Pulmonary sequestration in adulthood: clinical-morphological study

OBJECTIVES

The aim of the study was to evaluate pulmonary sequestration (PS). We report on location, blood supply, histology, clinical manifestation, and surgical treatment of PS, as well as on postoperative course in patients with PS.

BACKGROUND

PS is a rare congenital defect of the lower respiratory tract, it represents locus minoris resistentiae of the body. Occasionally, PS is diagnosed for the first time in adulthood.

METHODS

We evaluated 7 cases of PS treated at the Centre of Thoracic Surgery in Vyšné Hágy, Slovakia, between years 2013 and 2020.

RESULTS

Four of our seven patients were asymptomatic; the PS was found incidentally upon chest imaging. Three patients had recurrent bronchopneumonia related specifically to the intralobar type of sequestration. The most significant complication, observed in a singular patient, was a life-threatening episode of haemoptysis, requiring urgent surgical intervention. In the other 6 cases, the sequestra were surgically resected during the period when they were asymptomatic. and their sputum was confirmed negative upon microbiological examination. Anatomical resection of the affected pulmonary lobe by thoracotomy was the most common type of operation performed (4 cases, n = 7). There was no surgical mortality.

CONCLUSION

To prevent complications, it is crucial to perform surgical treatment for pulmonary sequestration in patients who have sufficient functional capacity (Tab. 2, Fig. 4, Ref. 30). Text in PDF www.elis.sk Keywords: pulmonary sequestration, anatomic lobectomy, haemoptysis.

Isolated bronchial hemangioma causing recurrent hemoptysis: A case report

RATIONAL

The development of bronchial hemangioma in adults is rare, and massive hemoptysis due to diffuse vascular proliferation of bronchial hemangioma is fatal.

PATIENT CONCERNS

A case of a 29-year-old woman kept massive hemoptysis even after being underwent repeated interventional embolization for recurrent massive hemoptysis. Eventually, the patient was performed the operation of right upper lung lobectomy and bronchial hemangioma with extracorporeal membrane oxygenation support and was followed up for 4 years without recurrent hemoptysis.

DIAGNOSES

Bronchial hemangioma.

CONCLUSION

For patients with bronchial angiomas bonded with bronchial artery-pulmonary arteriovenous fistulae, the early surgical resection is recommended if bronchial artery embolization (BAE) is considered ineffective.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BACKGROUND

Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.

CASE PRESENTATION

A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.

CONCLUSION

Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Intrapulmonary sequestration with destructive pneumonia and life-threatening hemoptysis in an adult patient: a case report

The article reports the case of a patient with bronchopulmonary sequestration complicated by destructive actinomycotic inflammation leading to life-threatening hemoptysis. It was an adult patient with the history of repeated right-sided pneumonia the cause of which had not been investigated in detail in the past. Only hemoptysis, which appeared as a complication, led to a closer investigation of the background of repeated right-sided pneumonia. CT scan of the chest revealed a lesion of the middle lobe of the right lung with anomalous vascularization - compatible with intralobar sequestration. Initially, conservative antibiotic treatment of pneumonia was provided at a local clinic. Embolization of the afferent vessels of the sequestrum was indicated due to persistent hemoptysis; this led to a reduction of its blood supply, proven by a follow-up CT examination of the chest. Clinically, the hemoptysis subsided. Three weeks later, the hemoptysis reocurred. The patient was acutely hospitalized at a specialized thoracic surgery department where shortly after admission, hemoptysis progressed to life-threatening hemoptea. Urgent middle lobectomy of the right lung was approached via thoracotomy to treat the source of bleeding. The case describes unrecognized bronchopulmonary sequestration as a possible cause of recurrent ipsilateral pneumonia in adulthood; additionally, it emphasizes the possible risks associated with a pathologically altered tissue microenvironment of pulmonary sequestration, and the need for surgical removal in all indicated cases.

[An Anastomotic Aneurysm Thirty Years After Open Surgery of the Descending Thoracic Aorta:Report of a Case]

An 86-year-old man was hospitalized urgently to our department because of his worsening hemoptysis. He had undergone open thoracic aortic grafting for the Stanford type B chronic aortic dissecting aneurysm 30 years earlier. Contrast enhanced computed tomography (CT) revealed the distal anastomotic aneurysm, leakage of the contrast medium around the distal anastomotic site. We urgently performed thoracic endovascular aneurysm repair( TEVAR) for the distal anastomotic aneurysm. TEVAR was done under local anesthesia because of his poor respiratory condition due to hemoptysis. He recovered well without hemoptysis. Patients after open aortic surgery are expected to survive longer. Thus, special attention should be paid to the occurrence of anastomotic aneurysms.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

