Emergent pneumonectomy for hemoptysis in a patient with previous thoracoplasty

Hemoptysis is a life-threatening episode of respiratory disease. By means of every possible treatment, hemostasis should be obtained to secure the airway as well as to prevent blood loss. We describe an emergent pneumonectomy for massive hemoptysis from destroyed lung in a patient with previous thoracoplasty. After prolonged ventilation support postoperatively, the patient with compromised lung function recovered well.

[Bronchial bleeding]

The acute and general management of patients with massive hemoptysis is described. Initial priorities are insuring adequate airway protection, ventilation, and cardiovascular function. Major priorities of ongoing hemoptysis to prevent gas exchange are intubation with a large bore endotracheal tube and protection of nonbleeding lung by selective intubation into nonbleeding main stem bronchus. Once the patient stabilized, bronchoscopic procedure to stop bleeding following by bronchial arterial embolization should be planned. While surgery remains only definitive therapy, it should not be used in the acute emergent setting unless it cannot be avoided. Bronchial artery and other feeding arteries in the chest wall should be shut off before surgery to prevent massive bleeding during operation.

[Hemoptysis]

Hemoptysis is a potentially life-threatening complication of various diseases. The most common causes are infectious and inflammatory processes, followed by neoplasms, pulmonary embolisms, mitral stenoses, coagulopathies, and multiple systemic disorders. Primary examinations include a chest x-ray, an angio CT and a bronchoscopy. Sometimes, a bronchial artery angiogram is required. The patient is at risk of suffocation because blood and clots can severely obstruct his airways. Thus, the most important measures are: supplemental oxygen, positioning the patient with the bleeding side down, bronchoscopical suctioning and removal of blood and clots. Coagulopathies have to be corrected. Application of vasoactive drugs may help temporarily. In cases of bleeding from central lesions, coagulation with laser or argon-plasma-coagulator is feasible. Heavy bleeding from the periphery requires a balloon or tube tamponade. Depending on the cause and the severity of the bleeding either anti-inflammatory medical treatment, hemostyptic radiation therapy, bronchial artery embolisation or a surgical procedure must follow.

The role of surgery in hemoptysis caused by thoracic actinomycosis; a forgotten disease

OBJECTIVE

Thoracic actinomycosis is a relatively uncommon anaerobic infection caused by Actinomyces israelii. Rarely, it may be complicated by an unusual but significant hemoptysis manifestation. We describe our experiences of surgical treatment for hemoptysis in patients with pulmonary actinomycosis.

METHODS

From 1984 to 2002, 14 patients with thoracic actinomycosis and hemoptysis were diagnosed after thoracotomy. There were 11 male and three female patients with a mean age of 53.6 years. They all had non-specific symptoms and radiographic findings, and no case was an accurate diagnosis made at the time of hospital admission, including echo-guide aspiration, serial bronchoscopic biopsy and computed tomography biopsy. The indications of surgical intervention in our patients were for treating complications such as hemoptysis, chronic sinus discharge, or empyema, also limited to diagnostic purposes. Preoperative embolization was performed in seven cases; however, none was successful.

RESULTS

Among the 14 patients, all the lesions were unilateral. The disease was confined to the lung in all patients; and chest wall involvement in one patient. The surgical procedures included were as follows: pneumonectomy (n=1), bilobectomy (n=1), lobectomy (n=10), wedge resection (n=2), and lung lesion with concomitant chest wall resection and chest wall reconstruction (n=1). Mean intraoperative and postoperative blood loss within the first 24 h was 192.3 ml, and five patients required blood transfusion. All of the specimens from the lesion site showed histological evidence of Actinomyces infection. All patients regularly took 12 million units per day of intravenous crystalline penicillin G during their hospitalization, and oral procaine penicillin for up to 2 months. During the follow-up, all patients had an uneventful postoperative course.

CONCLUSIONS

A high index of suspicion for this disease is advised for the surgeon engaged in the treatment of hemoptysis. Surgical resection of pulmonary actinomycosis is effective in preventing recurrence of hemoptysis. After diagnosis, it is treated using penicillin chemotherapy for at least 2 months.

Endovascular Treatment of an Aortobronchial Fistula

A 67-year-old man operated on 8 years previously for type B aortic dissection presented with two episodes of massive hemoptysis. An aortobronchial fistula was suspected with spiral computed tomography angiography, and showed a small pseudoaneurysm corresponding to the distal anastomotic site. The patient underwent endovascular stent-graft implantation and is asymptomatic 8 months after the procedure.

