Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery

We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.

Comparison of bronchoscopic diagnostic techniques with histological findings in brain dead organ donors without suspected pneumonia

BACKGROUND

The techniques for recognising pneumonia in mechanically ventilated patients were evaluated as no "gold standard" is available to establish the diagnosis in these patients.

METHODS

A prospective study was performed on nine brain dead organ donors not suspected of having pneumonia to assess the specificity of bacteriological results from different samples by comparing them with the histological findings from an open pulmonary biopsy specimen taken immediately after death through a mini-thoracotomy.

RESULTS

Seven of the nine organ donors without clinical evidence of pulmonary infection and not on antibiotic therapy showed histological features of bronchopneumonia. There was no association between the histological findings and quantitative cultures of the lung biopsy specimen.

CONCLUSIONS

Histological evidence of pneumonia was common in this group of ventilated patients who had no clinical signs of the disease.

Massive hemoptysis as a manifestation of fistulized thoracic aortic aneurysms into the bronchial tree

Aortobronchial fistulas are an uncommon and serious cause of hemoptysis. We present three cases of aortobronchial fistulas that were diagnosed and treated at our hospital. They were presented as massive hemoptysis. The clinical suspicion of a leaking thoracic aortic aneurysm into the bronchial tree should prompt the correct diagnostic procedures since early surgery is the only way to manage this condition.

[Traumatic hemothorax treated by video-assisted thoracoscopic surgery]

The introduction of video-assisted thoracic surgery (VTS) has significantly furthered the use of the thoracoscope in surgery. In the case we describe, a 79-years-old man at high risk for surgery came to our hospital with hemothorax due to trauma. The necessary procedure was performed successfully with VTS, which allowed for the repair of an acute condition that would otherwise have been treated conventionally by way of posterolateral thoracotomy. We conclude that VTS may play an important role in the diagnosis and treatment of certain thoracic injuries, so that surgery involving more extensive bleeding is rendered unnecessary.

Colonisation with Aspergillus of an intralobar pulmonary sequestration

Pulmonary sequestration is a term used to describe an area of embryonic lung tissue supplied by an anomalous systemic artery. Two forms are recognised-extralobar and intralobar-with different clinical presentations. A patient is reported with intralobar pulmonary sequestration in the left lung and colonisation with Aspergillus which was successfully treated by lower lobectomy.

[Primary spontaneous pneumothorax. A retrospective study of 495 cases]

We conducted a retrospective study of patients treated in our department for primary spontaneous pneumothorax (PSP) between 1986 and 1993. The 495 patients were between 12 and 81 years old (mean 28.2 years). Four hundred fifteen (83.8%) were men and 80 (16.2%) were women. PSP was in the right lung in 262 cases (52.9%) and in the left lung in 215 (43.5%). Both sides were affected in 18 cases (3.6%). The initial treatment was pleural drainage; small caliber drains were used in 85 and no associated complications were observed. On 185 occasions (37.3%), patients required surgical repair as a result of air leaks, recurrence or acute hemorrhage. There were postsurgical complications in 15 cases (8.1%) but no recurrences or deaths after surgery. We observed no significant differences in the number of recurrences after use of conventional drains or small caliber drains. Nor were there differences in mean time of hospital stay or complications after conventional surgery or video assisted surgery, a technique that has only recently been introduced. We conclude that PSP responds well to treatment with pleural drains and that small caliber catheters offer a good alternative for treating first episodes. Surgery is indicated when there is recurrence or when air leaks are persistent. At present, video assisted thoracoscopic surgery has successfully replaced axillary thoracotomy for most patients.

Surgical treatment of childhood mediastinal tuberculous lymphadenitis

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.

Pulmonary arteriovenous fistula ruptured to pleural cavity in pregnancy

Congenital pulmonary arteriovenous fistula is frequently associated with hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease). With the increased blood flow in pregnancy such fistulas enlarge, occasionally giving rise to haemothorax, which generally has a poor prognosis. A familial case is presented in which massive haemothorax required emergency thoracotomy in the 27th week of pregnancy.

Extended cervical mediastinoscopy: prospective study of fifty cases

To assess the usefulness of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma, an ECM was performed prospectively in 50 patients with bronchogenic carcinoma of the left lung. The ECM was used after evaluation of disease operability and computed tomographic findings, and was performed simultaneously with standard cervical mediastinoscopy. In ECM, using the same cervical incision as in a standard cervical mediastinoscopy, dissection is performed behind the anterior face of the sternum. The aortic arch is reached at the level of the origin of the innominate artery. The mediastinoscope is then passed by sliding it along the left anterolateral face of the aortic arch until it reaches the aortopulmonary window. Extended cervical mediastinoscopy was considered positive when a nodal biopsy result consistent with a neoformative process or direct invasion of the mediastinal structures was found. Four patients with positive standard cervical mediastinoscopy and negative ECM were excluded. A false negative ECM was defined as the presence of infiltrated adenopathies at the paraaortic level detected on postoperative histologic study. The ECM was positive in 5 patients in whom operation was contraindicated. Resectability in the remaining 41 patients was 97.6%. Postoperative pathologic study showed infiltrated adenopathy in 3 patients (2 subcarinal, 1 subaortic) accounting for 40 true negatives (the subcarinal group is inaccessible by ECM). This study suggests that ECM has outstanding specificity (100%), sensitivity of 83.3%, and a diagnostic accuracy of 97.8%. A positive predictive value of 100% and a negative predictive value of 97.5% were also identified by this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental tracheal revascularization with omentum

