The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy

OBJECTIVE

To evaluate two different approaches used to perform fused fissures in lobectomies in terms of persistent air leak (PAL) and their impact on length of hospital stay.

METHODS

One hundred and nineteen patients underwent lobectomy or bilobectomy in our unit. We focused on patients with fused fissures (63 patients), all of whom were selected intraoperatively based on predefined criteria. These patients with incomplete fissures were randomly assigned to two groups: Group A patients who underwent a 'traditional technique' to approach fused fissures and Group B patients who underwent a 'fissureless technique'. The latter technique avoids dissecting the lung parenchyma over the pulmonary artery, reducing the chances of air leak. Patients in both groups had shown no significant difference in preoperative variables (p>0.05).

RESULTS

The incidence of PAL was significantly higher among patients with incomplete or fused fissures (0 case vs 8 cases (Groups A and B), p<0.005). Furthermore, the incidence of PAL was significantly higher in the Group A (traditional technique) (7 vs 1) (p<0.05, OR=3.1, CI 0.22-0.51). The probability for air leak cessation was significantly higher in patients of Group B (fissureless technique) (log rank p<0.0001). The length of hospital stay was higher in Group A (5.76+/-3.1) compared with Group B (4.9+/-1.7) (p<0.05). No other variables were identified as risk factors for PAL in this series.

CONCLUSIONS

The fissureless technique appears to be a superior approach for fused fissures in terms of both preventing persistent air leak and reducing the length of hospitalisation. This technique can be performed safely at no additional cost and without adverse consequences.

Air drainage: an essential technique for preventing breast augmentation-related pneumothorax

BACKGROUND

Pneumothorax is one of the most poorly understood and least frequently reported complications associated with breast augmentation, yet this complication presents as a dramatic and often extremely distressing event to both the patient and the surgeon. In addition, this complication is associated with an estimated 10% occurrence of medicolegal consequence. A recent survey of 363 Californian Plastic Surgeons concerning the occurrence and outcome of breast augmentation related Pneumothorax suggested that the incidence of this complication could be more prevalent than previously reported. The author previously suggested barotrauma as the underlying mechanism responsible for the development of pneumothorax associated with breast augmentation. This study aimed to analyze the role of air drainage in preventing pneumothorax during insertion of breast implants.

METHODS

A control group of five patients who experienced pneumothorax was compared with a group of six consecutive patients whose surgical pocket was drained of air during insertion of the implant.

RESULTS

None of the study patients experienced pneumothorax.

CONCLUSIONS

Air drainage from the surgical cavity during insertion of the implant is extremely successful in preventing the development of breast augmentation-related pneumothorax. It is suggested that air drainage be introduced as a routine step in breast augmentation procedures, particularly in those that involve insertion of large implants through small incisions.

Absorption characteristics evaluation from pulsed photo-thermal radiometry in the determination of lung air-leak integrity by vital staining

We evaluated the absorption characteristics of the lung surface with vital staining non-invasively by means of pulsed photo thermal radiometry (PPTR) to improve the success rate of laser air leak sealing from the lung. To seal the air leak after lung resection, we investigated laser treatment using diode laser irradiation (wavelength: 810nm) and vital staining with Indocyanine green (ICG, absorption peak wavelength: 805nm). We used mu a square root alpha and defined as A(mu a: the absorption coefficient, alpha: the thermal diffusivity) in the approximate PPTR theory to analyze the PPTR signal as it was assumed the thermal diffusivity coefficient would be a constant when the lung collapsed during surgery. The accuracy of the constructed PPTR system with this assumption was A= +/-0.15s -1/2. In ex vivo studies, the measured A variation due to vital staining was 3.7s -1/2. This range was sufficiently large measured against the accuracy. We monitored the condition of the lung surface during continuous diode laser irradiation with our PPTR system. We successfully measured the absorption characteristic changes during laser irradiation. We believe this constructed PPTR system might be useful in improving the success rate of laser sealing with vital staining while arranging the laser energy by the value of A.

