Intrapleural Pneumonolysis Research Articles

The history of thoracoscopic surgery

The necessity for thoracoscopy became apparent with the adhesions that limited the success of Forlanini's introduction in 1882 of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. Thoracoscopy and division of adhesions (intrapleural pneumonolysis) then spread all over the world, with reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new explosion of thoracoscopic surgery. Surgeons, in whose hands the procedure now rests, should nevertheless be aware of the five unacceptable thoracoscopic disasters—wrong side, kebab lung, “clotted hemothorax,” artificial lunchothorax, and aorto-pleuro-cutaneous fistula.

Roentgenologic characteristics of the epipericardial fat pad, with a case report.

The small triangular epicardial fat pads which are so frequently seen in postero-anterior chest films at the cardiac apex, where they normally mask the blunt tip of the apex and fill in the left cardiophrenic angle, are now well known. A larger form, which may be found in the right as well as the left cardiophrenic angle, in spite of several published descriptions (1–3), is less readily identified by radiologists generally. Holt, in particular, described the roentgen characteristics of this deposit as observed in a series of probable cases. He demonstrated several conditions of pathological import closely mimicked by the epipericardial fat pad roentgenologically and stressed the importance of a differential diagnosis. In order further to develop the roentgen features of the condition and to facilitate its recognition, we are reporting here a case of epipericardial fat pad explored first by tomography and later at thoracotomy. Relatively few such cases have been definitely identified, since this can be done only in the event of a fortuitous thoracotomy undertaken for some other reason, or on postmortem examination. Case Report A. N., a 32-year-old white male, who was discovered to have pulmonary tuberculosis with a right infraclavicular cavity on May 2, 1946, was admitted to a sanatorium on May 13, 1946, where he was treated by right pneumothorax and intrapleural pneumonolysis. He was considered “arrested” and was discharged on Dec. 3, 1946. He did well until Feb. 20, 1953, when a routine follow up film showed a small area of fresh disease in the left apex. Following admission to a hospital, this lesion gradually resolved. Recently, x-ray examination had revealed an apparently typical tuberculoma in the right upper lung field. Tomographic examinations in July 1953, undertaken because of recurrence of positive sputum, suggested a small possible breakdown within the tuberculoma and it was decided to resect this lesion both as a possible source of the organisms in the sputum and a potential future hazard. It was about this time that right lateral tomography clearly demonstrated a triangular shadow in the right lower anterior thorax which subsequently proved to be an epipericardial fat pad. On Dec. 28, 1953, a segmental resection of the posterior segment of the right upper lobe was performed. The surgeon, alerted to the triangular radiopacity previously described, reported it to represent an epipericardial fat pad lying in the angle formed by the diaphragm, anterior chest wall, and pericardium. A photograph of the structure through the operative incision is shown in Figure 1. Discussion From Holt's article, it is possible to gather some of the roentgen characteristics of large right-sided epipericardial fat pads.

Empyema Complicating Closed Intrapleural Pneumonolysis and Artificial Pneumothorax

1)The incidence of the tuberculous empyema was studied in a group of difficult closed intrapleural pneumonolyses and in two control pneumothorax groups. 2)The pneumonolysis group showed an empyema rate of 31.7 per cent as compared with 8.4 and 12.9 per cent in the control groups. 3)The more important factors contributing to the high rate were the technical difficulty of the operation, the nature of the adhesions, and the nature of the pulmonary lesion. 4)The time of empyema development showed a common curve pattern for all groups. There is no one set time that can be designated as a pneumonolysis postoperative period but an indefinite time limited by the duration of the pneumothorax. For practical purposes a period of 18 months is adequate.

