was instrumentalised for political purposes.

The application of single-lumen endotracheal tube anaesthesia with artificial pneumothorax in thoracolaparoscopic oesophagectomy

Double-lumen endotracheal tube (DLET) anaesthesia is the commonly used method in minimally invasive oesophagectomy (MIE). However, DLET intubation does have its disadvantages. Firstly, the placement of the DLET needs a skilled anaesthetist with familiarity of the technique and subsequent ability to perform a fibre-optic bronchoscopy for confirmation. Secondly, DLET intubation and one-lung ventilation are associated with numerous complications, including hoarseness, tracheobronchial injury and vocal injury. In this report, a retrospective analysis was performed on 42 consecutive patients who underwent MIE using single-lumen endotracheal tube (SLET) anaesthesia with CO2 artificial pneumothorax compared with 81 patients who underwent the same procedure with DLET intubation. Our findings showed that SLET intubation with artificial pneumothorax by CO2 insufflation is a feasible and safe method for MIE procedures.

[A case of pyothorax-associated lymphoma treated by operation following radiation therapy]

A 70-year-old man was admitted to our hospital with complaints of right back to anterior chest pain and fever. He had a history of artificial pneumothorax for tuberculosis when he was 21 years old. The chest CT showed a partial thickness of right pleural cavity. The decortication and fenestration were performed for pyothorax, and a diagnosis of pyothorax-associated lymphoma (PAL) was obtained by pathological examination. After the surgery, chest CT revealed a rapid tumor growth in three months and suspicion of invasion to the ribs. After radiation therapy with a total dose of 40 Gy was performed, right pleuropneumonectomy was carried out. The tumor was not remained in the specimen. Postoperative chemotherapy was not performed. He lived for 5 years after the operation without recurrence. It is important to control local recurrence for PAL with the combined therapy of operation, chemotherapy and radiotherapy.

[Primary pleural lymphoma: a late complication of pleural decortication for tuberculosis: two cases in western countries]

Pleural lymphomas after a long standing pyothorax due to pleuropulmonary tuberculosis are now well identified, but rarely observed in Europe. We report two new cases in a non-immunocompromised patients. The two cases occurred 5455 years following artificial pneumothorax for pulmonary tuberculosis. The patients presented with a localized pleural tumor mass. Histology revealed high-grade lymphomas, diffuse large B-cell lymphoma and anaplastic lymphoma. Serology for Epstein-Barr virus was positive. Pleural lymphomas are an established complication of artificial pneumothorax. Epstein-Barr virus is known to play a crucial role in the pathogenesis, but despite the large number of artificial pneumothorax operations, these lymphomas remain rare, suggesting additional oncogenic factors.

Management of diaphragmatic injury during transperitoneal laparoscopic urological procedures

INTRODUCTION

Carbon dioxide pneumothorax is a rare complication in laparoscopic urology, but with the widespread use of laparoscopy and the increasing surgical pathologies managed by this technique this infrequent complication has become a potential risk.

MATERIALS AND METHODS

A total of 786 laparoscopic transperitoneal urologic operations were reviewed at our institution. All procedures were performed by the same surgeon and included 213 adrenalectomies, 181 simple nephrectomies, 143 lymphadenectomies, 118 radical nephrectomies, 107 partial nephrectomies and 24 nephroureterectomies. Mean patient age was 53.2 years (range 24 to 70). Mean BMI was 28.15 Kg/m2 (range 20 to 48.9).

RESULTS

A total of 6 cases (0.7%) of diaphragmatic injury were found. All reported patients had additional factors that may have contributed to diaphragmatic injury. Diaphragmatic repair was always carried out by intracorporeal suturing and only one case required chest tube placement. All patients evolved uneventfully.

CONCLUSIONS

Repair of diaphragmatic injuries should always be attempted with intracorporeal suture since this is a feasible, reproducible and reliable technique.

Severe tracheal compression as a late complication of plombage

Prior to the antituberculous drugs era, plombage was commonly performed for the management of pulmonary tuberculosis. However, this procedure has been associated with a variety of early and late complications depending on the technique as well as the material used. We report a rare case of severe tracheal compression as a late complication of plombage and a review of the literature.

Pyothorax-associated lymphoma: a review of 106 cases

PURPOSE

Pyothorax-associated lymphoma (PAL) is a non-Hodgkin's lymphoma developing in the pleural cavity after a long-standing history of pyothorax. Full details of PAL are provided here.

