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PubMed1979

Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia.

A thoracoscopic examination was performed in 41 patients under local anesthesia in the lateral decubitus position. Prior thoracocentesis (38 patients) and blind biopsy with an Abrams' needle (32 patients) had been nondiagnostic. The initial nine patients were examined with the flexible fiberoptic bronchoscope, yielding a diagnostic accuracy of 56 percent (five cases). This technique was discontinued when two patients had normal findings on biopsies, despite the visual observation of later diagnosed carcinoma. Subsequent thoracoscopic procedures were performed with a rigid 11-mm single-puncture thoracoscope (Storz), which was diagnostic in 28 (88 percent) of the remaining 32 patients. A hemothorax (400 ml) was the only potentially serious complication. Twelve patients were prospectively monitored during the thoracoscopic procedure for changes in cardiac rhythm and oxygen saturation. Sinus tachycardia was the only arrhythmia observed. The mean fall in oxygen saturation was 1.4 percent. We conclude that thoracoscopic examination with the rigid thoracoscope is diagnostically superior to the fiberoptic bronchoscope and is a safe procedure which can be performed under local anesthesia.

Anesthesia, Local↗
PubMed1980

The diagnostic value of pleural fluid pH.

One hundred eighty-three patients had simultaneous blood and pleural fluid pH determinations. Thirty-six effusions were transudates, and 147 were exudates. In 46 effusions, the pleural fluid pH was less than 7.30; all 46 were exudates. A pleural fluid pH less than 7.30 was associated with the following six diagnoses: (1) empyema; (2) malignancy; (3) collagen vascular disease; (4) tuberculosis; (5) esophageal rupture; and (6) hemothorax. The results of pleural fluid pH determination are immediately available, narrow the differential diagnosis of the exudate, and may expedite patient management. The pH of pleural fluid should be measured whenever a diagnostic thoracocentesis is performed.

Aged↗
PubMed1980

Pseudopseudotumor of the lung. Hepatic herniation into the right major fissure imitating a pseudotumor on chest roentgenogram.

A young man presented to us with an asymptomatic ovoid mass which appeared to be in the right major fissure. The roentgenographic appearance of the lesion was that of a pseudotumor. The computerized tomography scan suggested tissue density leading to exploration. At surgery, we found the mass to be a portion of liver herniated through a diaphragmatic defect. Thus, we add type 2 hepatic herniation to congestive heart failure, empyema, hemothorax, postinflammatory "fibromas" and malignancies as a cause of interlobar pleural densities.

Adult↗
PubMed1981

Aspiration biopsy in the diagnosis of pulmonary disease.

We reviewed the results of 146 aspiration lung biopsies (ALB) performed on 140 patients over a five-year period. A negative fiberoptic bronchoscopy in patients with a pulmonary mass lesion or infiltrate was the major indication for ALB in this group. Seventy-two patients had various malignant chest lesions, 63 had benign or inflammatory pulmonary disease. A definite diagnosis was not obtained in the remaining five patients. The diagnostic accuracy of ALB was 73.6 percent in malignant disease and 17.5 percent in benign disease with no false positive results. Of 50 patients ultimately proven to have unresectable cancer, 46 (92.6 percent) were spared the necessity of exploratory thoracotomy for diagnosis by prior ALB. Complications included pneumothorax in 30 percent necessitating chest tube drainage in 14.3 percent. Minor hemoptysis occurred in 3.4 percent, hemothorax in 0.68 percent and subcutaneous emphysema in 1.36 percent. There were no deaths directly attributable to the procedure. We conclude that ALB is a valuable procedure in the diagnosis of malignant chest lesions, sparing exploratory thoracotomy for histologic diagnosis in many patients.

Adenocarcinoma↗
PubMed1983

Osteomyelitis of both clavicles as a complication of subclavian venipuncture.

Complications of subclavian vein catheterization are common and include pneumothorax, hemothorax, and sepsis. Osteomyelitis is a rare complication. The present report describes a patient with osteomyelitis of both clavicles due to subclavian vein venipuncture, in whom fever and chills were absent and the sole clinical finding was local pain and tenderness in the involved area.

Aged↗
PubMed1987

Ultrasound-guided tissue-core biopsy of thoracic lesions with Trucut and Surecut needles.