Pulmonary resection for massive hemoptysis of benign etiology

OBJECTIVE

To assess the outcome of pulmonary resection in the management of massive hemoptysis caused by benign lung diseases.

METHODS

A longitudinal cohort study of 53 consecutive patients who presented with hemoptysis and were treated with either emergency (group 1) or elective (group 2) pulmonary resection from January 1995 to December 1999.

RESULTS

Fifty-three patients were studied, 27 in group 1 and 26 in group 2. The mean age of the patients was 47.2 years (range, 29-70 years). Urgent examination with a combination of rigid and flexible fiberoptic bronchoscope localized the bleeding site in 45 patients (85%). Age>50 years, hypertension, hemoglobin on admission<10 g/dl, cause of hemoptysis, and a prior attack of hemoptysis were the predictors for the need of emergency surgery. The overall hospital mortality rate was 4% (2/53). Postoperative complications occurred in 13 patients (25%). Complications were more common in patients who received blood transfusion than non-transfused patients (9/23 and 4/30, respectively; P=0.03). Patients with tuberculosis as the cause of massive hemoptysis had more complications 5/8 in comparison to all other patients (P=0.02). The mean follow-up was 4.5 years (range, 3-6 years) for all patients who survived. Hemoptysis recurred in four patients (8%) and all from group 1 (P=0.02).

CONCLUSIONS

Immediate pulmonary resection for massive hemoptysis is effective in case of life-threatening bleeding that is not controlled by conservative measures. Elderly patients with a prior history of hemoptysis and/or hypertension and bleeding due to a fungus ball, necrotizing pneumonia, tuberculosis or lung abscess should be considered for early operation in an attempt to reduce morbidity and mortality.

An unusual cause of hemoptysis: ventriculopulmonary fistula

A 55-year-old man presented with massive hemoptysis following coronary artery bypass grafting and repair of a left ventricular aneurysm. Radiological and bronchoscopic examinations revealed no bronchial cause. The findings of computed tomography (CT) of the chest and echocardiography showed a pseudoaneurysm of the left ventricle. Surgical exploration confirmed that the pseudoaneurysm communicated with the lung parenchyma.

Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis

Catamenial hemoptysis is a rare condition that is associated with the presence of intrapulmonary or endobronchial endometrial tissue. Diagnosis of and therapy for this condition are still a matter of debate. We describe a case of endobronchial endometriosis with catamenial hemoptysis. An endobronchial lesion was diagnosed by spiral CT scan, taken at the onset of the menses, and confirmed with flexible bronchoscopy. The patient was successfully treated with endoscopic Nd-YAG laser therapy with a 1-day in-hospital procedure. We suggest that endoscopic laser treatment should be the first line of therapy for central airway endometriosis, provided that the source of bleeding has been conclusively located and all of the lesions can be reached with the bronchoscope.

Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta

Salmonella mycotic aneurysms of the descending thoracic aorta are exceedingly rare. There are few case reports and even fewer reports of long term survival. The case of a 68-year-old female presenting with a mycotic aneurysm of the descending thoracic aorta caused by Salmonella species is described, which involved successful surgical intervention.

Management of massive hemoptysis in a thoracic surgical unit

OBJECTIVE

Massive hemoptysis is a life-threatening condition. Surgery is effective but we are sometimes reluctant to operate on patients with this condition. We reviewed our experience with patients who underwent emergency surgery for massive hemoptysis to verify the indications for non-emergency surgical intervention.

METHODS

We reviewed chest computed tomography (CT) and angiographic and pathological findings and the postoperative course of 25 patients who underwent emergency pulmonary resection in our department between 1979 and 2001 due to life-threatening hemoptysis.

RESULTS

CT revealed a persistent cavity within the radiological opacity before massive hemoptysis in 12 patients (48%). Of the 21 patients who underwent angiography, nine showed focal bleeding in one bronchial branch and the others showed bleeding in multiple branches. Of these nine patients, seven did not undergo embolotherapy mainly due to minor vascularity. In the remaining patients, embolotherapy was not indicated in six due to multiple bleeding feeders and recurrence after embolotherapy was seen in six. Pathological findings showed that eight of the 12 patients with multiple systemic shunts had a fungal infection. Operative morbidity and hospital mortality were 32 and 4%, respectively. There was no recurrence in patients who underwent surgical treatment.

