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PubMed2000

Surgical management of pulmonary aspergilloma. Role of single-stage cavernostomy with muscle transposition.

OBJECTIVE: We reviewed the outcome of the patients with aspergilloma who were treated surgically. METHODS: Between July 1991 and October 1996, 11 patients with pulmonary aspergilloma underwent surgery. One underwent sequential bilateral tboracotomy and two underwent re-operation. The total number of operations was 14. Surgical procedures consisted of 5 cavernostomies with muscle transposition, 3 cavernostomies with muscle transposition and thoracoplasty, 1 lobectomy 1 pneumonectomy, 1 segmentectomy and 3 partial resections. RESULTS: Morbidity and mortality rates were 28.6% and 7.1%, respectively Two patients who underwent cavernostomy and muscle transposition experienced a relapse of aspergilloma 19 and 29 months after the operation, respectively, but both successfully underwent re-operation, including cavernostomy. Both are free of symptoms 28 and 30 months after re-operation, respectively. All survivors except for one who died of multiple organ failure remain free of symptoms 14 to 60 months after the most recent operation. CONCLUSION: Our experience was not a controlled trial and two relapsed cases had undergone cavernostomy, our series may suggest that single-stage cavernostomy with muscle transposition is a viable surgical option for patients with pulmonary aspergilloma.

Aged↗
PubMed1997

Modern morbidity following pulmonary resection for postprimary tuberculosis.

Between January 1991 and March 1996, a total of 28 patients with postprimary tuberculosis underwent resection for disease progression (n = 8), multidrug resistance or noncompliance to the medical treatment (n = 11), parenchymal sequelae (n = 3), suspected cancer (n = 5), and for the correction of postpneumonectomy bronchopleural fistula and empyema (n = 1). On admission, eight patients presented with sputum positivity (28.6%). Similar to previous series, tubercular predilection for upper lobes was confirmed (21/28, 75%); accordingly, upper lobectomy through an extrapleural approach was the most common procedure (16/28, 57.1%). Atypical segmental resections or segmentectomies were performed in seven patients (25%), whereas a bilobectomy was necessary in another three patients (10.7%) and a completion pneumonectomy in one (3.6%). Additional procedures were an open-window thoracostomy with transpericardial closure of the main bronchus and a tailored thoracoplasty. No operative mortality was reported. Healing was achieved in 26 patients (93%). Bleeding, either from the chest wall or hilar dissection, was the only reported intraoperative complication. Median blood loss, inclusive of early postoperative collections from chest tubes, reached 1330 ml (range 100-3700 ml). Major postoperative complications included recurrent disease (2/28, 7%) in sputum-positive patients and segmental pulmonary embolism (3.5%). Causes of minor morbidity were air leaks resulting in residual space undergoing spontaneous resolution (18%), wound breakdown (14%), and, fever (11%). This limited series confirms the therapeutic value of the surgical treatment of postprimary tuberculosis, provided that correct indications, adequate pre- and post-operative medical coverage, and meticulous technique are applied.

Adolescent↗
PubMed2000

Surgical treatment for chronic pleural empyema.

Various surgical procedures have been developed in an attempt to alleviate the significant problems caused by chronic pleural empyema. The present study evaluates our 11-year experience of employing a number of therapeutic approaches for chronic empyema. Between 1987 and 1997, 45 consecutive patients underwent treatment for chronic empyema at our hospitals. They comprised 21 patients (47%) presenting with post-tuberculosis, 11 (24%) receiving cancer therapy including pulmonary resection, and 13 (29%) with postpneumonic empyema. Omentopexy, lung resection, and thoracoscopic surgery were performed in 10 (22%), 5 (11%), and 4 (9%) patients, respectively. Poor results of treatment were observed in two of the patients with post-tuberculous empyema, and three of the patients treated for cancer died of recurrence. The other 40 patients remain symptom-free. An improvement in quality of postoperative life was revealed by the exercise test rather than by static spirometry. Optimal therapy for chronic empyema requires selection of the most appropriate first and staged procedures for each patient. Moreover, lung resection should be minimal. In a critical state, open thoracostomy must be performed as the first procedure, while omentopexy or thoracoplasty should be restricted to selected cases. Dead space and minor air leakage may safely be left behind. A video-assisted procedure can be selected for postpneumonia empyema.

