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PubMed2006

Accuracy and complications in computed tomography fluoroscopy-guided needle biopsies of lung masses.

The aim of this study was to determine the diagnostic accuracy and frequency of complications of lung biopsy procedures with or without CTF guidance of needle insertion. Records and images of 99 consecutive percutaneous coaxial cutting needle lung biopsy procedures performed on 85 patients were reviewed retrospectively. Fifty-seven and 42 procedures had been done with and without CTF guidance, respectively. Histological results were compared to diagnosis after surgery or after a follow-up period of 12 months. Diagnostic accuracy and the occurrence of pneumothorax and/or bleeding related to the procedures were registered. The level of accuracy of the diagnosis was comparable. The diagnostic accuracy was 96% (50/52) and 95% (34/36) sensitivity 95% (35/37) and 93% (26/28), specificity 100% (15/15) and 100% (8/8) with CTF and conventional CT techniques, respectively. There were fewer post procedure pneumothoraces using the CTF than conventional technique [26% (15/57) vs. 38% (16/42)], but the difference was not statistically significant (P = 0.274). The insertion of a chest tube was required in only one (2%) procedure using the CTF technique, while this was needed in four (10%) using the conventional technique. Small or large hemorrhages occurred in 23% of the procedures, with no apparent difference between the two groups. In conclusion, CTF-guided biopsy of lung lesions provides high diagnostic accuracy, comparable to that of conventional CT-guided procedures, with a low rate of complications, even for small tumors.

Adolescent↗
PubMed1998

[Treatment strategies in malignant pleural effusion of breast carcinoma].

Symptoms are dyspnea, pain and reduced common feeling. Aine of the study was, to compare our results of talc pleurodesis with the literature. In a prospective trial we performed talc pleurodesis via a chest tube in 41 patients. All patients had radiologically proven pleural effusions. No additional therapy was permitted 30 days before or after entry into the study. Response was assessed monthly. Seven patients dies because of tumor progress. We examined 34 patients. Treatment was successful in 31 patients adverse effects we saw only a few times. Application of iodized talc for therapy of malignant pleural effusions is effective and cheep. We did not see major adverse effects or complications.

Adult↗
PubMed2005

Giant bulla mimicking pneumothorax.

It is usually thought by emergency physicians that the diagnosis of a pneumothorax is straightforward and easy to make and to treat, but the diagnosis may sometimes pose a challenge. The present report describes a case of a giant pulmonary bulla in a 40-year-old man that progressed to occupy almost the entire left hemithorax and also subsequently ruptured to produce a large left pneumothorax. The giant bulla was diagnosed only as a pneumothorax, and initially managed with a chest tube only. The differentiation between pneumothorax and a giant bulla can be very difficult, and often leads to inaccurate diagnosis and management. This case report demonstrates the clinical presentation of giant bulla and its complications such as pneumothorax and also highlights the difficulty in making this diagnosis and appropriately treating it. In this article, we emphasized how to differentiate between giant bulla and pneumothorax utilizing history, physical examination, and radiological studies including computed tomography (CT) scan.

Adult↗
PubMed2001

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.

OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. BENEFITS, HARMS, AND COSTS: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.

Adult↗
PubMed1999

Evaluation of patient-related and procedure-related factors contributing to pneumothorax following thoracentesis.

OBJECTIVE: To evaluate patient-related and procedure-related risk factors for thoracentesis-related pneumothorax. DESIGN: Prospective, nonrandomized cohort study. SETTING: Pulmonary Special Procedures Unit of a university medical center. METHODS: Thoracentesis using either a 22-gauge, a Boutin, or a Cope needle (depending on availability and operator preference) was performed by the pulmonary faculty or by pulmonary physicians-in-training under faculty supervision. In order to control for effusion size and the presence of loculations, chest radiography and pleural ultrasonography were performed prior to each thoracentesis. Potential patient-related and procedure-related risk factors for pneumothorax were analyzed at the procedure level using the presence or absence of pneumothorax on the postprocedure chest radiograph as the sole outcome variable. RESULTS: Two hundred fifty-five thoracenteses were performed in 205 adult patients (113 men and 92 women; mean age, 58.8+/-18 years) over a 3(1/2)-year period. One hundred fifty procedures were performed for diagnostic purposes, 28 procedures were performed for therapeutic purposes, and 77 procedures were performed for both diagnostic and therapeutic purposes. Based on the radiographic criteria, 152 effusions (60%) were small. Loculations were present in 76 patients (30%). Pneumothoraces occurred in 14 instances (5.4%), and chest tube drainage was required in 2 instances (0.78%). Hospitalization status, critical illness, effusion size or type, presence of loculations, operator, needle type, amount of fluid withdrawn, occurrence of dry tap, and type of thoracentesis were not associated with an increased frequency of pneumothorax. The only predictor variable demonstrating statistical significance was repeated thoracentesis. CONCLUSION: The results of a bivariate analysis suggest that pneumothorax following thoracentesis is a rare event that is not easily predictable when the procedure is performed by experienced operators in a controlled setting.

