Incomplete Lung Expansion Research Articles

Management of malignant pleural effusion and trapped lung: a survey of respiratory physicians and thoracic surgeons in Australasia.

Malignant pleural effusions (MPEs) are common, and a third of them have underlying trapped lung (TL). Management of MPE and TL is suspected to be heterogeneous. Understanding current practices in Australasia is important in guiding policies and future research. Electronic survey of Australia-New Zealand respiratory physicians, thoracic surgeons and their respective trainees to determine practice of MPE and TL management. Of the 132 respondents, 56% were respiratory physicians, 23% were surgeons and 20% were trainees. Many respondents defined TL as >25% or any level of incomplete lung expansion; 75% would use large-volume thoracentesis to determine whether TL was present. For patients with TL, indwelling pleural catheters (IPCs) were the preferred treatment irrespective of prognosis. In those without TL, surgical pleurodesis was the most common choice if prognosis was >6 months, whereas IPC was the preferred option if survival was <3 months. Only 5% of respondents considered decortication having a definite role in TL, but 55% would consider it in select cases. Forty-nine per cent of surgeons would not perform decortication when the lung does not fully expand intra-operatively. Perceived advantages of IPCs were minimisation of hospital time, effusion re-intervention and usefulness irrespective of TL status. Perceived disadvantages of IPCs were lack of suitable drainage care, potentially indefinite duration of catheter-in-situ and catheter complications. This survey highlights the lack of definition of TL and heterogeneity of MPE management in Australasia, especially for patients with expandable lungs. This survey also identified the main hurdles of IPC use that should be targeted.

Risk factors related to pleural empyema after talc slurry pleurodesis

ObjectiveEmpyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. MethodsPatients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. ResultsOf the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87‒33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90‒22.86; p = 0.067), and patients with 50‒70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98‒15; p = 0.053) after pleurodesis. ConclusionThe study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.

Surgical management of chronic pulmonary aspergillosis in Africa: A systematic review of 891 cases

Chronic pulmonary aspergillosis (CPA) is an emerging fungal infectious disease of public health importance. We conducted a systematic review of studies reporting the outcomes of patients with CPA managed surgically in Africa. A search of Medline, Embase, Web of Science, Google Scholar and African Journals Online was conducted to identify studies indexed from inception to June 2021 that examined surgical management of CPA in Africa. All articles that presented primary data, including case reports and case series, were included. We excluded review articles. A total of 891 cases (557 males (62.5%), mean age 39.3years) extracted from 27 eligible studies published between 1976 and 2020 from 11 African countries were included. Morocco (524, 59%) and Senegal (99, 11%) contributed the majority of cases. Active or previous pulmonary tuberculosis was reported in 677 (76.0%) cases. Haemoptysis was reported in 682 (76.5%) cases. Lobectomy (either unilateral or bilateral, n=493, 55.3%), pneumonectomy (n=154, 17.3%) and segmentectomy (n=117, 13.1%) were the most frequently performed surgical procedures. Thirty (4.9%) cases from South Africa received bronchial artery embolisation. Empyema (n=59, 27.4%), significant haemorrhage (n=38, 173.7%), incomplete lung expansion (n=26, 12.1%) and prolonged air leak (n=24, 11.2%) were the most frequent complications. Overall, 45 (5.1%) patients died. The causes of death included respiratory failure (n=14), bacterial superinfection/sepsis (n=10), severe haemorrhage (n=5), cardiopulmonary arrest (n=3) and complications of chronic obstructive pulmonary disease (n=3). The cause of death was either unknown or unspecified in 9 cases. We conclude that surgical treatment had very low mortality rates and maybe considered as first-line management option in centres with experience and expertise in Africa.