[Emergent Treatment for Life-threating Hemoptysis]

Life-threatening hemoptysis results significant airway obstruction, abnormal gas exchange. When a patient presents with life-threatening hemoptysis, the initial steps are to provide adequate oxygenation and ventilation, secure the airway, position the patient lateral decubitus with bleeding side down, and perform initial treatments to control the bleeding. Bronchoscopy is an important early procedure and can be both diagnostic and therapeutic. For patients who are stable, contrast chest computed tomography (CT) provides diagnostic information before angiography. In most cases, initial measures are successful, allowing time for a more detailed diagnostic investigation and generation of a therapeutic plan. For most patients, arteriography is appropriate for identifying and embolizing a responsible lesion. For patients with refractory life-threatening hemoptysis, repeating previous interventions or evaluating for surgery is appropriate. Patients with aneurysms should be evaluated for urgent surgery.

Rare broncho-pulmonary arterial fistula in a healthy 9-year-old girl

A 9-year-old previously well girl presented with multiple episodes of large volume haemoptysis and right sided consolidation. She continued to have haemoptysis despite intravenous antibiotics. CT chest suggested a right mainstem endobronchial lesion; this was not seen on bronchoscopy where an extensive blood clot was removed. Distal flexible bronchoscopy could not identify the source of bleeding. CT angiogram revealed a broncho-pulmonary arterial fistula, a rare cause of haemoptysis in children. Endovascular embolisation resulted in short-term symptom resolution; however, haemoptysis recurred months later, leading to re-embolisation. This case highlights a stepwise approach to the workup of large volume haemoptysis.

Pulmonary Artery Pseudoaneurysm Associated With Abandoned Epicardial Defibrillator Patch

We describe an 84-year-old man who presented with hemoptysis and acute blood loss anemia due to a pulmonary artery pseudoaneurysm (PAP). The etiology of his PAP was thought to be an abandoned epicardial defibrillator patch that was implanted at age 55. To our knowledge, PAP has never been reported as a possible complication of an abandoned epicardial defibrillator patch.

Dieulafoy disease of the bronchus involving bilateral arteries: A case report and literature review

RATIONALE

Dieulafoy disease of the bronchus is a rare vascular deformity. To the best of our knowledge, reports of these involving both lung vascular are hitherto absent.

PATIENT CONCERNS

A 67-year-old male was admitted to our department due to agnogenic hemoptysis.

DIAGNOSES

Bronchoscopy was performed and some smooth, pulsatile nodular lesions were found in the middle and lower lobes, Computed tomography angiography of the bronchial artery confirmed a left bronchial artery arising from the aortic arch at T4 level, and both bronchial arteries were dilated and tortuous.

INTERVENTIONS

Bronchial artery embolization was performed successfully.

OUTCOMES

The patient was discharged with no hemoptysis. In addition, patient is under follow-up until today without any further incidents.

LESSONS

This case reminds us that Dieulafoy disease of the bronchus could be a potential etiology for unexplained hemoptysis. The clinician should be aware of this disease when bronchoscopy revealed multiple some smooth, pulsatile nodular lesions, thereafter, bronchoscope biopsy should be avoided, as it could lead to fatal hemoptysis.

Bronchial Dieulafoy's disease: a retrospective analysis of 73 cases

BACKGROUND

Bronchial Dieulafoy's disease (BDD) is a rare disease that is known to be a cause of hemorrhage. The characteristics of this disease are still unknown. The present study describes the disorder based on a review of the world's literature, emphasizing the diagnostic and therapeutic views.

METHODS

A comprehensive research of BDD of the PubMed, Google Scholar, and Web of Science databases was performed. The following data were collected: patient characteristics; chest imaging, bronchoscopy, vascular angiography, and histopathologic examination findings; and treatment rendered.

RESULTS

73 cases of BDD have been reported from 1995 to 2019. Most of the cases occurred in Asia (52.1%), followed by Europe (31.5%). Chest imaging findings were non-specific. The main bronchoscopy finding was a nodular or protruding lesion (60.9%). 19 patients underwent bronchoscopic biopsies, 17 had bleeding, and 6 died. Four patients were successfully shown to have vascular malformations under mucosal protrusion by endobronchial ultrasound scan (EBUS). Vascular angiography mainly showed tortuous, dilated bronchial arteries. Vascular angiography mainly showed tortuous, dilated bronchial arteries. The arterial supply was mainly provided by bronchial arteries (48 cases) and the pulmonary circulation (4 cases). The lesions were mainly located in the right bronchus (53 cases). Selective bronchial artery embolization (BAE) was attempted in 38 patients and 20 patients underwent lobectomies. Emergency resection was performed in 15 patients, all of whom survived and had no recurrent hemoptysis.

