Pneumonectomy for inflammatory lung disease

Severe Bacterial Superinfection of Influenza Pneumonia in Immunocompetent Young Patients: Case Reports

Influenza can lead to or coexist with severe bacterial pneumonia, with the potential to permanently damage lung tissue, refractory to conservative treatment in the post-COVID-19 period. It can lead to serious complications; therefore, annual vaccinations are recommended. This case series with a literature review pertains to two young female patients with an insignificant past medical history, who required emergency lobectomy due to bacterial complications after influenza infection. Urgent lobectomy proves to be a feasible therapeutic option for selected patients with pleural complications.

Left Versus Right Destroyed Lung Pneumonectomy: Long Term Prognosis and Key Factors Associated With Poor Treatment Outcomes

INTRODUCTION

To compare and analyze postoperative short-term and long-term prognosis of destroyed lung (DL) disease patients undergoing left versus right pneumonectomy and to identify potential key factors associated with poor treatment outcomes.

METHODS

Retrospective analysis was conducted on clinical data of 128 DL patients who underwent pneumonectomy in the thoracic surgery department of the Beijing Chest Hospital from November 2001 to May 2022. Cases were assigned to two groups according to lesion site: a left pneumonectomy group (104 cases) and right pneumonectomy group (24 cases). Postoperative short-term and long-term DL disease clinical features and prognostic factors were analyzed and compared between groups.

RESULTS

As compared with the left pneumonectomy group, the right pneumonectomy group experienced greater rates of preoperative diabetes, chronic pulmonary aspergillosis, intraoperative blood loss, postoperative respiratory failure, rehospitalization, tuberculosis (TB) recurrence, bronchopleural fistula (BPF) and empyema. Binary logistic regression analysis revealed a potential correlation between chronic pulmonary aspergillosis and increased odds of developing secondary respiratory failure (adjusted odds ratio: 5.234, 95% confidence interval [CI]: 1.768-15.498). Results of Cox Proportional Hazards Model regression analysis suggested that right pneumonectomy was correlated with increased odds of TB recurrence (adjusted hazard ratio: 4.017, 95% CI: 1.282-12.933) and BPF/empyema (adjusted hazard ratio: 5.655, 95% CI: 1.254-25.505).

CONCLUSIONS

Compared to the group undergoing left pneumonectomy, patients with DL who undergo right-sided pneumonectomy may be at a heightened risk of experiencing secondary postoperative TB recurrence and BPF or edema. It is advised to exercise utmost caution and deliberate consideration of these potential risks when contemplating pneumonectomy, with the intention of proactively preventing adverse events.

Risk Factors of Tuberculosis Destroyed Lung in Patients with Pulmonary Tuberculosis and Structural Lung Diseases: A Retrospective Observational Study

Background

Tuberculosis destroyed lung constitutes a significant worldwide public health challenge, little is known about its associated risk factors and prognosis. Our study aimed to identify the risk factors of tuberculosis destroyed lung among pulmonary tuberculosis and structural lung diseases.

Methods

Between January 2019 and December 2021, a case-control study was conducted at the Third People's Hospital of Shenzhen in China. We collected the clinical data among patients with pulmonary tuberculosis and structural lung diseases. Cases were defined as patients with tuberculosis destroyed lung. Controls were not diagnosed with the tuberculosis destroyed lung. A binary logistic regression was performed.

Results

In our study, a total of 341 patients met the inclusion criteria, including 182 cases and 159 controls. We found that age ranges of 46-60 years (aOR: 4.879; 95% CI: 2.338-10.180), >60 years (aOR: 3.384; 95% CI: 1.481-7.735); history of TB treatment (aOR: 2.729; 95% CI: 1.606-4.638); malnutrition (aOR: 5.126; 95% CI: 1.359-19.335); respiratory failure (aOR: 5.080; 95% CI: 1.491-17.306); and bronchiarctia (aOR: 3.499; 95% CI: 1.330-9.209) were the independent risk factors for tuberculosis destroyed lung. Conversely, having a normal (aOR: 0.207; 95% CI: 0.116-0.371) or overweight BMI (aOR: 0.259; 95% CI: 0.090-0.747) emerged as a protective factor against tuberculosis destroyed lung.

Conclusion

This study indicated that tuberculosis destroyed lung is a common condition among patients with pulmonary tuberculosis and structural lung diseases. The independent risk factors for tuberculosis destroyed lung were identified as being within the age groups of 46-60 and over 60 years, having a previous history of TB treatment, malnutrition, respiratory failure, and bronchiarctia. It is essential to closely monitor patients possessing these risk factors to prevent the progression towards tuberculosis destroyed lung.

