Treatment of spontaneous pneumothorax--an ongoing debate.
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Cost-Benefit Analysis↗
Biomedical subjects
M Noppen
Publications and source records attributed to M Noppen.
Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists.
Intractable pain is the most invalidating symptom in patients suffering from chronic pancreatitis. Anatomical interruption of the major afferent pain nerves is indicated in severe refractory cases. Among the various techniques and sites of interruption, thoracoscopic splanchnicectomy has emerged as an efficient alternative for the more aggressive open surgical splanchnicectomy, and for the (solely temporarily efficacious) transcutaneous neural blocks, which moreover bear some serious complications. Until now, all reports on thoracoscopic splanchnicectomy were typically surgical, using video-assisted thoracoscopic surgery techniques, double-lumen intubation, and so on. In analogy with thoracoscopic upper dorsal T2-T3 sympathicolysis for essential hyperhidrosis, a simplified thoracoscopic splanchnicolysis technique used in 8 patients suffering from either severe refractory chronic pancreatitis pain (7 patients) or postsurgical epigastric pain is described. Pain control was achieved in 5 of the 7 patients with chronic pancreatitis with a short (20+/-8 min) intervention, short hospitalization (2 days), and simple (single-lumen intubation, no chest drains) procedure. Thus, this simplified thoracoscopic splanchnicolysis technique may represent a valid alternative in the often difficult treatment of refractory chronic pancreatitis pain or other upper abdominal pain.
Abdominal Pain↗
[Treatment of essential hyperhidrosis using thoracoscopic high dorsal sympathectomy].
Essential hyperhidrosis (EH) is a little-known disorder which may have a strong adverse effect on the patient's functioning. Conservative treatment of EH is often disappointing and the 'classical' surgical treatment is very radical and complicated. Thoracoscopic sympathectomy is efficacious in the treatment of palmar (and axillary) EH.
Humans↗
Effects of non-pharmacological sympathetic sudomotor denervation on sweating in humans with essential palmar hyperhidrosis.
OBJECTIVE: Quantitative sweat production and -ionic composition in Essential Hyperhidrosis (EH), and the effects of T2-T3 thoracoscopic sympathicolysis (TS) hereon, are unknown. Standardised pilocarpine iontophoresis sweat tests were performed before and after TS in order to study these issues. DESIGN AND METHODS: Pilocarpine iontophoretic sweat tests measuring maximal sweat production (mg) and sweat Na+, K+ and Cl- concentrations (mMol/L) were performed on both forearms of 10 EH patients, before and six weeks after TS, and in normal volunteers. RESULTS: As compared to normals, preoperative maximal sweat production was 30% higher (199.4 +/- 68.8 (SD) vs. 150.6 +/- 45.6 mg) in EH patients; due to type II error, however, statistical significance was not reached. Na+ and Cl- concentrations were similar, and K+ concentration was slightly lower in EH patients. After TS, sweat production had decreased to equal levels as in normals (149.1 +/- 52.1 mg), whereas the Na+ (from 33.6 +/- 6.9 to 51.0 +/- 6.4 mMol/L), Cl- (from 21.5 +/- 6.6 to 37.2 +/- 7.1 mMol/L) and K+ (from 7.5 +/- 1.3 to 8.6 +/- 2.2 mMol/L) concentrations had increased. CONCLUSIONS: EH patients present 30% higher maximal sweat production at their forearms. This increase may be due to an increased activity of the adrenergic component of sweat gland innervation. The post-TS increase in Na+, Cl- and K+ concentrations suggests that the adrenergic component of sweat gland innervation in itself decreases sweat ion concentrations.
Adult↗
Plasma catecholamine concentrations in essential hyperhidrosis and effects of thoracoscopic D2-D3 sympathicolysis.
