Oblique Fissure Research Articles

Linear shadows that connect oblique fissures and costal pleurae on the superior segments of lower lobes: evaluating the imaging findings on thin-slice lung CT.

To retrospectively analyse the imaging findings of the linear shadows that connect the oblique fissures and the costal pleurae on the superior segments of the lower lobes on thin-slice lung CT. Thin-slice CT scans of 221 cases of normal lungs and 86 abnormal lungs were collected. The parameters of the imaging observations included the existence of the superior segmental linear shadow, its morphology, length, and starting position, bird-beak sign, and adjacent structures on the pleural end. The linear shadows were more common on the left lower lobe (43.44%) than on the right side (19.46%). The pleural origins of the linear shadows were mainly located above the carina (69.78%); the adjacent structure on the left lung was the descending aorta (70.83%), and for the right lung, it was next to the thoracic vertebrae (60.47%). In the presence of pulmonary lobectomy or atelectasis, the linear shadows could be extended, which could pull the oblique fissures and costal pleurae to form the bird-beak sign. The linear shadows on the superior segments of the lower lobes are common structures fixing the oblique fissures. Recognition of the linear shadows can help radiologists distinguish normal structures from abnormal ones.

Creating a tunnel for separation of S3 from the middle lobe in a patient with a thick minor fissure

Creating a tunnel for separation of S3 from the middle lobe in a patient with a thick minor fissure

Dissection of Incomplete Fissure Using Electrocautery Is a Safe and Acceptable Method for Thoracoscopic Right Upper Lobectomy

The incidence of prolonged air leak may be highest after right upper lobectomy due to incomplete minor fissure. The objective of this study was to compare the efficacy of direct electrocautery division and suture with that of a fissureless technique during thoracoscopic right upper lobectomy with incomplete fissure. One hundred and two patients underwent right upper lobectomy between January 2016 and December 2016. Of these, 60 patients underwent a right upper lobectomy conducted using the fissureless technique (group A), and 42 consecutive patients underwent a right upper lobectomy via electrocautery division of the fissure and suture (group B). The preoperative, operative, and postoperative parameters were compared between the two groups. The electrocautery and suture group had a higher incidence of prolonged air leak (> 5 days) (30% [12/40] vs 11% [7/62], p = 0.00), a higher incidence of air leakage (20 [32%] vs 38 [95%], p = 0.00), a longer air leak duration (days) (4.93 ± 0.86 vs 3.00 ± 1.60 days, p = 0.00), a longer duration of chest tube (mean 5.30 ± 1.20 vs 3.13 ± 1.88 days, p = 0.00), and a lower hospitalization cost (6463.28 ± 958.30 vs 7459.07 ± 1185.00 €, p = 0.00) than did the fissureless technique group. No differences were observed with respect to patient characteristics, operative characteristics, perioperative mortality, or duration of hospital stay after surgery. The number of patients with prolonged air leak was higher in the electrocautery group. However, electrocautery does not prolong overall length of stay and decreases hospitalization costs. Dissection of incomplete fissure using electrocautery is a safe and acceptable method for thoracoscopic right upper lobectomy.

Creating a tunnel for separation of S3 from the middle lobe in a patient with a thin minor fissure

Creating a tunnel for separation of S3 from the middle lobe in a patient with a thin minor fissure

Pulmonary lobe separation in expiration chest CT scans based on subject-specific priors derived from inspiration scans.

Segmentation of pulmonary lobes in inspiration and expiration chest CT scan pairs is an important prerequisite for lobe-based quantitative disease assessment. Conventional methods process each CT scan independently, resulting typically in lower segmentation performance at expiration compared to inspiration. To address this issue, we present an approach, which utilizes CT scans at both respiratory states. It consists of two main parts: a base method that processes a single CT scan and an extended method that utilizes the segmentation result obtained on the inspiration scan as a subject-specific prior for segmentation of the expiration scan. We evaluated the methods on a diverse set of 40 CT scan pairs. In addition, we compare the performance of our method to a registration-based approach. On inspiration scans, the base method achieved an average distance error of 0.59, 0.64, and 0.91mm for the left oblique, right oblique, and right horizontal fissures, respectively, when compared with expert-based reference tracings. On expiration scans, the base method's errors were 1.54, 3.24, and 3.34mm, respectively. In comparison, utilizing proposed subject-specific priors for segmentation of expiration scans allowed decreasing average distance errors to 0.82, 0.79, and 1.04mm, which represents a significant improvement ([Formula: see text]) compared with all other methods investigated.

