Persistent Pneumothorax Research Articles

Early and Persistent Hemothorax and Pneumothorax

The incidence of traumatic injury to the thorax is estimated at up to 40 % of patients that require hospitalization. The vast majority of these injuries can be managed with observation. However, the presence of pneumothorax or hemothorax has traditionally mandated tube thoracostomy placement and the inherent morbidities that may arise. Persistent pneumothorax is typically defined as the presence of pneumothorax and/or air leak for 5–7 days after tube placement. This morbidity may be managed expectantly or with video-assisted thoracoscopic surgery (VATS). The most feared complication after hemothorax is the presence of retained blood and the risk of infection that follows. Most authorities support the early use of VATS to resolve retained hemothoraces with the hopes of avoiding more invasive procedures aimed at the treatment of fibrothorax and empyema.

LONG-TERM RESULTS OF COMBINED TREATMENT OF METASTASES OF SARCOMA OF THE MUSCULOSKELETAL SYSTEM IN THE LUNGS

From 2004 to 2014 forty-six patients with sarcomas of the musculoskeletal system with metastatic lesions in the lungs were operated in MRRC. In 22 patients with a primary bone sarcoma metastases were detected in 27% cases, and in 29% of 24 patients with soft tissue sarcomas metastases were identified at the time of diagnosis. Twenty women and twenty-six men aged 16 to 72 years (mean age was 39 years) were operated. In most cases metastases were located subpleurally. Solitary metastases were observed in 8 patients (17%), single in 11 (24%) and multiple in 27 (68%) and 18 patients of them had bilateral disease. In all cases, chemotherapy was conducted at the first stage of treatment, according to histology of the tumor. In cases of large metastases or close location to the root of the lung (27 patients) preoperative distal radiotherapy was conducted in hyperfraction regimen with a daily dividing of the dose (2 times a day with an interval of 4 h every other day with single dose of 3 Gy and the total dose of 30 Gy that was isoefficiency to 42 Gy), after that the removal of pulmonary metastases was performed. A total of 73 surgical interventions performed in 46 patients. Most often precision resection of the lung using a neodymium YAG surgical laser MY 40 (wavelength 1318 nm) was performed. One patient underwent pneumonectomy. Videothoracoscopy was used in 6 cases. From 1 to 103 metastases were excised during one intervention. Pneumonia with abscesses were diagnosed in 3 patients, persistent pneumothorax in 5 patients, all complications were treated conservatively. There was no postoperative mortality. Fourteen patients underwent 2 procedures, two patients – 3 procedures, two patients – 4 procedures and one patient had 6 procedures. Follow-up ranged from 3 to 126 months. Twenty-six patients died due to progression of the disease. 3-year and 5-year survival was 46% and 41% respectively. Median survival was 32 months. Thus, the combined treatment of generalized forms of sarcomas of the musculoskeletal system can achieve long-term remission and significantly prolong life. Surgical resection should be applied in patients with solitary and with multiple metastases in the lungs and should be combined with systemic treatment (PCT) and, if indicated, with additional local treatment (distant radiotherapy) of metastases. Precision resection is adequate and well-tolerated method of surgical treatment of metastases in the lungs and does not correlate with severe postoperative complications.

Independent lung ventilation in the management of pneumothorax

Introduction: Independent lung ventilation (ILV) with double lumen endotracheal tube (DLt) or endobroncial blockade has a known role in managing pneumothorax or by isolating the diseased lung. We report a case in which ILV was used along with a bronchial blocker for treatment of severe persistent pneumothorax (PtX). case report: We report a 66-year-old female admitted with septic shock and respiratory failure from right lobar pneumonia who developed a rightsided pneumothorax. Despite the placement of two chest tubes, the patient had persistent acidosis and air leak. she required independent lung ventilation with a double lumen endotracheal tube and a bronchial blocker. this isolated the right lower lobe airleak and provided lung protective concordant positive pressure ventilation to the right middle and upper lobes. conclusion: Persistent air leaks in an intubated patient can be challenging. Our case highlights the concept of anatomical lung separation. With this clinicians can to allow provide isolation of the diseased lung, while using other subsegments to maintain adequate gas exchange. Muna Beg1, Pantea Mahtosh1, Sudhir Rajan1, Hekmat Nasiri1, Vincent Liu1,2 Affiliations: 1Kaiser Permanente Santa Clara Medical Center, Homestead Campus, 3rd floor, Department 384, 710 Lawrence Expressway, Santa Clara, CA 95051, USA; 2Kaiser Permanente Division of Research 2000 Broadway Oakland, CA 94612, USA. Corresponding Author: Muna Beg, MD, 1-562-481-4328, Kaiser Permanente Santa Clara Medical Center, Graduate Medical Education Department, Homestead Campus, 3rd floor, Department 384, 710 Lawrence Expressway, Santa Clara, CA 95051, USA; E-mail: Muna.a.beg@kp.org Received: 26 May 2015 Accepted: 02 June 2015 Published: 03 September 2015