Chest Tubes↗
PubMed1998

Multicenter VATS experience with mediastinal tumors.

BACKGROUND: The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood. METHODS: We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged 41 +/- 16 years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were 5.2 +/- 3.3 cm. RESULTS: Operations were briefer for 24 posterior (93 +/- 41 min) than 5 anterior (195 +/- 46 min, p < 0.01) or 19 middle mediastinal tumors (170 +/- 78 min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n = 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group (3.2 +/- 2.8 versus 5.5 +/- 2.1 days, p = 0.05), as was chest tube duration (1.7 +/- 1.4 days versus 3.2 +/- 1.9 days, p = 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised. CONCLUSIONS: Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum.

Adult↗
PubMedDate not supplied

Thoracoscopic limited resection of bronchogenic carcinoma in patients over the age of 80.

Video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive therapy of bronchogenic carcinoma, when the diseases occur in patients unable to tolerate open thoracotomy who are 80 years old or older. We report on an 80-year-old man with poor pulmonary function and an 83-year-old man, who were treated with a complete VATS resection of bronchogenic carcinoma. Mean chest tube duration of the two patients was one day and mean postoperative hospital stay was 7 days with an uncomplicated postoperative course. Compared with patients with open thoracotomy, there were early mobility, less morbidity, and less mortality. We believe that when the indication for treatment of bronchogenic carcinoma in patients over the age of 80 with concomitant systemic disorders, a thoracoscopic limited resection should be considered.

Aged↗
PubMedDate not supplied

Aprotinin therapy for insertion of ventricular assist devices for staged heart transplantation.

Bleeding after insertion of ventricular assist devices is a common problem which carries a major risk of immediate and late complications. We evaluated the safety and efficacy of aprotinin in six patients undergoing staged heart transplantation and compared the results with those of six patients who received no aprotinin. The groups did not differ significantly with respect to age, gender, preoperative cause of cardiomyopathy, or cardiopulmonary bypass time. Patients treated with aprotinin had a significant reduction in postoperative chest tube drainage (743 +/- 457 versus 2036 +/- 1184 cc, respectively, for aprotinin therapy versus no therapy; p = 0.047). Blood transfusion requirements were reduced in patients treated with aprotinin (2.2 +/- 2.2 versus 10.7 +/- 7.1 U respectively, for aprotinin therapy versus no therapy; p = 0.038). No demonstrable serious side effects were attributed to the aprotinin treatment. We conclude that aprotinin is effective in reducing bleeding and transfusion requirements without increasing the incidence of clinically significant renal dysfunction or thromboembolic events.

Adult↗
PubMed2004

[Video-assisted thoracoscopic surgery (VATS) for treatment of pleural empyema].

During 1996-2003 a total of 359 patients were treated for empyema. Forty eight of them (with parapneumonic empyema) were prospectively randomized into 2 groups of 24 patients who underwent early decortication either by thoracotomy or VATS. Comparing to thoracotomy group, VATS group had a significantly shorter chest tube duration (5.8+/-1.1 vs 9+/-1.3 days; p=0.03) and postoperative in-hospital stay with parapneumonic empyema (8.7+/-0.9 vs 12.8+/-1.1 days; p=0.009). VATS has been found to be particularly useful for treating the fibrinopurulent phase of empyema, in which multiple loculations could be easily disrupted to allow adequate drainage of a "cleaned" pleural space. On the other hand, although VATS is highly effective, it is not indicated in every patient and it's indiscriminate use may lead to none required operative interventions.