An Unusual Intrathoracic Tumour on Pleural Ultrasound for Suspected Effusion

A 52-year-old man presented with sudden-onset pleuritic left chest pain and a 2-week history of dry cough. He reported being otherwise well with no prior imaging of the chest. Posteroanterior chest radiograph demonstrated opacification of the left lower zone with obliteration of the left heart border, diaphragm, and left costophrenic angle. Pleural ultrasound revealed a small anechoic effusion adjacent to a mass. Computed tomography with contrast in pleural phase was performed to further define the mass. However, computed tomography showed a large, homogenous, anteroinferior lesion with an average density of 14 Hounsfield units, suggestive of a loculated pleural effusion. Thoracocentesis with real-time ultrasound guidance was performed, and again showed a small volume of anechoic fluid adjacent to an echogenic mass-like lesion. Both substances were sampled, yielding haemoserous fluid and a haemogelatinous material, respectively. Laboratory analysis of both samples was nondiagnostic. Diagnostic VATS demonstrated a 600 mL haemoserous effusion and a large haematocystic mass in the oblique fissure, abutting the pericardium medially and compressing the lower lobe. Biopsy yielded a spindle-cell tumour, which was subsequently resected via thoracotomy. Radiological, intraoperative, and histopathology images are presented. We believe this case demonstrates both an unusual intrathoracic pathology and the utility of pleural ultrasound in diagnostic imaging of the chest.

Identifying interlobar fissure in a Craig grade 4 fissureless patient by near-infrared thoracoscopy

Traditionally, surgeons can only count on their naked eyes to identify the fissure in patients with incomplete fissures, which often cause surgical approach into the fissural parenchyma and may lead to postoperative prolonged air leak (PAL). We describe a novel technique using near-infrared (NIR) thoracoscopy with indocyanine green (ICG) to identify the fissure accurately and real-timely for the first time in a patient with totally fused oblique fissure (Craig grade 4).

Variations in human pulmonary fissures and lobes: a study conducted in nepalese cadavers.

The fissures of lungs are embryologically separating the bronchopulmonary segments, which later on persist in interlobar planes of fully developed lung. Fifty lungs (23 right side and 27 left side), obtained during routine dissection and preserved in formalin constituted the material for present study. In them, variations in fissures and lobes of lung were observed and compared with the previous studies. Seven right sided and 14 left sided lungs showed incomplete oblique fissure. Incomplete horizontal fissure of right lung was observed in eight lungs while it was completely missing in three specimens. A right lung with “lobe of the azygos vein” separated by a supernumerary fissure in medial surface was found. One of the right lung had both superior accessory fissure and inferior accessory fissure and four other right lungs and one left lung presented only with inferior accessory fissure. A vertical notch was found in middle lobe of one right lung. Eight left lungs exhibited with left minor fissure among them two lungs had lingula appearing as a separate lobe. Knowledge of variations in fissures and lobes is of interest to all medical professionals to exactly interpret radiographs, computed tomography scans, to diagnose, plan and modify a surgical procedure depending on the merit of the case and also in certain classical clinical cases pertaining to lung pathologies.

Transthoracic Littre’s hernia presenting with faecopneumothorax following perforation of the Meckel’s diverticulum: a late complication of oesophagectomy

A Littre’s hernia is an unusual phenomenon where a Meckel’s diverticulum protrudes through a potential abdominal opening. We wish to present a unique case of a 79-year-old man with respiratory...