PATIENTS AND METHODS

Clinical and pathologic findings were reviewed in 106 patients with PAL collected through a nationwide survey in Japan.

RESULTS

Age of the patients with PAL was 46 to 82 years (median, 64 years), with a male/female ratio of 12.3:1. All patients had a 20- to 64-year (median, 37-year) history of pyothorax resulting from artificial pneumothorax for treatment of pulmonary tuberculosis (80%) or tuberculous pleuritis (17%). The most common symptoms on admission were chest and/or back pain (57%) and fever (43%). Laboratory data showed that the serum neuron-specific enolase level was occasionally elevated (3.55 to 168.7 ng/mL; median, 18.65 ng/mL), suggesting a possible diagnosis of small-cell lung cancer. Histologically, PAL usually showed a diffuse proliferation of large cells of B-cell type (88%). In situ hybridization study showed that PAL in 70% of the patients was Epstein-Barr virus (EBV)-positive. PAL was responsive to chemotherapy, but the overall prognosis was poor, with a 5-year survival of 21.6%.

CONCLUSION

This study established the distinct nature of PAL as a disease entity. PAL is a non-Hodgkin's lymphoma of exclusively B-cell phenotype in the pleural cavity of patients with long-standing history of pyothorax, and is strongly associated with EBV infection. Development of PAL is closely related to antecedent chronic inflammatory condition; therefore, PAL should be defined as malignant lymphoma developing in chronic inflammation.

Impact of temperature and humidity of carbon dioxide pneumoperitoneum on body temperature and peritoneal morphology

BACKGROUND

The insufflation of cold gas during laparoscopic surgery exposes patients to the risk for hypothermia. The objectives of this study were to investigate whether heating or humidification of insufflation gas could prevent peroperative hypothermia in a rat model, and to assess whether the peritoneum was affected by heating or humidification of the insufflation gas.

METHODS

Rats were exposed to insufflation with either cold, dry carbon dioxide CO2 (group I); cold, humidified CO2 (group II); warm, dry CO2 (group III); or warm, humidified CO2 (group IV); another group underwent gasless laparoscopy (group V). Core temperature and intraperitoneal temperature were registered in all animals during 120 minutes. Specimens of the parietal peritoneum were taken directly after desufflation and 2 and 24 hours after the procedure. All specimens were analyzed with scanning electron microscopy (SEM).

RESULTS

During the 120-minute study period, core temperature and intraperitoneal temperature were significantly reduced in groups I, II, and III. In the animals that underwent warm, humidified insufflation (group IV) and the gasless controls (group V), intraoperative hypothermia did not develop. At SEM, retraction and bulging of mesothelial cells and exposure of the basal lamina were seen in the four insufflation groups (groups I-IV) and also in the gasless controls (group V).

CONCLUSION

Insufflation with cold, dry CO2 may lower the body temperature during laparoscopic surgery. Hypothermia can be prevented by both heating and humidifying the insufflation gas. Changes of the peritoneal surface occur after CO2 insufflation, despite heating or humidifying, and also after gasless surgery.

Carbon dioxide pneumothorax during laparoscopic surgery

BACKGROUND

Anesthetic considerations for laparoscopic cholecystectomy are similar to those for other laparoscopic procedures and result from the creation of a pneumoperitoneum by insufflation of carbon dioxide (CO 2) into the abdominal cavity. The resultant problems such as decreased functional residual capacity, increased airway pressure, hypercarbia, and circulatory impairment are well known [1]. The reported case is that of a healthy 45-yr-old man who underwent elective laparoscopic cholecystectomy under general anesthesia. As surgery proceeded he developed hypercapnia (arterial blood partial pressure of CO 2 [pCO] 2], 97.1 mmHg; extrapolated end-tidal CO 2 tension [P ETCO 2], 90 mmHg) and hypoxemia (partial pressure of oxygen [pO 2], 53.1 mmHg). The cause was attributed to absorption of CO 2 directly related to the surgical pneumoperitoneum. This report illustrates the diagnosis and management of an unusual case of CO 2 absorption, resulting in hypercapnia and hypoxemia, and a spontaneous recovery within 30 to 60 min without need of thoracentesis.