CONCLUSIONS

Early pulmonary resection is indicated in patients with hemoptysis of multiple branches from the cavity and chest wall, such as in fungal infections. When a bronchial branch is the only bleeding focus, superselective embolotherapy should be considered prior to surgery even if the localized focus of the bronchial branch shows minor vascularity on the angiography.

Parallel technique of endobronchial balloon catheter tamponade for transient alleviation of massive hemoptysis

Endobronchial balloon tamponade is an alternative method that can be used to control massive hemoptysis. Several different techniques have been used for this purpose. We describe a new parallel method, in which biopsy forceps introduced through a bronchoscope channel is used to grasp a balloon catheter. As the bronchoscope is advanced to the bleeding site, the balloon catheter is pulled into position, and subsequently inflated. There are several advantages of this technique. It needs no specialized catheter or guide wire, the procedure is relatively easy to perform, and applicable to other purposes such as introduction of an additional suction catheter.

Severe unilateral pulmonary vascular changes in child with polysplenia

A 12-year-old boy with polysplenia and single ventricle experienced recurrent episodes of pneumonia, hemoptysis, and pulmonary hypertension. Unilateral pulmonary vein obstruction was diagnosed, and a left pneumonectomy was performed. Microscopy of the resected specimen revealed pulmonary veno-occlusive disease in the small pulmonary venules, and old arteritis in the small pulmonary arteries.

Role of surgery in pulmonary tuberculosis

BACKGROUND

The purpose of our study was to analyze current indications for surgery in tuberculosis (TB). We present our experience with TB patients presenting with indications for surgery between 1990 and 1998.

MATERIAL/METHODS

The indications for surgical intervention included 25 cases of pulmonary aspergilloma, 19 cases of pneumothorax, 16 cases of pulmonary nodes and masses without histological diagnosis, 15 cases of bronchiectasis, 12 cases of massive hemoptysis, 12 cases of pleural empyema, and 33 cases of other complications. No patients with multidrug-resistant tuberculosis required surgical intervention, although 56 were treated during this period.

RESULTS

The techniques utilized included lobectomy in 45 cases, pleural drainage in 32 cases, segmented pulmonary resection in 32 cases, surgical procedures on the thoracic wall in 17 cases, pneumonectomy in 10 cases, pleuropulmonary decortication in 8 cases, mediastinoscopy in 6 cases, and thoracoscopy in 5 cases. In 25 cases two or more procedures were performed on the same patient. In 36 cases (27.3%) there were complications, of which persistent air leakage after pulmonary resection was the most frequent (n=10). There was a mortality rate of 5.3% (7

CONCLUSIONS

In our experience, surgery in the treatment of TB is indicated to resolve sequelae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable.

Cardiac bronchus: a rare cause of hemoptysis

In this paper, we present a case history, involving a 70-year-old male patient with hemoptysis due to an accessory cardiac bronchus, which was treated successfully by resection.

Massive hemoptysis: what place for medical and surgical treatment

OBJECTIVE

The objective of the study was to define timing of surgical treatment in management of massive hemoptysis.

METHODS

We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment.

RESULTS

Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death.

CONCLUSION

Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed.

[Massive hemoptysis from an aortobronchial fistula]

This is a report of a 61 year old man who was admitted at the Intensive Care Unit because of massive hemoptysis and respiratory failure. Four years before he had had an aortic dissection type A, and at that time an aortic valve, ascending aorta and aortic arch replacement, had been carried out. A thorax CT scan showed an aneurysm of the ascending aorta. A bronchoscopy was normal. In the angiography, a collateral of the left mammary artery was identified as the cause of bleeding and was subsequently embolized. After the procedure, the patient had a new episode of massive hemoptysis, and surgery was recommended. During surgery, the diagnosis of aortobronchial fistula was confirmed but the patient died during the intervention.

Endoluminal stent graft repair of aortobronchial fistulas

OBJECTIVE

To describe our experience with endoluminal stent graft repair of aortobronchial fistulas.

METHODS

We reviewed the records of patients treated with endoluminal stent grafting of aortobronchial fistulas at a private teaching hospital. All patients underwent the following diagnostic studies: computed tomography, angiography, bronchoscopy, and transesophageal echocardiography. With standard endovascular techniques, two different devices were implanted.