Adult↗
PubMed1990

Giant chest wall tumor resulting from tissue reaction to foreign bodies.

Three patients are reported in whom chest wall tumors developed 19 to 28 years after thoracoplasty and increased in size with time. The tumors could be removed operatively with good results. All tumors were composed of hematoma and necrotic material, and in all cases they revealed foreign bodies microscopically. Diagnosis and possible etiological factors are discussed.

Female↗
PubMed1995

Current role of surgery in Mycobacterium tuberculosis.

From January 1986 through December 1993, we operated on 59 patients with documented Mycobacterium tuberculosis infection. Indications for operation were as follows: multidrug-resistant tuberculosis (MDRTB) in 19 patients; bronchopleural fistula secondary to Mycobacterium tuberculosis infection in 12; massive hemoptysis in 5; destroyed lung in 7; solitary nodule in 7; trapped lung in 3; complicated cavity in 4; and empyema in 2. Sixty-five operative procedures were performed: pneumonectomy with latissimus muscle flap in 15 patients; pneumonectomy in 3; lobectomy in 16; segmental or wedge resection in 11; decortication in 5; window thoracostomy in 3; thoracoplasty with myoplasty in 4; tube thoracostomy in 4; return to operating room for bleeding in 2; Clagett procedure in 1; and drainage of a cold abscess in 1. There were no operative deaths. Major postoperative complications occurred in 5 patients. The two late deaths were in patients with MDRTB: 1 with progressive disease and massive hemoptysis and the other with a relapse of MDRTB. Of the patients operated on as part of their therapeutic regimen for MDRTB, 17 (89%) of 19 have remained culture negative. We conclude that (1) surgery still plays an important role in the management of patients with Mycobacterium tuberculosis infection; (2) surgical intervention can be performed with acceptable mortality and morbidity; (3) a variety of procedures are needed to effect cure; and (4) encouraging results in patients with MDRTB support surgical therapy in this difficult group of patients.

Adolescent↗
PubMed1992

Open-window thoracostomy in pleural empyema.

Open-window thoracostomy (OWT) was performed in 21 cases of empyema. The indications were postpneumonectomy empyema with (n = 6) or without (n = 1) fistula, early recurrent empyema after decortication (n = 6), chronical empyema in ill elderly patients with (n = 5) or without fistula (n = 2), and total unilateral lung gangrene with a large fistula of the main bronchus after radiotherapy and chemotherapy (n = 1). All cases presented with severe sepsis, eight of them with acute septic shock, and six with signs of multiorgan failure. Three to five ribs were resected, the muscles and skin were sutured to the ribs confining the window located at the lowest point of the empyema cavity, while the intercostal muscles of the resected ribs were used to close fistulae. The cavity was packed with dressings every day. In all cases, the sepsis subsided immediately after OWT. With the exception of one patient with postpneumonectomy empyema, who died of contralateral pneumonia on day 36, no surgery-related complications were seen. Four further patients died of unrelated causes 2, 4, 5, and 7 months, respectively, after OWT. In one of them, the OWT had been closed. Up to this time, obliteration and closure of the cavity has been carried out in 7 cases by using thoracoplasty (n = 2) or predicted muscle flaps (n = 5) either in the early course or after a delay of 11 to 23 months, with fair functional and cosmetic results. In one further case, operative closure has been planned. In seven of the eight remaining patients, four of whom declined further operations, the cavities closed spontaneously, despite their initial size after intervals of between 11 and 21 months.

Adult↗
PubMed2006

Noninvasive positive pressure ventilation prevents postoperative pulmonary complications in chronic ventilators users.

