Indwelling Chest Tube Research Articles

RETRACTED ARTICLE: The role of acute care surgeons in treating rib fractures—a retrospective cohort study from a single level I trauma center

BackgroundRib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years.MethodsData from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons.ResultsA total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group.ConclusionsAcute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.

Preemptive analgesia in the "non-tube no fasting" fast track program for resectable esophageal carcinoma.

BackgroundSurgery is the main treatment for esophageal cancer, but postoperative incision pain seriously reduces patients’ quality of life. The aim of this study was to investigate the feasibility and effectiveness of preemptive analgesia of the upper abdomen with ropivacaine in the “non-tube no fasting” fast track recovery program for esophageal carcinoma.MethodsWe retrospectively analyzed the medical records of patients who underwent minimally invasive esophagectomy (MIE) from February 2014 to August 2014. Patients in the study group underwent a conventional analgesia program together with local infiltration injection of ropivacaine in the upper abdominal incision 30 min before the operation, while patients in the control group underwent the conventional analgesia program alone. Ropivacaine was injected locally around the planned surgical incision, including intradermally, subcutaneously, in the fascial muscles, and in the parietal peritoneum layers. Li’s anastomosis method was performed in the neck after MIE. No indwelling chest tube or abdominal cavity tube was placed in any patients. The use of analgesic pumps in the two groups of patients was recorded.ResultsA total of 102 patients were enrolled in the study, with 52 patients in the study group and 50 patients in the control group. Patients in both groups completed the surgery successfully as planned, and the anesthesia methods and drugs used during the operation were the same. The surgical duration, blood loss, and the number of resected lymph nodes did not differ significantly between the two groups. Three patients in the study group and 10 patients in the control group used analgesia pumps (P=0.031). The visual analog scale (VAS) score at 30 days after surgery in the group with preemptive analgesia was significantly better than that in the control group (P=0.048).ConclusionsPreemptive analgesia for the upper abdomen with ropivacaine in the “non-tube no fasting” fast track recovery program for esophageal carcinoma is feasible and worthy of promotion.

Outcomes of Single-Incision Thoracoscopic Surgery Using the Spinal Needle Anchoring Technique for Primary Spontaneous Pneumothorax.

BackgroundAlthough classical multi-port video-assisted thoracic surgery has been widely performed, single-incision thoracoscopic surgery (SITS) is a popular surgical technique for the treatment of primary spontaneous pneumothorax (PSP). However, the inconvenient alignment of instruments and the limited field of view occasionally make surgeons convert from SITS to multi-port surgery or extend the incision. This study aimed to present an easy and safe SITS technique for PSP using a spinal needle.MethodsIn total, 139 patients underwent SITS between May 2011 and December 2017. We used a spinal needle to hook the bulla or bleb, and wedge resection was performed through a small incision. Patients’ medical records were reviewed retrospectively, and a telephone survey was conducted to investigate the recurrence rate.ResultsThe mean age of the 139 patients was 23.62±9.60 years. The mean operative time was 36.69±14.64 minutes, and multi-port conversion was not performed. The mean postoperative hospital stay was 3.00±0.78 days, and the mean indwelling chest tube duration was 1.97±0.77 days. No complications were observed. In the mean follow-up period of 86.75±23.20 months, recurrence of pneumothorax was found in 3 patients.ConclusionWe suggest that SITS for PSP with the aid of a spinal needle to replace a grasper is a safe and easy technique that only requires a small incision.

ABCDEF pulmonary rehabilitation program can improve the mid-term lung function of lung cancer patients after thoracoscopic surgery: A randomized controlled study