Interventional bronchoscopy in pediatric pulmonary tuberculosis

INTRODUCTION

Lymphobronchial tuberculosis (TB) is common in children with primary TB and enlarged lymph nodes can cause airway compression of the large airways. If not treated correctly, airway compression can result in persistent and permanent parenchymal pathology, as well as irreversible lung destruction. Bronchoscopy was originally used to collect diagnostic samples; however, its role has evolved, and it is now used as an interventional tool in the diagnosis and management of complicated airway disease. Endoscopic treatment guidelines for children with TB are scarce.

AREAS COVERED

The role of interventional bronchoscopy in the diagnosis and management of complicated pulmonary TB will be discussed. This review will provide practical insights into how and when to perform interventional procedures in children with complicated TB for both diagnostic and therapeutic purposes. This discussion incorporates current scientific evidence and refers to adult literature, as some of the interventions have only been done in adults but may have a role in children. Limitations and future perspectives will be examined.

EXPERT OPINION

Pediatric pulmonary TB lends itself to endoscopic interventions as it is a disease with a good outcome if treated correctly. However, interventions must be limited to safeguard the parenchyma and prevent permanent damage.

Long-term follow-up of tuberculosis-destroyed lung patients after surgical treatment

Background

To monitor dypsnea and mortality at 5 and 10 years, respectively, after surgical treatment of tuberculosis-destroyed lung (TDL) patients.

Methods

TDL patients treated surgically at Beijing Chest Hospital from November 2007 to June 2019 were monitored in this observational study. Follow-up assessments of respiratory function indicators and survival conducted 5 and 10 years post-surgery led to patient grouping based on mMRC score into a dyspnea group (mMRC ≥ 1) and a non-dyspnea group (mMRC = 0). Cox regression analysis detected effects of patient demographics, clinical characteristics, surgical factors and respiratory function on 5 year post-surgical survival.

Results

By study completion (June 30, 2020), 32 of 104 patients were lost and 72 completed follow-up for a study total of 258.9 person-years. 45 patients (62.5%, 45/72) had mMRC scores of 0, while 12 (16.7%, 12/72), 21 (36.2%, 21/58) and 27 (60.0%, 27/45) patients exhibited dyspnea by 1, 3 and 5 years post-surgery, respectively. Low lung carbon monoxide diffusion score (DLCO% pred) and scoliosis contributed to dyspnea occurrence.

Conclusions

Most TDL patients lacked subjective dyspnea signs post-surgery, while dyspnea rates increased with time. Preoperative low lung diffusion function and Scoliosis were associated with factors for postoperative dyspnea. Surgical treatment increased TDL patient survival overall.

Factors affecting complication rates of pneumonectomy in destroyed lung

Background

This study aims to investigate the relationship between characteristics of patients who were performed pneumonectomy for destroyed lung and their surgical procedures with postoperative complications.

Methods

Thirty-nine patients (19 males, 20 females; mean age 35 years; range, 6 to 71 years) who were performed pneumonectomy with a diagnosis of destroyed lung between February 2007 and October 2014 were retrospectively evaluated. Patients were divided into two as those who did not develop any postoperative complication (group 1) and those who developed a postoperative complication (group 2). Patients' characteristics and details of the surgical procedures were compared between the two groups.

Results

Twenty-nine patients (74%) were performed left pneumonectomy. Mean duration of hospital stay was nine days. During the postoperative three-month follow-up period, morbidity and mortality were reported for 13 patients (33.3%) and one patient (2.6%), respectively. No significant difference was found between groups 1 and 2 in terms of age, gender, concomitant diseases, spirometric findings, blood transfusion status, surgical resection width or methods of bronchial stump closure.

Conclusion

Low albumin levels increased the risk of developing postoperative complications in patients who were performed surgical resection for destroyed lung. Postpneumonectomy morbidity and mortality rates were at acceptable levels. Pneumonectomy should not be avoided as surgical treatment in eligible patients with destroyed lung.

Video-assisted versus conventional thoracotomy pneumonectomy: a comparison of perioperative outcomes and short-term measures of convalescence

BACKGROUND

Pneumonectomy is a proven treatment for lung diseases. We sought to present a comparison between video-assisted thoracic surgery pneumonectomy (VATS-P) and conventional thoracotomy pneumonectomy (CP) on perioperative outcomes and short-term measures of convalescence.