Essential hyperhidrosis (EH) is caused by a poorly understood overactivity of the sympathetic fibres passing through the upper dorsal sympathetic ganglia D2 and D3. These ganglia are also in the pathway of the sympathetic innervation of the heart and lungs. Therefore, although the predominant sympathetic neurotransmitter at the eccrine sweat glands is acetylcholine, the plasma concentration of noradrenaline (NA) (which is the main sympathetic neurotransmitter at the end organs including the heart and the lungs) may be elevated. Furthermore, as there are some indications for generalized sympathetic overactivity in EH, the plasma concentration of adrenaline (A) may also be elevated. Plasma levels of NA and A were therefore determined in 13 EH patients before and after thoracoscopic D2-D3 sympathicolysis (TS). Preoperative NA and A plasma levels were all within the normal limits used in our laboratory. After TS, mean NA plasma levels are significantly decreased, whereas mean A are unchanged. We conclude that sympathetic overactivity in EH is limited to the upper dorsal sympathetic ganglia and that some of the cardiovascular and pulmonary effects that are observed after TS may be associated with the decrease in NA.
Adolescent↗
A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions.
In comparative studies with other agents, insufflated talc has been shown to be the most effective agent in achieving chemical pleurodesis in patients with malignant pleural effusions. The objective of this study is to compare the efficacy of talc administered as slurry (5 g in 50 mL saline) via tube thoracostomy with that of bleomycin (1 mg/kg in 50 mL saline) (which is the most effective agent other than talc). In a randomised, prospective comparative study, twenty-six consecutive patients with proven malignant pleural effusions (recurrent after at least two pleuroscenteses) in whom no pleurodesis attempt had yet been made, and who were symptomatic, had a Karnovski index < or = 50, and an expected survival of one year or less, were included. Therapeutic failure was defined as recurrent pleural fluid > or = 50% of initial volume or requiring pleurocentesis. Recurrence rates (25% vs 21.4%, NS), fever (25% vs 35.7%, NS), pain (0% both groups) and survival (3.75 +/- 3 vs 5.82 +/- 7.15 months, NS) did not differ between bleomycin or talc treated patients. There were no major complications (e.g., empyema) or side-effects. In conclusion, talc slurry and bleomycin are equally effective in achieving chemical pleurodesis via thoracostomy in patients with malignant pleural effusions, and the safety profile of both agents is similar. Since talc is substantially less expensive than bleomycin, talc slurry probably represents the agent of choice for chemical tube thoracostomy pleurodesis.
Adult↗
Interventional bronchoscopy: 5-year experience at the Academic Hospital of the Vrije Universiteit Brussel (AZ-VUB).
Our experience with interventional bronchoscopic techniques in a University Hospital is described: in 93 patients during a 5-year period, 149 interventional procedures (i.e., Nd-YAG laser photoresection and/or airway stenting and/or balloon dilatation) have been performed. Laser resection was successful in relieving major symptoms (intractable dyspnea, hemoptysis or retro-obstructive complications) in 35/41 (85%) of malignant indications, and in 18/19 (94%) of benign obstructions. Major complications included one death (1.6%) early in the series, and major nonfatal hemorrhage in three patients (5%), all with malignant disease. In 31/35 (89%) of malignant central airway stenoses treated with stents, respiratory symptoms could be palliated successfully. Mean survival after stenting was 6 +/- 5.3 months. In 20/23 (87%) of benign tracheal stenoses, temporary or permanent stenting allowed for complete restoration of airway patency. The development of inexpensive and simplified insertion techniques for existing stents, and of a new (and even less expensive) type of tracheal stent has enabled the use of airway stenting in all categories of patients. Bronchoscopic balloon dilatation was helpful in the mechanical dilatation of stenoses, and in the unfolding of unopened stents. Finally, a plea for an organised referral system and for active collaboration between interventional bronchoscopy centers is made.
Adult↗
Essential hyperhidrosis in Turner syndrome.
We describe two Turner patients suffering from severe essential hyperhidrosis. Since both disorders are rare (1 in 5000 live female births for Turner syndrome and approximately 1 in 1000 persons for essential hyperhidrosis), our finding of two patients with these disorders in a total of 150 essential hyperhidrosis patients may suggest that this association is more frequent in Turner syndrome than previously thought.
Child↗
Ventilation distribution during histamine provocation.