DNA sequences of the immunoglobulin heavy chain variable region gene in pyothorax-associated lymphoma

B cell lymphoma develops in the pleural cavity of patients affected by long-standing pyothorax resulting from lung tuberculosis, thus termed pyothorax-associated lymphoma (PAL). PAL usually shows a diffuse large cell morphology, and constantly contains Epstein-Barr virus (EBV) genome. To investigate whether PAL cells proliferate in response to specific antigenic stimuli and its stage in B cell differentiation, immunoglobulin heavy chain gene in 7 cases and 2 cell lines from PAL, all confirmed by histological studies to be EBV-positive diffuse large B cell lymphoma, were examined by using polymerase chain reaction (PCR) method. Clonal rearrangement of the gene was detected in 4 cases of PAL tissues and one cell line. As for the usage of the V region gene (V(H)), the V(H)3 family gene was used in 3 of these 5 cases with different homologous germlines, suggesting that the origin of PAL cells from a repertoire of B lymphocytes responsive to specific antigenic epitope was unlikely. Compared to the homologous germline, the mutation frequency of PAL was 9% on average. Only one case might have more replacement mutations in the complementarity-determining regions than expected by chance, thus antigen-selected maturation might not take place in PAL. Intraclonal sequence heterogeneity in the V(H) gene was found in another case. From these findings, it is concluded that PAL is composed of B lymphocytes at the differentiation stage of the postgerminal center. Antigen-selected maturation might not take place in PAL, which is distinct from the majority of B cell lymphomas.

Pyothorax-associated lymphoma: a peculiar clinicopathologic entity derived from B cells at late stage of differentiation and with occasional aberrant dual B- and T-cell phenotype

We report 12 European cases of pyothorax-associated lymphomas occurring 30-67 years following artificial pneumothorax for pleuropulmonar tuberculosis. Eleven patients presented with a localized pleural tumor mass, whereas one patient also had liver involvement. Histologic examination showed a diffuse proliferation of large lymphoid cells with frequent plasmacytoid differentiation (n = 8), expressing CD20 (n = 10), CD79a (n = 11), and/or CD138 (n = 5) B-cell antigens. Aberrant expression of T-cell markers (CD2, CD3, CD4) was noted in five cases. The B-cell origin of lymphoma cells was confirmed by the demonstration of immunoglobulin light chain restriction or clonal B cell population in six cases. In 11 of 12 cases in situ hybridization disclosed Epstein-Barr virus genome in most tumor cells and immunohistochemistry a type III LMP-1+/ EBNA-2+ latency profile. HHV-8/ORF73 antigen was not detected in all tested cases (n = 11). All investigated cases (10 of 10) disclosed a uniform CD10-/BCL-6-/MUM1+/CD138+/- phenotype, consistent with a derivation from late germinal center (GC)/post-GC B cells. Clinical outcome was poor with a median survival time of 5 months. Only one patient was in complete remission after 34 months. This study further confirms that pyothorax-associated lymphoma represents a distinct clinicopathologic entity among diffuse large B-cell lymphoma, which is characterized by a peculiar clinical presentation, frequent plasmacytoid features, and a strong association with EBV. Moreover, we show that this lymphoma entity likely originates from B cells at a late stage of differentiation and occasionally shares an aberrant dual B/T phenotype.

Helium and other alternative insufflation gases for laparoscopy

BACKGROUND

Carbon dioxide (CO(2)) is currently the insufflation gas of choice for laparoscopy. It fulfills most of the requirements for an ideal insufflation gas, being colorless, noninflammable, and rapidly excreted from the circulation. However, its use is associated with adverse cardiorespiratory effects, especially in patients with preexisting cardiorespiratory compromise.

METHODS

The descriptive review of relevant literature, moreover, has been proposed that it increases the incidence of port site (wound) metastases from abdominal cancers when used during oncological surgery. In addition, it may cause postoperative pain due to peritoneal irritation, and its use is associated with physiological and immunological impairment. Hence, there is scope for the investigation of alternative insufflation gases. Other possibilities include gasless laparoscopy, helium, nitrous oxide, (N(2)O), and argon. Helium insufflation has been used extensively in animal models but only to a limited extent in humans. In experimental studies, it has been shown to produce fewer changes in cardiorespiratory and intraperitoneal immunological status than CO(2) insufflation, and its use is associated with less spread of tumors to port sites in a variety of small animal tumor models. However, helium also has the potential for some adverse effects. Helium pneumothorax probably resolves more slowly than CO(2) pneumothorax, and helium gas embolism is tolerated poorly in animal models. The clinical significance of these potential problems has yet to be determined.