METHODS

A retrospective cohort study was performed to assess perioperative outcomes among patients underwent VATS-P and CP. A total of 32 patients undergoing VATS-P were matched 2:1 about comorbidity, surgical indication, tumour size and lesion location to a previous cohort of 64 patients who underwent CP. Demographic and perioperative data were obtained. Statistical analysis was performed.

RESULTS

Mean patient age was 55.4 years for both groups, with equal sex distribution. Pneumonectomy for malignant and benign lesion patients was evaluated individually. For malignant tumour patients, median tumour size was 3.9 cm for both groups. There was no difference between VATS-P and CP cases in transfusion rates (2% vs. 10%, P=0.50), dissected lymph node numbers (11.9 vs. 14.2, P=0.26), dissected lymph node stations (5.0 vs. 4.9, P=0.75), estimated blood loss (226.0 vs. 261.3 mL, P=0.40), complication rate (20.0% vs. 22.5%, P=0.82), postoperative drainage time (5.9 vs. 6.2, P=0.50) or length of hospital stay (7.5 vs. 8.1, P=0.50). Operation time in VATS-P was higher than conventional groups (187.5 vs. 146.3 min, P=0.00) but the mean pain score was significantly less. For benign patients, over 1,000 mL blood losing (1,033.3 vs. 1,233.3 mL, P=0.78) and 180 minutes (186.6 vs. 105.8, P=0.73) OR time was found in both groups. The Length of stay (7.6 vs. 6.3 d, P=0.57), transfusion rates (66.7% vs. 33.3%), complications rates (zero in both group) and length of drainage (6.7 vs. 6.7 d, P=1.0) between two groups are identical.

CONCLUSIONS

Complete video-assisted thoracic surgery (VATS) pneumonectomy is feasible and safe technique and can be recommended as a surgical treatment for lung cancer patients. However, long-term benefits need to be evaluated by further studies and large sample tests.

Risk factors for morbidities and mortality in children following pneumonectomy

BACKGROUND AND OBJECTIVE

Pneumonectomy (PNE) is a procedure infrequently performed in children. A high morbidity/mortality rate associated with PNE has been described. Few series have been published in the last 15 years. Risk factors associated with morbidity/mortality after PNE were evaluated. Indications, course, survival and complications of PNE in children were also analized.

METHODS

In a case series of 51 children who underwent PNE, death within 30 days of surgery, pneumonia, empyema, sepsis, adult respiratory distress syndrome, bronchopleural fistula, bleeding, pneumothorax and post-PNE syndrome were considered major morbidities. Scoliosis, wound infection and atelectasis were considered minor morbidities.

RESULTS

Median age at PNE was 7.4 years; 45% were males. Indications of pneumonectomy were postinfectious bronchiectasis (61%), tumours (17%), pulmonary malformations (17%), aspiration syndrome (14%), cystic fibrosis (6%), immunodeficiency (4%) and trauma (2%). Mortality rate was 4% at 1 month. Major and minor morbidities were present in 23% and 27% of patients, respectively. Risk factors for development of morbidities after PNE were age ≤ 3 years (OR: 16.7; 95% CI: 2.4-117) and the need for mechanical ventilation for at least 4 days (OR: 8; 95% CI: 1.5-43.6).

CONCLUSION

Children are at high risk of death, major and minor morbidities following PNE. Caution is recommended for this group of patients.

Lung Resection for Multidrug-Resistant Tuberculosis

The emergence of multidrug-resistant tuberculosis poses a serious challenge to traditional drug therapy. In view of the relapse rate of up to 50% following medical management, there has been renewed interest in the role of surgery for this problem. We report our experience with lung resection for this condition. Over a 5-year period, resection was performed in 23 patients who were diagnosed with multidrug resistance after completing a course of standard chemotherapy and at least 3 months of second-line therapy. Pneumonectomy was performed in 17 patients and lobectomy in 6. There was no operative or postoperative mortality. Major complications developed in 4 patients (17.4%): 2 had post-pneumonectomy empyema and 2 underwent rethoracotomy for bleeding. Ten patients were sputum positive preoperatively, and only 1 remained positive after surgery. The patients were put on appropriate chemotherapy and followed up for 18 months. The cure rate was 95.6%. Pulmonary resection can be considered as an important adjunct to medical therapy in carefully selected patients: those who have localized disease with adequate pulmonary reserve, or who have multiple previous relapses, or whose sputum remains positive after 4 to 6 months of appropriate medical treatment. Surgery offers high cure rates with acceptable morbidity and mortality.