OBJECTIVE: To evaluate the postoperative pulmonary complications and the long-term impact on pulmonary function of different surgical procedures with general anaesthesia in chronic respiratory failure (CRF) patients who were using noninvasive positive pressure ventilation (NPPV). DESIGN: We retrospectively studied 20 stable patients on NPPV for CRF secondary to: kyphoscoliosis (eight), morbid obesity (six), thoracoplasty (four), neuromuscular diseases (two), who underwent surgical procedures with general anaesthesia, between January 1998 and December 2003. MATERIAL AND METHODS: The variables studied were: type of surgery, hours of orotracheal intubation, hours of stay in the postsurgical reanimation unit (PRU), postoperative pulmonary complications and days of hospital stay. These results were compared with those obtained in patients without respiratory pathology and who were submitted to the same type of surgical interventions during the study period. All patients were tested for: arterial blood gases, forced vital capacity (FVC) and forced expiratory volume in 1s (FVE1). These tests were carried out both prior to surgical intervention and 12 months after this intervention, and the use of medical assistance resources the year prior to and the year after the surgical intervention were also analysed. RESULTS: Sixteen patients were using NPPV at home at the time of the intervention and four patients were adapted to NPPV before surgery. The surgical procedures were: gastroplasty: six; mastectomy: five; septoplasty: three; hip prosthesis: two; cholecystectomy: one; Gasserian ganglion thermocoagulation: one; hysterectomy: one; and endoscopic retrograde cholangiopancreatography (ERCP): one. The mean postoperative intubation time was 3.8+/-3.2h, and only one patient remained intubated for more than 12h. The mean stay in the PRU was 19+/-9h (vs 19+/-6h in the general population, p>0.05). The days of hospital stay for the different pathologies were in the majority of cases greater than in the general population. We did not find significant differences on comparing the arterial blood gases, in pulmonary function or in use of assistance resources between the year previous to and the year following the surgical intervention. CONCLUSIONS: In high-risk patients with chronic respiratory failure as a consequence of a restrictive lung pathology, NPPV can play an important role to confront surgical procedure with general anaesthesia with greater security. To obtain these results, it was fundamental to coordinate between the Pulmonary Services and the Anaesthesia Services as well as to follow up jointly in the PRU.

Anesthesia, General↗
PubMed2006

Chest wall/diaphragmatic complications.

This article discusses the prevention and management of chest wall and diaphragmatic complications after extrapleural pneumonectomy, the prevention of thoracoplasty scoliosis, the complications after chest wall resection, and the presentation, prevention, and management of chest wall hernia. Appropriate preoperative assessment and patient selection, meticulous attention to detail intraoperatively, and diligent postoperative observation and care are needed to prevent these events.

Flail Chest↗
PubMed2002

Simultaneous bronchopleural and esophagopleural fistulas after pneumonectomy.

The simultaneous occurrence of bronchopleural fistula (BPF) and esophagopleural fistula (EPF) after pneumonectomy is very rare. We describe a 60-year-old man who developed empyema associated with bronchopleural fistula as a complication of a right pneumonectomy. Initial chest tube drainage and antibiotic therapy were ineffective. Five months later ingested food particles appeared in the drainage fluid. Esophagoscopy revealed an esophageal fistula of 10 mm in diameter. After nutritional support by feeding jejunostomy both BPF and EPF were repaired by subscapular muscle myoplasty and extensive thoracoplasty through a right thoracotomy. Endoscopic examination performed 1 month after surgery showed complete closure of both fistulas and 9 months after surgery the patient was eating and gaining weight. The patient's death was due to aspiration pneumonia of another origin.

Adenocarcinoma↗
PubMed1996

Paraffin plombage of the chest revisited.