Efficiency of fleece-bound sealing (TachoSil) of air leaks in lung surgery: a prospective randomised trial

OBJECTIVE

Persistent air leakage following pulmonary resection is a major limiting factor for discharge from hospital. The aim of this study was to evaluate the sealing capacity of TachoSil for the closure of alveolar air leaks following parenchymal resections and to determine its effect on time to chest drain removal and duration of hospitalisation.

METHODS

A total of 173 patients undergoing lobectomy or segmentectomy were enrolled in a single-centre, randomised study to compare the efficacy of TachoSil with standard treatment. Alveolar air leaks were evaluated intraoperatively by submersion of the resection site in saline and were graded according to the Macchiarini scale as 0 (no bubbles), 1 (single bubbles), 2 (stream of bubbles), 3 (coalescent bubbles). Patients with grade 1 or 2 air leaks were randomised to TachoSil or standard treatment. Grade 3 patients received standard treatment until the air leak was downgraded to grade 1 or 2 at which point they were randomised. Patients with grade 0 leakage were excluded. The primary efficacy endpoints of the study were postoperative quantification of air leakage on postoperative days 1 and 2. Other efficacy measurements included mean time to chest drain removal and mean time to hospital discharge.

RESULTS

The mean intraoperative post-treatment air leakage was significantly lower in the TachoSil group (153.32ml/min, range: 10-450ml/min) compared with the standard treatment group (251.04ml/min, range: 15-970ml/min; P=0.009). The significant difference in air leakage volume observed intraoperatively post-treatment was maintained postoperatively. TachoSil showed a trend towards reduced incidence of postoperative leakage when measured >48h or >7 days after surgery (30.7% vs 38.96% and 24% vs 32.46%, respectively). The mean times to chest drain removal and to hospital discharge were significantly reduced following the use of TachoSil (5.1 days vs 6.3 days, P=0.022 and 6.2 days vs 7.7 days, P=0.01, respectively).

CONCLUSIONS

The use of TachoSil following pulmonary resection resulted in a reduction in air leakage compared with standard techniques. This reduction in air leakage resulted in a significant reduction in both the time to chest drain removal and the period of hospitalisation.

Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check?

BACKGROUND

After the insertion of a central venous catheter, a chest radiograph is usually obtained to ensure correct positioning of the catheter tip.

OBJECTIVE

To determine in a paediatric population whether B-mode and colour Doppler sonography after central venous access is useful to evaluate catheter position, thus obviating the need for a postprocedural radiograph.

MATERIALS AND METHODS

A prospective study of 107 consecutive central venous access procedures placed in a paediatric intensive care unit was performed. At the end of the procedure, B-mode and colour Doppler sonography were used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients.

RESULTS

In 96 patients postprocedural B-mode and colour Doppler sonography showed colour Doppler signals within the vena cava. Among the 11 patients predicted to have a potential complication, there was one pneumothorax and ten malpositions. Chest radiography showed a total of 13 complications-1 pneumothorax and 12 malpositions. The concordance between colour Doppler sonography and chest radiography was 98.1% in the detection of catheter position; sonography had a sensitivity of 84.6% and a specificity of 100%.

CONCLUSIONS

The close concordance between B-mode and colour Doppler sonography and chest radiography justifies the more frequent use of sonography to evaluate catheter position because ionizing radiation is eliminated. Chest radiography may then be performed only when there is suspected inappropriate catheter tip position after sonography.

Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial

CONTEXT

Postoperative pulmonary complications (PPCs) after coronary artery bypass graft (CABG) surgery are a major source of morbidity and mortality, and increase length of hospital stay and resource utilization. The prehospitalization period before CABG surgery may be used to improve a patient's pulmonary condition. The efficacy of preoperative inspiratory muscle training (IMT) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined.

OBJECTIVE

To evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery.

DESIGN, SETTING, AND PATIENTS

A single-blind, randomized clinical trial conducted at the University Medical Center Utrecht, Utrecht, the Netherlands, with enrollment between July 2002 and August 2005. Of 655 patients referred for elective CABG surgery, 299 (45.6%) met criteria for high risk of developing PPCs, of whom 279 were enrolled and followed up until discharge from hospital.