Active Pulmonary Tuberculosis: Experience with Resection in 106 Cases

The surgical management of pulmonary tuberculosis has evolved since collapse therapy was the mainstay of treatment. Despite this, resection for active tuberculosis is viewed with circumspection. Details of 106 patients with pathologically proven active pulmonary tuberculosis, who were operated on from January 1997 to January 2005, were reviewed retrospectively. Demographic data, radiographic profiles, indications for surgery, sputum status, and preoperative drug therapy were analyzed in relation to outcomes. The indications for surgery included multidrug-resistant tuberculosis in 27 patients, hemoptysis in 44, bronchiectasis in 27, and diagnostic dilemmas where a tumor could not be excluded in 8. All patients were operated on while receiving antituberculous therapy, and 17 were sputum positive at the time of surgery. Two (1.9%) patients died postoperatively. Morbidity was 16.9%, including 6 cases of postpneumonectomy empyema and one of bronchopleural fistula. Surgery for active tuberculosis may be undertaken with acceptable morbidity and mortality.

Successful Treatment of Aspergillus Empyema Using Open Window Thoracostomy Salvage Treatment and the Local Administration of an Antifungal Agent

A 76-year-old woman received long-term immunosuppressive treatment for collagen vascular disease-associated interstitial pneumonia. The patient developed a cavitary mass lesion in the right lower lung field, and both nontuberculous mycobacteria and Aspergillus spp. were isolated after bronchial washing. The patient underwent a right lower lobectomy but developed Aspergillus empyema. Empyema due to Aspergillus spp. is a rare and life-threatening condition; however, the standard therapeutic strategies for treating Aspergillus empyema are not clear. We herein report a case of Aspergillus empyema that was successfully treated with a combination therapy which included open-window thoracostomy and the administration of antifungal agents (systemic micafungin and local amphotericin-B).

[Pneumonectomy for benign disease: indication and factors affecting the postoperative course]

Pneumonectomy for benign disease is rare but may generate more postoperative morbimortality than when performed for lung cancer. We questioned this assessment and retrospectively reviewed 1436 pneumonectomies and 54 completions of which 82 and 10 performed for benign disease (5.7% and 18.5%, respectively): left n=65 and right n=27. Indications were: post-tuberculosis destroyed lung (n=37), aspergilloma (n=18), bronchiectasis (n=19), infection (n=5), congenital malformations (n=5), inflammatory pseudotumor (n=3), trauma (n=2), post-radiation (n=2) and mucormycosis (n=1). Pneumonectomy consisted of 48 standard and 44 pleuro-pneumonectomies. Stump coverage by flaps was performed in 66.3% (61/92). Complications occurred in 21.7% (20/92) and postoperative deaths in 7.6% (7/92, of which 5 with fungal infections), which was not different than what was observed in lung cancer. There was no difference in fistula formation and mortality regarding the side, the type of resection and the protective role of stump coverage. Considering patients with fungal infections versus others, mortality was 26.3% (n=5/19) and 2.7% (n=2/74), respectively (P=0.0028). Pneumonectomy for benign disease achieves cure with acceptable mortality and morbidity. However, presence of fungal infection should raise the attention for possibility of increased postoperative risks.

Pneumonectomy for benign disease: indications and postoperative outcomes, a nationwide study

OBJECTIVES

Pneumonectomy for benign disease is rare but is thought to have a higher more postoperative morbidity and mortality than when performed for lung cancer. We questioned this by assessing and analysing indications and postoperative outcomes of patients who underwent this type of resection.

METHODS

We used Epithor, the French national thoracic database including 91 public and private institutions with more than 220 000 procedures. We prospectively collected data of 5975 patients who underwent pneumonectomy between January 2003 and June 2013. The 321 patients (5.4%) who underwent pneumonectomy (n = 201) or completion pneumonectomy (n = 120) for benign disease were compared with those treated for malignant disease.