Complications of Pneumothorax and Pneumonolysis

Closed intrapleural pneumonolysis is a highly valuable procedure which has a definite place in surgical collapse therapy of pulmonary tuberculosis. In well selected cases which show that the pneumothorax is unsatisfactory due to single or multiple adhesions, lysis of adhesions will convert it to a satisfactory one. Suitability of adhesions for lysis can only be predicted with a fair degree of accuracy prior to thoracoscopy. Therefore, this should be performed in all cases of unsatisfactory pneumothorax where there is a possibility of division of the adhesions. The percentage of complete technical failures in our series (6.8 per cent) is lower than in Kunstler (9.4 per cent), but this is probably because in recent years there has been a gradual trend toward the use of pneumoperitoneum and phrenic crush, so that fewer cases are having pneumothorax, therefore fewer cases for thoracoscopy. Complications, resulting from pneumothorax and pneumonolysis are mainly those from prolonged pneumothorax, but are increased by thoracoscopy and lysis of adhesions. Of 110 cases, in whom thoracoscopy was performed 132 times, only 60 had satisfactory pneumothorax. In 33 cases pneumothorax was abandoned, six had subsequent thoracoplasty and two, major pulmonary resection. It is this high incidence of complications, which often render pneumothorax irreversible that has resulted in the loss of popularity of pneumothorax and pneumonolysis. Nevertheless it is a valuable procedure in well selected cases, and rightfully occupies a place in the surgical collapse therapy of pulmonary tuberculosis.

Surgical Therapy of Pulmonary Tuberculosis at a Veterans Administration Chest Center

The surgical therapy in pulmonary tuberculosis at a Veterans Administration chest center (Castle Point), has been described with a discussion of indications and results of various procedures. Stress has been placed on recent additions to the field including: 1)Indications for open pneumonolysis. 2)Surgical intervention for the establishment of a pneumothorax space in cases in whom attempt at pneumothorax was unsuccessful. 3)Revision of thoracoplasty with intrapleural pneumonolysis. 4)Thoracoplasty performed from below upwards. 5)Combined pneumonectomy and pleurectomy.

Thoracoscopy and closed intrapleural pneumonolysis.

Thoracoscopy and closed intrapleural pneumonolysis.

Open intra-pleural pneumonolysis in the treatment of pulmonary tuberculosis

If this brief report has made out a case for re-assessment of the operation of open pneumonolysis in the treatment of pulmonary tuberculosis, in a surgical field in which certain bogeys of a decade ago have been laid, it will have achieved a purpose. So long as relaxation of the diseased lung remains a vital matter for the patient, I would submit that the possibilities of the operation should not too readily be put out of mind for the young patient with a short history of disease and a recently induced artificial pneumothorax, if the findings at thoracoscopy suggest the feasibility of a safe enucleation or section of adhesions by open operation, when closed pneumonolysis has failed. The results in the 13 patients described in this paper were satisfactory in all but 3, despite the general feeling against the operation.

Closed Intrapleural Pneumonolysis

Closed Intrapleural Pneumonolysis

Intrapleural Pneumonolysis

From 1934 to 1944 inclusive, 612 patients at the Boston Sanatorium were submitted to thoracoscopy. In 533 patients a series of 605 pneumonolyses were performed. In 79 cases a pneumonolysis was not attempted because of the character of the adhesions. The Coryllos thoracoscope and galvanocautery was employed in every case. The optimum time for pneumonolysis is 2 to 3 months following induction of pneumothorax. Sputum conversion was effected in 63 per cent of the cases operated upon. The operation is not without danger. The complications are enumerated. Intrapleural pneumonolysis is a highly valuable operation in helping to bring about a satisfactory and effective collapse.

Closed intrapleural pneumonolysis and thoracoscopy.

Closed intrapleural pneumonolysis and thoracoscopy.

Bronchiolar spasm as a cause of reëxpansion of a lung following intrapleural pneumonolysis.

Bronchiolar spasm as a cause of reëxpansion of a lung following intrapleural pneumonolysis.

Indications for intrapleural pneumonolysis; a review of 567 thoracoscopic examinations.

Indications for intrapleural pneumonolysis; a review of 567 thoracoscopic examinations.

CLOSED INTRAPLEURAL PNEUMONOLYSIS

Medical Journal of AustraliaVolume 2, Issue 6 p. 129-137 Original Article CLOSED INTRAPLEURAL PNEUMONOLYSIS C. G. Bayliss, C. G. Bayliss SydneySearch for more papers by this author C. G. Bayliss, C. G. Bayliss SydneySearch for more papers by this author First published: 01 August 1944 https://doi.org/10.5694/j.1326-5377.1944.tb31206.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume2, Issue6August 1944Pages 129-137 RelatedInformation

Intrapleural Pneumonolysis

1) Remember the time factor and begin active pneumothorax treatment immediately upon an individual who has a cavity. Don't wait to see what happens to the case with prolonged bed rest. Too often the realization will be accompanied by disappointment and chagrin. 2) In about half the cases a pneumothorax will be complicated by adhesions. 3) Don't attempt to stretch adhesions by means of a positive pressure pneumothorax. 4) Make an attempt to sever them by intrapleural pneumonolysis—again remembering the importance of time—as soon as possible. 5) In the hands of an expert, the unfavorable consequences of the operation are insignificant and the complications rare, but when performed by one with little experience, the dangers are very real. 6) If it is impossible to improve the collapse by pneumonolysis, abandon the pneumothorax and perform a thoracoplasty.