Background Pulmonary rehabilitation is recommended for most patients with lung diseases. However, some previous studies have shown that pulmonary rehabilitation has no obvious effect on short-term lung function in patients with lung cancer.Objective The purpose of this study was to evaluate the effect of the ABCDEF pulmonary rehabilitation program on lung cancer patients who have undergone surgery.Design This was a randomized controlled trial with repeated measures.Settings The study was conducted in the Cardiothoracic Surgery Department of a 4000-bed comprising training and research hospital from 2019 to 2020.Participants A total of 90 patients who underwent thoracoscopic pneumonectomy were divided into two groups of 45, using a completely randomized model.Methods Patients in the experimental group participated in an ABCDEF program (Acapella positive vibration pressure training, breathing exercise, cycling training, dance in the square, education, and follow-up) after surgery. In contrast, the regular care provided to the control group focused on breathing and expectoration guidance. The study outcomes were the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, 6 min walking distance, Borg score, incidence of postoperative complications, length of indwelling chest tube, and length of postoperative stay. Generalized estimating equation models were used to compare the changes in the outcomes between the groups over time.Results The ABCDEF pulmonary rehabilitation program for patients who underwent thoracoscopic pneumonectomy was found to be more effective in increasing lung function at 3 months after discharge (p<0.05). However, there was no statistically significant difference on the day of discharge (p>0.05). Exercise tolerance was different at both time points (p<0.05). The incidence of postoperative complications in the experimental group was lower than that in the control group (p<0.05). The length of postoperative stay in the experimental group was also shorter (p<0.05), however, the length of the indwelling chest tube was not significantly different between the intervention and control groups (p>0.05).Conclusions This study showed that the ABCDEF pulmonary rehabilitation program could effectively improve mid-term lung function and exercise tolerance in patients after thoracoscopic pneumonectomy, and reduce the incidence of postoperative complications along with the length of postoperative hospital stay.

Implication of a novel postoperative recovery protocol to increase day 1 discharge rate after anatomic lung resection.

BackgroundChest-tube drainage and prolonged air leak after anatomic lung resection (ALR) continue to drive admission days for most programs employing minimal access techniques. The aim of the study was to evaluate the impact of a novel postoperative recovery protocol with revised chest tube management strategies to target discharge on post-operative day 1 (POD1) after ALR.MethodsThis is a pilot study investigating a novel enhanced recovery protocol which either allowed chest tube removal on POD1 or ambulatory management with indwelling chest tube using a portable closed drainage system. We included all patients undergoing video-assisted thoracoscopic surgery (VATS)-ALR; exclusion criteria were open surgery, non-anatomic or extended resections.ResultsA total of 139 patients were included in the study [N=29 portable drainage (PD), N=110 standard pathway (SP)]. POD1 discharge rate was 72% in PD vs. 15% in SP cohort (P<0.001). Median length of stay (LOS) was 1 day [interquartile range (IQR), 1–2 days] in PD cohort, while it was 3 days (IQR, 2–5 days) in SP cohort (P<0.001). There were no significant differences in length of indwelling chest-tube, rate of discharge with chest-tube, post-operative complications, or readmissions. On multivariate analysis, PD pathway as well as short surgical time were significant predictors of discharge on POD1.ConclusionsOur results indicate that POD1 discharge rates of 72% after VATS-ALR can be safely achieved by a well-developed perioperative care pathway and simple chest tube drainage interventions. Based on these findings we are currently drafting a follow-up study to investigate the possibility of performing ALRs as day surgery.

Deep Learning-Based CT Imaging in Perioperative Period and Nursing of Esophageal Carcinoma Patients

The study focused on the performance of Convolutional Neural Network- (CNN-) based lymph node recognition model as well as the effects of different rehabilitation nursing methods on patients with esophageal cancer. Specifically, the activation function and loss function were optimized by CNN, to establish a U-Net lymph node recognition model. It was compared with Mean Shift and Fuzzy C-means (FCM) algorithm for the loss value, the mean pixel accuracy (mPA), and intersection over union (IOU). 158 patients with esophageal cancer undergoing radical resection were selected as research subjects. With pathological diagnosis results as the gold standard, the role of CT imaging was evaluated in the diagnosis of esophageal cancer lymph nodes. All subjects were divided into control group (routine nursing) and intervention group (routine nursing + rehabilitation nursing) according to different nursing methods, with 79 cases in each. The two groups were compared in terms of the time in bed, hospital stay, indwelling chest tube time, and VAS scores. It was found that the loss value of the U-Net model was close to 0 when it was stable, and its IOU value and mPA value were significantly higher than those of the Mean Shift and FCM algorithms. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the U-Net model were 84.37%, 80.74%, 88.65%, 85.02%, and 87.16%, respectively. When it came to lymph node metastasis number of 1-2, there were notable differences between CT results and postoperative pathology results, and the difference was statistically significant ( P &lt; 0.05 ). As for their identifying lymph node metastasis area, there was no statistically significant difference ( P &gt; 0.05 ). The intervention group exhibited lower postoperative VAS score, shorter time in bed, and shorter hospital stay and indwelling chest tube time versus the control group ( P &lt; 0.01 ). It suggested that the U-Net model optimized by CNN has high diagnostic efficiency for lymph nodes, and the rehabilitation nursing intervention significantly mitigates postoperative pain and accelerates postoperative recovery.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study

BackgroundThe few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound.MethodsWe compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax.ResultsWe performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population .ConclusionsMost of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions.Trial registrationDRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216

Pleural effusion aetiology, presentation, treatment and outcome in haematological diseases: a review.