RESULTS

Between March 1997 and October 2000, we treated four patients with postsurgical fistulas. The patients were diagnosed with hemoptysis between 3 and 23 years after aortic replacement grafting for thoracic aneurysms. Diagnostic studies varied in their ability to find the fistula. Transesophageal echocardiography most reliably demonstrated the fistula in the patients. All were successfully treated by exclusion with endoluminal stent grafting. The patients had no complications and no further episodes of hemoptysis.

CONCLUSION

Endoluminal stent grafting of aortobronchial fistulas is feasible and may become the preferred method of management in patients at high risk.

Emergent pneumonectomy for hemoptysis in a patient with previous thoracoplasty

Hemoptysis is a life-threatening episode of respiratory disease. By means of every possible treatment, hemostasis should be obtained to secure the airway as well as to prevent blood loss. We describe an emergency pneumonectomy for massive hemoptysis from destroyed lung in a patient with previous thoracoplasty. After the prolonged ventilation support postoperatively, the patient with compromised lung function recovered well.

Aortobronchial fistula presenting as recurrent hemoptysis and successfully treated with an endovascular stent graft

Aortobronchial fistula (ABF) (aortopulmonary fistula) may cause a massive fatal hemoptysis. We have recently seen a patient with ABF presenting with recurrent, massive hemoptysis. She was successfully treated with an endovascular stent graft. The endovascular stent graft may provide an alternative treatment of in patients considered to be poor surgical candidates.

Hemoptysis as an unusual presenting symptom of invasion of a descending thoracic aortic aneurysmal dissection by lung cancer

A 70-year-old woman with a known chronic dissecting aneurysm of the descending thoracic aorta presented with new-onset back pain and hemoptysis. The hemoptysis was thought to be the result of invasion of the bronchial tree by the aneurysm. During surgical repair, a lesion that appeared to be a pulmonary abscess was discovered to be adhering to the aortic tissue, and the patient underwent a localized pulmonary resection. The pathology report of the surgical specimens revealed squamous cell carcinoma of the lung with infiltration of the aortic wall. The patient died of lung cancer 6 months later. Hemoptysis was an unusual presentation in a case of lung cancer that had invaded a stable chronic aortic aneurysm.

[Endoluminal therapy of the trachea and bronchus]

The application of endoscopic techniques is common in the treatment of tracheal and bronchial diseases today. Bronchoscopic interventions are used in both elective and emergency situations. Laser therapy for malignant tumors is purely palliative in most cases and should only be performed in nonsurgical patients. However, 30% of lung cancers cause obstruction in the trachea and main bronchi. Benign tumors and tracheal stenoses could require laser recanalization or the implantation of stents, if surgery will be the second step or will not be possible. In patients with foreign body aspiration, massive hemoptysis, or severe obstruction of the trachea, emergency bronchoscopy is necessary. A more recent type of bronchoscopic intervention is the treatment of bronchial stump or anastomosis insufficiency as well as minimal iatrogenic injuries using spongiotic fillings or stent implantation. The use of therapeutic bronchoscopy requires great experience in rigid and flexible bronchoscopy, the possibility of high-frequency jet ventilation as well as laser and argon application, and the possibility to implant different types of stents. More advanced bronchoscopic interventions should only be done if a department of thoracic surgery exists, in view of the potential need to control complications or perform further treatment. Especially the bronchoscopic treatment of tracheal stenosis should be performed by the thoracic surgeon himself or in close contact with a thoracic surgeon who is experienced in tracheal resections.

Pulmonary venous obstruction requiring lobectomy for hemoptysis after a Glenn operation

Right atrial isomerism is well known to be associated with anomalous pulmonary venous drainage and a potentially dangerous sequel to pulmonary venous obstruction, and is associated with high mortality. We report a 16-month-old girl with pulmonary venous obstruction requiring lobectomy for hemoptysis after a Glenn operation. Two years after surgery, she is doing well with 80% oxygen saturation and no further episodes of hemoptysis.

Near-fatal hemoptysis and emergency surgical repair after aortic patch-plasty

A 38-year-old man presented with massive hemoptysis followed by hemorrhage shock. The patient's history revealed a Dacron patch repair for aortic coarctation and recoarctation carried out twice, once 23 and once 10 years ago. Diagnosis of a ruptured descending aortic aneurysm with an aortobronchial fistula into the left lower lobe was established using CT scan. Emergency surgery consisted of left pneumonectomy and descending aortic graft replacement during deep hypothermic circulatory arrest. The patient was discharged 12 days later.