CONCLUSIONS

Massive hemoptysis was the common manifestation of BDD. Vascular angiography and EBUS is a very useful examination before biopsy. BAE may be used in stable patients, or patients who cannot tolerate surgery, while surgical resection should be considered in patients who are unstable, patients with uncontrolled hemoptysis, or following BAE failure.

Successful Long-term Management of Two Cases of Moderate Hemoptysis Due to Chronic Cavitary Pulmonary Aspergillosis with Bronchial Occlusion Using Silicone Spigots

Chronic pulmonary aspergillosis is a major cause of life-threatening hemoptysis. In symptomatic patients with simple aspergillomas, surgery is the main therapeutic method for preventing or treating life-threatening hemoptysis. However, the risks of both death and complications are higher in chronic cavitary pulmonary aspergillosis than in simple aspergilloma. We herein report two patients with persistent moderate hemoptysis due to chronic cavitary pulmonary aspergillosis who were not indicated for surgery, but were able to undergo successful long-term management with bronchial occlusion using silicone spigots. In diseases with a high recurrence rate of hemoptysis, the continuous placement of silicone spigots might therefore be effective to prevent rebleeding.

Two cases of Dieulafoy lesions of the bronchus with novel comorbid associations and endobronchial ablative management

RATIONALE

Dieulafoy lesions are aberrantly large submucosal arteries most frequently associated with gastrointestinal hemorrhage. They are rarely identified in the bronchial submucosa and can cause massive hemoptysis.

PATIENT CONCERNS

We present three episodes of massive hemoptysis in two patients, the first with comorbid Alagille syndrome including multiple cardiac and pulmonary vascular abnormalities and the second with thyroid cancer metastatic to the mediastinum.

DIAGNOSES

All episodes were due to Dieulafoy lesions of the bronchus based on bronchoscopic appearance.

INTERVENTIONS

Bronchoscopic ablation using Nd:YAP laser was attempted both patients.

OUTCOMES

Nd:YAP laser successfully ablated the Dieulafoy lesion in the first case with long-term relief from recurrent hemoptysis. The first episode in the second patient responded to bronchial artery embolization; laser ablation of a different Dieulafoy lesion responsible for the second episode was unsuccessful but additional bronchial artery embolization has provided relief from further episodes.

LESSONS

Bronchoscopic ablation of Dieulafoy lesions of the bronchus can provide durable relief from recurrent symptoms. Clinical and anatomical features should be considered carefully before intervention, which should only be attempted by experienced operators with appropriate ancillary support available.

A novel endobronchial approach to massive hemoptysis complicating silicone Y-stent placement for tracheobronchomalacia: A case report

RATIONALE

Airway stabilization for severe, symptomatic tracheobronchomalacia (TBM) may be accomplished by silicone Y-stent placement. Common complications of the Y-stent include mucus plugging and granulation tissue formation.

PATIENT CONCERNS

We describe a rare case of massive hemoptysis originating from a silicone Y-stent placed for TBM.

DIAGNOSES

An emergent bronchoscopy showed an actively bleeding, pulsatile vessel at the distal end of the left bronchial limb of the Y-stent. It was felt that the bleeding was caused by, or at least impacted by, the distal left bronchial limb of the Y-stent eroding into the airway wall.

INTERVENTIONS

We hypothesized that placement of oxidized regenerated cellulose (ORC) would provide initial hemostasis, and the subsequent placement of a biocompatible surgical sealant would lead to definitive resolution.

OUTCOMES

ORC provided sufficient hemostasis and the subsequent synthetic polymer reinforced the tissue for complete cessation of the bleed.

LESSONS

The combined use of ORC and a biocompatible surgical sealant provided long-term management for life-threatening hemoptysis, and potentially morbid procedures such as embolization or surgery were avoided by advanced endobronchial therapy.

Massive Hemoptysis with a Fungus Ball-like Shadow in an Old Tuberculosis Cavity That Was Shown to Be a Clot by Bronchoscopy

Development of aspergilloma is common in cases with a fungus ball-like shadow in cavities due to old tuberculosis. Some reports have shown that blood clots tend to appear as a fungus ball-like shadow. A 71-year-old man with a history of pulmonary tuberculosis presented with a fungus ball-like shadow in an old cavity and hemoptysis. There was no evidence of aspergillus infection on various examinations. We confirmed a blood clot and aneurysm of an artery under direct vision by bronchoscopy. A lateral thoracic artery aneurysm was detected by angiography. Transcatheter arterial embolization was performed. After treatment, the artery aneurysm disappeared.

