Septal structure of incomplete interlobar fissures of the lung

Thoracoscopic lobectomy through the pulmonary hilum approach for the treatment of congenital lung malformation

BACKGROUND

Thoracoscopic lobectomy is widely accepted for the treatment of congenital lung malformations (CLM), owing to its advantages. However, severe incomplete interlobar fissure may lead to a high rate of conversion to thoracotomy and postoperational complications. Thoracoscopic lobectomy utilizing the pulmonary hilum approach may be an effective and safe method to resolve these problems. This retrospective study was conducted to estimate the safety and efficiency of this approach.

METHODS

A retrospective review of medical records was performed in our institution, from January 2014 to December 2019, and 432 patients with CLM who underwent thoracoscopic lobectomy through the pulmonary hilum approach were included in this study. Patients were divided into the incomplete fissure (IF) group and complete fissure (CF) group according to the level of fissure, which was proposed by an anatomical classification of pulmonary fissures.

RESULTS

Patients in the IF and CF groups were 131 and 301, respectively. In univariate analysis, there were statistical significances between the two groups in terms of intraoperative blood loss (P = 0.04), surgical time (P = 0.01), the number of chest tube drainages (P < 0.01), and the total length of hospital stay (P = 0.03). However, no patients experienced bronchopleural fistula, postoperative pneumonia, or conversion to thoracotomy in either group. Five patients experienced prolonged air leakage in the IF group, and no prolonged air leakage occurred in the CF group.

CONCLUSION

An IF would certainly increase the difficulty of CLM surgery, and thoracoscopic lobectomy using the pulmonary hilum approach is an effective and safe method for CLM patients.

Comparison of Iodixanol with Iohexol for Delayed Pelvic Venous Opacification:A Preliminary Study of Potential Use for CT Venography

OBJECTIVE

The goal of this prospective randomized study was to determine whether isosmolar contrast material offers an advantage over low-osmolar contrast material for delayed venous opacification in CT venography. SUBJECTS AND METHODS. We prospectively enrolled 200 adult outpatients. Patients were randomized to receive either the low-osmolar (hyperosmolar to blood) nonionic contrast medium, iohexol, or the nonionic isosmolar contrast medium, iodixanol. Images were obtained before contrast administration and 180 sec after contrast administration through the pelvis at the level of the external iliac vessels. Opacification of the external iliac vessels was assessed both objectively and subjectively.

RESULTS

The arterial and venous densities before contrast administration were approximately 45 H for both groups. On delayed images obtained after contrast administration, the mean venous density was 95.2 H for iohexol and 101.4 H for iodixanol. Changes in venous density due to administration of iohexol and iodixanol were 49.8 and 56.1 H, respectively. This 12.5% difference was highly significant (p = 0.002). Sixty-six percent of the images in the iodixanol group were rated either 4 (good) or 5 (excellent), whereas only 36% of the iohexol group achieved a similar rating on our subjective rating scale. This difference was statistically significant (chi(2) = 16.4, p < 0.001, df = 1).

CONCLUSION

Our study shows that isosmolar contrast material provides significant improvement in delayed opacification of the external iliac vessels in comparison with conventional low-osmolar contrast medium (hyperosmolar to blood).

Vascular anatomy at the medial ends of incomplete major fissures

Purpose of this study was to examine the relationship of the pulmonary vasculature with the medial ends of incomplete major fissures.

METHODS

All of the 2-mm thickness conventional CT and 2-mm collimated helical CT scans of the chest of the past 3 (1/2) years were reviewed. The right lungs of 132 patients and left lungs of 133 patients were examined to evaluate the pulmonary vasculature at the medial ends of the major fissures.

RESULTS AND CONCLUSION

After excluding patients with complete major fissures, in 45 of 86 right lungs (52.3%) and 30 of 75 left lungs (40.0%), the pulmonary vasculature ran at the medial ends of the incomplete major fissures. In all patients, in 25.5% of conventional CT slices and 18.2% of helical CT slices of the right lungs, and in 15.1% of conventional CT slices and 11.0% of helical CT slices of the left lungs, the pulmonary vasculature was seen at the medial ends of the incomplete major fissures.

Anatomy of the pleura

The lung and heart, the vital organs, have to be protected and also have to move and change volume continuously to function. For the best protection and function of the lung, the thorax is shaped almost like a bellows with the diaphragm as the moving part. Furthermore, the outer surface of the lung and the inner surface of the protective thoracic cage are covered by an elastic, serous, and lubricating membrane to form the pleural cavity. This is almost like inserting a sealed-wet and stretchable-plastic bag between the lung and the thoracic wall and diaphragm to decrease friction. The lubrication is accomplished by the facing mesothelial cells that have bushy-surface microvilli enmeshing hyaluronic acid-rich glycoproteins. The amount of fluid in the pleural cavity is regulated by the hydrostatic-osmotic pressure relationship and pleuro-lymphatic drainage. Excess fluid, large particles, and cells in the pleural cavity are removed through preformed stomas assisted by respiratory movements. The stoma is found only in the anterior lower thoracic wall and diaphragm and is like the drain of a sink. Finally, clinical and subclinical injuries of the pleura appear to occur often. Reactive mesothelial cells constantly repair the damages and keep the pleural cavity open. Without mesothelial cells, the lung cannot function properly and the pleural cavity will be quickly obliterated by fibrosis.

Preparation of human whole lungs inflated and fixed for radiologic-pathologic correlation

RATIONALE AND OBJECTIVES

The authors evaluated a modified method of lung inflation and fixation for radiologic-pathologic correlation of lung disease.

METHODS

Fifty-five whole human lungs obtained at autopsy were examined. Fifty lungs were cannulated via the main bronchus and distended with 20% formalin. The cannula was clamped for 15 minutes, 30 minutes, 2 hours, 2 days, 4 days, or 6 days. Then the formalin was expelled with air at a pressure of 10 cm H2O. The lung was fixed with a mixture of polyethylene glycol 400, 95% ethyl alcohol, 40% formalin, and water. In the five lungs that were not cannulated, the formalin was expelled manually.

RESULTS

The degree of inflation of 46 cannulated specimens was rated as good in 42, moderate in four, and poor in nine. Histologic preservation was not evaluated in 23 of 55 specimens because of postmortem autolysis. It was rated as good or moderate in 29 specimens. Both inflation and staining were rated as good in 21 specimens.

CONCLUSION

This modified method of preparation of inflated, fixed lung provides good histologic preservation and radiographic appearance of lung.