INTERVENTION

Patients were randomly assigned to receive either preoperative IMT (n = 140) or usual care (n = 139). Both groups received the same postoperative physical therapy.

MAIN OUTCOME MEASURES

Incidence of PPCs, especially pneumonia, and duration of postoperative hospitalization.

RESULTS

Both groups were comparable at baseline. After CABG surgery, PPCs were present in 25 (18.0%) of 139 patients in the IMT group and 48 (35.0%) of 137 patients in the usual care group (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.30-0.92). Pneumonia occurred in 9 (6.5%) of 139 patients in the IMT group and in 22 (16.1%) of 137 patients in the usual care group (OR, 0.40; 95% CI, 0.19-0.84). Median duration of postoperative hospitalization was 7 days (range, 5-41 days) in the IMT group vs 8 days (range, 6-70 days) in the usual care group by Mann-Whitney U statistic (z = -2.42; P = .02).

CONCLUSION

Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN17691887.

Optimal Timing for Surgical Treatment to Prevent Recurrence of Spontaneous Pneumothorax

PURPOSE

Persistent air leakage and recurrence are the most common indications for the surgical treatment of spontaneous pneumothorax; however, the optimal timing for surgery is still unclear.

METHODS

The subjects of this study were 90 patients treated for either primary spontaneous pneumothorax (PSP; n = 58) or secondary spontaneous pneumothorax (SSP; n = 32). We compared the incidence of prolonged air leak, the rate of recurrence of pneumothorax, the time from the first episode of pneumothorax to recurrence, and the postoperative complications in the two groups. We also analyzed the recurrence rate after treatment with observation and tube drainage versus surgery.

RESULTS

Seventy-three patients were treated with tube thoracostomy or oxygen therapy for the first episode of pneumothorax. Surgery was performed in 32 patients; for the first episode of pneumothorax in 17 and for the second or third episode in 15. Postoperative complications developed in six (18.7%) patients and 24 of 73 patients who did not undergo thoracotomy suffered recurrence. The incidence of a second episode was 32.9% and the incidence of a third episode in the 18 patients who suffered recurrence after conservative treatment was 61.1%. None of the patients who underwent surgery suffered recurrence.

CONCLUSIONS

Tube thoracostomy is still the treatment of choice for first-time spontaneous pneumothorax. However, because the incidence of a third episode of pneumothorax after conservative treatment is high, surgical treatment should always be considered for patients with recurrence. In short, surgical intervention is safe and effective and minimizes the chance of recurrence of both PSP and SSP.

Symptomatic spontaneous pneumothorax in term newborns

The causes and risk factors of symptomatic spontaneous pneumothorax in term newborns are not completely understood. In the present study, our aim was to investigate the risk factors for and clinical and laboratory characteristics of term newborns with spontaneous symptomatic pneumothorax and to evaluate the outcome of management in this condition. A total of 11 term newborns admitted to the newborn intensive care unit with a diagnosis of symptomatic spontaneous pneumothorax were included during a 22-month period. Female to male ratio was 4:7, mean gestational age was 39.5 weeks, and 63% were delivered with a cesarean section, 18% of patients had renal and 55% had congenital cardiac anomalies. Rate of cardiac anomalies was more frequent in the study group compared to control group. Echocardiography in addition to renal ultrasonography may also be needed in term newborns with spontaneous symptomatic pneumothorax and further studies may be warranted to evaluate this association.

Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial

BACKGROUND

Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak.

METHODS

Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak.

RESULTS

Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005).

CONCLUSIONS

Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.

Mechanical ventilation and air leaks after lung biopsy for acute respiratory distress syndrome

BACKGROUND

Open lung biopsy in acute respiratory distress syndrome (ARDS) may provide a specific etiology and change clinical management, yet concerns about complications remain. Persistent air leak is the most common postoperative complication. Risk factors in this setting are not known.

METHODS

We performed a retrospective analysis of 53 patients who underwent open lung biopsy for clinical ARDS (based on American European Consensus Conference criteria) between 1989 and 2000.