Successful Pulmonary Artery Embolization for the Management of Hemoptysis in a Patient with Eisenmenger Syndrome Caused by Patent Ductus Arteriosus

The patient was a 19-year-old woman who was diagnosed with patent ductus arteriosus complicating Eisenmenger syndrome at a previous medical institution. She was referred to our hospital and arranged for lung transplantation. She developed hemoptysis after the introduction of i.v. epoprostenol, which was administered as a bridging treatment while the patient awaited lung transplantation. She continued to suffer from recurrent hemoptysis, even after switching from i.v. epoprostenol to i.v. treprostinil. Angiography of the systemic and pulmonary arteries revealed the vessel responsible for the recurrent hemoptysis and pulmonary artery embolization was successfully performed. It is essential to identify the culprit vessel and physicians must not hesitate in performing embolization when patients develop lethal hemoptysis.

[Usefulness of Thoracic Endovascular Aortic Repair for the Treatment of Massive Hemoptysis Due to Bronchiectasis;Report of Two Cases]

Massive hemoptysis caused by bronchiectasis threatens life, so early bronchial arterial embolization (BAE) is needed. In case 1, a 80-year-old female complained of hemoptysis and back pain caused by bronchiectasis and Stanford type B aortic dissection. In case 2, a 78-year-old male had history of the surgery of descending thoracic aortic aneurysm and bronchiectasis combined with aortopulmonary fistula. Both cases in bronchiectasis with massive hemoptysis were difficult to perform BAE due to complicated with acute aortic dissection and aortopulmonary fistula. We applied Thoracic endovascular aortic repair (TEVAR) to these cases by its occlusive effects of the orifice of bronchial artery and collateral flow from intercostal arteries. Their postoperative courses were satisfactory without hemoptysis. We suggest that TEVAR can become the one of the option for the treatment of massive hemoptysis that is not indicated to BAE.

Accessory-lobed accessory cardiac bronchus: Presentation and treatment in a pediatric patient

Accessory cardiac bronchus (ACB) is a supernumerary bronchus usually arising from right main or intermediate bronchus. We report the case of a 9-year-old male who presented a 6-month history characterized by two right pneumonia episodes followed by persistent productive cough, recurrent bloody sputum, and chest x-ray persistence of a segmental thickening of right inferior lobe. Bronchoscopy revealed no abnormalities. Computed tomography documented an accessory-lobed ACB originating from right lower brochus. Surgical removal of ACB and related parenchyma was approached thoracoscopically and converted to thoracotomy for evidence of a bronchial injury. Two-year follow-up showed no recurrent infections or respiratory symptoms.

Dieulafoy's disease of the bronchial tree: a case report

CONTEXT:

Dieulafoy's disease of the bronchial tree is a very rare condition. Few cases have been reported in the literature. It can be asymptomatic or manifest with massive hemoptysis. This disease should be considered among heavy smokers when recurrent massive hemoptysis is present amid otherwise normal findings. The treatment can be arterial embolization or surgical intervention.

CASE REPORT:

A 16-year-old girl was admitted to the emergency department due to hemoptysis with an unknown lesion in the bronchi. She had suffered massive hemoptysis and respiratory failure one week before admission. Fiberoptic bronchoscopy revealed a lesion in the bronchus of the right lower lobe, which was suspected to be a Dieulafoy lesion. Segmentectomy of the right lower lobe and excision of the lesion was carried out. The outcome for this patient was excellent.

CONCLUSION:

Dieulafoy's disease is a rare vascular anomaly and it is extremely rare in the bronchial tree. In bronchial Dieulafoy's disease, selective embolization has been suggested as a method for cessation of bleeding. Nevertheless, standard anatomical lung resection is a safe and curative alternative.

[The place of surgery in bilateral sequelae bronchiectasis]

INTRODUCTION

The aim of our study is to report our surgery results in bilateral sequelae bronchiectasis and to assess its impact on the life quality of our patients.

METHOD

This is a retrospective descriptive study in thoracic surgery department of Teaching Hospital Hassan II of Fez in Morocco. It involved all patients with bilateral bronchiectasis which is predominant on a few lobes or segments (localized) and who underwent surgery during the period 2010-2015. The epidemiological, clinical and paraclinical data, the surgery results, the evolution and the impact on life quality were assessed.