CONCLUSIONS

Although the use of alternative gases appears to be promising, further evaluation is needed within both clinical and laboratory settings before their routine clinical use can be supported.

Expression profile of human herpesvirus 8 (HHV-8) in pyothorax associated lymphoma and in effusion lymphoma

AIMS

Pyothorax associated lymphoma (PAL) occurs in a clinical setting of longstanding pyothorax or chronic inflammation of the pleura. Like primary effusion lymphoma, it has an association with Epstein-Barr virus (EBV), and is confined to the pleural cavity, but has differing morphological and phenotypic features. Human herpesvirus 8 (HHV-8) has been consistently reported in primary effusion lymphoma. This study examines the immunophenotype of two European cases of PAL, investigates the presence of HHV-8 and its expression profile, and assesses whether PAL is similar to other effusion lymphomas.

METHODS

Material was obtained from two European cases of PAL. Immunocytochemical analysis was performed using antibodies against CD45, CD20, CD79a, CD45RAA, CD3, CD43, CD45RO (UCHL1), CD30, BCL-2, CD68, epithelial membrane antigen (EMA), BCL-6, p53, Ki-67, kappa light chain, lambda light chain, and the EBV antigens latent membrane protein 1 (LMP-1) and EBV encoded nuclear antigen 2 (EBNA-2). The cases were examined for HHV-8 by means of polymerase chain reaction in situ hybridisation (PCR-ISH), solution phase PCR, in situ hybridisation (ISH), and real time quantitative TaqMan PCR to HHV-8 open reading frame 26 (ORF-26) and viral (v) cyclin encoding regions. The expression profile of HHV-8 in PAL and in BC-1 and BC-3 cells was assessed by RNA TaqMan PCR to the HHV-8 genes encoding v-cyclin, v-IL-6, and G protein coupled receptor (GPCR).

RESULTS

Both cases expressed CD24, CD20, CD79a, BCL-2, light chain restriction, and high Ki-67 staining. EBV was identified by EBER-ISH in one case. HHV-8 was not identified by solution phase PCR, but was detected by PCR-ISH (sensitivity of 1 viral genome copy/cell) in 35% of the cells and by TaqMan PCR, which showed 50-100 HHV-8 copies/2,000 cell genome equivalents (sensitivity of 1 viral genome in 10(6) contaminating sequences). HHV-8 v-IL-6, v-cyclin, and GPCR encoded transcripts were identified using RNA TaqMan PCR. v-IL-6 was high in PAL and in BC-1 and BC-3 cells.

CONCLUSION

The presence of HHV-8 in one of two patients with PAL raises interesting questions in relation to the pathobiology of the condition. Clearly, the results indicate that HHV-8 is not an obligate pathogen, necessary for the effusion phenotype, but might contribute to it by its secretion of specific cytokines.

Central nervous system involvement in pyothorax-associated lymphoma: ring enhancement on CT scan

A 71-year-old male was diagnosed as having pyothorax-associated lymphoma (PAL), a rare hematological malignancy associated with artificial pneumothorax for the treatment of pulmonary tuberculosis. Because of the low incidence, its clinical features have not been fully clarified. The PAL lesion in this patient disappeared after local radiotherapy and corticosteroid treatment. However, 8 months after the initial diagnosis, he developed a variety of neurological disorders and low-grade fever. Neither recurrence of the primary pulmonary lesion nor nodal enlargement was observed. Immediate magnetic resonance imaging of the brain revealed a ring-enhanced mass, suggesting a brain abscess. However, through a stereotactic biopsy of the brain lesion, infiltration of PAL cells was identified. The brain lesion rapidly enlarged despite intensive radiotherapy, and he finally died of lymphoma progression. This case demonstrates that PAL may progress as a type of extranodal lymphoma, and that brain lesions may produce a ring-enhanced pattern on computed tomography.