RESULTS

Sixteen patients (30.2%) developed an air leak lasting more than 7 days or died with an air leak. Univariate analyses showed no significant correlation with age, gender, sex, corticosteroid use, diabetes, immunocompromised status, or pathologic diagnosis. A lower risk of air leak was associated with lower peak airway pressure and tidal volume, use of pressure-cycled ventilation, and use of an endoscopic stapling device. In multivariate analyses, only peak airway pressure remained a significant predictor. The risk of prolonged air leak was reduced by 42% (95% confidence interval [CI: 17% to 60%]) for every 5 cm H2O reduction in peak airway pressure.

CONCLUSIONS

The use of a lung-protective ventilatory strategy that limits peak airway pressures is strongly associated with a reduced risk of postoperative air leak after open lung biopsy in ARDS. Using such a strategy may allow physicians to obtain information from open lung biopsy to make therapeutic decisions without undue harm to ARDS patients.

Treatment options of spontaneous pneumothorax

Penumothorax is a benign condition with high morbidity and high recurrence rate; and remains a significant clinical problem worldwide. The exact underlying pathogenesis is probably multifocal and is still unclear. The initial approach to the management of spontaneous pneumothorax differs from country to country and it is very difficult to establish an international standard protocol. Needless to say, that the safest and most cost-effective treatment protocol for a particular center should be used. However, first episode of primary spontaneous pneumothorax can be managed conservatively and there is no consensus on optimal treatment of patients presenting with spontaneous pneumothorax specially those with first event. On the contrary, there is some consensus that some treatment is mandatory with second or recurrent spontaneous pneumothorax. Regardless of the chosen therapeutic modality, the treatment goals of spontaneous pneumothorax consist of elimination of the pleural air and also prevention of future recurrence. Therapeutic options include bed rest, oxygen supplementation, manual aspiration, chest tube drainage, thoracoscopic and surgical interventions. Till present, there are no prospective, randomised comparative studies between various treatment strategies but only few between various therapeutic techniques are available.

A new bioabsorbable sleeve for lung staple-line reinforcement (FOREseal): report of a three-center phase II clinical trial

OBJECTIVE

To investigate on the feasibility, safety, and effectiveness of a new bioabsorbable material for lung staple-line reinforcement.

METHODS

This prospective open trial included 66 patients (mean age of 56+/-17 years) who underwent various types of lung resection using staplers with knitted calcium alginate sleeves for buttressing (FOREseal, Laboratoires Brothier, Nanterre, France) at three academic centers: 29 lobectomies, 22 emphysema surgeries, 15 wedge resections or lung biopsies. Intraoperative air leakage was assessed at a mean respiratory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, was assessed daily. The follow-up period was of 6 months.

RESULTS

No technical problem linked to the device occurred. Hemostasis of the cutting edges was completed in all patients. Fifty-six percent of the patients had no intraoperative air leak and 27.3% had grade 1 leaks. Mean postoperative air leaks and thoracic drainage times were 1.9+/-2.3 days and 6+/-5.3 days, respectively. In-hospital mortality was nil. There was no empyema. Mean hospital stay was 9.1+/-6.6 days. At follow-up, one patient underwent lung transplantation, and pathology of the explanted specimen showed the absence of device-related foreign-body inflammation. One patient complained from metalloptysis, and another one, with a metastatic invasive aspergillosis, developed an infectious recurrence that required reoperation.

CONCLUSIONS

FOREseal is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement. A randomized comparative study is now in progress.

Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax

RATIONALE

Ipsilateral recurrence rates of spontaneous pneumothorax after video-assisted thoracoscopic surgery are higher than rates after open thoracotomy.

OBJECTIVES

This study was conducted to determine whether additional minocycline pleurodesis would be effective in diminishing recurrence after video-assisted thoracoscopic surgery treatment of primary spontaneous pneumothorax.

METHODS

Between June 2001 and February 2004, 202 patients with primary spontaneous pneumothorax were treated by conventional or needlescopic video-assisted thoracoscopic surgery. The procedures included resection of blebs and mechanical pleurodesis by scrubbing the parietal pleura. After the operation, patients were randomly assigned to additional minocycline pleurodesis (103 patients) or to observation (99 patients).