Comparison of pediatric empyema secondary to tuberculosis or non‐tuberculosis community‐acquired pneumonia in those who underwent surgery in high TB burden areas

Tuberculous empyema (TE) in children is common in high-TB burden and medical resource-limited areas. However, studies that evaluate the characteristics of TE in children are sparse. This study aimed to analyze the clinical features of pediatric TE receiving surgical intervention. We performed a retrospective study of children with empyema secondary to community-acquired pneumoniawho underwent surgery in our institution. The clinical characteristics were compared between TE and empyema secondary non-tuberculosis infection (non-tuberculosis empyema, NTE). One hundred patients were included (27 with TE and 73 with NTE). Stage 3 empyema occupied 81.5% and 45.2% of TE and NTE in this study. The TE children had older age, longer duration of illness, and milder symptoms. Pleural fluid culture was positive for Mycobacterium tuberculosis in 7.4% of patients with TE. Lymph node enlargement, lymph node calcification, and pleural nodules presented in TE with high specificity (93.2%, 98.6%, and 98.5%) but low sensitivity (33.3%, 14.8%, and 29.6%) on CT scan. Thoracoscopy surgery was performed in 14 (51.9%) in TE and 39 (53.4%) in NTE. Postoperative chest-tube indwelling time was longer (7.85 ± 5.00 vs. 4.89 ± 1.81 days, p < .001), and more patients had incomplete lung expansion after 3 months in TE. Tuberculosis infection should be screened in management of children with empyema in high-TB burden areas. Pediatric TE usually presented atolder age and with milder respiratory symptoms. Pleural biopsy during surgery is often necessary to confirm the cause of infection. Thoracotomy is still required in some pediatric TE or NTE with delayed treatment in medical resource-limited area.

Efficacy and safety of autologous blood pleurodesis versus talc pleurodesis in symptomatic pleural effusions: A randomized trial

PURPOSE: This study aimed to compare the efficacy and safety of autologous blood pleurodesis with talc pleurodesis in patients with symptomatic pleural effusion.METHODS: This is a prospective, randomized, noninferiority trial. The smallest sample size was determined as 26 for each group by power analyses. For pleurodesis, 5 g of talc and 2 ml/kg blood were administered through the chest catheter. The success rate and complication were recorded in the 1st month after the procedures. The effect of the procedure on the successful pleurodesis was analyzed by univariate and then multivariate logistic regression analysis.RESULTS: A total of 60 patients were randomized. After randomization, 6 patients withdrew from the study. The overall success rate of pleurodesis was 72.0% in the autologous blood group and 69.0% in the talc group (P = 0.903). The most common complications were fever and pain, and both were higher in the talc group (P = 0.030 and P = 0.001, respectively). For successful pleurodesis, complete lung expansion and catheter duration (<7 days) were important factors in the talc group and in the autologous blood group, respectively (P = 0.001 and P = 0.034). The effect of the procedure on pleurodesis success was not significant (odds ratio [95% confidence interval): 1.51 [0.40–5.77]; P = 0.548) after adjustment for lung expansion and catheter duration.CONCLUSION: Autologous blood pleurodesis is a simple, inexpensive, effective procedure and no related to significant adverse events for patients with recurrent symptomatic pleural effusion. Especially, it can be preferred in patients with incomplete lung expansion. Further studies are required to confirm the results of this study.

OUTCOMES OF OPEN THORACIC SURGICAL DECORTICATION IN PATIENTS WITH TUBERCULOUS EMPYEMA

Objective: To analyze the outcome of open surgical decortication of tuberculous empyema patients at their late presentation.&#x0D; Study Design: Cross sectional study.&#x0D; Place and Duration of Study: Patients (n = 128) with tuberculous empyema were subjected to decortication for one and half year starting from July 2017 to December 2018. Pre, intra, and post-operative characteristics of all patients were studied thoroughly with a 6-month follow up evaluation of the surgical outcomes.&#x0D; Results: Preoperative conditions were as follows: 6.25% patient had Broncho pleural fistula, 90.9% patients were diagnosed with cough, 34.7 with night sweating, 64.2% chest pain and 79.6% chest tightness. Decortication was performed in all cases, with debridement of necrotic tissue and repair of air leaks in some patients. 70 (54.7%) patients went through right side decortication, whereas 56 (43.7%) patients went through left sided decortication and 2 (1.56%) patients had bilateral. Mortality was 2 (1.56%), 1 patient died of septicemia while 1 of pulmonary embolism. Whereas morbidity was 9 (7%), 3 patients had wound infection, 4 had incomplete lung expansion, 1 patient each had prolonged air leak and post-operative bleeding.&#x0D; Conclusions: Delayed referral for surgery causes irreversible changes in the lung, and prolonged disease condition, which causes increased thickness of the pleura and injury to the underlying lung with a delayed recovery. Open decortication gives satisfactory results.