[A case of malignant lymphoma showing a stratum of lymphoma cells]

A 74-year man suffered an artificial pneumothorax of the right lung because of pulmonary tuberculosis 41 years before. He was admitted, and enlargement of chronic pyothorax was noted in chest radiography in 1998. A 67Ga scintigram revealed uptake at the site of the chronic pyothorax. Cytological findings of the pleural effusion included many atypical lymphocytes. We suspected the presence of a malignant lymphoma and performed a biopsy under thoracoscopy, but could not arrive at a diagnosis. Therefore, resection of the chronic empyema was performed. Histological examination demonstrated the layer of lymphoma cells covering the wall of empyema between the layers of necrotic and connective tissue. Lymphoma cells were stained with L 26, which is known as a B cell marker. We diagnosed diffuse large cell lymphoma (B cell type). No case like this case has ever been published of malignant lymphoma bearing a layer of lymphoma cells. This case is thought to show early-phase malignant lymphoma complicated with chronic pyothorax after artificial pneumothorax. Malignant lymphoma should be suspected when chronic pyothorax undergoes enlargement, even if CT scanning or MRI does not show typical findings.

[Five cases of surgically resected chronic expanding hematoma in the chest]

We report surgically treated 5 cases of chronic expanding hematoma in the chest. Three were male and two were female, aged 53 to 76. All patients except one who was thought to have an early stage of chronic expanding hematoma, had severe dyspnea due to compression of lung parenchyma or heart. Complete removal of the hematoma with fibrous capsule was done in two cases, but in three cases the hematoma was removed but the capsule was not because of severe adhesion to the surrounding structures. Post operative course was different to each other. One patient whose capsule was not removed completely have recurrent hematoma in the chest. The pulmonary or cardiac function were improved greatly except for the two cases; an early stage case and a recurrent case. We conclude that surgical removal is the first treatment for chronic expanding hematoma and complete removal of it with capsule is recommended.

Treatment for pyothorax-associated lymphoma

In eight patients with pyothorax-associated lymphoma (PAL), which resulted from artificial pneumothorax for the treatment of pulmonary tuberculosis, seven patients received radiotherapy and five showed no local recurrence. All four patients treated by primary chemotherapy had disease progression. Radiotherapy of 50 Gy with wide margins is recommended to treat PAL.

[Primary pleural lymphoma after collapse therapy: modern aspects of an historic disease]

INTRODUCTION

Pleural lymphomas after long standing pyothorax due to pulmonary tuberculosis are now well identified. Most cases have been described by Japanese investigators and it seems rare or unrecognised in Western countries. We report the study of six cases observed in a single institution.

PATIENTS AND METHODS

Six pyothorax-associated pleural lymphomas, among 1,038 lymphoma (0.6%) collected during a period from 1989 to 1998, are described. Diagnosis was established by two pathologists with the usual histologic and immunohistochemical methods, according to the working formulation. The in situ hybridization method for Epstein-Barr virus was performed.

RESULTS

The average age of the patient was 73 years. Presenting symptoms combined chest pain and constitutional symptoms more than 45 years after artificial pneumothorax or tuberculous pleuritis. Computerized tomography revealed a pleural mass which involved the adjacent chest wall. Open biopsy by thoracotomy show a diffuse B-cell non-Hodgkin-lymphoma in all cases. Though the lymphoma was initially localized, many poor prognostic factors (age, performance status, LDH, histology) explain the pejorative evolution (average survival of five months). Patients died from an uncontrolled tumoral proliferation or by infectious complications. In situ hybridization confirms the presence of Epstein-Barr virus in tumoral cells.

CONCLUSION

Pleural lymphoma is an established complication of artificial pneumothorax. Even if the Epstein-Barr virus plays a crucial role in the pathogenesis, and despite the number of artificial pneumothorax operations that have been widely performed, this lymphoma remains rare, suggesting additional oncogenic factors.

Anaesthetic implications of thoracoscopic surgery in children

As the equipment and technique have improved, minimally invasive surgery is being applied to younger and younger children. With the advent of this valuable surgical technique, there are also specific modifications necessary in the anaesthetic technique. When considering the anaesthetic implications of these patients, one must account for both the patient's underlying status as well as physiological derangements induced by the surgical procedure. The following article attempts to address and review the specific anaesthetic implications of thoracoscopic procedures in neonates, infants, and children including the preoperative evaluation, intraoperative care and monitoring, and postoperative issues including analgesia. The techniques of one-lung anaesthesia, commonly required for thoracoscopy, are reviewed as well as consideration of the adverse effects which can occur during thoracoscopy including inadvertent intravascular CO2 embolism.