Complications related to previous thoracic plombage procedures are not uncommon. The management of these complication can be challenging. We present a patient who had a partial resection of the left upper lobe, a seven-rib thoracoplasty, and paraffin wax plombage 38 years previously, in whom a chest wall mass and a discharging sinus developed. She underwent excision and debridement of the paraffin wax mass followed by serratus anterior and latissimus dorsi pedicled muscle intrathoracic transposition. Follow-up at 2 years revealed excellent cosmetic and functional results.

Aged↗
PubMed1996

Late empyema after lobectomy for echinococcal disease of the lung.

The case of a 57-year-old man who had previously undergone left lobectomy for echinococcal disease of the lung is described. Sixteen years later he presented with empyema and bronchopleural fistula, which were treated using a pedicled intercostal muscle bundle, an omental pedicle and partial thoracoplasty. The patient recovered and is well 6 years later.

Bronchial Fistula↗
PubMedDate not supplied

[New treatment concept for children with thoracic insufficiency syndrome due to congenital spine deformity].

BACKGROUND: Children with congenital thoracic scoliosis associated with fused ribs and unilateral unsegmented bars adjacent to convex hemivertebrae will inevitably develop thoracic insufficiency syndrome and curve progression with hemithorax compression without treatment. It is assumed that the concave side of such curves and their unilateral unsegmented bars do not grow. In the past early spinal fusion was performed with consecutive short thoracic spines and loss of lung volume. Little attention has been paid to lung function. These patients often suffered from lung failure and early death due to a small thorax. METHOD: A new surgical technique is based on an indirect deformity correction and enlargement of the thorax due to a longitudinal implant, the vertical expandable prosthetic titanium rib (VEPTR). The spine is not fused, thus promoting growth of the spine, the thorax and the lungs. Elongation of the implant is done every six months. Since 2002 this method has been performed on fifteen children in Basel as the first European center. RESULTS: Patients (mean age 6 years; 11 months to 12 years) were suffering from thoracic insufficiency syndrome due to unilateral unsegmented bars with fused ribs (n = 4), absent ribs (n = 2), bilaterally fused ribs (n = 2), hemivertebrae (n = 3) or neuromuscular scoliosis (n = 6). Doing fifteen primarily implantations and thirteen elongations there were three complications (two hook dislocations, one skin breakage). All patients improved cosmetically, functionally and radiologically which was shown on X-rays as a reduction of the Cobb angle from an average of 76 degrees (40-110 degrees ) to 55 degrees (30-67 degrees ). CONCLUSIONS: Expansion thoracoplasty and VEPTR implantation is a new treatment concept for children with thoracic insufficiency syndrome due to spinal deformities, which is based on distraction and expansion of the thorax thus allowing growth of the spine, the thorax and probably lungs. Presently it seems to be superior to any other method for the treatment of small children with progressive scoliosis and thoracic insufficiency syndrome.

Age Factors↗
PubMed2000

A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis.