Influence of fissure integrity on quantitative CT and emphysema distribution in emphysema-type COPD using a dedicated COPD software

ObjectivesFissure integrity (FI) plays a key role in selecting patients for interventional emphysema therapy. We investigated its interference with automated lobar segmentation in quantitative computed tomography (CT) and emphysema distribution. MethodsCT was available for 50 patients with chronic obstructive pulmonary disease (COPD). Lobe segmentation was performed fully automated by software and corrected manually. FI was evaluated visually using a %-scale. The influence of FI on emphysema ratio (ER=percentage of lung volume with density values<−950 HU), mean lung density (MLD), emphysema and total volume of adjacent lobes was analyzed. Lobe-based results were compared with respect to FI. ResultsDifferences in ER in adjacent lobes for complete vs. incomplete fissures were 12.4% for the right horizontal, 0.2% and 3% for the right oblique and 4.4% for the left oblique fissure (all p>0.05). Results for emphysema comparing automated vs. manually corrected segmentation exceeded clinically acceptable values, but were not significantly affected by FI (p>0.05). The widest limits of agreement for ER and MLD were noted in the right middle lobe ([−14, 17.4%], [−22.4, 32.4 Hounsfield Units]). ConclusionsAutomated lobe segmentation and emphysema distribution are not significantly affected by FI. Manual correction of automated lobar segmentation is still recommended in severe emphysema.

The bronchial anatomy after complete division of the oblique fissure between upper and lower lobe

The bronchial anatomy after complete division of the oblique fissure between upper and lower lobe

Bilateral Accessory Lung Fissures with a Variant Left Bronchial Tree

Accessory lung fissures are commonly noted, while bronchial branching abnormalities are less frequently found and are proposed to occur in 0.1–2% of the general population. Multiple accessory fissures, variant normal fissures of both lungs, and an altered left bronchial tree are unique to this case and is being reported due to its clinical significance. During a routine dissection of the thoracic cavity of an 85‐year‐old female cadaver, abnormal fissures were noted on both the right and left lungs, which were photographed. The bronchial branching was further dissected by tracing the bronchus from the hilum to the lung tissue. The right lung had a normal oblique fissure, while the horizontal fissure was shallow and incomplete. The left lung had a normal oblique fissure, and a minor fissure was noted running along the junction of the anterior (S3) and superior lingular (S4) bronchopulmonary segments. Accessory fissures were noted on both right and left lungs. The left bronchus was short and displayed an early division into upper and lower divisions. The dissection of the bronchial tree of the left lung showed trifurcation of the upper division into apicoposterior, anterior, and lingular bronchi. The lower division was normal. The right bronchial tree showed normal division. Examination of the heart revealed an atrial septal defect. The other thoracic and abdominal structures were examined and appeared normal. Knowledge of accessory fissures in the lung have importance in the clinical diagnosis of lobar pneumonia versus atelectasis with imaging and during resection of bronchopulmonary segments. Understanding this bronchial variation and anomalies have implications in diagnosis and endobronchial treatment, including airway stenting, bronchoscopy, endoscopy biopsy, and laser therapy.Support or Funding InformationTouro College of Osteopathic Medicine, Department of Anatomy

Strength and Deformation Behavior of Fiber-Reinforced Cohesive Soil Under Varying Moisture and Compaction States

An experimental study was carried out to investigate the effects of glass fiber reinforcement on the strength and deformation behavior of a cohesive soil under different compaction states by means of unconfined compression tests. The specimens were prepared with varying fiber contents, fiber lengths, dry unit weight and moisture content other than maximum dry unit weight and optimum moisture content of the soil. From the test results, peak strength, failure axial strain, secant modulus and energy absorption capacity of the reinforced soil specimens were calculated and compared with that of the unreinforced soil. The results showed that the relative benefits of fiber reinforcement are highly dependent on the moisture content and dry unit weight of the soil specimens. The peak strength of the reinforced soil specimen increases gradually with increase in dry unit weight, whereas the improvement of peak strength with moisture content occurs up to optimum moisture content. The brittle failure pattern with a single distinct shear plane of the unreinforced soil specimens is gradually transformed to multi-shear failure pattern along with barreling shape at low fiber content, and then to plastic bulging failure with a network of minor fissures at higher fiber content.