Video-assisted thoracoscopic surgery for catamenial hemoptysis

Catamenial hemoptysis is a rare condition, and only 36 cases have been reported since the first published case. We describe a woman with catamenial hemoptysis recurring over 8 years. The lesion was diagnosed using chest CT scan during menses and was also visualized clearly via thoracoscopy. The patient was treated successfully with a partial resection of the lung using video-assisted thoracic surgery (VATS) and has been asymptomatic for 14 months since the operation. We suggest that VATS for catamenial hemoptysis is a more effective treatment than medical therapy.

Implantable cardioverter defibrillator patch erosion in a heart transplant patient

A 57-year-old man who had received an automatic implantable cardioverter defibrillator and subsequent orthotopic heart transplant presented to medical attention for hemoptysis. The hemoptysis was caused by the migration of the left ventricular patch of the automatic implantable cardioverter defibrillator, which had been left in place at the time of orthotopic heart transplant. The patch had eroded into the left lung. We recommend that implantable cardioverter defibrillators be removed completely at the time of heart transplantation to prevent subsequent complications.

Massive hemoptysis from a lung abscess due to retained gallstones

This case report describes a subhepatic abscess from spilled gallstones which eroded through the diaphragm causing a right lower lobe pulmonary abscess and presenting as massive hemoptysis.

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

OBJECTIVES

Pulmonary tuberculosis and bronchiectasis are the major causes of massive hemoptysis in developing countries. Lung resection remains the surgical treatment of choice. This may not always be possible and may even be hazardous in some patients due to fibrosis and dense vascular adhesions between the lung and the chest wall. This leads to marked blood loss and control of hilar vessels becomes dangerous.

METHODS

A series of 20 cases is described here. Nineteen presented with massive hemoptysis where control of bleeding was obtained by physiological lung exclusion. One patient had traumatic left main bronchus transection not suitable for repair or resection. Physiological lung exclusion was performed by surgical interruption of the bronchus and pulmonary artery of the involved lobe or lung, keeping pulmonary veins intact.

RESULTS

Hemoptysis could be controlled in all these patients without any significant morbidity. There was no mortality. There was no postoperative empyema and recurrence of hemoptysis on long-term follow-up. No patient required anatomical lung resection later on.

CONCLUSIONS

Physiological lung exclusion is a safe and effective method for control of massive hemoptysis in cases where lung resection is technically hazardous or difficult. This should be kept as an alternative or adjunct to anatomical lung resection.

The use of endoscopic argon plasma coagulation in airway complications after solid organ transplantation

The objective of the study was to describe a safe and effective treatment option for endobronchial complications after solid organ transplantation. A retrospective analysis was performed in a tertiary-care university hospital. The use of bronchoscopic argon plasma coagulation (APC) for the treatment of endobronchial lesions was studied in five solid organ transplant recipients. Four patients presented with variable degrees of endobronchial obstruction, and one patient presented with massive hemoptysis. Two of the patients with endobronchial obstruction were double lung transplant recipients who developed anastomotic strictures. The strictures were opened with endobronchial stents but became obstructed again by inflammatory granulation tissue overgrowth through the stent mesh. APC was used to maintain airway patency. One kidney transplant recipient developed pulmonary zygomycosis with secondary obstruction of the left main bronchus because of granulation tissue growth through endobronchial stents. Airway patency was reestablished with several treatments with APC. Another kidney transplant recipient developed subglottic and tracheal papillomatosis that was effectively removed with APC. A heart transplant recipient was referred with recurrent massive hemoptysis refractory to bronchial artery embolization. The bleeding was caused by hemorrhagic polypoid lesions, which were completely ablated by APC. Bronchoscopic use of the argon plasma coagulator is a safe and simple technique that can be used effectively to treat endobronchial pathology in solid organ transplant patients.

Endobronchial argon plasma coagulation for treatment of hemoptysis and neoplastic airway obstruction

STUDY OBJECTIVE

To evaluate the usefulness of endobronchial argon plasma coagulation (APC) for the treatment of hemoptysis and neoplastic airway obstruction.

DESIGN

Retrospective study.

SETTING

Bronchoscopy unit of a university hospital.