The value of ultrasound-guided tissue-core needle biopsy was assessed in 54 patients with thoracic lesions adjacent to the chest wall. Of these, six were apical and two mediastinal. Biopsy was performed with Trucut or Surecut (modified Menghini) needles in 22 patients, and with both in 32 patients in order to compare the two types of needle. Definitive diagnosis was made in 46 patients (85 percent), of whom 41 had malignancy of various cell types, and five had benign lesions. Of the remaining eight, three had apical lesions, and two had consolidation distal to a proximal tumor. There was complete histologic agreement in 25 of 32 patients where biopsy was performed with both needles. Roentgenographic size of the lesion had relatively little influence on the diagnostic yield. Complications comprise moderate hemoptysis in one patient (2 percent), trivial hemoptysis or hemothorax in three, and symptomless pneumothorax in two which resolved spontaneously. We conclude that tissue core needle biopsy of thoracic lesions under ultrasound guidance is an accurate and safe technique which provides specimens adequate for routine histologic examination. The diagnostic yield from Trucut and Surecut biopsies is comparable.

Adult↗
PubMed2006

Computed tomography guided needle biopsy: experience from 1,300 procedures.

CONTEXT AND OBJECTIVE: Computed tomography (CT) guided biopsy is widely accepted as effective and safe for diagnosis in many settings. Accuracy depends on target organ and needle type. Cutting needles present advantages over fine needles. This study presents experience from CT guided biopsies performed at an oncology center. DESIGN AND SETTING: Retrospective study at Hospital do Câncer A. C. Camargo, São Paulo. METHODS: 1,300 consecutive CT guided biopsies performed between July 1994 and February 2000 were analyzed. Nodules or masses were suspected as primary malignancy in 845 cases (65%) or metastatic lesion in 455 (35%). 628 lesions were thoracic, 281 abdominal, 208 retroperitoneal, 134 musculoskeletal and 49 head/neck. All biopsies were performed by one radiologist or under his supervision: 765 (59%) with 22-gauge fine-needle/aspiration technique and 535 (41%) with automated 16 or 18-gauge cutting-needle biopsy. RESULTS: Adequate samples were obtained in 70-92% of fine-needle and 93-100% of cutting-needle biopsies. The specific diagnosis rates were 54-67% for fine-needle and 82-100% for cutting-needle biopsies, according to biopsy site. For any site, sample adequacy and specific diagnosis rate were always better for cutting-needle biopsy. Among 530 lung biopsies, there were 84 pneumothorax (16%) and two hemothorax (0.3%) cases, with thoracic drainage in 24 (4.9%). Among abdominal and retroperitoneal biopsies, there were two cases of major bleeding and one of peritonitis. CONCLUSION: Both types of needle showed satisfactory results, but cutting-needle biopsy should be used when specific diagnosis is desired without greater incidence of complications.

Adolescent↗
PubMed1984

The role of motor vehicle crashes in causing certain injuries.

Hospital discharge data from Rhode Island were used to assess the role of motor vehicle crashes in causing several types of serious injuries. Motor vehicle crashes were the cause of injury for approximately two-thirds of patients hospitalized with injuries to the chest organs, liver, and spleen, and approximately one-third of those with traumatic pneumothorax or hemothorax, and injuries to the head, kidney, intestine, distal femur, pelvis, and patella.

Accidents, Traffic↗
PubMed2006

The need for an interdisciplinary network of investigations on HHT.

In the last years, the understanding of HHT has greatly progressed. The two genes for most on cromosomes 9 and 12 have been discovered and the existence of a third involved gene has been predicted. Recent progress in the field of genetics has allowed the identification of many gene mutation thus facilitating the characterisation of the at risk members of the same family. Complications from bleeding or shunting (pulmonary AVMs) may be sudden and life-threatening (hemothorax, haemoptysis, stroke and brain abscess). Catastrophic events are preventable by early diagnosis and treatment. Appropriate screening programmes are mandatory and multi-specialistic cooperation is needed. Special centers have been developed in the world, where physicians, who are specialised and trained in all aspects of HHT, are working to develop better therapeutic approaches for the disease and to locate new genes in view of the future potential of gene therapy for this condition.

Clinical Trials as Topic↗
PubMed1985

CT evaluation of thoracic infections after major trauma.

Thirty-seven septic patients with major multisystem trauma were evaluated by computed tomography (CT) to identify possible thoracic sources of infection. CT was 72% accurate in the diagnosis of empyema and 95% accurate in the diagnosis of lung abscess. While CT proved useful in demonstrating these sites of thoracic infections in septic trauma victims, the presence of concurrent thoracic pathology, particularly loculated hemothorax or hemopneumothorax and traumatic lung cysts with hemorrhage or surrounding parenchymal consolidation, introduced sources of diagnostic error. CT also proved helpful in guiding appropriate revisions of malpositioned and occluded thoracostomy tubes.