We investigated ventilation inhomogeneity during provocation with inhaled histamine in 20 asymptomatic nonsmoking subjects. We used N2 multiple-breath washout (MBW) to derive parameters Scond and Sacin as a measurement of ventilation inhomogeneity in conductive and acinar zones of the lungs, respectively. A 20% decrease of forced expiratory volume in 1 s (FEV1) was used to distinguish responders from nonresponders. In the responder group, average FEV1 decreased by 26%, whereas Scond increased by 390% with no significant change in Sacin. In the nonresponder group, FEV1 decreased by 11%, whereas Scond increased by 198% with no significant Sacin change. Despite the absence of change in Sacin during provocation, baseline Sacin was significantly larger in the responder vs. the nonresponder group. The main findings of our study are that during provocation large ventilation inhomogeneities occur, that the small airways affected by the provocation process are situated proximal to the acinar zone where the diffusion front stands, and that, in addition to overall decrease in airway caliber, there is inhomogeneous narrowing of parallel airways.
Airway Resistance↗
Comparison of video-assisted thoracoscopic talcage for recurrent primary versus persistent secondary spontaneous pneumothorax.
Thoracoscopic talcage (TT) is a safe and effective prophylactic treatment for patients suffering from recurrent primary spontaneous pneumothorax (PSP). Empirically, TT is considered equally effective in the treatment of persistent secondary spontaneous pneumothorax (SSP), although this has not yet been proved. In this study, the efficacy and safety of TT was prospectively evaluated in 28 patients (17 males and 11 females, mean age 27 +/- 8 yrs), with 31 episodes of recurrent PSP, and in 20 patients (13 males and 7 females, mean age 43 +/- 21 yrs) with persistent SSP. TT proved to be equally effective in achieving pleurodesis in both groups; there were 6.5% recurrences in the PSP group and 8.7% in the SSP group during a mean follow-up period of 18 months (p > 0.05). In the SSP group, there were significantly more prolonged postoperative air leaks (26 vs 0%; p = 0.004) and a longer postoperative chest tube drainage time (35.5 +/- 18 vs 24.9 +/- 3.2 hrs; p = 0.002) was necessary. All air leaks, however, ceased spontaneously during drainage. Duration of hospitalization was significantly longer in the SSP group (4.7 +/- 2 vs 3.2 +/- 0.5 days; p < 0.0001). Postoperative pain (90 vs 43%; p < 0.0001) and fever (65 vs 17%; p = 0.001) were more frequent in the PSP group than in the SSP group. There were no major peri- or postoperative complications in either group. We conclude that thoracoscopic talcage is as efficient and safe in achieving pleurodesis in persistent spontaneous pnuemothorax as in recurrent primary spontaneous pneumothorax.
Adult↗
Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults.
Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.
Adult↗
Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis.
Essential hyperhidrosis (EH) is caused by an unexplained overactivity of the sympathetic fibers which pass through the upper dorsal sympathetic ganglia D2 and D3. Since the D2 and D3 ganglia are also involved in the sympathetic cardiac innervation, cardiocirculatory autonomic function may also be abnormal in EH. In order to study the function of the sympathetic nervous system in EH, and to assess the effects of thoracoscopic sympathiocolysis, cardiocirculatory autonomic function tests were performed in 13 consecutive patients with EH, before (baseline) and 6 weeks after the thoracoscopic intervention. Baseline data were also compared with data obtained from 13 matched healthy volunteers: EH patients showed an increased heart rate at rest, but only in the standing position (94 +/- 18.5 vs 78 +/- 10.9 bpm, P < 0.01), as well as an increased ratio of low to high frequency power of the heart rate variability in the standing position (5.92 +/- 4.4 vs 2.8 +/- 2.5, P < 0.05). Exercise tests were normal in every EH patient. After sympathiocolysis, heart rate at rest (sitting on the cycloergometer) had decreased (75.4 +/- 13 vs 90.4 +/- 16.5 bpm, P < 0.05), as well as heart rate at maximal exercise (165.2 +/- 14.8 vs 180 +/- 10 bpm, P < 0.05). Exercise capacity and the cardiorespiratory responses to exercise were, however, unchanged after sympathicolysis. Resting heart rate in the lying (66 +/- 10 vs 76 +/- 15 bpm, P < 0.05) and standing positions (82 +/- 13.8 vs 94 +/- 18.5 bpm, P < 0.05), and the diastolic blood pressure reaction to a handgrip test (73.6 +/- 8.6 vs 84.7 +/- 11.6 mmHg, P < 0.05) were also lowered after sympathicolysis. In conclusion, patients with EH show an overfunctioning of the sympathetic system which is characterised by an increased reaction to stress (standing, exercise), whereas resting sympathetic tone is unaffected. Thoracoscopic D2-D3 sympathicolysis corrects this hyperfunction and has a partial beta-blocker-like activity, which results in a decrease in heart rate at rest and during maximal exercise, and in the diastolic blood pressure response to the handgrip test. Further studies are needed to assess the long-term consequences of this procedure.