RESULTS

From a total of 47 patients with bilateral bronchiectasis, 13 were operated, thus a frequency of 27.6%. The average age was 32years, ranging from 15 to 54years. Women were in majority (61.5%) representing a sex ratio of 1.6. The association of chronic bronchorrhea and hemoptysis was the main reason of medical consultation in 46.16%, followed by isolated chronic bronchorrhea in 38.46%. Surgical resection involved the left side in 61.5% of cases. The left lower lobectomy was the most accomplished gesture. An improvement in symptoms was found in 11 patients (84.6%) as a decrease in bronchorrhea, hemoptysis episodes and decreasing use of antibiotics.

CONCLUSION

Bilateral bronchiectasis surgery can be performed with acceptable morbidity and mortality in well-selected patients with an improvement in symptoms.

Pulsed Angiolytic Laser Treatment of Ectasias and Varices in Singers

Objectives:

Varices and ectasias in singers are typically the result of phonotraumatic shearing stresses and/or collision forces on the microcirculation within the superficial lamina propria. These lesions can be debilitating in performing vocalists because of the effect of recurrent hemorrhage and/or as a contributing factor to the morbidity of other mass lesions such as polyps, nodules, and cysts. Phonomicrosurgical treatment of performers is understandably approached with great trepidation, as the vocal liability of surgically disturbing the superficial lamina propria and epithelium must be balanced with the inherent detrimental vocal effect(s) of the lesion(s). Pulsed angiolytic lasers that emit radiation at high absorbance peaks of oxyhemoglobin were examined to determine whether they were an efficacious treatment approach for ectasias and varices based on these lasers' mechanisms of action and prior experience in phonomicrosurgery.

Methods:

A prospective trial was done in 39 patients (40 procedures in 54 vocal folds) without complication to evaluate the effectiveness of a 585-nm pulsed dye laser (PDL; 25 cases) and a 532-nm pulsed KTP laser (15 cases) in a noncontact mode to treat 65 varices and 43 ectasias. Twenty-nine of 39 patients had varices and ectasias associated with other phonotraumatic mass lesions that required resection.

Results:

All patients have resumed full vocal activities, and no patient has had a subsequent hemorrhage or vocal deterioration.

Conclusions:

Both the 585-nm PDL and the 532-nm pulsed KTP laser were found to be efficacious and relatively safe treatment modalities for vascular abnormalities of the vocal folds in singers. Noncontact selective photoangiolysis of the aberrant vessels prevented future bleeding without substantial photothermal trauma to the overlying epithelium and surrounding delicate superficial lamina propria, thereby allowing for optimal postoperative mucosal pliability and glottal sound production. However, the pulsed KTP laser was substantially easier to use because of its enhanced hemostasis due to its longer pulse width. Vessel wall rupture was commonplace during use of the 585-nm PDL, but rarely occurred during photoangiolysis with the 532-nm pulsed KTP laser.

Surgical Management of Pulmonary Aspergilloma

Records of 59 patients (41 males and 18 females) who underwent 70 operations for pulmonary aspergilloma in a 23-year period were examined retrospectively. Sixty-three operations were for primary treatment of pulmonary aspergilloma, and 7 were for complications of surgery. Twenty-six postoperative complications occurred in 19 patients. Three lobectomies that resulted in bronchopleural fistula were managed by intercostal muscle-flap closure and partial thoracomyoplasty. Two patients died within the first week of surgery. Surgery is the treatment of choice for most patients with pulmonary aspergilloma. Selective bronchial artery embolization is helpful only in combating hemoptysis, and this has been considered a temporary measure in most reports. Thus, open thoracotomy and anatomical resection are recommended as early as possible after the diagnosis is established.

[Massive haemoptysis revealing bilateral sequestration in an adult: 3-year follow-up after embolization and surgery]

Pulmonary sequestration is a rare vascular malformation which is most of the time unilateral. We report here the case of a 35-year-old male admitted for severe haemoptysis revealing bilateral pulmonary sequestration: one type 1 of Pryce in the right lower lobe and one type 2 of Pryce in the left lower lobe. Bilateral embolization was performed followed by a segmental resection of the left lower lobe sequestration by thoracotomy. After 3-year follow-up, the patient was asymptomatic and had no recurrence of haemoptysis. Enhanced computed tomography scan showed proximal occlusion of the right lower lobe sequestration systemic artery.

Bronchoscopy in patients with haemoptysis and normal computed tomography of the chest is unlikely to result in significant findings

INTRODUCTION

The standard evaluation of haemoptysis in a department of respiratory medicine would currently consist of chest radiography, contrast-enhanced computed tomography (CT) and fibre-optic bronchoscopy (FOB), regardless of the result of the CT. Our aim was to evaluate whether patients presenting with haemoptysis but no positive finding on a contrast-enhanced CT of the chest are at risk for having serious disease, first of all lung cancer, and thus whether FOB is mandatory for such patients.

