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PubMed1999

Thoracoscopic surgery for pulmonary tuberculosis.

Tuberculosis historically was a major impetus for the development of thoracic surgery, and it remains a serious health problem of global proportion. Thoracoscopy was first introduced at the turn of this century for closed chest adhesiolysis as an adjunct to collapse therapy for treatment of tuberculosis. This indication became obsolete with the discovery of streptomycin during the 1940s; and for a long time since then thoracoscopy was used only sporadically for the diagnosis of pleural disease. However, over the last few years, modern video-assisted thoracoscopic surgery (VATS) has provided a new approach to the management of pulmonary tuberculosis. Over the last 5 years we have used VATS for diagnosis or treatment (or both) of 62 patients with pulmonary tuberculosis, including 20 pleural biopsies, 8 decortications, 17 wedge lung resections, 8 drainages of empyema, and 9 lobectomies. There was no surgical mortality, and complications were few. We conclude that VATS provides a safe, effective diagnostic modality (pleural biopsy, wedge resections) and therapeutic modality (decortications, drainage of empyema) for selected patients with pulmonary tuberculosis.

Adolescent↗
PubMed1994

A thoracoscopic peek: what did Jacobaeus see?

More than 80 years ago, Jacobaeus inserted a cystoscope into the pleural space of patients with pleural diseases to visually examine the pathology. Subsequently, he courageously inserted a galvanocautery instrument into the pleural space through a separate entry site to divide adhesions between the lung and chest wall under direct vision. This was done to establish therapeutic pneumothorax for patients with pulmonary tuberculosis. The discovery of effective antituberculosis chemotherapy eliminated the need for lung collapse therapy, and thoracoscopy was discarded as no longer useful. Today, the enthusiasm for thoracoscopic surgical intervention, both diagnostic and therapeutic, is a result of applied technologic innovations. Rediscovery of thoracoscopy is exciting and expands the vision for both diagnostic and therapeutic applications predicted by Jacobaeus.

History, 19th Century↗
PubMed1985

The modern use of thoracoplasty.

Thoracoplasty is a time-honored but, at present, rarely indicated procedure for reducing thoracic cavity volume. This study reviews a series of 30 patients treated with thoracoplasty over a 14-year period (1970 through 1983). Indications were to close a persistent pleural space in 28 patients and to tailor the thoracic cavity to accept diminished lung volume concomitant with a pulmonary resection in 2 patients. Persistent pleural space, often associated with a bronchopleural fistula (24 patients), occurred after operation in 19 patients: following pulmonary resection in 17 patients, resection of mesothelioma in 1 patient, and following decortication without resection in 1. In the remaining 9 patients with a persistent pleural space, problems developed from primary lung destruction due to tuberculosis (4 patients), postpneumonic empyema (1 patient), or as late infection of a residual pleural space many years after therapeutic pneumothorax and collapse therapy for tuberculosis (4 patients). The overall success rate of thoracoplasty in eliminating intrathoracic space problems was 73%. There were 3 deaths (10%) and 5 failures to heal, representing a 33% failure in the first half of the series (to 1976) and a 17% failure rate thereafter (1 death and 1 nonhealing patient). The primary underlying disease was tuberculosis in 23 patients, 8 of whom had concomitant aspergilloma and 1, atypical tuberculosis. The failures were analyzed and reviewed to clarify the principles for the successful use of thoracoplasty. It is concluded that thoracoplasty is a rarely required salvage-type procedure applicable to moderately debilitated patients in whom it is considered desirable to eliminate open drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

Long-term complications of extraperiosteal plombage.