Adolescent↗
Second primary lung cancer in Flanders: frequency, clinical presentation, treatment and prognosis.
Patient and tumour characteristics of 23 patients presenting with a second primary lung cancer were analysed and compared with 534 patients with radically resected stage 1 non-small cell lung cancer (NSCLC). None of these characteristics is associated with a higher occurrence rate for second primary lung cancer. Prognosis in the latter patients is significantly worse than after resection of a 'solitary' NSCLC: the median survival time (MST) after resection of the first tumour is 50 months; after diagnosis of the second tumour only 14 months. Surgically retreated patients have a prognosis that is similar to that after resection of a 'solitary' NSCLC. No separate independent prognostic factors responsible for this survival difference could be isolated. Squamous histology and central location are associated with a longer recurrence free survival time. We conclude that the occurrence of a second primary lung cancer can not be predicted based on patient or tumour characteristics and that only surgical retreatment offers a chance of long survival in these patients.
Adult↗
Total intravenous anesthesia and high-frequency jet ventilation during transthoracic endoscopic sympathectomy for treatment of essential hyperhidrosis palmaris: a new approach.
OBJECTIVE: To evaluate the effects of high-frequency jet ventilation (HFJV) applied to both lungs on hemodynamic parameters, oxygenation, and operating conditions during bilateral videothoracoscopic sympathectomy. DESIGN: A prospective, unblinded study. SETTING: An ambulatory surgical unit at a university medical center. PARTICIPANTS: 30 patients (11 men, 19 women), ASA status 1. INTERVENTION: Bilateral videothoracoscopic sympathectomies were performed using total intravenous anesthesia with propofol, alfentanil, and atracurium, and the patients were ventilated with an oxygen-air mixture using HFJV delivered to both lungs with a Hi-Lo Jet tracheal tube (Mallinckrodt). MEASUREMENTS AND MAIN RESULTS: Mean total anesthesia time was 55 +/- 13 minutes. Hemodynamic parameters remained stable during surgery, although ablation of the sympathetic ganglia induced three incidences of bradycardia (10% of the patients), which were responsive to atropine. Four patients developed oxygen desaturation (Sa O2 < 90%) after the creation of the pneumothorax. Surgical conditions were considered excellent by the surgeons. Concerning postoperative complications, a temporary Horner's syndrome was observed in one patient. Another patient had a mild residual pneumothorax on the first postoperative day that resolved without insertion of a chest tube. CONCLUSIONS: It was concluded that HFJV applied to both lungs is an easy and safe anesthetic technique that provides excellent surgical conditions and causes a minor incidence of morbidity.
Adolescent↗
Thoracoscopic sympathicolysis for essential hyperhidrosis: immediate and one year follow-up results in 35 patients and review of the literature.
Various treatments for essential hyperhidrosis are available. The aim of this study is to present our experience with a simplified thoracoscopic sympathicolysis technique in this disorder, and to confront our results with data in the literature, 35 consecutive patients (11 male, 24 female, age 12-44 years) with essential hyperhidrosis, refractory to "conventional" medical treatment presenting between August 1993 and May 1994 were studied. Bilateral D2-D3 sympathicolysis was performed using a simplified one-time bilateral thoracoscopic procedure under general anaesthesia. Clinical scores, complications and side effects were recorded one week, one month and one year after the intervention. Severe hyperhidrosis was present in the hands in 100%, axillae in 66% and soles of the feet in 86% of patients. In one patient, only a unilateral intervention was possible due to pleural adhesions. In the other 34 patients, palmar hyperhidrosis was completely and permanently relieved in 100% of cases. Axillar hyperhidrosis was significantly improved after one year in 91% of patients, 52% of which showed a complete disappearance of hyperhidrosis. Side effects and complications were minimal. There were no permanent pleural, neurological (Horner) or other sequellae. Patient satisfaction was invariably very high. These findings compare favourably with historical data in the literature.