RESULTS

The patients' mean age was 55.2 years (53.5; 56.8) for benign indications vs 61.6 years (61.4; 61.9) for malignant disease; the sex ratio was 1.8 (207 males) and 4 (4543 males), respectively; 53% of patients (n = 169) had an American Society of Anesthesiologist (ASA) score of ≥3 vs 29% (n = 1598) for malignant disease. For benign disease, most frequent indications were infection or abscess (n = 114, 37.1%), post-tuberculosis destroyed lung (n = 47, 15.3%), aspergillosis or aspergilloma (n = 33, 10.7%), bronchiectasis (n = 41, 13.3%), haemorrhage (n = 26, 8.5%) and benign tumour (n = 20, 6.5%). Complications occurred in 53% (n = 170) of patients and the postoperative in-hospital mortality rate was 22.1% (n = 71). These results were significantly worse than those for malignant indications: 38.9% (n = 2198) of morbidity (P < 0.0001) and 5.1% (n = 288) of in-hospital mortality (P < 0.0001). For benign disease, there was no difference in fistula formation regarding side (P = 0.07) or type of resection (P = 0.6). Morbidity was higher for completion pneumonectomy: 62.5 vs 47.3% (P = 0.008). Mortality was significantly higher in case of resection for infection or abscess (P = 0.01) and for haemorrhage (P = 0.002). Emergency procedures were associated with worse postoperative outcomes (P < 0.0001).

CONCLUSIONS

Pneumonectomy for benign disease achieves cure with very high levels of morbidity and mortality. This type of surgical treatment should be considered as a salvage procedure.

Anesthetic management of a malnourished, 7-year-old child in Malawi undergoing a pneumonectomy

In this report, we describe the case of a 7-year-old girl presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, with hypoxia and respiratory distress. Investigations demonstrated an endobronchial tumor, and she underwent a radical left-sided pneumonectomy. This case highlights the challenges of anesthesia in a resource-depleted setting.

Outcomes after pneumonectomy for benign disease: the impact of urgent resection

BACKGROUND

Pneumonectomy for benign disease is often complicated by inflammatory processes that obscure operative planes. We reviewed our experience to evaluate the impact of requiring urgent or emergent pneumonectomy on outcomes.

STUDY DESIGN

All pneumonectomies for benign conditions from 1997 to 2012 at a single institution were retrospectively reviewed. Mortality was assessed using multivariable logistic regression that included laterality, age, and surgery status, which was emergent if performed within 24 hours of initial evaluation, urgent if performed after 24 hours but within the same hospital stay, and otherwise elective.

RESULTS

Among 42 pneumonectomies, completion pneumonectomy after previous ipsilateral lung resection was performed in 14 patients (33%). Resection was elective in 22 patients (52%), urgent in 12 (28%), and emergent in 8 (19%). The most common indication was for necrotic lung (n = 12; 29%). Muscle flaps were used in 26 patients (62%). Perioperative mortality for the entire cohort was 29% (n = 12) and was significantly higher when surgery was urgent (5 of 12; 42%) or emergent (5 of 8; 62.5%) compared with elective (2 of 22; 9.1%) (p = 0.03). Requiring urgent or emergent surgery remained a significant predictor of mortality in multivariable analysis (odds ratio 10.4, p = 0.01).

CONCLUSIONS

Pneumonectomy for benign disease has significant risk for mortality, particularly when not performed electively. Although surgery cannot be planned in the setting of trauma or some situations of acute infection, patients known to have conditions that are likely to require pneumonectomy should be considered for surgery earlier in their disease course, before developing an acute problem that requires urgent or emergent resection.

Pneumonectomy for nonmalignant disease

Background

Pneumonectomy for nonmalignant disease is unusual. We wondered about the incidence, predisposing risks, and outcomes of this entity.

Methods

We interrogated the Society of Thoracic Surgeons General Thoracic Surgery Database to compare patients undergoing pneumonectomy for benign or malignant indications between 2006 and 2010.

Results

309 of 3081 (10%) patients underwent pneumonectomy for nonmalignant conditions. The benign group were younger (56 vs. 62 years), more likely to be on steroid therapy (11.3% vs. 2.7%), and less likely to be current smokers (14.4% vs. 20.1%). Both groups had an equal incidence of comorbidities. Preoperative pulmonary function was decreased in the nonmalignant group: forced expiratory volume in 1 s 61% vs. 74% of predicted; carbon monoxide diffusion in the lung 61% vs. 71% of predicted. The most common nonmalignant etiologies requiring pneumonectomy were lung and pleural infections. The benign group had increased postoperative bleeding, infections, and lung-related complications.

Conclusions

Approximately 10% of patients undergoing pneumonectomy have nonmalignant disease. In these cases, careful patient selection with detailed preoperative preparation including improvement in nutrition and functional status are indicated. Technical aspects of pneumonectomy, which minimize perioperative bleeding and infectious complications, are particularly important when this surgery is performed for nonmalignant conditions.