A cadaveric study on morphological variations of fissures and lobes in the human lungs and its clinical significance

Background: Knowledge of the anatomy and variations of the major fissures are essential to recognize pulmonary abnormalities, for segmental lung resection and radiological interpretations. Objective: To study the morphological variations of fissures and lobes in the human cadaveric lungs. Materials and Methods: One hundred specimens of formalin-fixed adult lungs of unknown gender were studied and the following parameters were measured bilaterally: (a) presence or absence of complete or incomplete fissure, (b) presence of accessory fissure, and (c) length of fissures. The observations and measurements were recorded, compiled, and tabulated and the result was compared with the other studies. Results: Length of oblique fissure was 29.36 ± 5.61cm with range of 17.9 - 42.0 cm on the right side and 26.81 ± 8.18 cm with range of 10.8–38.9 cm on the left side. Length of horizontal fissure was 10.2 ± 8.4 cm with range of 6.1–12.8 cm on the right side. Oblique fissure was complete in 84.0% cases on the right side and was in 82.0% cases on the right side. It was incomplete or absent in 16% (R) and 18% (L) cases. Horizontal fissure was complete in 74% and incomplete or absent in 26% of cases. Accessory fissure was found in a total of eight lung specimens. Conclusions: The knowledge of anatomy of fissures of the lung provides information on lobar anatomy with variations. The present study result and its comparison with other researches confirmed that lobar architecture is not constant. It emphasizes its usefulness in the diagnostic and surgical field.

Morphological Variation of Fissure and Lobe of the Left Lung: A Case Report

Abstract The left lung usually has an oblique fissure that divides it into superior and inferior lobes. Some variants in the lobar fissure are well known, but the knowledge of certain uncommon variants will enhance our anatomical understanding and proper identification of the bronchopulmonary segments. Several imaging techniques have been used to describe anatomical variations of the lung, but studies that utilize dissections as tools for understanding lobar variations were limited. In this report, we described an incomplete horizontal fissure, bifurcated accessory fissure, incomplete superior and middle lobes, and fibrous condensation of the left lung pulmonary pleura observed during dissection. The knowledge of these anatomical variations will be useful in surgical segmental resection and lobectomy, and for accurate interpretations of medical diagnostic images.

Pleural effusion resembling a lung tumor: phantom tumor of the lung

78-years- old female known case of Congestive Heart failure, with ejection fraction of 55% on recent echocardiograph, presented with complains of Shortness of breath, Cough and sputum without fever. She had stopped taking medications recently and examination showed patient in fluid overload. Conventional posteroanterior Chest radiograph revealed a mass like opacity in lower zone of the right lung while Lateral view radiograph showed cigar shaped opacity due to pleural effusion in oblique fissure of the right lung. Patient was given diuretics on the basis of clinical and radiographic findings and the rounded opacity disappeared on repeat radiograph. Thus the diagnosis of Phantom tumor of lung was made. It is therefore suggested to get a lateral chest radiograph and give a trial of diuretics in such cases before going for other investigations or surgical procedures.

Thoracoscopic Lobectomy in Infants and Children Utilizing a 5 mm Stapling Device.

Purpose: Thoracoscopic lobectomy for congenital cystic lung disease has become an accepted and in many institutions the preferred technique. However, the technical challenges are many. Previous endoscopic staplers (12 mm) used commonly in adults are too large for use in infants This study evaluates the safety and efficacy of using a 5 mm stapling device to seal and divide major pulmonary structures.Methods: From July 2014 to March 2016, 26 patients of age 6 weeks to 13 months underwent thoracoscopic lobectomy for CPAM or sequestration. Weights ranged from 3.2 to 11.4 kg. There were 7 upper lobectomies, 2 middle, and 17 lower lobectomies. In each case, the 5 mm stapler (Justright Surgical; Louisville, Colorado) was the primary device for vessel and bronchial sealing and division. It is 4.8 mm in diameter with an anvil length of 25 mm and lays down four rows of staples and divides between them. A 3 mm sealing device was used for dissection and to take smaller segmental vessels as necessary. Stump lines were evaluated for bleeding or air leak in all cases.Results: All procedures were accomplished successfully thoracoscopically. The stapler was used on the main lobar artery cases and vein in 24 cases, a large systemic sequestration vessel in 5 cases, and the bronchus in all 26. The stapler was also used to complete the minor fissure in 1 case and the major fissure in 1 case. A total of 96 staple loads were fired. Operative times ranged from 35 to 135 minutes. There was no significant bleeding of any vascular stump. In 1 case, the edge of the bronchial stump had to be reinforced, this was thought to be secondary to too much tissue being enclosed in the jaws. There were no postoperative complications.Conclusion: The use of a 5 mm stapling device appears to be safe and effective in thoracoscopic lobectomy in infants. It allows for safe management of major pulmonary vessels and bronchi in the confined chest of an infant through a single 5 mm port.