Adolescent↗
A simplified T2-T3 thoracoscopic sympathicolysis technique for the treatment of essential hyperhidrosis: short-term results in 100 patients.
A simplified one-time bilateral thoracoscopic T2-T3 sympathicolysis technique using single-lumen endotracheal intubation with high frequency jet ventilation and electrocautery destruction ("sympathicolysis") of the sympathetic ganglia was applied in 100 consecutive patients with severe essential hyperhidrosis (EH). Providing a pleural space can be created, this technique was proven simple and safe, and short-term clinical results were excellent: palmar hyperhidrosis was cured in 98% of patients, and axillar and plantar improvement was achieved in 62 and 65% of patients, respectively. Side-effects and complications were minor (compensatory hyperhidrosis) or self-limiting (pain). These data confirm the safety and efficacy of thoracoscopic sympathetic interventions for the treatment of EH, and support the evolution toward simplified methodologies.
Adolescent↗
Broncho-mediastinal fistula following perforation of the oesophagus.
We present a 63-year old female with mediastinitis following an esophageal perforation, possibly favoured by an oesophageal motility-disorder and the use of non-steroidal anti-inflammatory drugs, who developed a broncho-mediastinal fistula in the left main bronchus. She was successfully treated with intravenous antibiotics, a cervical oesophagostomy and secondary isoperistaltic coloplasty.
Anti-Bacterial Agents↗
Thoracoscopic sympathicolysis for essential hyperhidrosis: effects on pulmonary function.
Bilateral interruption of the upper dorsal sympathetic chain at the D2 and D3 level represents the only permanent cure for essential hyperhidrosis. Following surgical sympathectomy, significant and symptomatic changes in pulmonary function have been observed. Since functional effects of the surgical intervention cannot be excluded, we wondered whether such alterations also occurred after thoracoscopic sympathicolysis; these should then be attributable to the surgical denervation itself. Pulmonary function tests (PFTs), including spirometry and body plethysmographic measurement of lung volumes and airway resistance and conductance, were compared before and 6 weeks after thoracoscopic sympathicolysis in 47 patients. In order to virtually exclude any effects of thoracoscopy on the test results PFTs were repeated 6 months after thoracoscopic sympathicolysis in 35 patients. Essential hyperhidrosis was completely relieved in all patients, thereby confirming the interruption of the D2-D3 sympathetic chain. None of the patients developed respiratory symptoms after thoracoscopic sympathicolysis. Forced expiratory volume in one second (FEV1) (-3%), forced expiratory flow after exhaling 75% of vital capacity (FEF75) (-8%) and total lung capacity (TLC) (-3%) were slightly but significantly reduced at six weeks after thoracoscopic sympathicolysis; whereas airway resistance (Raw) had increased (+12%). After correction for the small decrease in lung volume (FEV1/forced vital capacity (FVC), specific airway resistance (sRaw), specific airway conductance (sGaw))significant changes in "volume-dependent" PFT parameters were no longer observed. Smoking status had no influence on the reduction in FEF75. At 6 months after thoracoscopic sympathicolysis, TLC had returned to preoperative values, whereas FEF75 remained decreased (-8.6%). The decrease in airway calibre was confirmed by small but significant changes in FEV1/FVC (-2%) and Raw (+29%). We conclude that thoracoscopic sympathicolysis in patients with essential hyperhidrosis causes only minimal and subclinical changes in pulmonary function secondary to a temporary small decrease in lung volume, which in turn is probably inherent to the thoracoscopic procedure. D2-D3 sympathicolysis, in itself, is responsible only for a small and permanent decrease in forced expiratory flow, which suggests that, at least in essential hyperhidrosis patients, airway bronchomotor tone is influenced by sympathetic innervation.
Adolescent↗