Video-assisted thoracoscopic management for emphysema associated with contralateral destroyed lung

BACKGROUND

Surgery can be quite challenging in condition that contralateral lung has no function. We report 3 cases of emphysema associated with contralateral destroyed lung managed with the use of video-assisted thoracic surgery (VATS).

METHODS

From December 2007 to December 2008, 3 patients of emphysema associated with contralateral destroyed lung were operated on by VATS. There were two pulmonary wedge resections and mechanical pleurodesises for pneumothorax and one lung volume reduction surgery (LVRS) for worsening dyspnea. Their records were reviewed retrospectively.

RESULTS

No postoperative mortality was observed. One case for pneumothorax experienced prolonged postoperative air leakage. Of all the three cases, two cases for pneumothorax had no recurrence and one case for worsening dyspnea had improved lung function.

CONCLUSIONS

VATS for emphysema associated with contralateral destroyed lung is feasible in selected patients.

Early and Long-term Outcomes of Pneumonectomy for Treating Sequelae of Pulmonary Tuberculosis

Background

Pneumonectomy remains the ultimate curative treatment modality for destroyed lung caused by tuberculosis despite multiple risks involved in the procedure. We retrospectively evaluated patients who underwent pneumonectomy for treatment of sequelae of pulmonary tuberculosis to determine the risk factors of early and long-term outcomes.

Materials and Methods

Between January 1980 and December 2008, pneumonectomy or pleuropneumonectomy was performed in 73 consecutive patients with destroyed lung caused by tuberculosis. There were 48 patients with empyema (12 with bronchopleural fistula [BPF]), 11 with aspergilloma and 7 with multidrug resistant tuberculosis.

Results

There were 5 operative mortalities (6.8%). One patient had intraoperative uncontrolled arrhythmia, one had a postoperative cardiac arrest, and three had postoperative respiratory failure. A total of 29 patients (39.7%) suffered from postoperative complications. Twelve patients (16.7%) were found to have postpneumonectomy empyema (PPE), 4 patients had wound infections (5.6%), and 7 patients required re-exploration due to postoperative bleeding (9.7%). The prevalence of PPE increased in patients with preoperative empyema (p=0.019). There were five patients with postoperative BPF, four of which occurred in right-side operation. The only risk factor for BPF was the right-side operation (p=0.023). The 5- and 10-year survival rates were 88.9% and 76.2%, respectively. The risk factors for late deaths were old age (≥50 years, p=0.02) and low predicted postoperative forced expiratory volume in one second (FEV1) (<1.2 L, p=0.02).

Conclusion

Although PPE increases in patients with preoperative empyema and postoperative BPF increases in right-side operation, the mortality rates and long-term survival rates were found to be satisfactory. However, the follow-up care for patients with low predicted postoperative FEV1 should continue for prevention and early detection of pulmonary complication related to impaired pulmonary function.

Tuberculous damaged lung in a child

Tuberculosis (TB) remains the "great pretender." We report the case of a 10-year-old female, who presented with a mass in the left chest that was suspected initially to be a tumor. This was later confirmed to be tuberculous in nature, with dissemination to the liver. A large granuloma eventually replaced the left lung, leaving her with "tuberculous destroyed lung" (TDL), an extremely rare, life-threatening sequela of the disease. We review the pathophysiology, radiologic findings, and management options, which includes pneumonectomy, for this seldom seen but preventable condition.

Pneumonectomy in children for destroyed lung: evaluation of 18 cases

BACKGROUND

Destroyed lung is an uncommon condition; it describes a nonfunctional lung and is most often caused by inflammatory diseases. Surgical resection is used to resolve or prevent complications and improve quality of life. We reviewed our experience in surgery for destroyed lung in children.

METHODS

The records of 18 children aged 16 years and younger who had undergone pneumonectomy for destroyed lung between 1991 and 2007 were analyzed retrospectively.

RESULTS

Eighteen children, 10 males (55.5%) and 8 females, aged 5 to 16 years, with a mean age of 12.3 underwent pneumonectomy. Cough was the major presenting symptom (n = 18, 100%). The median preoperative period for symptoms was 6 years. Radiologic diagnostic methods included chest radiograph, computed tomography, bronchoscopy, and bronchography. Bronchiectasis (n = 13), tuberculosis (n = 4), and aspergillosis (n = 1) were the main pathologies. Five patients had tuberculosis history, and tuberculosis culture was positive in 2 patients. Pneumonectomy was applied to the left side in 14 and right side in 4 patients. There was no mortality. Complication occurred in 3 patients (atelectasis [n = 1], fistula and empyema [n = 1], and wound infection [n = 1]). Atelectasis was treated with bronchoscopy and stoma was needed for another patient for empyema. The mean follow-up was 64.9 months (range, 19 to 164 months). In their follow-up period, scoliosis was found in 1 patient.