The Relationship of Pleural Manometry With Postthoracentesis Chest Radiographic Findings in Malignant Pleural Effusion

Both elevated pleural elastance (E-PEL) and radiographic evidence of incomplete lung expansion following thoracentesis have been used to exclude patients with a malignant pleural effusion (MPE) from undergoing pleurodesis. This article reports on a cohort of patients with MPE in whom complete drainage was attempted with pleural manometry to determine the frequency of E-PEL and its relation with postthoracentesis radiographic findings. Seventy consecutive patients with MPE who underwent therapeutic pleural drainage with pleural manometry were identified. The pressure/volume curves were constructed and analyzed to determine the frequency of E-PEL and the relation of PEL to the postthoracentesis chest radiographic findings. E-PEL and incomplete lung expansion were identified in 36 of 70 (51.4%) and 38 of 70 (54%) patients, respectively. Patients with normal PEL had an OR of 6.3 of having complete lung expansion compared with those with E-PEL (P= .0006). However, 20 of 70 (29%) patients exhibited discordance between postprocedural chest radiographic findings and the pleural manometry results. Among patients who achieved complete lung expansion on the postdrainage chest radiograph, 9 of 32 (28%) had an E-PEL. In addition, PEL was normal in 11 of 38 (34%) patients who had incomplete lung expansion as detected according to the postthoracentesis chest radiograph. E-PEL and incomplete lung expansion postthoracentesis are frequently observed in patients with MPE. Nearly one-third of the cohort exhibited discordance between the postprocedural chest radiographic findings and pleural manometry results. These findings suggest that a prospective randomized trial should be performed to compare both modalities (chest radiograph and pleural manometry) in predicting pleurodesis outcome.

Factors Affecting Postoperative Lung Expansion in Patients with Pyogenic Empyema.

In patients with parapneumonic empyema, decortication is usually preferred to ensure functional lung re-expansion. However, there could be patients exhibiting incomplete postoperative lung expansion and inadequate drainage despite decortication. Therefore, we evaluated factors affecting postoperative lung expansion in patients undergoing decortication. A total of 221 patients with pyogenic empyema who underwent video-assisted thoracoscopic surgery (VATS) between January and October 2016 in our hospital were reviewed in terms of surgical success. The following factors were evaluated: age; the time between identification of a localized effusion and surgical referral; chest tube drainage durations; any underlying morbidity preoperative blood culture data; and the thickness of the visceral pleura. Several factors that significantly prolonged the postoperative time to lung expansion were evident in patients with diabetes mellitus (DM) and bacteremia; postoperative chest tube drainage was significantly longer in those with DM (p = 0.009) and bacteremia (p = 0.01); and postoperative hospitalization time was significantly longer in patients with bacteremia (p = 0.01). The thickness of the visceral pleura was strongly correlated with postoperative chest tube drainage duration and postoperative hospitalization time (Pearson correlation coefficient, r = 0.245, p = 0.00). In patients with DM, bacteremia, or thickened pleura, the time to lung expansion after operation was longer. Therefore, stricter pre- and post-operative control of blood-sugar levels and adequate antibiotics are required to facilitate postoperative lung re-expansion. In patients with thickened pleurae, prolonged chest tube placement is unavoidable.

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study.