PATIENTS

A total of 60 patients with bronchogenic carcinoma (n = 43), metastatic tumors affecting the bronchi (n = 14), or benign bronchial disease (n = 3). Indications for intervention were hemoptysis (n = 31), symptomatic airway obstruction (n = 14), and both obstruction and hemoptysis (n = 25). Hemoptysis was stratified as a volume of > 200 mL/d (n = 6), > 50 to 200 mL/d (n = 23), or < or = 50 mL/d but persistence for > 1 week (n = 27). The mean (+/- SD) duration of hemoptysis was 16.5 +/- 16.1 days before intervention. Obstruction sites were the trachea (n = 8), mainstem bronchi (n = 21), and lobar bronchi (n = 30). In 24 cases, the patient had obstructions at multiple sites. The mean size of the pretreatment obstruction was 76 +/- 24.9%.

INTERVENTIONS

APC, a noncontact form of electrocoagulation, was performed via flexible bronchoscopy. Sixty patients underwent 70 procedures. Conscious sedation without endotracheal intubation was used in all patients except four, who were mechanically ventilated because of underlying respiratory failure.

MEASUREMENTS AND RESULTS

All patients with hemoptysis experienced a resolution of bleeding immediately after APC. Hemoptysis from treated sites did not recur during a mean follow-up duration of 97 +/- 91.9 days. Patients with endoluminal airway lesions had an overall decrease in mean obstruction size to 18.4 +/- 22.1%. All patients with obstructive lesions, except one who died of sepsis, experienced symptom improvement. In these patients, symptom control was maintained during a median follow-up period of 53 days (range, 18 to 321 days). There were no complications related to the procedure.

CONCLUSIONS

APC is effective for the treatment of endoluminal hemoptysis and airway obstruction. The procedure can be performed in an outpatient setting or at the bedside in the ICUs. APC provides a simpler, lower-risk alternative to other interventional endobronchial techniques.

[A case of primary racemose hemangioma of bronchial artery with recurrent hemoptysis]

A 42-year old man was admitted to our hospital because of hemoptysis. Bronchial arteriography revealed a tortuous and dilated left bronchial artery with a shunt formation between the bronchial and pulmonary arteries. Bronchial artery embolization using a sponge was performed three times to treat the hemoptysis, but all attempts failed. The patient therefore underwent left lower lobectomy, after which no hemoptysis was observed. Histopathologically, the resected tissue showed no inflammatory change. Interestingly, abnormal vessels resembling arteriovenous malformations were also found. Although the embolization therapy was effective in several reported cases, we concluded that surgery was required for this patient with persistent hemoptysis because of the development of collaterals and a bronchial-pulmonary artery shunt.

The closure and the rings: when a physician disregards a patient's wish

SUMMARY. Recent reports document that many physicians do not know their patients' preferences for life-sustaining interventions as part of end-of-life care, or fail to carry out those expressed preferences. This report describes a patient with cystic fibrosis who deteriorated unexpectedly; the physician chose to disregard his patient's preference not to be intubated. As an unintended result, the patient's family was able to achieve closure and find meaning in the apparent final phase of the patient's life. Thus, this report illustrates the delicate balance that must be struck between a physician's respect for a patient's wishes, his assessment of unexpected circumstances which arise as part of clinical care, and his responsibility to acknowledge and allow time for the family to psychosocially and spiritually prepare for a patient's impending death.

Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis

BACKGROUND AND OBJECTIVE

Conventionally, pulmonary resection with thoracoplasty is used to treat fibrocavernous complication of pulmonary tuberculosis. This operation is usually bloody, time-consuming with complicated postoperative course. To prevent massive blood loss and preserved pulmonary function, a more simplified operative procedure, cavernostomy combined intrathoracic muscle flap transposition was used and the outcome was evaluated in this study.

DESIGN

Retrospective review.

METHODOLOGY

Between December 1989 and June 1996, a total of ten patients with fibrocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic muscle flap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary tuberculosis. The muscle flap was used to plombage the cavity and reinforce the closure of bronchopleural fistula after cavernostomy.

RESULTS

Six postoperative complications occurred in five patients, including reformation of cavity (2), bronchopleurocutaneous fistulae (3), and postoperative bleeding (1). The success or failure of intrathoracic muscle flap transposition on patients with fibrocavernous tuberculosis was significantly correlated with the size of the cavity (194.0+/-11.2 vs. 283.0+/-44.6 cm(3), P=0.016) and the number of bronchopleural fistulae (1.6+/-0.4 vs. 4.0+/-0.4, P=0.008). There was no operative death and in long term follow-up, there was no recurrence of hemoptysis or deterioration of pulmonary function in the successful group of patients.