Adult↗
PubMed1996

Defining the role of aprotinin in heart transplantation.

BACKGROUND: Heart transplantation is associated with excessive bleeding due to recipient coagulopathy, frequent need for reoperative median sternotomy, and prolonged cardiopulmonary bypass. Aprotinin reduces bleeding and the inflammatory response after cardiopulmonary bypass, but there are concerns about efficacy and side effects. METHODS: To determine the role of aprotinin in primary and reoperative sternotomy heart transplantation, we studied 70 patients undergoing heart transplantation between August 1993 and October 1994. Thirty-eight undergoing primary sternotomy for heart transplantation and receiving no aprotinin were randomized to group A (n = 20); patients in group B (n = 18) received the full recommended dose. Similarly, 32 patients undergoing reoperative heart transplantation were randomized to group C (n = 16), receiving no aprotinin, and to group D (n = 16), receiving aprotinin at the full recommended dose. All patients received the same immunosuppression regimen. Similarities in the groups included recipient age, weight, preoperative hemodynamic indices, creatinine, creatinine clearance, platelet count, hemoglobin, percentage receiving warfarin, prothrombin time, partial thromboplastin time, cardiopulmonary bypass time, and creatinine level at 48 hours. RESULTS: There were no significant differences postoperatively between groups A and B. Differences (p < 0.05) 24 hours postoperatively between groups C and D, respectively, included: total blood product requirement (5.9 +/- 3.8 versus 3.6 +/- 2.0 U), total fluid balance (+752 +/- 300 versus -250 +/- 185 mL), chest tube drainage (894 +/- 120 versus 526 +/- 95 mL), alveolar-arterial O2 difference (120.4 +/- 45.9 versus 95.5 +/- 33.5), and pulmonary artery mean pressures (28.2 +/- 4.6 versus 21.1 +/- 3.5 mm Hg). CONCLUSIONS: Aprotinin decreases bleeding after reoperative heart transplantation without renal dysfunction. Decreased inflammation is manifested as reduced fluid requirement and improved pulmonary and right heart function, which benefit patients during the posttransplantation period. Aprotinin at recommended doses is effective and safe for patients undergoing reoperative heart transplantation.

Aprotinin↗
PubMed1995

Parapneumonic effusions secondary to community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients.

The purpose of this study was to determine whether the clinical and microbiological characteristics of parapneumonic effusions in patients with community-acquired pneumonia (CAP) infected with the human immunodeficiency virus (HIV) were different from those observed in patients without HIV infection. One hundred and thirty seven patients with parapneumonic effusions were included and divided into two groups depending on whether they had HIV infection or not. The parapneumonic effusion rate was significantly higher in HIV-positive than in noninfected patients (21 vs 13%). Their clinical course was more severe, presenting a higher rate of bacteraemias (58 vs 18%). Pleural fluid in patients infected with HIV had significantly lower glucose levels than that of patients without HIV infection. Chest tube drainage was more frequent in parapneumonic effusions of patients infected with HIV than in those without HIV infection (71 vs 44%). Staphylococcus aureus was the most common microorganism found in the bacteriological samples of patients with CAP infected with HIV (53 vs 12%). We conclude that patients with community-acquired pneumonia and HIV infection have a higher rate of parapneumonic effusions and a more severe clinical course than non-HIV patients, and that Staphylococcus aureus predominates in their bacteriological samples.

Adult↗
PubMed1998

[Pleural empyema].

Thoracic empyema may be based on four different etiologic mechanisms of infection: (1) parapneumonic, (2) posttraumatic, (3) postspecific, (4) postsurgical. According to morphologic processes, three different time-dependent stages may be present: (1) exudative phase, (2) fibrino-purulent phase, (3) organization and pleural peel formation. Diagnosis and pleural puncture are based on the findings of thoracic CT and transthoracic ultrasonography. Thoracocentesis, however--even if performed repeatedly--is not an appropriate treatment of empyema. Chest tube drainage and irrigation of the pleural cavity is appropriate only in stage I and early stage II disease to re-establish total lung inflation and healing without pleural peel formation. Selected stage II cases may benefit from video-assisted debridement, but a 30% conversion rate to open thoracotomy has to be assumed. Residual organized cavities, loculated peels etc. require open thoracotomy and empyemectomy, decortication or combined maneuvers. For treatment quality and outcome it is not only decisive to remove the source of infection but also to reexpand the entire lung without remaining restrictive peels and without relevant leaks.