METHODS

We searched the literature and retrospectively reviewed all records of patients referred with haemoptysis between 2000 and 2010 at the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Denmark.

RESULTS

A total of 379 patient records were reviewed for inclusion in the clinical part of the study. Of these, 269 had the information required for the study and had been examined with CT. In all, 16 of the 269 patients were diagnosed with lung cancer. In all of these, a tumour or other findings indicating a possible tumour were seen on the chest CT. No additional cases of lung cancer were discovered during FOB, and no cases had been missed by the CT.

CONCLUSION

CT should be used as first-line examination in patients with a history of haemoptysis. Furthermore, in patients above 40 years of age with positive findings of any kind on the CT, further examination with FOB is indicated. However, if the chest CT is without pathological findings, it is most unlikely that FOB will reveal anything of significance.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Surgical management of pulmonary aspergilloma: clinical experience with 77 cases

BACKGROUND/AIM

This retrospective study evaluated the clinical presentation, underlying lung disease, surgical indications, technique, treatment outcomes, and postoperative complications of pulmonary aspergilloma.

MATERIALS AND METHODS

We evaluated 77 patients who underwent pulmonary resection of an aspergilloma at Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital between January 2000 and December 2013. The initial operations were 4 pneumonectomies, 24 lobectomies, 9 lobectomy plus myoplasties, 10 segmental resections, and 30 wedge resections. Six reoperations were carried out to deal with postoperative complications: 1 myoplasty, 2 completion lobectomies plus myoplasties, 2 myoplasties with rib resections, and 1 completion lobectomy.

RESULTS

The subjects comprised 53 males (mean age: 44.26 (range: 10-73) years) and 24 females (mean age: 48.25 (range: 26-70) years). The most common indication for surgery was hemoptysis in 52 patients (67.53%). The most common underlying lung disease was tuberculosis in 37 patients (48.05%). Forty patients (51.94%) had a simple pulmonary aspergilloma and 37 (48.05%) had a complex pulmonary aspergilloma. Major complications occurred in 18 patients (23.37%). The postoperative mortality rate was 3.89%, with 3 patients dying.

CONCLUSION

Surgical resection of pulmonary aspergilloma is the best way to prevent recurrent hemoptysis with low morbidity and mortality.

[A rare and unusual cause of dysphonia: The leech]

We report a case of dysphonia associated with intermittent episodes of hemoptysis low abundance in a patient aged 32, clinical examination is normal, nasofibroscopie objective a leech at the laryngeal orifice, extracted by direct laryngoscopy in emergency.

Interventional pulmonology procedures: an update

Bronchoscopy is the most important tool in diagnosis of respiratory diseases, but also provides therapeutic options in various disorders. Besides hemoptysis, airway stenoses are a frequent indication for therapeutic bronchoscopy interventions. Thereby, a broad spectrum of endoscopic techniques including electrocautery, argon plasma coagulation, laser treatment, cryosurgery and stent implantation is available. In the last decade, development of new endoscopic modalities provides also treatment of patients with chronic obstructive pulmonary disease and uncontrolled asthma.

A case of pulmonary carcinoid tumour in a pregnant woman successfully treated with bronchoscopic (electrocautery) therapy

We present an uncommon case of a carcinoid tumour of the bronchus that was diagnosed during pregnancy in a 28-year-old woman. The patient was admitted at the emergency department with massive haemoptysis. Owing to the patient's critical condition, she underwent urgent flexible bronchoscopy. Bleeding was controlled by local injection of 500 mg tranexamic acid and electrocautery. After the bleeding has stopped, multiple specimens were taken. Histological examination confirmed typical carcinoid tumour. Owing to repeated haemoptysis, she was treated with bronchoscopic (electrocautery) therapy, and, after delivery, she underwent pulmonary lobectomy. Only a few similar cases were found in the literature reporting bronchopulmonary carcinoid tumour during pregnancy and we could not find any similar case which was treated by electrocautery.