CONCLUSIONS

The morbidity and mortality rates of pneumonectomy are acceptable for selected and well prepared children. Antibiotics and antituberculosis treatment in certain cases and good timing in pneumonectomy are essential. Children grew and developed normally after pneumonectomy.

Surgery for pulmonary tuberculosis

PURPOSE OF REVIEW

The role of thoracic surgery in pulmonary tuberculosis, in either a diagnostic or a therapeutic role, is well established. This review aims to underline the current indications for lung resection, surgical strategy and outcomes associated with surgery.

RECENT FINDINGS

There has been a renewed interest in surgery, mainly in the multidrug-resistant tuberculosis (MDRTB) group as an adjunct to medical therapy. Lung resection in this group of patients has been undertaken with acceptable morbidity and mortality, and with cure rates of over 90%. The current strategy favours early surgical intervention for patients with multidrug-resistant tuberculosis to prevent the development of bilateral disease. Early surgery for haemoptysis is advocated, for sometimes it is necessary to operate on these patients without a full course of antituberculous therapy. Medical stabilization and early inpatient surgery is favoured in view of the excessive mortality associated with emergency surgery. There is still no consensus on the management of the bronchial stump at the time of lung resection, although the current trend favours closure, either sutured or stapled, without muscle reinforcement.

SUMMARY

Lung resection for pulmonary tuberculosis, in carefully selected and prepared patients, is safe with acceptable morbidity and mortality.

Fibrin glue closure of persistent bronchopleural fistula following pneumonectomy for post-tuberculosis bronchiectasis

We report a case of a persistent bronchopleural fistula following a pneumonectomy for post-tuberculosis bronchiectasis. The patient had two unsuccessful surgical attempts at closing of the fistula. Further surgical attempts were technically were not possible. Bronchoscopic closure was achieved by injecting human fibrin glue into the fistula via a catheter. Closure of the broncho-pleural fistula was confirmed by repeated ventilation scan over a period of 2 months. Endoscopic closure of small bronchopleural fistulae is an attractive option in children with significant underlying lung disease.

Current surgical treatment of thoracic empyema in adults

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

Genetics of postoperative complications following thoracic surgery

The field of complex trait-gene interaction research has expanded exponentially in recent years, and new insights into the ways patients respond to surgical stimuli have arisen from this body of work. From a physiological systems perspective, thoracic surgical procedures (thoracotomy in particular) represent a massive input stimulus, and it is, therefore, not surprising that approximately 30% of these patients experience an adverse postoperative event. The best risk prediction models have typically explained about 60% to 70% of the risk, leaving a large residual component unaccounted for. It is quite possible that there is a genetic (heritable) component to this residual risk. This article explores some of the concepts underlying gene-disease interactions, the preliminary work that has been done to date in this area, and finally discusses some of the more important methodological issues involved in complex trait association study design.

Surgical management of acute necrotizing lung infections

BACKGROUND

Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.

OBJECTIVE

To review results of resection in the setting of acute necrotizing lung infections.

METHODS

A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.

RESULTS

Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n = 17), hemoptysis (n = 5), air leak (n = 7), septic shock requiring pressors (n = 8) and inability to oxygenate adequately (n = 7). Twenty-four patients were ventilated preoperatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n = 4), thoracoscopic decortication (n = 4) and open decortication (n = 2). Procedures included pneumonectomy (n = 4), lobectomy (n = 18), segmentectomy (n = 2), wedge resection (n = 4) and debridement (n = 7). There were three (8.5%) postoperative deaths--two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.

CONCLUSIONS

Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.

[Surgical management of lungs destroyed by tuberculosis]

OBJECTIVE

The purpose of this work was to report our experience with surgical management of lungs destroyed by tuberculosis and to analyze our results.

MATERIAL AND METHODS

We reviewed the cases of 45 patients who underwent surgery between January 1978 and December 2004 after medical treatment for pulmonary tuberculosis considered successful. The series included 31 men and 14 women, mean age 31 years (range: 7-55 yr). Indications for surgery were chronic bronchorrhea (91.1%) and hemoptoic sputum associated with bronchorrhea (8.9%). Lung function tests were preformed in 42 patients and noted a restrictive syndrome with shunt in all: mean FEV1 was 1 890 ml. All patients were given a preoperative medical regimen for at least four weeks. Pneumectomy (17 right and 28 left) was performed; all bronchial sutures were made manually and protected. Operative bleeding was a constant feature and blood transfusion was needed (mean 1,500 cc).