CONCLUSIONS

Cavernostomy combined with intrathoracic muscle flap transposition can be used to treat well-selected fibrocavernous pulmonary tuberculosis patients, except on patients with large size cavity, multiple bronchopleural fistulae or multiple drug resistance tuberculosis.

Lobectomy for cavitating lung abscess with haemoptysis: strategy for protecting the contralateral lung and also the non-involved lobe of the ipsilateral lung

We describe the anaesthetic management of a patient undergoing lobectomy for cavitating lung abscess complicated by haemoptysis. Surgery for lung abscess is one of the absolute indications for the use of a double-lumen tube (DLT). Because pus or blood could impede fibreoptic-assisted DLT placement, a traditional, blind placement of the DLT was performed. To protect the uninvolved parts of the operated lung, ventilation of the lung with the abscess was not performed until the resection of the involved lobe had been completed.

Extrapleural bronchial artery ligation for life-threatening hemoptysis in cystic fibrosis--a case report

Hemoptyses are common in cystic fibrosis (CF) patients. They range from massive life-threatening (> 240 mL/24 hours) to recurrent minor streaking. Limited pulmonary reserve, potential concurrent chest infection, and the progressive nature of CF pose a high risk to this subgroup. Conservative management and selective bronchial artery embolization (BAE) control most acute episodes, but the recurrence rate is high. The possible need for lung transplantation in future makes an extrapleural approach for bronchial artery ligation desirable. The aim of this study was to assess the role of extrapleural bronchial artery ligation in the treatment of recurrent hemoptysis in CF patients. This is a retrospective analysis of four patients between 1986 and 1999 treated by extrapleural thoracotomy and ligation of bronchial arteries. Indications, surgical experience, and outcome are presented. Three patients underwent unilateral, and one patient bilateral extrapleural thoracotomy (in two separate sessions) for bronchial artery ligation. There were three men and one woman, with a mean age of 26.6 years (range 19-32 years). Indications were failure to stabilize the bronchial arterial catheter for BAE (three cases), recurrence after BAE previously controlled bleeding (one case), and communication with the right costocervical trunk signifying risk to the spinal circulation (one case). The mean follow-up was 68 months (range 3-144 months). There was one death in this series, a patient who was asphyxiated with hemoptysis, requiring ventilation preoperatively. He underwent successful extrapleural thoracotomy for bronchial artery ligation, with no further bleeding but succumbed to severe chest infection and multiorgan failure a few days later. Two patients had recurrent bleeding 12 and 36 months after surgery. Selective bronchial angiography proved the contralateral bronchial arteries to be the culprit. Extrapleural bronchial artery ligation is an effective method of controlling hemoptysis in CF, when BAE has failed. This approach minimizes pleural adhesions and is, therefore, desirable in the future consideration for lung transplantation. In this experience, muscle-sparing thoracotomy and postoperative epidural analgesia significantly improved the postoperative recovery.

Recurrent hemoptysis following a systemic-to-pulmonary anastomosis in a child with a complex congenital cardiomyopathy

A 14-year-old boy with a history of congenital cardiopathy is presented. At age 4, a left systemic-to-pulmonary fistula was performed, using a tubular prosthesis to anastomose the left subclavian artery to the left pulmonary artery. Following this procedure, he developed recurrent episodes of hemoptysis, cough, and left upper lobe consolidation. Treatment resulted in clinical but no radiologic resolution. At age 6, a new right systemic-to-pulmonary anastomosis was needed, as the left one was no longer functioning. After placement of the second shunt, the hemoptysis disappeared. At age 14, flexible bronchoscopy revealed a foreign body granuloma at the left secondary carina. Rigid bronchoscopy and laser photoresection showed it to be the left vascular prosthesis, placed 10 years before. Surgery failed to remove it.

Management of massive hemoptysis: a single institution experience

BACKGROUND

Massive hemoptysis is a life threatening condition. Several therapeutic strategies have been applied in the clinical setting, with variable results. We reviewed our recent experience on this subject.

MATERIAL AND METHODS

In a 5-year period, fifty-four patients (41 males, mean age 57.9 years) were treated for massive hemoptysis in our unit. The underlying pathology included bronchiectasis (n=31), active tuberculosis (n=9), pneumoconiosis (n=3), lung cancer (n=2) and pulmonary angiodysplasia (n=1). These patients often present with continuous bleeding with large volume of hemoptysis, or with recurrent episodes of bleeding. Bronchoscopic assessment and interventions were performed upon admission in all patients. Surgery was considered if the patient had acceptable pulmonary reserve and a bleeding source was clearly identified. If the patient was not considered fit for surgery, bronchial artery embolization was attempted.