One-stoma carinoplasty: right upper sleeve lobectomy with hemicarinectomy for resection of right-tracheobronchial-angle tumors

Tracheobronchial-angle tumors involve the right main bronchus, the right upper lobar bronchus, and the lateral wall of the lower trachea. Resecting these tumors is one of the most complex procedures in thoracic surgery. In cases of high-caliber mismatch, the selection of a suitable anastomotic technique can be challenging. We found that our use of a one-stoma carinoplasty technique overcame high-caliber mismatch after the resection of these tumors. From 2009 through 2012, 8 men (mean age, 59 ± 6.2 yr; range, 46-66 yr) underwent complete resection of non-small-cell right-tracheobronchial-angle tumors at our institution. In every case, right upper sleeve lobectomy, wedge carinal resection, and one-stoma carinoplasty were applied. After tumor resection, one patient with hemoptysis and bronchopleural fistula underwent a completion pneumonectomy and died 10 days postoperatively. Bronchoscopy was necessary in 2 patients who had atelectasis in the contralateral lung. At a mean follow-up duration of 19.43 ± 8.4 months (range, 0.2-27.1 mo), 6 patients were alive and free of disease. We conclude that our one-stoma carinoplasty technique enables the resection of tumors at the right tracheobronchial angle, with acceptable morbidity and mortality rates. This method saves the unaffected part of the ipsilateral lung and can overcome high-caliber mismatch. Because of these and other advantages, we suggest that using our method first might preclude having to perform a right carinal sleeve pneumonectomy or using Barclay's method.

[Emergent thoracic endovascular aortic repair in a patient with hemoptysis due to bronchial fistula: a case for airway management]

Bronchial fistula due to bronchial compression is a rare complication following both open surgical and endovascular repair of thoracic aortic aneurysms. We report on the airway management for a case of emergent thoracic endovascular aortic repair (TEVAR) in a patient with left bronchial obstruction due to hemoptysis. A 68-year-old man had undergone total arch replacement 8 years before, and was preoperatively diagnosed with aortobronchial fistula in the left lung. To prevent obstruction of the right lung by rebleeding in the left bronchus, we planned to exchange the single lumen endotracheal tube placed following hemoptysis to a double lumen tube prior to the operation. With assisted spontaneous breathing, bronchoscopy performed before replacing of the endotracheal tube showed obstruction of the left bronchus with many clots. With bronchoscopic assistance, clots were removed from the left bronchus and oxygenation improved significantly. We found a blue nylon suture penetrating the bronchial wall, most likely from a previous operation. However, bronchoscopy did not disclose aortobronchial fistula. Following TEVAR, the patient was diagnosed with bronchopleural fistula induced by bronchial compression due to blood vessel prosthesis and surrounding felt strips. Cooperation from surgeons and careful airway management were required to prevent life-threatening oxygenation insufficiency.

[Bronchial artery ligation for the management of hemoptysis]

Hemoptysis is defined by the expectoration of blood from infra-glottal airway. Massive hemoptysis can be a life-threatening intrathoracic disease that requires urgent investigations and management. The chest radiography and the computed tomography (CT) are useful to localize the bleeding site and to identify the cause of hemoptysis. Bronchial artery embolization is the most effective nonsurgical treatment in the management of massive and recurrent hemoptysis. This article reviews the role of radiology in the diagnosis and treatment of hemoptysis.

Massive hemoptysis during pregnancy

We report a case of pulmonary carcinoid presenting as massive hemoptysis in a pregnant patient. In our patient, diagnosis of carcinoid tumor was suspected after ruling out other probable and possible causes of hemoptysis. It was confirmed provisionally on flexible fiber optic bronchoscopy and later confirmed on histopathology. Our patient had two consecutive emergency surgeries, emergency cesarean section on one day followed by emergency pneumonectomy on next day. The lives of both, the mother and baby could be saved. At three month follow up, the mother did not have any symptoms.

Aquatic leech as a rare cause of respiratory distress and hemoptysis

This paper presents a 73 years old male with three weeks history of intermittent hemoptysis, dysphagia, dyspnea, stridor, and suffocations sensation. By means of fibrotic bronchoscopic examination, the cause was found to be a leech in the glottis. It was removed by injection of 4 ml lidocaine 2%. Infestation into the respiratory tract by a leech may become lethal because of hypoxia and death secondary to airway obstruction. A high index of suspicion of leech infestation sould be considered in patients presenting with hemoptysis, hoarseness and respiratory distress and a history of recent contact with fresh water streams.

[Diagnostics and treatment of pulmonary hemorrhage by the closed thoracic trauma]

Results of diagnostic and treatment of 156 patients with pulmonary hemorrhage, caused by the closed thoracic trauma, were analyzed. All patients had lung bruise, 101 of them had lung rupture. 115 (73.7%) patients demonstrated hemopneumothorax, bleeding was diagnosed in 86 (55.1%) cases and mediastinal emphysema was diagnosed in 52 (33.3%). Pulmonary hemorrhage developed more often by polytrauma of the chest, rather then by solitary lesions. Spiral computed tomography proved to be the best diagnostic means of thoracic trauma. Surgical tactics was defined mainly by the severity of intrapleural or pulmonary bleeding. Conservative treatment allowed successful recovery in the majority of patients. Only 5.1% of patients required surgery. High level of septic complications of pulmonary hemorrhage was registered/ Pneumonia developed in 28.8% and lung abscess was diagnosed in 14.1% of patients. The lethality rate was 9.6%.