Background and aim:Pleural effusions (PE) can complicate the course of hematologic disorders (HD) and may arise in the form of malignant PE or as a consequence of non-neoplastic complications. While a certain amount of data has been published regarding infectious and iatrogenic HD-associated PE (HPE), no comprehensive review regarding the other types of HPE has ever been conducted. To address this issue, we performed a systematic review of the literature regarding HPE, focusing on the clinical and chemical characteristics of PE, therapeutic approaches and ì outcomes at the one-year follow-up.Methods:We conducted our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Results:Overall, 283 manuscripts and 1216 cases were included. In summary, PE frequently signals an underlying HD, especially Hodgkin’s lymphoma and IgG4-related disease; it mainly consists of exudate, although chylothorax is diagnosed in some cases. Although cytological examination has a discrete diagnostic yield, it is generally insufficient to render a definitive diagnosis; pleural biopsy remains an important diagnostic means in such cases. Invasive diagnostic procedures are not frequently performed because of an increased risk of haemorrhagic complications. The majority of PE are resolved by means of systemic therapy. When local treatments are attempted, the most frequently adopted procedures are evacuative thoracentesis and indwelling chest tube placement.Conclusions:This review highlights the need for well-designed prospective studies comparing diagnostic means and therapeutic interventions for HPE to increase the quality of available data. (www.actabiomedica.it)

Reversed Approach through Lymphocele/Lymphatic Fluid Collection for Glue Embolization of Injured Lymphatic Vessels

A total of 9 glue embolization procedures of injured lymphatic vessels with a reversed approach from the lymphocele/lymphatic fluid collection in 8 patients were retrospectively reviewed. The approach routes were via the indwelling chest tube for pleural effusion (n = 2), the drainage catheter tract for abdominopelvic lymphocele/lymphatic fluid collection/thigh lymphocele (n = 4), and the direct puncture of the lymphatic fluid collection at the operation bed (n = 2). All the procedures were technically successful without complications. The mean daily leakage rate decreased from 465 mL/d before the procedure to 42 mL/d after the procedure, and the drainage catheters could be removed after 8 procedures, achieving a clinical success rate of 88.9% (8 of 9 procedures).

Safety of Pleuroscopy Performed in Negative Pressure Bronchoscopy Rooms.

The use of pleuroscopy has expanded over the last decade due to its higher diagnostic yield and low complications rate. Whether the infectious complications of pleuroscopy performed in negative pressure rooms is similar to that of pleuroscopy performed in positive pressure rooms remain unclear. To assess the safety of pleuroscopy performed in negative pressure rooms, we sought to determine the rate of infectious complications in patients who underwent pleuroscopy in negative pressure bronchoscopy rooms at our institution. This was a retrospective cohort study of all patients who underwent pleuroscopy in our institution's negative pressure bronchoscopy rooms between January 2005 and January 2018. The primary outcome was the incidence of infectious complications at 14 and 30 days after the procedure. We identified 318 patients. Of the 318 patients, 47 (15%) had hematological malignancies, 118 (37%) had lung cancer, 121 (38%) had solid non-lung cancers, and 32 (10%) had no cancer diagnosis before the procedure. At the end of pleuroscopy, 255 patients (80%) had an indwelling pleural catheter placed, 63 patients (20%) had only a chest tube placed, and 31 patients (9%) had both an indwelling pleural catheter and chest tube placed. No patients developed empyema within 14 days. Three patients (0.9%) developed empyema within 30 days after the procedure and was presumed to be due to pleural catheter infection in all cases. Our findings show that pleuroscopy performed in negative pressure rooms has a low incidence of infectious complications, provided that proper sterile precautions are maintained.

Discharged With Indwelling Chest Tube and Valve

Discharged With Indwelling Chest Tube and Valve

Quantitative computed tomography for predicting cardiopulmonary complications after lobectomy for lung cancer in patients with chronic obstructive pulmonary disease.