STUDY DESIGN: A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis undergoing surgical correction. OBJECTIVES: 1) To evaluate prospectively, at regular intervals, the changes in pulmonary function after surgical arthrodesis of primary thoracic and double primary thoracic-lumbar (double major) types of adolescent idiopathic scoliosis in a homogeneous population; 2) to compare the changes in pulmonary function after surgical correction relative to the surgical approach used for spinal arthrodesis; and 3) to determine if short- to midterm morbidity with respect to pulmonary function is associated with the type of surgical approach used for spinal arthrodesis. SUMMARY OF BACKGROUND DATA: The effect of surgical correction on the pulmonary function of patients with adolescent idiopathic scoliosis is controversial. Studies have shown improvement, decline, or no change in pulmonary function after surgical correction of idiopathic scoliosis. METHODS: Ninety-eight patients with adolescent idiopathic scoliosis undergoing surgical treatment at the authors' institution were prospectively evaluated with pulmonary function tests assessing volume (forced vital capacity and total lung capacity) and flow (forced expiratory volume in 1 second). Pulmonary functions were evaluated before surgery and after surgery at 3 months, 1 year, 2 years, and at the final follow-up visit. All patients were divided into four groups depending on the surgical approach used for spinal fusion: Group 1 (n = 47) underwent a posterior spinal fusion with iliac crest bone graft; Group 2 (n = 33) underwent a posterior spinal fusion with rib resection thoracoplasty; Group 3 (n = 7) underwent an anterior spinal fusion with a rib resection thoracotomy; and Group 4 (n = 11) underwent a combined anterior and posterior spinal fusion with autogenous rib and iliac crest graft used, respectively. RESULTS: Patients in Group 1 had improved pulmonary function values at 3 months after surgery, whereas patients in Groups 2, 3, and 4 showed a decline at 3 months after surgery. Two years after surgery, Group 1 had significantly improved pulmonary function values (P < 0.0001), whereas the pulmonary function values of patients in Groups 2, 3, and 4 had returned to preoperative values. CONCLUSIONS: 1) Patients with chest cage disruption during surgical treatment showed a decline in pulmonary function at 3 months after surgery. 2) In contrast, patients without chest cage disruption showed an improvement in pulmonary function at 3 months after surgery. 3) Irrespective of the surgical approach used for spinal arthrodesis, postoperative pulmonary function tests (absolute values) returned to preoperative values at 2 years after surgery. 4) Patients who had no chest cage disruption experienced a significantly greater improvement in two of their pulmonary function values at 2 years after surgery than patients with chest cage disruption.

Adolescent↗
PubMed2003

Ventilator weaning after staged anteroposterior spine fusion in a ventilator-dependent patient with congenital scoliosis: a case report.

STUDY DESIGN: Ventilator weaning after staged revision anteroposterior spine fusion in a ventilator-dependent child with congenital scoliosis is reported. OBJECTIVE: To describe the improvement of pulmonary performance after deformity correction in a patient with severe deformity and severe restrictive lung disease. SUMMARY OF BACKGROUND DATA: The effect of scoliotic deformity correction on postoperative pulmonary function is debatable. Recent prospective studies suggest that corrective surgery, especially that involving violation of the chest cage, adversely affect pulmonary function in patients with adolescent idiopathic scoliosis. For patients with severe deformity and severely compromised preoperative pulmonary function, the effect of deformity correction has not been well studied. METHODS: A 15-year-old ventilator-dependent girl with progressive congenital thoracic scoliosis of 130 degrees and a forced vital capacity of 18% underwent staged revision anteroposterior spine fusion. Anterior release, multiple vertebral osteotomies, apical vertebrectomy, and multiple internal thoracoplasties were performed. Five weeks later, when she was medically stable, she underwent posterior reconstruction with multiple vertebral osteotomies, apical vertebrectomy, and translation and cantilever corrective techniques using Isola instrumentation. RESULTS: The patient's pulmonary function was stable 6 months after surgery, and her forced vital capacity was 19%. Currently, 1 year after surgery, she has been weaned to night-only ventilation. Her walking ability has improved. Her spine is well balanced with a thoracic scoliosis of 40 degrees, and she is neurologically intact. CONCLUSIONS: Surgical correction of a severe thoracic spinal deformity in the setting of severe restrictive lung disease can be performed successfully with stabilization of pulmonary volumes and improvement in pulmonary performance.

Abnormalities, Multiple↗
PubMed1981

Comparison between irrigation and conventional treatment for empyema and pneumonectomy space infection.

A new method of treating pleural empyema or pneumonectomy space infection by irrigation was evaluated in 11 patients. The infected cavities were filled with an antibiotic or antiseptic solution for three hours, and allowed to drain for one hour. This cycle was repeated every four hours for seven to 10 days. When cultures of the infected cavity became sterile the irrigation tube was removed and the wound sealed. Using this method, infection was eradicated after an average of 11 days in five of six patients with pleural empyema and in all five patients treated for an infected pneumonectomy space, including one with a bronchopleural fistula. The results of treating 58 similar cases of intrapleural sepsis over a 10-year period by the standard methods of aspiration, open drainage, decortication, or thoracoplasty were compared with the results of irrigation. In general, cyclical irrigation resulted in a shorter hospital stay and a shorter period of wound drainage than other methods.