BACKGROUND: As soon as complications due to migration of extraperiosteal plombage material had been documented, early removal became the rule. Some patients who have escaped this rule may still present with long-term complications. METHODS: Since 1980, 14 patients aged 54 +/- 10 years were admitted 28 +/- 11 years after collapse therapy. Eight presented with signs of infection, 4 with hemoptysis, and 2 with periscapular pain. Vascular erosion, suspected in 3 patients, was demonstrated with angiograms in 1. RESULTS: Ablation of the material was combined with excision of the devitalized ribs in 13 patients. Femorofemoral bypass was used in 2 patients for repair of an aortic erosion. Single ablation of subcutaneously migrated material was performed in a poor-risk patient. Operative bleeding was moderate except in 2 patients; 1 of them died intraoperatively during repair of an aortic erosion. A second patient died postoperatively with a massive pulmonary embolus on day 11. Infection was diagnosed in 8 patients (Mycobacterium tuberculosis, 4; and pyogens, 4). Operative outcome was satisfactory in all 12 operative survivors. A single patient presented with an infected apical space at 1 year and underwent complementary resection of the first rib. CONCLUSIONS: We recommend routine ablation of any residual plombage material whenever operative risk is acceptable because of the high incidence of spontaneous complications.

Adult↗
PubMed2002

Role of Eloesser flap and thoracoplasty in the third millennium.

In the modern era of thoracic surgery, few indications remain for thoracoplasty. Indeed, many surgeons believe that the resulting deformity outweighs the usefulness of collapse therapy. Rather than trying to obliterate chronic spaces, these surgeons advocate myoplasty techniques to fill the space. Unfortunately, these techniques are not minor procedures and two to three operations are often necessary to solve the problem. This is the reason why thoracoplasty remains the best option in selected patients. In some cases, it should be a first-line procedure rather than as a last resort when everything else has failed. In their discussion of the article by Horrigan and Snow [31], Pairolero and Trastek [44] summarized well the current attitudes toward these different concepts: "Although management of the chronically infected pleural space has changed over the years, the goals of therapy remain the same to conserve the patient's life with a healed chest wall without evidence of infection. Determination of which techniques are necessary to achieve these goals must be tailored to the individual patients."

Bandages↗
PubMed1999

Thoracoscopic procedures for intrathoracic and pulmonary diseases.

Since Jacobaeus performed the first thoracoscopy to explore pleural space and mechanically broke pleural adhesions to facilitate the collapse therapy for pulmonary tuberculosis in 1910, numerous thoracic surgeons have been attempting this technique as a means of accomplishing many intrathoracic procedures previously done through open thoracotomy. As the refinement of video technology has advanced, thoracoscopic surgery has played a very important role in thoracic surgery especially since the early 1990s. Because the advantages of video-assisted thoracoscopic surgery for patients include low post-thoracotomy-related morbidity, cosmetic considerations, low pain, earlier post-operative mobilization, and a shorter operation time in some indications, surgeons have been demonstrating its increasing utility in the diagnosis and treatment of the pleura, lung, mediastinum, great vessels, pericardium, and oesophagus. The most common application of the thoracoscopic approach still remains in the management of pleuropulmonary disease. The indications for the thoracoscopic technique are very broad, but its role in the management of primary lung and oesophageal cancer has yet to be confirmed. Thus, the surgeon who uses the technique in these cancerous diseases should be prudent. In conclusion, these thoracoscopic procedures will play more important roles in the practice of thoracic surgery in the future.

Humans↗
PubMed2004

Speed of initial atropinisation in significant organophosphorus pesticide poisoning--a systematic comparison of recommended regimens.

OBJECTIVE: Early deaths from organophosphorus (OP) pesticide self-poisoning result from respiratory failure and cardiovascular collapse. Therapy requires the urgent use of atropine to reverse cholinergic excess, thereby improving respiratory function, heart rate, and blood pressure. We aimed to assess variation in textbook recommendations for early atropinisation and to see whether this variation affected time to stabilisation using model data from 22 severely poisoned patients seen in a Sri Lankan clinical trial. METHODS: We extracted prospectively recorded data on atropine requirements for 22 OP poisoned patients who required intubation but survived to discharge. We did a systematic search for textbook recommendations for initial atropinisation regimens. These regimens were then applied to data from the Sri Lankan patients. RESULTS: The patients required a mean of 23.4 mg (standard deviation 22.0, range 1-75 mg) atropine to clear the lungs, raise the pulse above 80 bpm, and restore systolic blood pressure to more than 80 mmHg. Textbook recommendations varied markedly--atropinisation of an average patient, requiring the mean dose of 23.4 mg, would have taken 8 to 1380 mins; atropinisation of a very ill patient, requiring 75 mg, would have taken 25 to 4440 mins. Atropinisation was attained most rapidly with a regimen of increasing bolus doses after failure to respond to the previous bolus. CONCLUSIONS: There is great variation in recommendations for atropinisation, with some regimens taking hours and even days to stabilise a patient. The guidelines are very flexible--possibly appropriate for experienced emergency physicians or clinical toxicologists, but completely inappropriate for the inexperienced junior doctors who see most cases worldwide. We recommend that a consensus guideline be developed by appropriate organisations to bring order to this important part of OP therapy, while acknowledging the paucity of data to drive the guidelines.