Abscess↗
PubMed1985

Percutaneous catheter drainage of pleural effusion and empyema.

Fluoroscopy-guided percutaneous catheter drainage (PCD) was used in 38 patients to diagnose and/or treat pleural effusions (21), hemothorax (one), symptomatic malignant effusions (four), and empyemas (12). Fluoroscopic guidance combined with the use of a small needle, J-tip guide wire, and pigtail catheter made it possible to safely drain both free and loculated fluid collections, including areas with difficult access. In 11 of the 12 patients with empyema, the pus (or purulent fluid) was successfully drained using PCD. Two or more catheters were used in all but one patient. In four of the empyemas, PCD was used successfully after incomplete or unsuccessful chest tube drainage. In five, PCD was used as the sole means of drainage. In three patients, chest-tube drainage was used to drain residual (one) or recurrent (two) empyemas after PCD. The safety and relative ease of PCD makes it an attractive alternative method for closed drainage of pleural fluid collections.

Adult↗
PubMed1990

Percutaneous biopsy of thoracic lesions: value of sonography for needle guidance.

Fluoroscopy and CT are widely used to guide percutaneous needle biopsy of thoracic lesions. However, some lesions are not sufficiently visible on fluoroscopy and others are dangerous to access on CT without real-time monitoring. When these are the circumstances, sonographic guidance may be helpful. Real-time sonography was used to guide percutaneous needle biopsy in 124 patients with thoracic lesions. The indications for sonographic guidance included pulmonary, pleural, or mediastinal lesions in contact with the chest wall, including lesions near the heart or great vessels (n = 12); lesions in the apical region (n = 5); lesions in a juxtadiaphragmatic location (n = 6); small lung nodules adjacent to the chest wall (n = 16); and peripheral tumors with adjacent pleural effusion (n = 4). A diagnosis was made in 74 (90%) of 82 malignant lesions and in 24 (67%) of 36 benign lesions. Complications included pneumothorax (n = 5), hemoptysis (n = 1), and hemothorax (n = 1). The advantages of sonographic guidance are that the sonographic equipment is mobile and real-time monitoring makes the procedure safer. Its limitations are that it cannot be used when aerated lung or free air (pneumothorax) lies between the chest wall and the lesion and that cavitary lesions are difficult to sample by biopsy. Our results show that the use of sonographic guidance considerably expands the number of thoracic lesions amenable to percutaneous biopsy.

Biopsy, Needle↗
PubMed1993

Localization of peripheral pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement.

OBJECTIVE: One of the indications for the rapidly expanding use of thoracoscopic surgery as an alternative to thoracotomy is the excision of peripheral lung nodules. Nodules judged too small or too far from the pleural surface to be seen or palpated during thoracoscopy must be localized beforehand. The purpose of this study was to evaluate the feasibility and effectiveness of percutaneous placement of spring hookwires to localize such nodules before video-assisted thoracoscopy. SUBJECTS AND METHODS: Under CT guidance, 17 nodules in 14 patients were preoperatively localized with the Kopans breast lesion localization system. Three patients who had solitary nodules had thoracoscopic resections for diagnosis because a previous transthoracic needle or transbronchial biopsy had been unsuccessful. Four patients who had lesions less than 8 mm in diameter had thoracoscopic biopsies because transthoracic fine-needle aspiration biopsy was not likely to be diagnostic. Seven patients, who had a total of 10 nodules, had therapeutic wedge resections of either limited metastases or a second bronchogenic carcinoma. Mean nodule diameter was 10 mm (range, 3-20 mm). The mean distance from nodule to costal pleura was 9 mm (range, 0-25 mm). At the end of the procedure, wire placement was confirmed by CT scanning. After thoracoscopy, the surgeons were questioned about the stability and utility of each hookwire localization. RESULTS: In all 17 procedures, a hookwire was placed successfully. In one case, the wire dislodged before thoracoscopy (after a 6-hr preoperative delay and severe bending of the wire during induction of anesthesia). In 16 of the 17 resections, the surgeon thought that thoracoscopic identification of the lesion would not have been possible without hookwire localization. Only one localization, across a major fissure, required placement of a second wire to localize a nodule. Wire-related complications included two instances of serious pain, five cases of clinically insignificant pneumothorax, and one large pneumothorax requiring drainage before a second nodule in the same lung was localized. CT scanning showed presumed local pulmonary hemorrhage in six cases without hemoptysis or hemothorax. CONCLUSION: CT-guided hookwire localization is easily and safely performed and permits thoracoscopic resection of lung nodules, which might otherwise be impossible.