Talcoma: A Diagnostic Challenge in Differential Diagnosis of Pleural Masses.

Talcoma is a pleural mass which may develop as a rare complication following talc pleurodesis. Talc pleurodesis is performed to obliterate the pleural space to prevent recurrent pleural effusions or persistent pneumothoraces. The present report describes a case of a patient who developed enlarging pleural mass (talcoma) following talc pleurodesis.

Anaesthetic management of primary repair of complete right bronchial rupture following blunt chest trauma

Tracheobronchial injury is a rare incidence after blunt trauma injury. Isolated complete bronchial tear is very rare. If it is not managed properly and timely, it can lead to significant morbidity and mortality. Clinical manifestations of tracheobronchial injury include persistent pneumothorax, subcutaneous emphysema, pneumomediastinum and respiratory insufficiency. Anaesthesiologists face challenges while securing the airway, controlling oxygenation, managing one-lung ventilation and maintaining anaesthesia during airway surgery. The preferred airway management technique is to intubate the healthy bronchus with a single-lumen or double-lumen endotracheal tube. We report successful anaesthetic management of complete traumatic rupture of the right main bronchus at the carina in adult male patients by using a left-sided double-lumen endotracheal tube. After induction, right thoracotomy was performed and bronchial transection was repaired successfully. Early correct diagnosis and proper repair can lead to excellent outcome.

Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax.

The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection. Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschueren's classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only. From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1-11) and 3 days (range of 2-11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported. The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia.

Pleuroparenchymal fibroelastosis: one more walk on the wild side of drugs?

In this issue of the European Respiratory Journal , Beynat-Mouterde et al. [1] report on six young adults (three of whom were female) who developed a clinical imaging pattern of predominant upper lobe fibrosis with apical pneumothoraces (fig. 1). Presentation in all six patients was similar with cough, dyspnoea, occasional chest pain and weight loss. Imaging was distinctive and showed a cephalad, irregular, pleural-based thickening that encroached on the lung bilaterally. Five patients presented with “platythorax” (fig. 2), a preferential reduction in the anterio-posterior diameter of the chest wall. In all patients, severe restrictive or restrictive-obstructive lung dysfunction progressed to hypoxaemic and hypercarbic respiratory failure, which was fatal in four patients despite intensive care unit support. This outcome was all the more tragic as these four patients had survived previous malignant conditions, including haematological malignancy (n=3) and brain tumour (n=1). Figure 1– a) Frontal chest radiograph in a patient following chemotherapy for acute lymphoblastic leukaemia showing a typical appearance of pleuropulmonary fibroelastosis (corresponding to case 2 in [1]). Note the markedly thickened pleural dome on the right and partial spontaneous pneumothorax on the left. b) Computed tomography scan of the same patient taken several months later. A chest tube had been inserted and removed in the interim. A smaller, persistent pneumothorax is visible. Figure 2– Advanced cases may show markedly restrictive physiology and reduced anterio-posterior diameter of the thorax; a trait known as platythorax. Pathology in four patients showed a pattern consistent with pleuropulmonary fibroelastosis (PPFE). Due to similar clinical imaging presentation, two additional patients without biopsy were included in the study of Beynat-Mouterde et al. [1]. There was a history (6 months to 16 years previously) of multi-agent chemotherapy in all six patients; the alkylators cyclophosphamide (n=5) and BCNU (bis-chloroethylnitrosourea; n=1) …

Retrospective evaluation of the use of autologous blood-patch treatment for persistent pneumothorax in 8 dogs (2009-2012).