ObjectiveThis study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax.Materials and MethodsFrom November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16–64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance.ResultsTechnical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0–5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3–13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016.ConclusionTV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

P3.04-045 Primary Lung Cancer Presenting as Pneumothorax: Topic: Miscellaneous II

Analysis of our patients with primary lung cancer presenting as pneumothorax. Between 2010 -2015 we treated in our clinic among 338 adults (258 men and 80 women) presenting with spontaneous pneumothorax, there were nine men and two woman with lung cancer: Seven squamous cell carcinoma, three adenocarcinoma and one oat cell carcinoma. Pneumothorax led to the diagnosis in 11 cases and the remaining occurred as a complication of known neoplastic disease. The average age was 60 years from (32-72 years old). We analyze these 11 cases treated in our hospital. In patients with normal chest x-ray film findings after lung expansion, further investigation for neoplastic disease is not justified. But we need to perform and chest CT and other investigation in patients with, heavy smoking, chronic bronchitis, bullous emphysema and incomplete lung expansion after chest drainage also patients with age over 50 years old. The occurrence of a pneumothorax in patients with lung cancer, worsening prognosis. Five-year survival is poor, suggesting that lung cancers present as pneumothorax at an advanced stage of disease.

Pneumothorax associated with nontuberculous mycobacteria: A retrospective study of 69 patients.

The incidence of nontuberculous mycobacterial pulmonary disease (NTMPD) is increasing worldwide. Secondary spontaneous pneumothorax occurs as a complication of underlying lung disease and is associated with higher morbidity, mortality, and recurrence than primary spontaneous pneumothorax. We here investigated the clinical features and long-term outcomes of pneumothorax associated with NTMPD.We conducted a retrospective study on consecutive adult patients with pneumothorax associated with NTMPD at Fukujuji Hospital and Keio University Hospital from January 1992 to December 2013. We reviewed the medical records of 69 such patients to obtain clinical characteristics, radiological findings, and long-term outcomes, including pneumothorax recurrence and mortality.The median age of the patients was 68 years; 34 patients were women. The median body mass index was 16.8 kg/m2. Underlying pulmonary diseases mainly included chronic obstructive pulmonary disease and pulmonary tuberculosis. On computed tomography, nodules and bronchiectasis were observed in 46 (98%) and 45 (96%) patients, respectively. Consolidation, pleural thickening, interlobular septal thickening, and cavities were most common, and observed in 40 (85%), 40 (85%), 37 (79%), and 36 (77%) patients, respectively. Regarding pneumothorax treatment outcomes, complete and incomplete lung expansion were observed in 49 patients (71%) and 15 patients (22%), respectively. The survival rate after pneumothorax was 48% at 5 years. By the end of the follow-up, 33 patients had died, and the median survival was 4.4 years with a median follow-up period of 1.7 years. The rate of absence of recurrence after the first pneumothorax was 59% at 3 years. By the end of the follow-up, 18 patients had experienced pneumothorax recurrence. Furthermore, 12/18 patients (66%) with recurrent pneumothorax died during the study period. Twenty-three patients (70%) died because of NTMPD progression. Low body mass index (BMI) was a negative prognostic factor for pneumothorax associated with NTMPD in multivariate analysis (HR 0.79, 95% CI 0.64−0.96; P = 0.018)Patients with pneumothorax associated with NTMPD have advanced disease, a high rate of pneumothorax recurrence, and poor prognosis, regardless of the pneumothorax treatment used. Further improvements in early diagnosis of NTMPD and appropriate management in both NTMPD and NTMPD-associated pneumothorax are needed.