Absence of horizontal fissure right lung

Objectives : To examine the dissected cadavaric right lungs for the presence or absence of minor (horizontal) fissure right lung . Design: Descriptive study. (cadavaric study). Place and duration: - The study was conducted in dissection halls of various Medical colleges of Lahore (FMHC, FJMC &amp; KEMC) from January 2003 to February 2004. Material &amp;methods: A total number of 112 cadavaric specimens of right lung were dissected &amp;examined for the presence or absence of minor fissure. Results: - Out of 112 specimens 9(9%) of specimens were showing the absence of minor fissure of right lung whereas 103(91%) of specimens of right lungs were showing presence of minor fissure. Conclusion: The percentage of anatomical variation (absence)of minor fissure of right lung is 09%. The study of anatomical variations of fissures of lungs is important for anatomists, surgeons&amp; radiologists.

Double-domed horizontal fissure

We read with interest the article entitled “Volumetric thin-section CT: evaluation of pulmonary interlobar fissures” by Guan et al. (1) in the November-December 2015 issue of Diagnostic and Interventional Radiology. The authors gave detailed information about interlobar fissures, their incompleteness, relationship to vascular structures, CT appearance, and defect location. The interlobar fissures and their variations are important for identifying pulmonary lesion locations, evaluating disease progression, and selecting appropriate surgical or interventional approaches. Therefore, it is important to know any detail about fissural anatomy and its variations. All horizontal (minor) interlobar fissures have been described as having one dome in the literature (2, 3). We would like to contribute by noting that they may also have a double dome. During the last five-year period, out of approximately 35 000 thorax CT scans, we came across five patients with double-domed horizontal fissure (Figs. 1, ​,2).2). Those patients did not have any abnormality that might change fissural anatomy like atelectasis or fibrosis. Although double-domed horizontal fissure is a very rare entity, it is important to keep it in mind to avoid misinterpretation. Figure 1 A 35-year-old male patient. Axial CT image, 1 mm slice thickness, shows double-domed horizontal fissure (empty arrows, anterior dome; solid arrows, posterior dome; curved arrows, oblique fissure). Figure 2. a, b A 74-year-old male patient. Axial CT image 1 mm slice thickness (a) and sagittal oblique 2 mm reformatted CT image (b) show double-domed horizontal fissure (empty arrows, anterior dome; solid arrows, posterior dome; curved arrows, oblique fissure).

The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema.

In patients with severe emphysema, bronchoscopic lung volume reduction using one-way valves is a promising therapeutic option to improve lung function and quality of life. The goal of this treatment is to achieve a complete lobar atelectasis. In a significant proportion of patients, this atelectasis cannot be achieved due to interlobar collateral ventilation. This collateral ventilation is generated through incomplete lobar fissures. Therefore, only patients with complete fissures and no collateral ventilation can be selected for endobronchial therapy with one-way valves.Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%–85% for the right major fissure, 19%–74% for the left major fissure, and 20%–90% for the minor fissure. There are several methods of measuring or predicting the presence of collateral ventilation, with computed tomography (CT)-fissure analysis and the Chartis measurement being the most important. CT-fissure analysis is an indirect method to measure the completeness of fissures as a surrogate for collateral ventilation. The Chartis system is an endobronchial method to directly measure the presence of collateral ventilation. Both methods have unique value, and the combination of both can accurately predict the treatment response to the bronchoscopic placement of endobronchial valves. This review provides an in-depth view of lung fissure and collateral ventilation to help understand its importance in selecting the appropriate patients for new emphysema treatments and thus avoid useless treatment in unsuitable patients.