In lung cancer resection, chronic obstructive pulmonary disease is a risk factor for post-operative complications. Few studies on post-operative complications of lung cancer resection have considered radiographic emphysematous change as an index. Here, we have examined the relationship between the regional ratio of the emphysematous area in pre-operative computed tomography images and cardiopulmonary complications in patients with chronic obstructive pulmonary disease who underwent lung cancer resection. We retrospectively evaluated 159 patients with chronic obstructive pulmonary disease who underwent lobectomy for lung cancer at Shizuoka Cancer Center Hospital, Shizuoka, Japan, between 2002 and 2011. Pre-operative factors, including the proportion of the emphysematous area measured by computed tomography as a percentage of the low attenuation area (LAA%), as well as intraoperative factors were analyzed. Cardiopulmonary complications, including pyothorax, pneumonia and atelectasis, acute pulmonary injury, indwelling chest tube, long duration of oxygen supply, and arrhythmia, were evaluated. Cardiopulmonary complications were observed among 61 patients (38%). Univariate analysis revealed that patient age, percentage of forced expiratory volume in 1s, LAA%, and volume of blood loss were significantly associated with cardiopulmonary complications. Multivariate analysis indicated patient age and LAA% as being significant independent predictors of cardiopulmonary complications. The regional ratio of the emphysematous area is useful for predicting cardiopulmonary complications in patients with chronic obstructive pulmonary disease who undergo lobectomy for lung cancer. In such patients who are also ≥ 70years of age and exhibit LAA% ≥ 1.0%, careful intra- and post-operative management is warranted.

Abstract 17326: The Effect of Maintenance of Antegrade Pulmonary Blood Flow Upon Bidirectional Glenn on Pre- and Post-Fontan Outcomes

Introduction: Maintaining pulsatility at the time of bidirectional Glenn (BDG) has theoretical advantages and disadvantages. The practice is diverse throughout the centers and individual surgeons without clear rationale behind its application. We sought to investigate the impact of antegrade pulmonary blood flow on pre- and post-Fontan outcomes. Methods: From 2003 through June 2014, among 237 patients who underwent BDG as an interim palliation for functional single ventricle (FSV), patients with preexisting pulmonary blood flow from the ventricle before BDG were included and patients undergoing Kawashima operation or having history of Norwood operation or bilateral pulmonary arterial band were excluded (n=151). Patients were grouped by their presence or absence of antegrade pulmonary blood flow following BDG: group 1 (pulsatile) (n=73) or group 2 (non-pulsatile) (n=78). The pre- and post-Fontan outcomes were compared between two groups. Results: Age and weight at BDG were 7 months and 7.8kg. Oxygen saturation was higher in group 1 (84±4%) compared to group 2 (82±4%) before Fontan (p&lt;0.001). The level of brain natriuretic peptide (BNP) was similar before Fontan (p=0.966). In pre-Fontan cardiac catheterization, mean pulmonary arterial pressure was similar (Group 1: 11±4mmHg vs. Group 2: 10±4mmHg, p=0.146), McGoon ratio seemed higher in group 1(2.6±0.6) compared to group 2(2.3±0.4) (p=0.057), and pulmonary vascular resistance was lower in group 1(1.3±0.7) compared to group 2(1.6±0.7)(p=0.038). A total of 136 patients (90%) underwent Fontan operation. Duration of stay in the intensive care unit (p=0.766), stay in hospital (p=0.142), and indwelling chest tube (p=0.128) was not different between groups. Overall survival after BDG was better in group 2 (p=0.046) [Figure]. In multivariable analysis, maintenance of pulsatility was identified as a risk factor for survival after BDG (p=0.012, HR 4.1 [CI 1.4-12.4]). Conclusions: Maintaining pulsatility at the time of BDG in FSV might be beneficial for pulmonary arterial growth and oxygen saturation without increasing BNP. However, such beneficial effect did not have a positive effect on subsequent Fontan outcome. Attention must be paid to the negative effect of pulsatility on overall post-BDG survival.

Postoperative chest tube placement after thoracoscopic wedge resection of lung for primary spontaneous pneumothorax: is it mandatory?