Adult↗
PubMed1995

Pleural hemorrhage in neonates on extracorporeal membrane oxygenation and after repair of congenital diaphragmatic hernia: imaging findings.

OBJECTIVE: The purpose of this study was to determine the frequency and range of radiographic and sonographic findings of clinically significant pleural hemorrhage in neonates who have had repair of a congenital diaphragmatic hernia and are being treated with extracorporeal membrane oxygenation (ECMO) for severe respiratory failure due to a combination of pulmonary hypoplasia and persistent pulmonary hypertension. Drainage and control of larger pleural hemorrhages and hemorrhagic pleural effusions, which may not be apparent clinically, can be essential to the successful completion of ECMO bypass support. MATERIALS AND METHODS: The medical records, chest radiographs, and thoracic sonograms of 32 neonates with repaired congenital diaphragmatic hernia who were being treated with ECMO bypass were reviewed for radiographic and sonographic findings associated with significant pleural hemorrhage, defined as sufficient in amount to be recognizable by bedside imaging. Drainage of these hemorrhages was considered likely to result in improvement in the patient's clinical status and possibly to be essential to the patient's survival. The imaging findings most likely to reflect these large pleural hemorrhages were radiographic evidence of a rapid accumulation of pleural fluid or an atypical shift of mediastinal structures and sonographic demonstration of echogenic fluid in the pleural space. RESULTS: Nine patients had 11 episodes of pleural hemorrhage significant enough to produce recognizable radiographic and/or sonographic findings and to effect a change in clinical management. The imaging findings varied with the evolution of the usual thoracic changes after repair of the hernia, severity of pleural hemorrhage, and ability to drain the hemorrhage. Both tension and nontension hemothoraces and hemopneumothoraces were observed on portable chest radiographs before treatment. Atypical shift of mediastinal structures and/or rapid accumulation of pleural space fluid were the radiographic findings most suggestive of significant pleural hemorrhage and occurred in six of the nine patients. Sonography of the thorax confirmed pleural hemorrhage in eight patients and was nondiagnostic owing to overlying bandage material in one patient. CONCLUSION: The frequency of significant pleural hemorrhage in neonates with repaired congenital diaphragmatic hernia who were on ECMO bypass support was approximately 30%. The chest radiograph may be the initial indicator of large pleural hemorrhages in these patients. The radiographic findings can vary widely, from partial to complete opacification of the involved hemithorax and with varying degrees of contralateral mediastinal displacement. A shift in position of the ECMO cannulas may be the initial and only radiographic sign of pleural hemorrhage when both lungs are completely opaque and airless. Sonography is helpful in distinguishing hemothorax from pleural effusion. The combined radiographic and sonographic findings can be essential in deciding on appropriate therapeutic intervention.

Extracorporeal Membrane Oxygenation↗
PubMed1996

Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT.

OBJECTIVE: The purpose of this study was to determine the diagnostic sensitivity and specificity of CT in detecting acute rupture of the diaphragm after blunt trauma. MATERIALS AND METHODS: Abdominal CT scans taken before surgery of 11 patients with diaphragmatic rupture (eight left and three right) and 21 patients with intact diaphragms after major acute blunt abdominal trauma were independently reviewed by three observers who were unaware of surgical findings. Retrospective note was made of diaphragmatic discontinuity, intrathoracic herniation of abdominal contents, waistlike constriction of bowel ("collar sign"), and associated findings. Right and left hemidiaphragms were graded as intact or ruptured, and these findings were correlated with surgical findings. Individual and average observer sensitivity and specificity in detecting acute diaphragmatic rupture were calculated. RESULTS: Of the 11 cases of diaphragmatic rupture, diaphragmatic discontinuity was seen in eight, visceral herniation was seen in six, and the "collar sign" was seen in four cases. Hemoperitoneum of hemothorax completely obscured visualization of the ruptured diaphragm in three cases. Individual diagnostic sensitivity for detecting diaphragmatic rupture was 54-73% and specificity was 86-90%. Average sensitivity for the three observers was 61% (95% confidence interval, 41-81%), and average specificity was 87% (95% confidence interval, 76-99%). CONCLUSION: CT is highly specific in diagnosing acute diaphragmatic rupture and detects approximately two thirds of acute diaphragmatic ruptures after blunt trauma.

Abdominal Injuries↗
PubMed2005

Helical CT of blunt diaphragmatic rupture.