Chest Tubes↗
PubMed1995

Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma. A randomized trial of local radiotherapy.

The purpose of this randomized prospective study was to assess the efficacy of local radiotherapy in preventing malignant seeding along invasive diagnostic procedures (cytology, needle biopsy, thoracoscopy, or chest tube placement) in patients with malignant pleural mesothelioma. Forty consecutive patients with histologically proven malignant mesothelioma were enrolled. Twenty patients received three daily sessions of radiotherapy at a dosage of 7 Gy 10 to 15 days after thoracoscopy. The other 20 patients did not receive radiotherapy. None of the 20 patients treated developed entry tract metastasis. In contrast, 8 of the 20 (40%) patients who were not treated developed metastases. These findings confirm the efficacy and safety of early local radiotherapy in preventing malignant seeding after invasive diagnostic procedures in patients with malignant pleural mesothelioma.

Aged↗
PubMed1999

The diaphragmatic flap: A multiuse material in thoracic surgery.

BACKGROUND: The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages. METHODS: Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours. RESULTS: No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions. CONCLUSIONS: We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.

Adult↗
PubMed2001

[Experiences in stage-adapted therapy of pleural empyema].

INTRODUCTION: Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. PATIENTS AND METHODS: In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. RESULTS: 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. CONCLUSION: Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.

Adolescent↗
PubMed2002

Efficacy of a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage.

The purpose of this randomized trial was to investigate the effect of using a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage. Thirty consecutive patients with lung cancer, who had moderate alveolar air leaks after pulmonary resection, were randomized into two groups: in group A fibrin glue was applied onto the surface of the leaking raw lung and in group B, after applying fibrin glue in the same manner as in group A, a pedicled pericardial fat pad was immediately fixed to the leaking lung surface with fibrin glue. The duration of the postoperative air leakage and chest tube drainage was recorded. In 6 of 15 patients in group B the air leakage ceased within the first 24h after pulmonary resection, while in group A only 1 of 15 patients showed a cessation of the air leakage, and a significant difference was noticed between the two groups (P = 0.0309). The duration of the postoperative air leakage was 4.8+/-4.6 days in group A and 3.6+/-3.4 days in group B. The pedicled pericardial fat pad fixed onto the surface of the leaking raw lung using fibrin glue was found to reduce alveolar air leakage after pulmonary resection.

Adipose Tissue↗
PubMed2001

Spontaneous pneumothorax: pragmatic management and long-term outcome.

We prospectively considered 65 patients admitted for a spontaneous pneumothorax (SP) to describe the pragmatic management of SP, the first recurrence-free interval after medical therapeutic procedure and to specify the first recurrence risk factors over a 7-year period in these patients treated medically. The treatment options were observation alone (9%), needle aspiration (6%), small calibre chest tube (Pleurocatheter) drainage (28%) or thoracic tube drainage (49%), and pleurodesis with video-assisted thoracic surgery procedure (8%). Duration of the drainage and length of hospital stay were shorter in the Pleurocatheter group than in the thoracic tube group (P < 0.01). Among the 47 patients (72%) with a first SP and treated medically, nine patients (19%) had a first homolateral recurrence (FHR) during a mean follow-up of 84+/-13 months. Recurrence-free intervals ranged from 1 to 24 months (mean +/- SD: 9.3+/-8.4 months). FHR cases were more frequent in the Pleurocatheter group (P < 0 04). Analysis of potential risk factors showed that the patient's height and a previous homolateral SP episode are independent recurrence risk factors.

Adolescent↗
PubMed1999

Thoracoscopic resection of posterior neurogenic tumors.

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1-4), and hospital stay was 2 days (range, 1-9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posterior neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.

Adolescent↗