Necessity of lung resection in neglected cases of pulmonary hydatidosis

In pulmonary hydatid disease, lung resection is not a desirable treatment. Two young boys, aged 9 and 15, presented at our institution, the 9-year-old with a destroyed lung as the result of a delayed diagnosis of a giant cyst; the second with a massive hemoptysis as the result of preoperative albendazole use. Both children underwent a lobectomy for the treatment of pulmonary hydatidosis. Delayed diagnosis and use of albendazole, respectively, were considered the causes necessitating lung resection in these cases of giant and complicated pulmonary hydatid disease.

[Is emergency revascularization of tracheo-innominate artery fistulae mandatory?]

Tracheo-innominate artery fistulas are a rare but life-threatening complications (incidence between 0.1 and 1 %) occurring in tracheostomy patients. Surgery is the treatment of choice. Most authors recommend ligation of the innominate artery, which provides better results in terms of morbidity/mortality than revascularization surgery. We report here a case of innominate artery revascularization isolated from the trachea by a sternocleidomastoid pediculate interposition graft. The procedure was successful as demonstrated by the 2 years follow-up. Revascularization surgery should be reserved of specific cases. The risk of tracheal-mediated infections developing in contact with the vascular sutures warrants systematic use of an interposition graft isolating the trachea from the innominate artery.

Hemoptysis in a single lung Fontan: percutaneous approach

BACKGROUND

The Fontan procedure is sometimes the last palliative surgery for complex congenital heart disease with single-ventricle physiology. According to some authors, atrial-baffle fenestrations with right-to-left shunts have improved the surgical outcome of the Fontan operation. Percutaneous fenestration closure at a later stage may increase saturations and reduce the risk of embolic complications. A case could be made that the fenestration should be left patent if the patient, having lost the continuity of the pulmonary artery to one lung, only has a single functional lung.

CASE REPORT

The case of an 11-year-old boy with a severe form of Ebstein anomaly is reported. He had undergone a fenestrated Fontan procedure and had lost the continuity to the left pulmonary artery. Further intervention was discouraged at other centers but he was eventually referred to our institution due to increasing cyanosis and severe hemoptysis. Several right-sided arteriovenous pulmonary malformations and collateral arteries were embolized percutaneously; a major right-to-left shunt at the fenestration in the atrial baffle was also occluded with an Amplatzer device. His saturation rose from 78 to 94% and his exercise tolerance increased, without further hemoptysis.

[Spinal cord ischemia after bronchial artery embolization and right thoracotomy]

Bronchial artery embolization was attempted several times in a 74-year-old man undergoing right pneumonectomy for persistent hemoptysis. Paraplegia developed after surgery. Both thoracotomy for lung surgery and bronchial artery embolization have been reported to cause spinal cord ischemia. We analyze the possible mechanisms through which such ischemia may develop.

[Indications and results of lung resection in bronchiectasis]

The prevalence of bronchiectasis has decreased significantly over recent decades in developed countries. However, resection for bronchiectasis still plays an important role in thoracic surgery practice in some countries such as Portugal. Between 1994 and 2004, 51 patients (29 female and 22 male) with a mean age of 38.6 years (range, 4-65 years) underwent pulmonary resection for bronchiectasis. Mean duration of symptoms was 4.8 years. Surgery was indicated because of unsuccessful medical therapy in 25 patients (49.1%), hemoptysis in 12 (23.5%), lung mass in 9 (17.6%) and lung abscess in 5 (9.8%). The surgical treatment was as follows: pneumectomy in 7 patients, bilobectomy in 3, lobectomy in 36 segmentectomy in 5. There was no operative mortality. Complications occurred in 8 patients and the morbidity rate was 15.7%. Follow-up was complete in 45 (88.2%) patients with a mean of 3.4 years. Overall, 35 (77.7%) patients were asymptomatic after surgery symptoms were improved in 7 (15.6%). Unsuccessful medical therapy was still our main indication for surgery of bronchiectasis, despite aggressive antibiotic therapy. Surgical resection was performed with acceptable morbidity and morbility rates and markedly improved symptoms in the majority of patients.