Pleural Pressure Swing and Lung Expansion After Malignant Pleural Effusion Drainage

Malignant pleural effusion is a common complication in end-stage cancer patients and can cause severe dyspnea. Therapeutic thoracentesis is often limited to 1 to 1.5 L. Pleural manometry can be used to recognize a not-expanded lung. Interval pleural pressure measurements with a high temporal resolution were performed after each removal of 200 mL of fluid to observe pleural pressure swings. Pleural elastance was defined as the difference in pleural pressure divided by the change in volume. Chest x-rays were performed to evaluate lung expansion, reexpansion pulmonary edema, and fluid residue. Thirty-four procedures in 30 patients were eligible for analysis. Four patients had incomplete lung expansion after drainage. No reexpansion pulmonary edema was observed. Pleural pressure swing after 200 mL drainage was higher when the lung did not expand. Pleural elastance after removal of 500 mL was higher in the not-expanded subgroup. We demonstrated that a high pleural pressure swing after removal of only 200 mL was related to incomplete lung expansion. We confirmed the association between pleural elastance and lung expansion.

Saucerization: A Modified Uncapitonnage Method of Surgery for Pulmonary Hydatidosis

There are contrary opinions regarding the surgical treatment of pulmonary hydatid cysts. We report our experience performing a modified version of uncapitonnage surgery, called "saucerization," for treating pulmonary hydatid cysts. A total of 78 patients with pulmonary hydatid cysts were studied regarding their surgery outcome and the complication rate. The procedure used for cyst evacuation depended on whether the cyst had ruptured. If ruptured, cystotomy was done; otherwise, enucleation was preferred. To deal with the residual cavity in an uncapitonnage manner, we removed the thin margins of the pericyst and closed the bronchial openings at the cavity floor. All patients were followed up at least for 6 months. The intensive care unit stay ranged from 1 to 9 days. Incomplete lung expansion (six patients) was the main postoperative complication followed by wound infection (four patients) and persistent air leak (≥7 days) (one patient). There was one death. Dependence on mechanical ventilation and subsequent septic shock were also observed. The other patients exhibited no complications during the follow-up period. Our experience demonstrated a low complication rate associated with removing the thin margins of the residual cavity and changing the shape of it into a "saucer." The results were satisfactory and comparable to the results of other studies on pulmonary hydatid cysts.

Bronchoscopic Ethanolamine Injection Therapy in Patients with Persistent Air Leak from Chest Tube Drainage

BackgroundChest tube drainage (CTD) is an indication for the treatment of pneumothorax, hemothroax and is used after a thoracic surgery. But, in the case of incomplete lung expansion, and/or persistent air leak from CTD, medical or surgical thoracoscopy or, if that is unavailable, limited thoracotomy, should be considered. We evaluate the efficacy of bronchoscopic injection of ethanolamine to control the persistent air leak in patients with CTD.MethodsPatients who had persistent or prolonged air leak from CTD were included, consecutively. We directly injected 1.0 mL solution of 5% ethanolamine oleate into a subsegmental or its distal bronchus, where it is a probable air leakage site, 1 to 21 times using an injection needle through a fiberoptic bronchoscope.ResultsA total of 15 patients were enrolled; 14 cases of spontaneous pneumothorax [idiopathic 9, chronic obstructive pulmonary disease (COPD) 3, post-tuberculosis 2] and one case of empyema associated with broncho-pleural fistula. Of these, five were patients with persistent air leak from CTD, just after a surgical therapy, wedge resection with plication for blebs or bullae. With an ethanolamine injection therapy, 12 were successful but three (idiopathic, COPD and post-tuberculosis) failed, and were followed by a surgery (2 cases) or pleurodesis (1 case). Some adverse reactions, such as fever, chest pain and increased radiographic opacities occurred transiently, but resolved without any further events. With success, the time from the procedure to discharge was about 3 days (median).ConclusionBronchoscopic ethanolamine injection therapy may be partially useful in controlling air leakage, and reducing the hospital stay in patients with persistent air leak from CTD.

