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.