OBJECTIVE: This study evaluated CT findings for signs of blunt diaphragmatic rupture. MATERIALS AND METHODS: CT examinations of 179 blunt trauma patients, including 11 with left-sided and five with right-sided blunt diaphragmatic rupture, were reviewed by two staff radiologists who first decided by consensus on the presence or absence of 11 published signs of blunt diaphragmatic rupture and then formulated the diagnosis in terms of absence of, presence of, or suggestion of blunt diaphragmatic rupture. The significance of the findings was assessed by multivariate logistic regression. Four other reviewers interpreted the CT findings independently. They were asked first to formulate a diagnosis in terms of absence of, presence of, or suggestion of blunt diaphragmatic rupture and then to enumerate the findings supporting a diagnosis or suggestion of blunt diaphragmatic rupture. These findings were compared with those of the staff radiologists. RESULTS: Diaphragmatic discontinuity, diaphragmatic thickening, segmental nonrecognition of the diaphragm, intrathoracic herniation of abdominal viscera, elevation of the diaphragm, and both hemothorax and hemoperitoneum were strong predictors of blunt diaphragmatic rupture (p < 0.001). The combination of the first three findings was 100% sensitive (16/16). The staff radiologists' sensitivity for diagnosing blunt diaphragmatic rupture was 100% (16/16). The four reviewers' sensitivities were 56.2% (9/16), 81.2% (13/16), 62.5% (10/16), and 87.5% (14/16). CONCLUSION: Six of 11 signs were good predictors of blunt diaphragmatic rupture. Despite diaphragmatic thickening, focal defect and segmental nonrecognition had 100% cumulative sensitivity; the reviewers formulating the diagnosis before analyzing CT signs overlooked blunt diaphragmatic rupture on CT in 12.5-43.8% of the patients.

Adolescent↗
PubMed1997

Anterior decompression and fusion via the extrapleural approach for thoracic disc herniation causing myelopathy.

Anterior decompression and fusion via an extrapleural approach was performed for 33 patients with myelopathy arising from thoracic disc herniation and the clinical usefulness and problems related to this procedure were assessed on the basis of surgical results and complications. The severity of the myelopathy was evaluated by the Japanese Orthopaedic Association score, and the surgical results were based on the recovery rate. The upper-level limit of decompression and fusion via the extrapleural approach was T4-5. The recovery rate for the mean postoperative follow-up period of 41 months was 66.7%. An age of 60 years or more, long duration of illness and severe preoperative myelopathy were indicators of a poor prognosis. Two patients suffered from a postoperative transient pulmonary complication due to hemothorax. X-ray examinations revealed good bone union in all the patients. The present study indicates that anterior decompression and fusion via the extrapleural approach is a useful technique which can be used to achieve a high success rate in the surgical treatment of thoracic disc herniation, if intervention is early.

Adult↗
PubMed2002

Safety and efficacy of a technique for thoracoscopically guided pulmonary wedge resection in horses.

OBJECTIVE: To evaluate the safety and efficacy of thoracoscopically guided pulmonary wedge resection in horses. ANIMALS: 10 horses (5 control horses and 5 horses affected with recurrent airway obstruction [ie, heaves]). PROCEDURE: Each horse underwent a thoracoscopically guided pulmonary wedge resection. Before, during, and after surgery, heart rate, respiratory rate, arterial blood gases, and systemic and pulmonary arterial pressures were measured. Physical examination, CBC, and thoracic radiography and ultrasonography were performed 24 hours before and 2 and 48 hours after surgery. Pulmonary specimens were assessed by histologic examination. A second thoracoscopic procedure 14 days later was used to evaluate the resection site. RESULTS: The technique provided excellent specimens for histologic evaluation of the lung. Heart and respiratory rates decreased significantly after horses were administered sedatives. A significant transient decrease in Pao2 was detected immediately after pulmonary wedge resection, but we did not detect significant effects on arterial pH, Paco2, or mean arterial and pulmonary arterial pressures. All horses except 1 were clinically normal after thoracoscopic surgery; that horse developed hemothorax attributable to iatrogenic injury to the diaphragm. The second thoracoscopy revealed minimal inflammation, and there were no adhesions. CONCLUSIONS AND CLINICAL RELEVANCE: Thoracoscopically guided pulmonary wedge resection provides a minimally invasive method for use in obtaining specimens of lung tissues from healthy horses and those with lung disease. This technique may be useful for the diagnosis of diseases of the lungs and thoracic cavity.

Animals↗