Résultats à court terme de la décortication pulmonaire pour pyothorax

To evaluate the short term outcome of patients who underwent pleuro-pulmonary decortication. This is a retrospective study of 174 patients treated for thoracic empyema in Point G Hospital, Bamako/Mali, between 2004 and 2007. Perioperative data of 51 patients who underwent pleuro-pulmonary decortication had been recorded. Of the 174 patients treated, 51 (29.3%) underwent pleuro-pulmonary decortication. 84.5% were male and 70.6% were less than 45 years old. A recent history of tuberculosis was found in 59%. Among the four patients selected for a thoracoscopic procedure, only two were treated successfully. A conventional postero-lateral thoracotomy was used in the remaining 49 patients. The lung expansion, estimated intraoperatively, was complete in 43 cases and incomplete in eight cases. Among these eight patients with incomplete lung expansion, four developed a secondary empyema and required a thoracoplasty. The postoperative mortality was 6% (three patients). In our hospital, one third of patients with thoracic empyema required a pleuro-pulmonary decortication. Incomplete lung expansion is a potential risk factor of postoperative infection necessitating re-operation or more extensive surgical procedures.

Long-term indwelling pleural catheter (PleurX) for malignant pleural effusion unsuitable for talc pleurodesis

Aims Talc pleurodesis using talc slurry via chest tube is a primary option in malignant pleural effusion, since life expectancy is short and surgical decortication is hazardous. Incomplete lung expansion after fluid evacuation, and/or excessive fluid secretion predicts failure of pleurodesis. A mini-invasive alternative was investigated. Methods Between March 2004 and September 2005, 51 consecutive patients with malignant pleural effusion, and clinically considered unsuitable for talc pleurodesis, received an indwelling pleural catheter (Denver PleurX). In 47, implantation was done bedside using local anaesthesia. There were 24 men and 27 women, median age 63 (range 36–85) years, receiving 39 right side, 10 left side, and 2 bilateral catheters. There were 19 non-small cell lung cancer cases, 7 mesothelioma, and 25 with other malignancy. Chemotherapy was being given to 18 patients and was not interrupted. Results Discharge to home was possible in 71% (36 of 71 patients) on the following day. At 2 years follow-up in September 2007, one patient was alive. Mean survival was 3 months (range 5 days to 37+ months) for all patients, with best median survivals of 5.5–6 months in breast and ovarian cancer. Catheter was removed or replaced in 15% (8 of 51 patients) due to infection, air leak, or blockage. One patient requested decortication for excessive fluid secretion. None required surgery or died due to catheter-related complications. Pleural fusion with subsequent catheter removal was achieved in 21% (11 of 51 patients). Conclusions An indwelling pleural catheter is a safe alternative for patients with malignant pleural effusion unsuitable for talc pleurodesis. In some, pleural fusion may be achieved.

Utilization of a Synthetic Absorbable Sealant Activated by Helium Cadmium Laser Bronchoscopy for Successful Closure of a Persistent Bronchopleural Fistula Following Lobectom

INTRODUCTION: A bronchopleural fistula (BPF) may be one of the most disappointing complications of pneumonectomy or lobectomy. The clinical sequela may include incomplete lung expansion, empyema, prolonged ventilator support, and often gas exchange problems in addition to increased morbidity and mortality. Numerous modalities using chemical agents and mechanical devices have been reported for fistula closure.

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy

Background. The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy.Methods. This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS.Results. In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant.Conclusions. Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy.

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

Spontaneous Pneumothorax: A Complication of Lung Cancer?

Among 338 adults (258 men and 80 women) presenting with spontaneous pneumothorax, there were six men with lung cancer: five squamous cell carcinoma and one oat cell carcinoma. Pneumothorax led to the diagnosis in five cases and the remaining occurred as a complication of known neoplastic disease. The average age was 67 years. We analyze these six cases, along with 46 others from the literature. In patients less than 40 years old with normal chest x-ray film findings after lung expansion, further investigation for neoplastic disease is not justified. However, heavy smoking, chronic bronchitis, bullous emphysema and incomplete lung expansion after chest drainage in patients over 40 years old are indications for cancer screening through sputum cytologic study, bronchoscopic examination and surgical exploration. The occurrence of a pneumothorax neither alters the treatment of the underlying disease nor modifies the one-year prognosis. Five-year survival is nil, suggesting that lung cancers present as pneumothorax at an advanced stage of disease.