To describe the clinical course, outcome and success rate of 8 dogs with persistent pneumothorax treated with autologous blood-patch pleurodesis (ABP). Retrospective case series. University teaching hospital Eight client-owned dogs. Non-coagulated blood was aseptically collected from the jugular vein and injected immediately into the pleural cavity of dogs with persistent pneumothorax. The procedure was successful in 7 of 8 dogs. The median duration of pneumothorax until the ABP was performed was 4 days (range 2-6 days). Pneumothorax resolved immediately after 1 treatment in 4 dogs. Pleurodesis was repeated once in 3 dogs, and twice in 1 case after which it resolved in 3 of the 4 dogs. Out of a total of 13 ABP procedures performed in 8 dogs, 5 (62.5%) were successful after 1 procedure and the success rate increased to 87.5% after additional procedures. One dog failed ABP and was euthanized 3 days later due to continued deterioration and a hospital acquired pneumonia. Mild to moderate complications occurred in 2 other dogs and resolved in both. ABP is a simple, inexpensive, and relatively safe procedure which can be considered in dogs with persistent pneumothorax that have failed conservative or surgical management. Infections following ABP were documented in 2 of the 8 dogs and resolved in 1 dog.

Abstract No. 446 - Lung cryoablation offers procedure flexibility

Abstract No. 446 - Lung cryoablation offers procedure flexibility

Pneumothorax following flexible fiberoptic bronchoscopy: A rare occurrence.

Sir, Pneumothorax following flexible fibreoptic bronhoscopy is rare. It occurs 1 in 450 bronchoscopy.[1] We report a case of such event in a trauma victim. A 34-year-old male patient with alleged history of road traffic accident admitted in our trauma center. On initial examination, his airway was patent, he was breathing at the rate of 22 breaths/min with air entry diminished over the right lung. Initial hemodynamics were stable with heart rate of 96 beats/min and blood pressure of 126/88 mmHg. Contrast-enhanced computed tomography scan chest revealed the fracture of 1st, 2nd, 3rd, and 7th ribs on the right side with hemopneumothorax and multifocal contusions in all lobes of the right lung. A right-sided intercostal tube drain (ICD) was placed. Pneumothorax and hemothorax resolved subsequently. He was shifted to the general ward. After 4 days of admission, patient developed acute respiratory distress with fall in oxygen saturation (90%) and was transferred to trauma intensive care unit (ICU). On initial evaluation, his chest X-ray showed [Figure 1] right lung collapsed with mediastinal shift toward the right side. A flexible bronchoscopy was contemplated in view of provisional diagnosis of mucus plug obstructing the major airways. A flexible bronchoscopy was carried out and a large mucus plug was aspirated from the right bronchus thereby clearing the airway. The patient was kept on positive pressure ventilation after the procedure. Immediately following the flexible bronchoscopy a large air leak became apparent in right-sided ICD. A follow-up chest X-ray showed a new large pneumothorax and collapse whole lung [Figure 2]. Ventilatory settings were adjusted to minimize the leak and the ICD was connected to negative pressure of 15 mmHg. A second ICD was inserted in order to control the leak and expand the lung. After 2 days, air leak controlled and lung got expanded. Patient was shifted to high dependency unit for further care. Figure 1 Chest X-ray showed collapsed right lung with mediastinal shift toward the right side Figure 2 Chest X-ray demonstrated a new large pneumothorax and collapse of whole the right lung Flexible fiberoptic bronchoscopy is a safe procedure carried out in patients admitted to ICUs. Its indication varies between diagnostic to therapeutic interventions including regular bronchoalveolar lavage for microbiological sampling, diagnosis of pulmonary hemorrhage, use in cases of difficult intubation, as a control in percutaneous tracheostomies, and aspirations of secretions.[2] Its use in clearing the airway because of mucus plug is considered as a standard practice particularly in patients where physiotherapy has failed to do so. However, its complications are infrequent. Most frequent complications cited in the literature are supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).[2] Pneumothorax following flexible bronchoscopy has been reported infrequently in literature. Pue et al. have reported pneumothorax following flexible bronchoscopy in 0.16% of cases. Predominantly, it followed transbronchial biopsy procedure.[3] de Blic et al. analyzed prospectively in 1328 flexible bronchoscopy procedures in children and noted 0.1% incidence of pneumothorax.[4] In both the above analysis, none has reported pneumothorax following aspiration of secretion or mucus plug in case of chest injury following trauma. Moreover, flexible fiberoptic bronchoscopy was used here as a diagnostic modality to identify the cause of persistent pneumothorax and bronchial injuries. Mechanism that might have led to pneumothorax in our patient can be attributed to initial lung injury. Probably, the mucus plug had sealed the existent bronchial rent underlying lacerated lung and corrected the initial hemopneumothorax. As soon as the mucus plug got aspirated during flexible bronchoscopy the lung laceration got expose to high airway pressures and caused escaping of air into the pleural cavity. To conclude, although flexible bronchoscopy is a safe procedure, it mandates close monitoring during and after the procedure. It is important to have a high index of suspicion and a follow-up chest X-ray to identify a potentially dangerous complication.

Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic mechanism

IntroductionThe management and removal of thoracostomy tubes for trauma-related hemothorax and pneumothorax is controversial. General recommendations exist; however, institutional data related to an algorithmic approach has not been well described. The difficulty in establishing an algorithm centers about individualized patients’ needs for subsequent management after thoracostomy tube placement. In our institution, we use the same protocol for all trauma patients who receive a thoracostomy tube with minimal complications.PurposeTo present the clinical outcomes of patients who required a tube thoracostomy for traumatic injury and were managed by an institutional protocol.MethodsA retrospective chart review of 313 trauma patients at a single level I trauma institution from January 2008 through June 2012 was conducted. Inclusion criteria were patient age ≥ 18 years, involvement in a trauma, and requirement of a thoracostomy tube. The patients’ charts were reviewed for demographic data, injury severity score (ISS), length of stay (LOS), and chest-tube specific data. Thoracostomy tube complications were defined as persistent air leak, persistent pneumothorax, recurrent pneumothorax, and clotting of thoracostomy tube. The patients were managed per our institutional algorithm. Descriptive statistics were performed.ResultsMost of the patients who required a thoracostomy tube had blunt-related traumas (271/313; 86.6%), while 42 patients (13.4%) sustained penetrating injuries. There were 215 (68.7%) male patients. The average age at time of injury was 45.7 ± 21.1 years and the mean ISS was 24.9 ± 15.9 (mean ± SD). Elevated alcohol levels were found in 65 of the 247 patients who were tested upon admission (26.3%). Overall, 15 patients (4.8%) developed a thoracostomy tube related complication: persistent air leak in six patients, persistent pneumothorax in six patients, recurrent pneumothorax in two patients, and clotted thoracostomy tube in one patient. The average LOS was 10.4 ± 8.4 days, and the mean length of thoracostomy tube placement was 5.9 ± 4.3 days.ConclusionsOur algorithmic thoracostomy tube management protocol resulted in a complication rate of 4.8%. By managing thoracostomy tubes in a systematic manner, our patients have improved outcomes following placement and removal compared to other studies.

Repair of Tracheal Aspergillosis Perforation Causing Tension Pneumothorax

Tracheobronchial aspergillosis is a rare entity mainly observed in immune-compromised patients or those who have undergone transplantation. It may cause airway ulcerations or bleeding. We report the case ofa 17-year-old patient receiving chemotherapy foracute lymphoblastic leukemia who presented withright-sided tension pneumothorax. Chest tube drainage revealed a massive air leak without reexpansion of the lung, and bronchoscopy showed a15-× 15-mm defect of the distal trachea related to aspergillosis infection. The defect was closed by an intrathoracic transposition of a pedicled latissimus dorsi muscle flap, which was sutured into the debrided defect followed by temporary endotracheal stenting and antifungal medication.

Should pregnant patients with a recurrent or persistent pneumothorax undergo surgery?: Table 1:

A 29-year old woman at 26 weeks gestation (gravida 3 and para 0) presented with an acute left-sided pneumothorax. She had a 10 pack-year smoking history and no other relevant medical history. Over the next 3 weeks, she had three recurrences of her left-sided pneumothorax, each of which was managed by intercostal drain insertion. During the fourth episode of pneumothorax, after chest drain insertion there was a continued air-leak for 4 days. She was referred to the cardiothoracic service for further management of this problem. A best evidence topic was constructed according to a structured protocol to answer the question: in pregnant patients with a recurrent or persistent pneumothorax, is surgery safer compared with conservative treatment for the wellbeing of the patient and the foetus? The 2010 guidelines for the management of pneumothorax state that there is Level C evidence that simple observation and aspiration are usually effective during pregnancy, with elective assisted delivery and regional anaesthesia at or near term. The guidelines also state Level D evidence that a video-assisted thoracoscopic surgery (VATS) procedure should be considered after birth. Three hundred and eighty-four papers were found, and from these, four papers were identified describing 79 cases of pneumothorax in pregnancy to provide the best evidence to answer the question. Conservative treatment by observation alone with or without tube thoracostomy compared with surgical treatment by VATS or thoracotomy are the options used in the observed literature reviews. All reports observe no difference in outcome to the mother or foetus if a conservative approach (observation or tube thoracostomy) is used compared with surgery prior to the delivery of the baby. However, an initial conservative approach could lead to surgery after delivery for a persistent pneumothorax in as much as 40% of patients. A persistent pneumothorax after delivery that might require surgery delays discharge home and compromises the normal interaction between the mother and new-born child, which might be distressing. For informed consent, the implications of the risk of persistent pneumothorax requiring surgery after delivery where a conservative approach is used initially should be discussed with the patient and family to aid decision making.

Bronchopleural Fistula Mimicking Chronic Obstructive Lung Disease on 133Xe Scan

A 56-y-old woman with a history of non–small cell lung cancer presented with a persistent left pneumothorax and a left bronchopleural fistula after bronchial balloon occlusion. A ventilation–perfusion scan using 133Xe and 99mTc-macroaggregated albumin (MAA) was requested to evaluate for possible

O-075TIMING FOR SURGICAL FIXATION OF MULTIPLE SIMPLE RIB FRACTURES AND FLAIL CHEST: A SINGLE-CENTRE EXPERIENCE

Objectives: The performance and timing of surgical fixation of multiple simple rib fractures and flail chest wall remains controversial. We report our experience with acute and delayed multiple simple rib fracture and flail chest wall surgical fixation. Methods: Since December 2006, 46 patients had surgical fixation using external titanium plates and bicortical screws for either multiple simple rib fractures or flail chest. We analysed operation details, hospital stay and complications. Results: 29 patients [Group 1, 21 males, median age 54 (range 31-77) years] underwent fixation within 6 days following injury (range 1-43). Indications included: significant deformity/displacement, n= 19; respiratory failure, n= 6; uncontrolled pain, n = 3; persistent pneumothorax, n= 1. 17 patients [Group 2, 12 males, median age 58 (range 25-76) years] had delayed fixation at 12 (range 4-159) months following injury due to persistent pain, dyspnoea or deformity. 24 patients in Group 1 had flail chest vs 5 in Group 2 (P < 0.001). Critical care stay was zero in Group 2. Eighteen patients in Group 1 had median critical care stay of 4 (range 0.5-34) days. Postoperative length of stay (PLOS) was longer in Group 1 for both flail chest and multiple simple rib fractures (13.6 ± 10 days vs 3.6 ± 0.6 days, P =0 .1, and 7.4 ±3 .8 days vs 7 ± 1.7 days, P = 0.01, respectively). Nine patients in Group 1 (31%) developed complications (chest infection, n = 5; sputum retention, n =1 ; deep wound infection, n = 1; prolonged respiratory wean, n = 1; internal jugular vein thrombosis, n = 1) vs 3 patients in Group 2 (17.6%, P =N S; surgical infection, n = 1; neurogenic pain, n =1 ; haemothorax,n =1 ). Although symptomatic improvement was noted in most Group 2 patients, 18% had persistent pain. Conclusions: Fixation of multiple rib fractures is safe and effective in both the acute and delayed setting. Patients undergoing acute repair have an acceptable critical care stay. Although early repair is recommended, delayed fixation may still be of benefit. Disclosure: All authors have declared no conflicts of interest. Interactive CardioVascular and Thoracic Surgery

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review

Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Spontaneous pneumothorax complicating lung emphysema. So, what’s the catch?