A randomized controlled trial to determine the effects of humidified carbon dioxide insufflation during thoracoscopy

BACKGROUND

The humidification of gas insufflated during laparoscopy can reduce the degree of postoperative hypothermia and may result in less peritoneal reaction and less postoperative pain. The present study was designed to determine whether the beneficial effects of humidified gas insufflation also applied to thoracoscopy.

METHODS

Six pigs were each studied on three separate occasions with insufflation into the right thoracic cavity of either humidified gas, standard dry gas, or with no insufflation (control procedure). Core body temperature was recorded every 15 min, and biopsies of the parietal pleura were taken at the end of each study for electron microscopy.

RESULTS

Humidification of insufflated gas significantly minimized the fall in core temperature during the procedure. Electron microscopy showed that dry gas insufflation resulted in greater structural injury to the pleura than humidified gas insufflation.

CONCLUSIONS

The potential benefits of humidifying insufflation gas during thoracoscopy warrant its evaluation in the clinical setting.

A randomized controlled trial assessing the benefit of humidified insufflation gas during laparoscopic surgery

BACKGROUND

We conducted a randomized controlled trial during laparoscopic cholecystectomy to determine the extent of heat preservation and postoperative pain reduction using humidified carbon dioxide (CO2) gas insufflation instead of standard dry insufflation gas.

METHODS

Forty consecutive patients were randomized. Twenty patients received humidified CO2, and 20 control patients received standard CO2 insufflation. A sample of 16 patients from each group was evaluated for postoperative pain levels.

RESULTS

No adverse effects from the humidification of insufflated gas were observed. There was no significant difference in core body temperature between the two groups for this brief operation. Pain, as assessed by the Analogue Pain Score (APS) was significantly less for the group with humidified gas insufflation than for the control group at 6 h postoperatively as well as on the 1st, 2nd, and 3rd postoperative day and at follow-up 10 days after the operation. In the humidified group, the mean time to return to normal activities was significantly less-5.9 days, as compared to 10.9 days in the control group.

CONCLUSIONS

The use of humidified insufflation gas reduces postoperative pain following laparoscopic cholecystectomy, but except for these relatively brief procedures, the heat-preserving effect of humidified gas insufflation is not significant.

[Delayed complications after extrapleural pneumonolysis for lung tuberculosis]

The epidemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculotic drugs led to a renaissance of surgical procedure such as plombage thoracoplasty, initiated in 1891 by Tuffier. Especially in Germany the insertion of paraffin and polyethylene was used in order to achieve an extrapleural pneumothorax in order to collapse the tuberculous cavities in the upper lobes. Due to a high rate of early complications and the assumed cancerogenicity, in a considerable number of cases the material was removed soon after its deployment. In some cases with the filling remaining in place, 30-40 years later infections and/or neoplasms occurred. From 1985 to 1996 in two centers of thoracic surgery 13 patients underwent procedures for removal of filling material. The patients suffered from infections (n = 11), malignant lymphoma associated with infection of the plombage (n = 1) and bronchial carcinoma (n = 1). Technically, we performed the thoracoplasty described by Schede (n = 9). Schede's thoracoplasty in combination with a muscle flap repair (n = 1) or partial resection of the thoracic wall (n = 1), an empyemectomy (n = 1), and an en-bloc pleuropneumonectomy (n = 1). All patients suffered from multiple underlying diseases (COPD, coronary heart disease, diabetes mellitus). However, apart from beside two procedure related deaths (pulmonary embolism n = 1, pneumonia complicated by multi-organ failure n = 1) no other major complications were observed. The plombage material in the case of malignant lymphoma is probably carcinogenic in relation to the time of exposure and should be removed in all cases.