MAIN RESULTS

Patients in the minocycline group had higher intensity chest pain and required a higher accumulated dose of meperidine. Short-term results showed that the two groups had comparable chest drainage duration, postoperative hospital stay, and complication rates. Patients in the minocycline group demonstrated a trend of decreased rate of prolonged air leaks (1.9 vs. 6.1%, p = 0.100). After a mean follow-up of 29 mo (12-47 mo), recurrent ipsilateral pneumothorax was noted in two patients in the minocycline group and eight patients in the observation group (p = 0.044 by the Kaplan-Meier method and log-rank test). Postoperative long-term residual chest pain and pulmonary function were comparable in both groups.

CONCLUSIONS

Although associated with intense immediate chest pain, additional minocycline pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

The increase of oxygen requirement as index to identify the infants at high risk of pneumothorax during nasal continuous positive airway pressure

AIM

The aim of this study was to evaluate the inspiration fraction of oxygen (FiO2) trend as an indicator of timing to suspend nasal continuous positive airway pressure (N-CPAP) and shift the babies to mechanical ventilation, in order to reduce the incidence of pneumothorax, comparing a similar population admitted in our division during the previous year.

METHODS

Seventy-five newborns (mean gestational age 33.5 weeks, mean birth weight 2,072 g) admitted during 2003 in our Neonatal Intensive Care Unit, treated with Infant Flow System Nasal-CPAP, were included. Patients with more than 40% increase of the starting FiO2 in the first 24 h of treatment, were intubated and shift on mechanical ventilation. Seventy-seven infants, admitted during the previous year, with similar characteristics (mean gestational age 33.7 weeks, mean birth weight 2,047 g) were considered as control.

RESULTS

Fifty-six neonates improved, 19 worsened and required mechanical ventilation. One of these developed pneumothorax (1.3%). Of the 77 infants admitted during the previous year, 26 worsened and were mechanically ventilated, and 8 developed pneumothorax (10.3%). The difference of incidence of pneumothorax was significant (P =0.0337).

CONCLUSIONS

An increase of FiO2 more than 40% of the initial value during the first 24 h of N-CPAP may be considered a useful marker to identify infants at high risk of pneumothorax.

New suction guide needle designed to reduce the incidence of biopsy-related pneumothorax: experimental evaluation in canine model

In an attempt to remove air that enters the pleural space during computed tomography (CT)-guided coaxial transthoracic needle biopsy, the authors fashioned an 18-gauge experimental suction guide needle and evaluated the incidence of pneumothorax with this needle in comparison to the incidence of pneumothorax with a standard 18-gauge guide needle in a canine model. This experiment had animal care and use committee approval. Ten dogs underwent a biopsy of each lung, for a total of 20 lung biopsies. Half of the biopsies were performed by using the experimental needle (five right lungs, five left lungs), and half were performed by using a standard guide needle. CT revealed pneumothorax during the procedure and was performed to reveal pneumothorax 1 and 3 hours after the procedure. A significant reduction (P < .016) in intraprocedural lung biopsy-associated pneumothorax was found when the experimental guide needle was used.

Neuromuscular paralysis for newborn infants receiving mechanical ventilation

BACKGROUND

Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or intraventricular hemorrhage, and are exposed to more severe barotrauma, which consequently could impair their clinical outcome. Neuromuscular paralysis, which eliminates spontaneous breathing efforts of the infant, has potential advantages in this respect. However, a number of complications have been reported with muscle relaxation in infants, so that concerns exist regarding the safety of prolonged neuromuscular paralysis in newborn infants.

OBJECTIVES

To determine whether routine neuromuscular paralysis of newborn infants receiving mechanical ventilation compared with no routine paralysis results in clinically important benefits or harms.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (from 1966 to April 2004) and EMBASE (from 1988 to April 2004) were searched. References of review articles were hand searched. Language restriction was not imposed.

SELECTION CRITERIA

All trials using random or quasi-random patient allocation, in which the routine use of neuromuscular blocking agents during mechanical ventilation was compared to no paralysis or selective paralysis in newborn infants. Methodological quality was assessed blindly and independently by the two authors.