Adolescent↗
PubMed1982

Lung function data on 123 persons followed up for 20 years after total pneumonectomy.

Consecutive spirographic data of 123 pneumonectomized patients obtained before pneumonectomy, at discharge from hospital, in 1955 (CU1) and in 1975 (CU2) are presented. The mean observation time was of more than 20 years. The loss in inspiratory vital capacity (VC) proved considerably smaller than predicted from transversal studies. It was most pronounced in patients with thoracoplasties and in persons with left remaining lungs. The FEV1 as a percentage of total lung capacity (FEV1%TLC) evidently obviated the qualitative pulmonary function loss over the years. At the same time, data from 25 of 33 patients who died between CU1 and CU2 are reported (mean survival time 15.1 years). The survival rate of the initial group of 168 persons at CU1 was 14% below that of a control group of the same population. Life expectancy in pneumonectomized patients proved to depend more on the quantity of the lung parenchyma available, i.e. the actual inspiratory VC than on the quality as judged from the FEV1 in relation to lung volume.

Adult↗
PubMed2003

The effect of pulmonary rehabilitation in patients with post-tuberculosis lung disorder.

STUDY OBJECTIVES: Although the benefit of pulmonary rehabilitation (PR) has been demonstrated for patients with COPD, the benefit for patients with non-COPD lung disorders is still unclear. In the present study, we compared the effect of PR on patients with post-tuberculosis (TBC) lung disorders and patients with COPD. DESIGN: We performed a prospective nonrandomized open trial over a 9-week period. PATIENTS AND METHODS: Thirty-two patients with post-TBC lung disorders (thoracoplasty, 25 patients; mean [+/- SD] age, 71 +/- 5 years; FEV(1), 0.84 +/- 0.29 L) and 32 age-matched and FEV(1)-matched COPD patients were enrolled in the study. First, we compared the exercise tolerance between groups using a 6-min walking test. Next, we trained the patients using a 9-week outpatient PR program. We assessed improvement using clinical dyspnea ratings, a daily activity score, and the results of a 6-min walking test. RESULTS: When age and FEV(1) were matched, the distance covered during the 6-min walking test did not differ between the groups. After rehabilitation, significant improvement was observed in both the post-TBC group and the COPD group in terms of Medical Research Council dyspnea grade, transition dyspnea index, activity score, and 6-min walking distance (42 m [p < 0.01] vs 47 m [p < 0.01], respectively). The magnitudes of the improvement in these parameters were comparable between the groups. CONCLUSIONS: PR is as beneficial in post-TBC lung disorder patients as in COPD patients if the severity of the disability is similar.

Aged↗
PubMed1998

Hydatidosis: experience with hepatic and pulmonary hydatid disease.

From 1989-1992, 35 cases comprising of 20 hepatic and 15 pulmonary hydatid cysts were seen. Four patients with pulmonary hydatid disease had previous or concomitant hepatic hydatidosis compared to no concomitant pulmonary hydatid disease in the hepatic group. Hepatic hydatid disease had a greater tendency to be right sides, infected and calcified. Anaphylactic reactions occurred in 3 of 20 patients with hepatic hydatid disease against none in 15 patients with pulmonary disease. Management consisted of evacuation, drainage and obliteration of the residual cavity by capittonage in the lung and omentoplasty in the liver. Two patients, one hepatic and one with pulmonary hydatid disease developed infection of the residual cavity. Bronchocystic fistula occurred in 4 pulmonary and cystobiliary fistula in 2 hepatic hydatid disease patients. One patient with severe pleuropulmonary hydatidosis required a thoracoplasty. No recurrences have been noted in either group over a mean follow-up of 11 months (range 3 weeks- 3 years).

Adolescent↗