Pyothorax-associated lymphoma

In 1987, we reported three patients with pleural lymphoma developed after a 22-30 year history of pyothorax resulting from artificial pneumothorax for the treatment of pulmonary tuberculosis or tuberculous pleuritis. Based on the pathologic and epidemiologic studies, we regarded the chronic pyothorax (CP) to be etiologically important in the development of pleural lymphoma. Through a nation-wide study in Japan, 37 cases of pleural lymphoma were collected. Pleural lymphoma had developed during the 20 year history of CP in all patients. Histologically all were non-Hodgkin's lymphoma with the diffuse large cell type being the most common. Immunologic and immunohistochemical studies revealed that 32 out of 33 cases were of B-cell lymphoma. From these findings, we proposed the term pyothorax-associated lymphoma (PAL). We examined the presence of Epstein-Barr virus (EBV) genome on the paraffin-embedded specimens in 34 PAL cases and 16 cases of CP alone. Combined polymerase chain reaction (PCR), in situ hybridization, and immunohistochemistry revealed that the EBV genome was detected in lymphoma cells in all PAL, but only one of the cases with CP alone. These findings suggested the etiological role of EBV for the development of PAL. We also described here the character of cell lines established from PAL, association of PAL with Kaposi's sarcoma-associated herpes virus, results of a case-control study on risk factors for development of PAL, and p53 mutations.

Pleural epidermoid carcinoma from displaced skin following extrapleural pneumothorax in a patient exposed to asbestos

This report illustrates a rare case of primary epidermoid carcinoma of the pleura in a patient previously treated by artificial extrapleural pneumothorax for active tuberculosis. The patient had also been occupationally exposed to asbestos. Light microscopic examination showed two different lesions: laminar pleural fragments were covered by normal squamous epithelium that was similar in all respects to epidermis, whereas nodular fragments were composed of well-differentiated infiltrating carcinoma. These findings support the hypothesis that the carcinoma arose from normal epidermis seeded in the pleural cavity during multiple air refills to maintain the pneumothorax. A possible interaction between asbestos fibres and chronic inflammation might have potentiated tumour development.

Primary Epstein-Barr virus-related non-Hodgkin's lymphoma of the pleural cavity following long-standing tuberculous empyema

Primary non-Hodgkin's lymphomas of the pleural cavity have been described mostly in Japan. We report a case of high-grade non-Hodgkin's lymphoma (immunoblastic type) of the pleural cavity occurring in a nonimmunocompromised patient 55 years after an artificial pneumothorax was performed for the treatment of pulmonary tuberculosis. Immunohistochemical study revealed a B phenotype (CD20), and an in situ hybridization detected small nuclear RNAs encoded by Epstein-Barr virus in most lymphomatous cells. A link between primary pleural lymphoma and the local long-standing chronic inflammation, inducing a clonal transformation of Epstein-Barr virus-infected immortalized B lymphocytes, is suspected.

[A case of thoracic empyema extended into the abdominal cavity]

A case of thoracic empyema after artificial pneumothorax for lung tuberculosis was presented, which extended into the abdominal cavity. 65 years old man, who was operated on for lung tuberculosis about 30 years ago, took the routine physical examination and the abdominal mass was picked up on examination. Echogram and CT showed huge homogeneous mass in the right thorax and the right upper abdominal cavity. The operative finding showed that thoracic empyema extended into the abdominal cavity and formed a huge mass. Decortication and extirpation of thoracic empyema and abdominal mass was performed with a combined partial resection of the lung, diaphragma, and thoracic wall. The histopathology of the abdominal mass showed chronic empyema and hematoma.

Hemodynamic effects of carbon dioxide insufflation during thoracoscopy

As more complex thoracoscopic procedures are performed, adequate exposure becomes increasingly more important. The insufflation of CO2 has been demonstrated to aid in the compression of lung parenchyma and the effacement of subpleural lesions, and to act as a retractor when combined with changes in patient position. However, a recent study demonstrated that CO2 insufflation during thoracoscopy in the pig had adverse hemodynamic consequences. We prospectively studied 32 patients undergoing thoracoscopy to evaluate the effects of CO2 insufflation in the clinical setting. The end-tidal CO2 pressure, arterial oxygen saturation, mean arterial pressure, heart rate, and central venous pressure were monitored. Measurements were determined at baseline, at the initiation of one-lung ventilation, and at intrapleural pressures of 2 to 14 mm Hg. We found that the insufflation of CO2 of 2 to 14 mm Hg had no significant effect on the end-tidal CO2 pressure, arterial oxygen saturation, heart rate, or mean arterial pressure, but the central venous pressure did rise from 7.00 +/- 1.5 mm Hg to 17.30 +/- 2.53 mm Hg (p < 0.05). We conclude from this that the insufflation of CO2 during thoracoscopy does not have adverse hemodynamic effects in the clinical setting. Therefore, we propose that low-pressure (< 10 mm Hg) insufflation is a safe adjunct to the conduct of routine thoracoscopic surgical procedures.