We assessed omental revascularization of heterotopic tracheal implants in rats, and investigated the influence of factors that can enhance revascularization. The trachea of the donor animal was excised in two parts, and each tracheal allograft was implanted in the omentum of two recipients. The influence of mechanical factors was evaluated by applying traction at both ends of the graft with and without drainage of the tracheal lumen, and the influence of pharmacologic factors by giving cefonicid, hydrocortisone, cefonicid plus hydrocortisone, or cyclosporine and azathioprine during the postoperative period. Revascularization of the graft from the omentum with preservation of the tracheal structure was established. Graft viability showed significant differences between the tracheal implants to which no traction had been applied and those with traction at both ends. Tracheal allografts from animals receiving immunosuppressants were completely viable and no significant differences were found between the controls and animals in this group.

[Evaluation of 2 techniques for ventilation support during single-lung ventilation]

In a group of 22 patients undergoing thoracotomy we compared two techniques of ventilatory assistance to the nondependent lung during single lung ventilation. We simultaneously administered a 0.5% FiO2 to the dependent lung. We used a CPAP system with continuous O2 flow limited by an underwater valve at a pressure of +5 cmH2O. We performed 33 ventilatory assistances: in 15 cases to the nondependent lung (CPAP group) and in 18 patients to the lower lobe of the nondependent lung (lobar CPAP group). Evaluation of both techniques was performed by means of arterial blood gas measurement and the mean values were compared using the student's t test. During single lung ventilation the PaO2 in CPAP group increased from 85.86 +/- 22.28 mmHg to 155.52 +/- 59.54 mmHg (p less than 0.001) and in the lobar CPAP series it increased from 88.75 +/- 24.34 mmHg to 122.36 +/- 43.21 mmHg (p less than 0.01). In 11 out of the 22 patients we firstly applied the lobar CPAP and thereafter the CPAP to the whole lung in order to compare the efficacy of both techniques in the same patient. The PaO2 during single lung ventilation was 86.9 +/- 22.7 mmHg and it increased to 111.1 +/- 37.9 mmHg after lobar CPAP (p less than 0.01) ant to 163.3 +/- 64 mmHg after total lung CPAP ventilation (p less than 0.001). Our results confirm the usefulness of both techniques and they indicate that CPAP to the whole nondependent lung is the most effective.

Surgical treatment of stage III non-small cell bronchogenic carcinoma involving the chest wall

Thirty-five patients who had undergone surgery for non-small cell bronchogenic carcinoma with isolated involvement of the chest wall were reviewed. The diagnosis was preoperatively suspected in 80% of cases. En-bloc resection of the invaded chest wall was performed in 25 cases and parietal pleurectomy in ten in which the pleura was easily dissectable from the costal plane. Of the eight patients with major complications in the early postoperative period, six, including the two who died perioperatively, had undergone en-block resection. The 5-year actuarial survival rate was 22% overall and 36% in the patients without lymph node involvement. No significant relationship between survival and type of operation or degree of chest wall invasion was found. Isolated involvement of the chest wall by non-small cell bronchogenic carcinoma does not necessarily contraindicate surgery with curative intent. Parietal pleurectomy is valid in selected cases. Long-term survival depends basically on node involvement.

Tracheal agenesis: an unresolved problem

A case of tracheal agenesis diagnosed at birth is discussed in which surgical correction was attempted. Both main bronchi were divided and anastomosis of the main right bronchus to the larynx was attempted, after intrapericardial release of the right lung and severing of the lower pulmonary ligament: bronchoplastic reconstruction of the trachea was impossible. We think that tracheal agenesis, a rare cause of respiratory distress in the newborn, has no suitable therapy today. It is justified to attempt surgical correction if any promising device is at hand or if any doubt exists that an uncorrectable situation is present.

Congenital bronchoesophageal fistula in adults. Report of three cases

Persistence of congenital bronchoesophageal fistulae into adulthood is rare. Three patients, one male and two female, of 52, 27 and 63 years of age, respectively, are reported. All three presented with chronic respiratory symptoms and coughing spells associated with ingestion. The barium swallow confirmed diagnoses. Treatment was surgical and consisted of excision of the fistulous tract, suture of the oesophageal and bronchial orifices and the interposition of a parietal pleura flap in two cases, and of biological glue in one. All three patients recovered and are free of symptoms.

[Ruptured mycotic aneurysm of the femoral artery]

After several commentaries about mycotic aneurysms related to drug addicts, author exposes the case of a young man attached to heroin, presenting a ruptured femoral mycotic aneurysm, surgically treated. Surgery in these cases is commented on.