RESULTS

Hemoptysis ceased with conservative management in 7 patients (13%) only. Twenty seven (50%) patients received surgical resection. The procedures included lobectomy (n=21), bilobectomy (n=4) and pneumonectomy (n=2). The in-hospital mortality after surgery was 15%. Postoperative morbidity occurred in 8 patients, including prolonged ventilatory support, bronchopleural fistulae, empyema and myocardial infarction. Twenty-one patients not suitable for surgery were treated with bronchial artery embolisation, which was successful in 17 patients without any complications.

CONCLUSION

The clinical outcome for massive hemoptysis reflects the generalized nature of a destructive disease process involving both lungs and a limited respiratory reserve. Surgery is associated with high risk of morbidity and mortality, and should be performed only in selected patients. Meanwhile, aggressive conservative therapy including bronchial artery embolization should be pursued.

Catamenial hemoptysis: report of a case treated with thoracoscopic wedge resection

Catamenial hemoptysis is a rare form of hemoptysis. It is a term for the condition of hemoptysis associated with menses. Few cases have been reported in the literature. Only one case, treated by video-assisted thoracoscopic wedge resection, has been described. We report the case of a 26-year-old woman who suffered from catamenial hemoptysis for 7 months and was treated successfully with a video-assisted thoracoscopic (VATS) wedge resection of the lesion. No evidence of recurrence was noted in the postoperative follow-up period of 48 months. We suggest that VATS is the good choice for single focus catamenial hemoptysis.

["Pseudomalignant" lung tumors--a permanent diagnostic and treatment challenge]

A clinical case of dysembryoplasic benign tumor, respectively a lung hamartoma, is presented. In this case, the pre-operational diagnosis was malignant tumor at the operationally limit, but the histopathological examination of the operational specimen was of lung hamartoma.

[Vegetal foreign body in the airway: an unusual cause of hemoptysis in childhood. Clinical case]

Hemoptysis is an infrequent symptom in childhood and potentially life threatening. The most common causes in this age group are bronchiectasis secondary to cystic fibrosis, cardiovascular and pulmonary congenital anomalies and a miscellaneous group of causes including retained intrabronchial aspirated foreign bodies. We report a previously healthy 5-year-old girl with recurrent pneumonias associated with episodes of hemoptysis. She was admitted in our institution to investigate the persistence of hemoptysis. Based on clinical history, aspiration of a vegetal foreign body was postulated as the etiology and it was confirmed in the pathological examination after surgical exploration, with pulmonary lobe resection. The importance of a good history taking in pediatric hemoptysis is emphasized.

[Tracheobronchomegaly: an exceptional predisposing factor for pulmonary aspergillomas and massive hemoptysis]

Mounier-Kuhn syndrome--or tracheobronchomegaly--is a rare congenital disorder characterized by significant dilation of the trachea and main bronchi. It is accompanied by ineffective cough and is often complicated by recurrent lung infections and bronchiectasis. Clinical presentation varies widely, ranging from forms with scarce involvement of functional capacity to others that progress to respiratory failure that can prove fatal. We report an exceptional case of massive hemoptysis secondary to the presence of pulmonary aspergillomas and bilateral bronchiectasis in which bronchial arteriography with embolization and surgical resection were insufficient for resolving the complications.

Retained intrathoracic surgical swab: CT appearances

A retained surgical swab (gossypiboma) is a rare but important complication of intrathoracic surgery. The radiographic and computed tomography (CT) appearances are variable and depend on the chronicity and site of the swab within the chest. Two cases of retained swabs within the chest are reported. In both cases, the swab had become surrounded by lung. The swab within the pleural space acted as a nidus and resulted in infolding of the lung, superficially resembling an intrapulmonary abscess on CT.

Bronchogenic cyst of the left lower lobe associated with severe hemoptysis

Bronchogenic cysts result from congenital disorders, are often asymptomatic at diagnosis, but complications are not uncommon. We report the case of a 19-year-old woman with severe hemoptysis. This rare presentation of an intrapulmonary bronchogenic cyst should be considered as differential diagnosis in patients with cavernous lesion of a lobe. Surgery was performed as a diagnostic and therapeutic measure.