DATA COLLECTION AND ANALYSIS

Data were abstracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with independent evaluation of trial quality, and abstraction and synthesis of data by both authors. Treatment effect was analysed using relative risk, risk difference and weighted mean difference.

MAIN RESULTS

Ten possibly eligible trials were identified, of which six were included in the review. All the included trials studied preterm infants ventilated for respiratory distress syndrome, and used pancuronium as the neuromuscular blocking agent. In the analysis of the results of all trials, no significant difference was found in mortality, air leak or chronic lung disease, but there was a significant reduction in intraventricular hemorrhage and a trend towards less severe intraventricular hemorrhages. In the subgroup analysis of trials studying a selected population of ventilated infants with evidence of asynchronous respiratory efforts, a significant reduction in intraventricular hemorrhage (any grade and severe IVH) was found, and a trend towards less air leak. In the subgroup analysis of trials studying an unselected population of ventilated infants, no significant differences were found for any of the outcomes.

AUTHORS' CONCLUSIONS

For ventilated preterm infants with evidence of asynchronous respiratory efforts, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular hemorrhage and possibly on air leak. Uncertainty remains, however, regarding the long term pulmonary and neurologic effects, and regarding the safety of prolonged use of pancuronium in ventilated newborn infants. There is no evidence from randomized trials on the effects of neuromuscular blocking agents other than pancuronium. The routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended based on current evidence.

Efficacy of Manual Aspiration Immediately after Complicated Pneumothorax in CT-guided Lung Biopsy

PURPOSE

The goal of this study was to evaluate the efficacy of simple aspiration of air from the pleural space to prevent increased pneumothorax and avoid chest tube placement in cases of pneumothorax after computed tomography (CT)-guided lung biopsy.

MATERIALS AND METHODS

This retrospective study was based on experience with 283 consecutive percutaneous needle lung biopsies with real-time CT fluoroscopic guidance. While patients were on the CT scanner table, percutaneous manual aspiration was performed in all those with moderate or large pneumothorax demonstrated on postbiopsy chest CT images regardless of symptoms. The authors evaluated the frequency of biopsy-induced pneumothorax, management of each such case, and factors that influenced the incidence of worsening pneumothorax that required chest tube placement despite manual aspiration.

RESULTS

Of the 104 (36.7%) pneumothoraces occurring after 283 biopsy procedures, 52 were treated with manual aspiration immediately after biopsy. In 95 of the 104 pneumothoraces (91.3%), the pneumothorax had resolved completely on follow-up chest radiographs without chest tube placement. Only nine patients (3.2% of the entire series; 8.7% of those who developed pneumothorax) required chest tube placement. Requirement of chest tube insertion significantly increased parallel to the increased volume of aspirated air. The optimal cutoff level of aspirated air on which to base a decision to abandon manual aspiration alone and resort to chest tube placement was 543 mL.

CONCLUSION

Percutaneous manual aspiration of biopsy-induced pneumothorax performed immediately after biopsy may prevent progressive pneumothorax and eliminate the need for chest tube placement. However, in cases in which the amount of aspirated air is large (such as more than 543 mL in this study), the possibility of required chest tube placement increases.

Effect of needle tract bleeding on occurrence of pneumothorax after transthoracic needle biopsy

PURPOSE

Occasionally bleeding along the needle trajectory is observed at post-biopsy computed tomographic sections. This study was designed to evaluate the possible effect of needle tract bleeding on the occurrence of pneumothorax and on requirement of chest tube insertion.

MATERIALS AND METHODS

Two hundred eighty-four needle biopsies performed in 275 patients in whom the needle traversed the aerated lung parenchyma were retrospectively reviewed. Bleeding along the needle tract, occurrence of pneumothorax and need for chest tube insertion, type and size of the needle, size of the lesion, length of the lung traversed by the needle, presence or absence of emphysema were noted. Effect of these factors on the rate of pneumothorax and needle-tract bleeding was evaluated. The data were analyzed by chi2 test.