Spontaneous pneumothorax secondary to lung carcinoma is very rare (0.05% of all pneumothoraces). We report a case of a 66-year-old male with persistent right-sided spontaneous pneumothorax, initially suspected as secondary to bullous emphysema. Intraoperative findings consisted of an apical bulla with a nonspecific carnification at its base and a bulla at the lower lobe. Surprisingly, histological examination revealed an undefined non-small cell carcinoma. Although spontaneous pneumothorax associated with lung carcinoma is rare, suspicion for malignancy should be raised in patients over 40 presenting with spontaneous pneumothorax, especially in high risk patients such as smokers or patients with chronic bronchitis or emphysema. (Med J Indones. 2013;22:54-6) Keywords: Emphysema, lung cancer, pneumothorax

Lung ossification: an orphan disease.

Diffuse pulmonary ossification (DPO) is a rare entity which is characterized by metaplastic bone formation in the lung parenchyma. It is an uncommon condition without significant symptoms, which is usually diagnosed on autopsy. Diffuse pulmonary ossification can be easily misdiagnosed as one of interstitial lung diseases due to diffuse pulmonary lesions. Two types of diffuse ossification are described in medicine: dendriform and nodular. In this article, the authors present a patient with persistent pneumothorax who underwent investigation of the cause of his disease and a diagnosis of DPO was revealed.

A Rare Case of Persistent Pneumothorax in Non-Small Cell Lung Cancer on Bevacizumab Therapy

Bevacizumab which is a humanized murine monoclonal antibody against vascular endothelial growth factor, given in combination with carboplatin and paclitaxel, was granted a labeling extension treatment of advanced-stage Non-Small Cell Lung Cancer (NSCLC). Common toxic effects include hypertension, proteinuria, and neutropenia. Rare complications include bleeding, particularly hemoptysis, and surgical wound dehiscence, but pneumothorax in NSCLC is rare. We report a case of persistent pneumothorax related to bevacizumab in a patient with NSCLC. *Corresponding author: Hidefumi Koh, Division of Pulmonary Medicine, Department of Internal Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashimachi, Utsunomiya-shi, Tochigi 321-0974, Japan, Tel: +81-28-6265500; Fax: +81-28-626-5594; E-mail: hdfmkoh@yahoo.com Received January 13, 2013; Accepted March 25, 2013; Published March 26, 2013 Citation: Koh H, Kamiishi N, Kimura Y, Tajima A, Yagami T, et al. (2013) A Rare Case of Persistent Pneumothorax in Non-Small Cell Lung Cancer on Bevacizumab Therapy. J Pulmon Resp Med S14: 001. doi:10.4172/2161-105X.S14-001 Copyright: © 2013 Koh H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Robot-Assisted Thoracoscopic Thymectomy for Treating Myasthenia Gravis in Children

In the United States, the prevalence of myasthenia gravis (MG) is approximately 14-20 per 100,000. One treatment option involves a thymectomy, which can lead to remission of symptoms. The amount of thymic tissue removed is correlated with a better outcome for patients. Thus, it is critical that the procedure used when performing a thymectomy maximize the resection of thymic tissue. Robotic-assisted thoracoscopic thymectomy provides a minimally invasive platform that avoids the mortality and morbidity of a median sternotomy while providing better visualization and a more delicate dissection than is available in a standard thoracoscopic procedure. Following Institutional Review Board approval, in total, 9 patients who underwent robotic thymectomy were reviewed. Intraoperative statistics such as operative time and blood loss were reviewed from operative records. Postoperative outcomes such as hospital stay, discharge medications, and complications were reviewed from hospital charts. Lastly, disease response was evaluated in consultation with a pediatric neurologist who specializes in MG. Age at operation ranged from 2 to 15 years of age (average, 9.4 years). A majority of patients had an MGFA classification of II or greater (n=5). All patients were on pyridostigmine preoperatively, and 7 of 9 (77%) were taking prednisone. Mean operative time was 160.1±6.1 minutes. Average postoperative hospital stay was 1.1±0.3 days. One patient had a documented persistent pneumothorax on postoperative Day 1, which was treated with nasal cannula oxygen for an additional day. There were no additional operative complications, and all patients were discharged home on acetaminophen with codeine for pain control. Eight of 9 patients had improvement in MG symptoms after the procedure. Robotic-assisted thoracoscopic thymectomy is a safe and effective operation for children with MG. Robotic assistance allows for articulating instruments, three-dimensional visualization, and minimal blood loss. These factors may allow for a more complete resection compared with a standard thoracoscopic thymectomy.