Capnothorax: implications for the anaesthetist

Ten patients underwent a laparoscopic surgical technique for thoracic and cervical dissection of the oesophagus during oesophagogastrectomy. Thoracotomy was avoided with potential benefits to the patient. To facilitate surgical access the right lung was collapsed using a double-lumen bronchial tube and carbon dioxide was insufflated into the right pleural cavity to compress the lung. Changes in haemodynamic and respiratory variables occurred. In the majority of the patients airway pressure and end-tidal CO2 increased, despite alterations in ventilation. In five patients systolic blood pressure decreased suddenly by between 15 and 35 mmHg, and in four patients SpO2 decreased to 91% or less, despite an FIO2 of 1.0. If carbon dioxide was insufflated too fast, or the lung failed to deflate adequately, the clinical picture was that of a tension pneumothorax. One patient developed surgical emphysema and a contralateral pneumothorax. Postoperatively two patients had recurrent laryngeal nerve damage. Suggestions are made to minimise the changes in haemodynamic and respiratory variables during carbon dioxide insufflation into the thorax.

[Malignant lymphoma developing from the wall of chronic empyema following artificial pneumothorax]

A 60-year-old man who had had chronic empyema following an artificial pneumothorax for pulmonary tuberculosis when he was 26 years old developed malignant lymphoma of the chest wall. The patient was admitted because of right pyothorax as a result of pseudomonas aeruginosa infection and underwent right thoracotomy. During lavage of the right thoracic cavity a tumor was found arising from the empyematic wall. Pathologic examination revealed that it was malignant lymphoma (diffuse large, immunoblastic, B cell type). Treatment with VEAP-Bleomycin elicited a good response. Seven months after chemotherapy, the patient underwent thoracoplasty in addition to packing the cavity with the latissimus dorsi and the greater omentum. Following this, the patient received chemotherapy once a month for one and a half years, after which he was kept under close observation without treatment. Complete remission has now lasted for 49 months since the initial treatment. This is the first reported lymphoma case with closure of the empyematic wall and is remarkable since this patient has remained in complete remission for the last two years without any treatment.

[A case of malignant lymphoma arising from chest wall in chronic empyema]

A 70-year-old male was admitted with complaints of anterior chest pain and tumor formation. He has a history of pulmonary tuberculosis and was performed artificial pneumothorax therapy 37 years ago. The diagnosis on admission was perforation of empyema cavity into the chest wall. But thoracotomy revealed that the chest tumor arising from chronic empyema wall was a malignant lymphoma. Decortication and extirpation of the tumor were performed with combined partial resection of chest wall. Immunohistological examination showed that the histology was diffuse large T cell type of Non-Hodgkin's malignant lymphoma. The patient has been alive and well for 24 months postoperatively.

Sputum wax-worms after plombage

Paraffin wax plombage was one of several plombage operations used for pulmonary tuberculosis about 40 years ago, and Shepherd included seven patients treated with wax plombage in her review of plombage in 1985. We describe another patient with wax plombage who coughed up wax 28 years after plombage, followed by much larger amounts of wax 15 years later. The pieces of wax were like worms and spirals, and we discuss possible causes for these shapes.

Late exudative complications of collapse therapy for pulmonary tuberculosis

In a retrospective study of 15 patients who were treated with collapse therapy for pulmonary tuberculosis on an average 30 years previously, we found 16 instances of exudation in the residual pocket: four were sterile and without fistula, ten had bronchial fistulae, one had an esophageal fistula, and one was a tuberculous empyema without fistula. Among the 11 exudations with bronchial or esophageal fistulae, none contained tubercle bacilli, six were infected with pyogenic microorganisms, and five remained sterile. In 12 cases, the diagnosis was suggested by chest x-ray film. Four of nine exudates which remained sterile and three of the seven infected ones could be stabilized by conservative measures; the others required a decortication, sometimes with parenchymal resection. This study shows that in late exudative complications of old collapse therapy, an initial conservative treatment can be curative in about 45 percent of the cases.

Tuberculous empyema--a case history extending over 30 years

A patient with chronic tuberculous empyema is described. The condition had been present for 30 years, following treatment by outpatient pneumothorax. A broncho-pleural fistula developed, the symptoms of which were aggravated during air-flight.

Late results of plombage

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