RESULTS

Pneumothorax developed in 100 (35%) out of 284 procedures requiring chest tube placement in 16 (16%). Variables that were significantly associated with an increased risk of pneumothorax were depth of the lesion (P < 0.001) and severity of emphysema (P < 0.05). There was bleeding along the needle tract in 18.6% (n = 53) of the procedures. Pneumothorax occurred in 18 (33.9%) out of 53 procedures in which tract-bleeding was observed and in 82 (35.4%) out of 231 procedures in which tract-bleeding was not seen. The difference between the two groups was not significant (P > 0.05). However, analysis of the relation between length of lung traversed by the needle, tract-bleeding and pneumothorax rate indicated that tract-bleeding had a preventive effect on development of pneumothorax (P < 0.001). Occurrence of tract bleeding also had preventive effect on pneumothorax in the presence of emphysema (P < 0.05). The only variable which had effect on occurrence of tract-bleeding was the length of the lung traversed by needle (p < 0.001). Requirement for chest tube insertion was smaller in the tract-bleeding group than non-tract bleeding group, 11% (2/18) to 17% (14/82), respectively. But this difference was not significant statistically (P > 0.05).

CONCLUSION

Bleeding in the needle tract has a preventive effect on the occurrence of the pneumothorax in deep-seated lesions and in the presence of emphysema, although it does not affect the overall rate of pneumothorax.

Prevention of Overlooked Bullae During Video-Assisted Thoracic Surgery (VATS) with a Combination of High Frequency Jet Ventilation (HFJV) and Positive End-Expiratory Pressure (PEEP) for Spontaneous Pneumothorax

BACKGROUND

Overlooked bullae have been reported to contribute to the higher incidence of recurrence of pneumothorax following video-assisted thoracic surgery (VATS). In this study, we investigated whether high frequency jet ventilation (HFJV) + positive end-expiratory pressure (PEEP) prevented overlooking of bullae by blowing up the bullae and inflating the lungs moderately during VATS for spontaneous pneumothorax patients.

METHODS

A total of 31 patients with spontaneous pneumothorax who underwent VATS were enrolled in this study. We examined the number, size, and location of bullae with and without HFJV+PEEP during VATS.

RESULTS

More bullae were found with HFJV + PEEP than without HFJV + PEEP in 15 of the 31 patients. Significantly more bullae smaller than 2 cm in diameter were detected with HFJV + PEEP than without HFJV + PEEP. In the patients with 1 - 3 bullae, the detection rate was significantly higher with HFJV + PEEP than without HFJV + PEEP. All bullae confirmed with VATS were detected only in one case (3.2 %) on preoperative chest X-ray, and in two cases (6.5 %) on chest CT. The recurrence rate of pneumothorax following VATS with HFJV + PEEP was 3.3 % (1/31).

CONCLUSION

Our results suggested that VATS combined with HFJV and PEEP might prevent the overlooking of bullae and reduce the postoperative recurrence of spontaneous pneumothorax.

The application of deep-frozen and radiation-sterilized human amnion as a biological dressing to prevent prolonged air leakage in thoracic surgery

Amnion allografts have been used in a number of clinical applications. However, no references of their use in thoracic surgery have been identified. Air leakage, is one of the most common complications in thoracic surgery, resulting from visceral pleura and lung injuries caused intraoperatively, in particular following rethoracotomy. Mechanical and manual sutures are also potential sites of air leakage. The aim of our study was to evaluate the usefulness of human amnion grafts in the treatment of air leakage following thoracic surgery. Deep-frozen, radiation-sterilized (35 kGy) human amnion grafts prepared in the Central Tissue Bank in Warsaw (Poland) were used. The amnion allografts were applied to 20 patients who had surgery: 11 thoracotomies and 9 rethoracotomies were performed (15 resections of 1-12 metastases, 3 lobectomies and 2 residual tumor resections). During lung ventilation the air leakage sites were covered by the amnion flap attached by moderate compression and stabilized by sutures. Air leakage and drainage were measured during the postoperative period. In 80% of the cases, no traces of air leakage was observed. The preliminary results suggest that the application of human amnion grafts may be a safe and effective method for preventing prolonged air leakage after thoracic surgery.