RESULTS

Operative mortality was 4.4% from hemorrhagic and infectious causes. Complications were non-fatal (16.3%) and marked by bleeding (0.9%) empyema with bronchopleural fistulae (8.9%). Mean postoperative hospital stay was 13 days without empyema and 150 days with empyema. Long-term outcome was satisfactory after a mean 7.5 years follow-up (range: 4 months - 20 years).

CONCLUSION

Indications are patient comfort and necessity. Morbidity and mortality are acceptable with adequate preoperative preparation.

Pneumonectomy in children for destroyed lung and the long-term consequences

OBJECTIVES

Destroyed lung introduces irreversible changes in lung parenchyma. This condition is uncommon in children. Operative intervention is essential for children in this state. We demonstrate our experience with this condition and report on the respective long-term results.

METHOD

Seventeen children who underwent pneumonectomy for destroyed lung during a 15-year period were retrospectively analyzed. Long-term results were detected in 13 patients.

RESULTS

Seventeen children underwent pneumonectomy. Five children were female (29.4%), and 12 children were male (70.5%). The median age of the study group children was 9.1 years (3-16 years). Sputum was the most common presenting symptom (n = 13, 76.4%). Bronchiectasis (n = 11), tuberculosis (n = 4), and necrotizing lung disease (n = 2) were the main underlying conditions. Destroyed lung was detected on the left side in 14 children (82.4%) and on the right side in 3 children (17.6%). Main bronchial stenosis was found in 4 children and mucosal thickening or congestion in 5 children. The median length of hospital stay was 15.5 days. The mortality rate was 11.7% (n = 2), and the morbidity rate was 23.5% (n = 4). Follow-up information was available for 13 patients, and this ranged from 1 year to 12 years (median 5.2 years). The respiratory capacity and scoliosis level of the patients were examined.

CONCLUSIONS

Although pneumonectomy is considered a difficult procedure in children, its use for destroyed lung resolves complications and improves a patient's quality of life. In time, the remaining lung expands to compensate for the loss of the removed lung. Children grew and developed normally after pneumonectomy. Patients tend not to have major skeletal deformation as the result of pneumonectomy in the short term.

The destroyed lung syndrome: report of a case after Harrington rod instrumentation and fusion for idiopathic scoliosis

STUDY DESIGN

A case report is described.

OBJECTIVE

To describe the very rare complication of destroyed lung syndrome after scoliosis correction.

SUMMARY OF BACKGROUND DATA

The destroyed lung syndrome has, to our knowledge, never been associated with scoliosis in the literature. Bronchial kinking and compression by the vertebral column have been described in severe scoliosis cases.

METHODS

The patient, a 40-year-old woman was operated on in 1976 for a thoracic scoliosis and hypokyphosis using Harrington rod instrumentation and fusion with autologous bone graft. With a follow-up of 26 years, she has developed a very severe functional defect of the right lung, the so-called destroyed lung syndrome.

RESULTS

After the index procedure, the patient developed various episodes of pneumonia and abscess formation in the right lung because of kinking and obstruction of the bronchial tree of the right lung. This seemed to be caused by a severe hypokyphosis and by residual scoliosis of the thoracic spine with direct compression of the right bronchus by the vertebral column. Eventually two stents were placed, but this prevented further deterioration only temporarily.

CONCLUSIONS

After Harrington instrumentation and fusion for thoracic hypokyphotic idiopathic scoliosis, kinking and obstruction of a main bronchus are possible. In this patient, this complication gave rise to recurrent infections of the right lung, eventually progressing to destroyed lung syndrome.

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

OBJECTIVE

Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption.

METHODS

Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10(6) kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated.

RESULTS

There was a significant reduction in perioperative use of donor blood (0.98+/-0.92 vs. 0.45+/-0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2+/-36.9 vs. 76.9+/-53.3 ml, P=0.0004) (mean+/-standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50+/-1.08 units in aprotinin group, compared with 1.94+/-0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53+/-0.56 vs. 1.38+/-0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41+/-28 ml vs. 121+/-68 ml; P=0.001).

CONCLUSION

Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.

Using povidone-iodine to treat empyema

A feared complication of major thoracic surgery is infection leading to empyema. Choosing the most effective treatment option, if it does occur, will help achieve a positive outcome.