The goal of present study is to assess the efficiency and feasibility of postoperative care without positioning of chest tube after video-assisted thoracoscopic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP). We conducted a prospective randomized trial of patients who have undergone video-assisted thoracoscopic wedge resection surgery for PSP. During the period of April 2015 until December 2016, 119 eligible patients undergoing VATS for PSP were consecutively included. We divided the patients into two groups at random: (I) avoiding chest tube (ACT) group, comprising 58 patients in whom chest tube was not placed intra or postoperatively, and (II) indwelling chest tube (ICT) group, comprising 61 patients in whom chest tube was placed conventionally. Primary end point was to evaluate and analyze the postoperative clinical data and relevant morbidities between two groups. The mean postoperative length of hospital stay (3.57±0.79 vs. 5.39±0.97 days) and postoperative pain (1.37±0.78 vs. 2.53±0.63) in ACT group were significantly lower than in the ICT group (P<0.05). However, there were no statistical differences between two groups regarding other clinical data and postoperative morbidities. There were no patients who experienced significant adverse events postoperatively. Postoperative management without chest tube placement is safe and feasible approach for patients undergoing thoracoscopic wedge resection for PSP.

Analysis of Patients Discharged From the Hospital With a Chest Tube in Place

Persistent air leak can complicate pulmonary resection, and one management option is dismissal with a chest tube in place. This study evaluated the rate of empyema and readmission after dismissal with a chest tube. A retrospective review of our prospective database from January 2004 to December 2013 identified 236 patients who were discharged from our institution with an indwelling chest tube and attached one-way valve for air leak. Empyema was defined by leukocytosis or fever and undrained effusion on chest roentgenogram or computed tomography. Readmission was defined as readmission for any reason. Logistic regression analyses were performed to identify risk factors for empyema or readmission. Median age was 67 years (range, 18 to 91 years). Median chest tube duration was 18 days (range, 6 to 90 days). Empyema occurred in 40 patients (16.9%), and 62 patients (26.3%) were readmitted. Treatment required included antibiotics alone in 45% (18 of 40), further drainage in 30% (12 of 40), fibrinolytic therapy in 12.5% (5 of 40), and operative decortication in 12.5% (5 of 40). Predictors of empyema included male sex, coronary artery disease, and peripheral vascular disease. A secondary analysis grouping patients into an earlier era (2004 to 2008) vs a later era (2009 to 2013) revealed that the use of thoracoscopy increased from 34% to 48% of lung resections and dismissal with a chest tube increased from 3.4% to 4.5% (p= 0.03). Dismissal with an indwelling chest tube is not without consequence, having significant risk for further complications and potential need for additional interventions.

The management of chemical pleurodesis with viscum album in patients with persistent air leakage.

Persistent air leak (PAL) after major pulmonary resection or involved with secondary lung disease is prevalent and associated with significant morbidity. Chemical pleurodesis is a practical therapeutic tool to manage the patients with PAL. Among various sclerosing substances, viscum album (fraxini) is considered effective and safe. The aim of this study was to evaluate the efficacy and safety of viscum album pleurodesis in patients with intractable prolonged air leakage. Between February 2013 and February 2015, 73 consecutive patients who underwent pleurodesis due to PAL were enrolled in this study. Pleurodesis was performed using 100 mg of viscum album (fraxini) at 1 time through the indwelling chest tube. Main studied outcomes were focused on success rate of pleurodesis assessed on chest radiography and cessation of the air leak after procedure. The study population was predominantly male (n=64, 87.7%). The overall success rate was 90.4%. One patient died of pneumonia not related to the viscum album pleurodesis. The mean length of stoppage to air leakage was 28.00±22.19 hours. The mean duration of chest tube drainage after pleurodesis was 2.78±1.35 days. The mean number of pleurodesis was 1.38±0.75. Thirty-six patients (49.3%) complained of chest pain requiring a prescription for pain control. There were no major relevant complications or mortalities. Air leaks remain an important cause of morbidity. This viscum album pleurodesis could be considered as an option for the treatment of prolonged air leak patients, associated with acceptable side effects.

Efficacy and Safety of Diagnostic Thoracoscopy in Undiagnosed Pleural Effusions

Background: The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. Objective: This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. Methods: Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. Results: During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. Conclusions: MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.