Giant Mediastinal Hernia in the Course of Bilateral Pneumothorax

Mediastinal hernia is a common occurrence in the course of artificial pneumothorax. Being for the most part innocuous, little thought is given it and there is wide divergence of opinion in estimating its actual frequency. Some authors, Eber among them, considered herniation of the mediastinum a constant feature in pneumothorax. This view had to be reconsidered after hypotensive pneumothorax, introduced by Ascoli, became generally used. In the majority of cases mediastinal hernia is a radiological finding only, and its presence does not influence the conduct of therapy. The following case presents some novel and interesting features, and is another example of perfect tolerance in this condition, even when herniation had attained a giant size. Case No. 4097—M. A. G., a 26-year-old, female, white cuban, was admitted to the Sanatorium in July, 1938, with ulcerative lesions of the left upper lobe and positive sputum. Left pneumothorax proved ineffective because of adhesions, necessitating intrapleural pneumonolysis. Subsequent involvement of the right lung also required its collapse by pneumothorax. Soon after institution of pneumothorax on the right side, a left mediastinal hernia was observed. This herniation became more prominent when insufflation of the left side was delayed. Inasmuch as the right side was kept between —8 and —16 inspiratory pressure, with refills of about 200 cc. of air at fifteen-day intervals, the hernia was regarded as caused by aspiration of the mediastinum into the left hemithorax. At the time we took charge of the case, finding a positive sputum with the right lung apparently clear, we were inclined to attribute the sputum findings to the more thoroughly collapsed left lung. Partial re-expansion of this lung was decided upon in order to ascertain its radiological aspect. In trying to do so, we observed an increase in the size of the hernial pouch. It ballooned out into the left hemithorax until it came in contact with the chest wall, taking the position and appearance of the left upper lobe. In order to re-collapse the left lung, air was injected into the corresponding hemithorax at the axillary level but only a further

Closed Intrapleural Pneumonolysis: A two-year experience with Negroes

We wish, in this article, to discuss general principles associated with the operation of closed intrapleural pneumonolysis. Our observations are based on a two-year experience with the procedure employed on 109 patients, representing a total of 132 thoracoscopic examinations, with or without severance of the adhesions. All of the work was done on Negroes and, with the exception of one patient, all were performed at the Maryland Tuberculosis Sanatorium (Colored Branch), Henryton, Maryland. Artificial pneumothorax, as a collapse measure, is widely employed. It is almost proverbial where pneumothorax is induced, adhesions will be encountered. Adhesions between the parietal and visceral pleurae may vary from a single cord adhesion to a widespread symphysis of the two pleurae completely obliterate the pleural space. In between these two extremes are encountered adhesions whose number, size, location, and appearance are truly protean. The adhesions, naturally, assume paramount importance since, in a large majority of the cases, they interfere with a satisfactory collapse. Figures showing the percentage of pneumothorax cases in which adhesions offer a barrier to an effectual collapse are given by Alexander as 4250 per Jones states that only 50 per cent become effective, and a successful end result was obtained in less than 50 per cent. Our experience shows a much higher percentage than the figures just quoted. A review of the records of 100 consecutive cases in which pneumothorax was induced shows in 26 per cent there was either complete obliteration of the pleural space, or adhesions so widespread only extremely insignificant collapse was obtained, and in 62 per cent adhesions prevented a satisfactory collapse. This brings clearly to the fore the fact pneumothorax, unless supplemented by some other collapse procedure, is an inadequate therapeutic measure in the treatment of pulmonary tuberculosis. To us it has become inconceivable a pneumothorax program can operate, with any appreciable degree of success, without facilities for performing, at the optimum time, some additional collapse measure. The extra hazards follow the maintenance of a pneumothorax, rendered ineffective due to adhesions, are an increase in the amount of spontaneous pneumothorax, an increase in the incidence of tuberculous empyema, and a greater frequency in contralateral or homolateral infection due to bronchogenic spread from uncollapsed cavities. In addition, a fair number of patients complain of pain due to the tug of adhesions on the parietal pleura. If the pain is not considered an important enough indication for relieving the pull of the adhesion, the potential danger of spontaneous rupture is. The purpose of inducing a pneumothorax is the closure of cavities and when, due to adhesions, the closure does not occur within a reasonable period of time, some supplementary procedure must be employed. In the vast majority of cases a closed pneumonolysis is the procedure of choice. There are other supplementary collapse measures can be employed, the most frequently used being surgery of the phrenic nerve. Some prefer to do the phrenic first, which if unsuccessful, is followed by a closed pneumonolysis. We never consider other supplementary surgery until it has been proven the adhesion cannot be severed. Our insistence upon performing a closed pneumonolysis as a primary supplementary measure is due to the fact we consider a closed pneumonolysis less of a hazard and less liable to produce complications than the maintenance of a poor pneumothorax beyond a reasonable time. Surgery of the phrenic nerve rarely causes sufficient rise of the diaphragm or relaxation of the lung in these cases to effect cavity closure; and this is all the more true when the adhesions are horizontal. Too much time is consumed in determining whether this measure will work. The possibility of a complication arising during this interval might cause the abandon-