Atropine↗
PubMed2005

Tuberculosis, bronchiectasis, and infertility: what ailed George Orwell?

In the last and most productive years of his life, George Orwell struggled with pulmonary tuberculosis, dying at the dawn of the era of chemotherapy. His case history illustrates clinical aspects of tuberculosis with contemporary relevance: the role of poverty in its spread, the limited efficacy of monotherapy, the potential toxicity of treatment, and the prominence of cachexia as a terminal symptom. Orwell's ordeals with collapse therapy may have influenced the portrayal of the tortures of Winston Smith in the novel 1984. I discuss unifying diagnoses for Orwell's respiratory problems and apparent infertility, including tuberculous epididymitis, Young syndrome, immotile cilia syndrome, and cystic fibrosis.

Antitubercular Agents↗
PubMed1993

Ten-year experience with artificial pneumoperitoneum for end-stage, drug-resistant pulmonary tuberculosis.

Artificial pneumoperitoneum is a form of collapse therapy that was used in the treatment of cavitary pulmonary tuberculosis before the availability of antimycobacterial chemotherapy. We report a series of cases of far-advanced pulmonary disease due to multiple-drug-resistant Mycobacterium tuberculosis, wherein artificial pneumoperitoneum with or without subsequent surgical extirpation was used as an adjunct to chemotherapy. Overall, among these desperate cases, therapeutic pneumoperitoneum provided no clear benefit.

Adult↗
PubMed1999

Pseudochylothorax. Report of 2 cases and review of the literature.

We report 2 cases of pseudochylothorax and review 172 published cases. Tuberculosis is by far the most frequent cause of pseudochylothorax, accounting for 54% of all caes, with a remarkable association with previous collapse therapy and long-term effusions. The remaining etiologies, including rheumatoid arthritis, are infrequent. Tuberculous pseudochylothorax is usually sterile. Successful treatment of an acute tuberculous pleurisy does not preclude the development of long-term complications such as pseudochylothorax. We do not recommend pleural biopsy initially because of its low yield for etiologic diagnosis. Currently, adenosine deaminase (ADA) values in pleural fluid are not useful to sustain diagnosis or therapeutic decisions. We advise draining only symptomatic cases and treating patients with positive Ziehl-Neelsen stain or Lowenstein culture, and those with growing effusions of suspected tuberculous origin, with antituberculous chemotherapy. Pulmonary decortication should be the last therapeutic step for recurrent and symptomatic cases.

Adult↗
PubMed2006

Epithelioid angiosarcoma of the lung: a rare late complication of Lucite plombage.

Epithelioid angiosarcoma of the lung is a rare late complication of Lucite plombage treatment of pulmonary tuberculosis. We describe the clinical, radiological and pathologic findings of a case of epithelioid angiosarcoma of the lung presenting with persistent haemoptysis who had undergone remote lung collapse therapy with Lucite plombage.

Aged↗
PubMed1995

Surgical treatment of complications 45 years after extraperiosteal pneumonolysis and plombage using acrylic resin balls for cavitary pulmonary tuberculosis.

An infected axillary sinus tract discharged balls made of an acrylic resin consisting essentially of polymerized methyl methacrylate (Lucite) 45 years following performance of an extraperiosteal pneumonolysis and Lucite ball plombage for collapse therapy of right upper lobe cavitary tuberculosis. Surgical extraction of the balls was performed, followed by a partial decortication of the lung and intrathoracic transposition of a pectoralis major muscle flap to fill the residual pleural space. Primary healing was attained, and the patient is well 1 1/2 years after surgery.

Axilla↗