Diagnostic value and safety of medical thoracoscopy in tuberculous pleural effusion

BackgroundDifferentiating tuberculous pleural effusion from other lymphocytic pleural effusions is often challenging. This retrospective study aimed to assess the efficacy and safety of medical thoracoscopy in patients with suspected tuberculous pleural effusion. MethodsBetween July 2005 and June 2014, patients with pleural effusions of unknown etiologies underwent medical thoracoscopy in our institute after less invasive means of diagnosis had failed. Demographic, radiographic, procedural, and histological data of patients with tuberculous pleural effusion were analyzed. ResultsDuring this 9-year study, 333 of 833 patients with pleural effusion were confirmed to have tuberculous pleurisy. Under thoracoscopy, we observed pleural nodules in 69.4%, pleural adhesion in 66.7%, hyperemia in 60.7%, plaque-like lesions in 6.0%, ulceration in 1.5% of patients with tuberculous pleurisy. Pleural biopsy revealed the presence of Mycobacterium tuberculosis in the pleural tissue or/and demonstration of caseating granulomas in 330 (99.1%) patients. No serious adverse events were recorded, and the most common minor complication was transient chest pain (43.2%) from the indwelling chest tube. ConclusionsOur data showed that medical thoracoscopy is a simple procedure with high diagnostic yield and excellent safety for the diagnosis of tuberculous pleural effusion.

Effects of modified intercostal nerve freezing technique on postoperative recovery of traditional thoracotomy

Objective To explore the application value and advantages of modified intercostal nerve freezing technique on postoperative recovery of traditional thoracotomy. Methods 100 patients undergoing conventional thoracotomy incision patients were randomly divided into 2 groups, group A as the modified intercostal nerve freezing group (n = 50) using the Beijing K001AND company JT-Ⅰ treatment only in the off-type freezer chest incision locating on intercostal and upper and lower intercostal space and the indwelling chest tube where the intercostal nerves were frozen;group B, continuous epidural analgesia group (n=50), using the Japanese company's electronic pump wells, plus droperidol with morphine-line continuous epidural analgesia (Patient control epidural analgesia, PCEA). All patients in two groups were using a visual analogue scale (Visual analogue scale, VAS) assessment of postoperative pain,observing patients 2 hours, 4 hours, 12 hours, 24 hours and 48 hours after surgery when the VAS score, nausea,vomiting, respiratory depression, itching, the incidence of intestinal paralysis. Results The post-operative pain of group A was better than that of group B, and the incidence rate of side effect was also lower than that of group B.Conclusions It suggested that the modified intercostal nerve freezing technique could effectively promote postoperative recovery after thoracotomy. Key words: Intercostal nerve freezing; Epidural; Postoperative analgesia; Thoracotomy

Mediastinal Dislocation of the Esophageal Stents

Purpose: Abstract: We report a case of mediastinal abscess associated with dislocation of esophageal stents and disruption of esophagogastric anastomosis. Introduction: Esophageal stents are mostly used as a non-surgical alternative for palliation of esophageal cancers. Though the complication rate is low, serious complications like rupture of esophageal wall and respiratory arrest may occur. Case Report: Our case is a 62 year- old white man diagnosed with stage III, T2N1M0 adenocarcinoma of distal esophagus in April of 2009. He had neoadjuvent chemoradiation followed by esophagectomy with gastric pull-through in September of 2009. One week after the surgery he developed esophagogastric anastomotic leak leading to sepsis. He had multiple stents placed to stop the leak and had indwelling chest tube for drainage. In December of 2009, he presented with intractable cough associated with swallowing and vomiting for three days. He was found to be in severe respiratory distress and in septic shock. CT scan of the chest showed dislocation of the stents (Image 1), air fluid level with possibility of abscess in right chest and mediastinum and diffuse patchy pulmonary infiltrates. He had surgical exploration of chest that revealed two migrated esophageal stents with abscess in the mediastinum. Discussion:Esophageal stents are self-expanding metal or plastic stents. Their use is mostly limited to palliation of symptoms for patients with esophageal cancer. Esophageal stents have also been used in patients with benign conditions such as refractory strictures, perforation, and postoperative leaks. Complications include chest pain, foreign body sensation, obstruction, aspiration, malposition, bleeding, migration. Severe complications like perforation and respiratory arrest are rare. Conclusion: There is always a possibility of esophageal stents getting dislodged if the supporting tissue around the ends of the stent is friable. Our case had radiation therapy to the esophagus preoperatively which induced radiation esophagitis rendering already diseased esophageal wall further weak. Patients with persistent anastomotic leaks are at high risk for stent dislocation and migration.Figure: [463] Dislocated stent in the mediastinum.