Closed Intrapleural Pneumonolysis

One hundred and thirty consecutive cases in which thoracoscopy was done are presented. In eight of the cases it was not deemed advisable to attempt to sever the adhesions. In one hundred and twenty-two either a partial or complete pneumonolysis was done. In five of the cases the adhesions were cut in two stages. At the time of discharge, the sputum was negative or absent and no cavity was visible in 48 patients, or 39.3 per cent of the patients who were subjected to pneumonolysis. In 29 patients (23.8%) no cavity was visible after operation but the sputum remained positive. In fourteen of these it is probable that the sputum was coming from disease in the contralateral lung. The cavity remained open and the sputum positive despite operation in 34 (27.9%). It is probable that some of these cavities could have been closed by further severence of the adhesions at a later date, had the patients remained in the sanatorium. Eleven or 9 per cent of the patients remained under observation less than a month and the results in these cases are not included. There was one death, which occurred twelve days after operation, possibly related to the procedure; the immediate cause of death was spontaneous pneumothorax. No other cases of spontaneous collapse occurred. Tuberculous empyema developed at some time during the postoperative course in sever patients. There were two cases in which definite hemorrhage into the pleural space occurred in these two and in one other in which bleeding was not a remarkable feature obliterative pleuritis occurred. At least a “drop” of fluid developed in practically every case. Before a policy of early and frequent aspirations was followed, large number of non-expansile lungs resulted The incidence of this complication was later greatly reduced by earlier aspiration of effusions. Contralateral spread of the disease following pneumonolysis occurred in a few patients but in none was there any evidence that operation was a causative factor. Subcutaneous emphysema of variable degree developed in practically every case.

Closed Intrapleural Pneumonolysis with the One-Piece Operating Thoracoscope

Closed Intrapleural Pneumonolysis with the One-Piece Operating Thoracoscope

The Significance of X-ray Control in Artificial Fixation of the Mediastinum Supplementing Closed Intrapleural Pneumonolysis in Cavernous Pulmonary Tuberculosis

AN artificial pneumothorax can be considered effective only if an anatomical closure of the tuberculous cavity can be proven radiographically. The clinician who, after pneumothorax treatment, is inclined to rely mainly on the improved clinical picture, gain of weight, disappearance of toxic symptoms and of tubercle bacilli, and who, therefore, considers the collapse as clinically effective, will often be disappointed to learn from the radiologist that in spite of an apparent clinical improvement the tuberculous cavity is still open and that his problem is far from being solved. In intrapleural pneumonolysis, for instance, it happens very frequently that a tuberculous cavity does not close in spite of a successful severance of pleural adhesions by the Jacobaeus method. The reason for such failures is mostly a stiffened wall of the cavity. Surgeons like Sauerbruch, therefore, often hesitate to try this method and prefer more radical procedures, such as thoracoplasty. We have learned from Potter,2 who has pr...