Pleural Space Complications Research Articles

Outcomes of right sleeve lower lobectomy vs. lower bilobectomy for lung malignancies

ObjectivesLower bilobectomy (LBL) leaves a residual pleural space potentially associated with adverse postoperative outcomes. In selected patients, right sleeve lower lobectomy (RSLL) with anastomosis between the middle lobe bronchus and intermediate bronchus is feasible. The outcomes of RSLL and LBL have not been compared. The aim of this study was to compare post-operative and long-term outcomes of RSLL and LBL in patients with lung cancer. MethodsWe retrospectively included patients managed by RSLL or LBL at our referral chest-surgery institution between 2001 and 2019. Post-operative complications and mortality were compared. Kaplan-Meier curves were plotted to compare overall and disease-free survival rates. ResultsWe identified 23 patients with RSLL and 96 with LBL. Postoperative mortality was 9 % after RSLL and 5 % after LBL (p = 0.41). Bronchial fistula developed in 3 (13 %) RSLL patients and 6 (6 %) LBL patients (p = 0.23). Pleural space complications were significantly less common after RSLL (4/23 [17 %] vs. 45/96 [47 %], p = 0.03). Long-term vital capacity was significantly higher in the RSLL group (91 % vs. 64 %, p < 0.01). Five-year survival did not differ significantly between groups (84 % vs. 72 %, p = 0.09). ConclusionsRSLL was associated with similar postoperative mortality and long-term survival compared to LBL. However, pleural space complications were less common and lung function was better after RSLL than after LBL. When feasible, RSLL may deserve preference over LBL in patients with lung cancer managed at highly experienced centres.

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.

Readmission for pleural space complications after chest wall injury: Who is at risk?

Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. Prognostic and epidemiologic, Level IV; Care management, Level V.

Pleural Space Complications from Tuberculous Empyema: A Case Report and Short Literature Review

Tuberculous empyema (TE) is an uncommon form of pleural tuberculous (TB). Although the incidence of TE has significantly decreased, it still threatens public health. Patients with TE experience a protracted illness and significant morbidity and mortality risk. Male sex is a significant risk factor for TE. Herein, we report an adult case of TE admitted to a tertiary care hospital of Iran with clinical characteristics, treatment modalities, and outcomes of this disease. The duration of illness and duration of chest tube drainage equaled 7 months and 48 days, respectively. Our patient required surgery despite the administration of antituberculosis drugs and chest tube drainage. Due to the presence of parenchymal lesions, bronchopleural fistula, and failure of lung re-expansion after chest tube insertion, the patient required decortication with the closure of the bronchopleural fistula and additional thoracoplasty. In the case presentation, we emphasize difficulties encountered in the treatment of such patients.

A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).

The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. Therapeutic, level II.

Predictors of Outcomes After Thoracic Surgery in Orthotopic Liver Transplant Recipients With Pleural Disease

Orthotopic liver transplant (OLT) recipients are at high risk for postoperative pulmonary complications. We aim to determine factors associated with morbidity and mortality in OLT recipients that required thoracic surgery for pleural space complications. A retrospective review was performed of 42 patients who underwent thoracic surgery after OLT between 2005 and 2015. Preoperative data and postoperative outcomes were reviewed. Time to mortality was summarized using Kaplan-Meier curves. Outcomes associated with 30-day morbidity and mortality as well as long-term mortality were analyzed with univariate analysis. Between 2005 and 2015, 1735 OLTs were performed at our institution. We identified 42 patients who required thoracic surgery. Of these 42 OLT recipients, 33 patients required thoracic surgery for pleural space complications. The median interval between OLT and thoracic surgery for pleural space complications was 5.7 months (interquartile range 2.2-14.1). The most common surgical indications were chronic pleural effusion (n = 12, 36.4%) and empyema (n = 10, 30.3%). The most common thoracic operations were decortication and empyema evacuation. The 30-day morbidity was 69.7%. Bilirubin and empyema were significantly associated with 30-day morbidity (odds ratio [OR] = 2.3, P = 0.023; OR = 16.3, P = 0.015). The 30-day, 1-year, and 5-year mortality rates were 15.2%, 57.6%, and 70.2%, respectively. Vasopressor requirement was significantly associated with 30-day mortality (OR = 10.2, P = 0.031). The development of pleural space complications requiring surgery in OLT recipients suggests a poor prognosis. Hyperbilirubinemia and pleural space infections were associated with high postoperative morbidity in OLT recipients requiring thoracic surgery for pleural space complications.

Bilobectomy for lung cancer: contemporary national early morbidity and mortality outcomes.

To determine contemporary early outcomes associated with bilobectomy for lung cancer and to identify their predictors using a nationally representative general thoracic surgery database. A total of 1831 patients, who underwent elective bilobectomy for primary lung cancer between 1 January 2004 and 31 December 2013, were selected. Logistic regression analysis was performed on variables for major adverse events. There were 670 upper and 1161 lower bilobectomies. Video-assisted thoracic surgery was seldom performed (2%). Induction therapy and extended resection were performed in 293 (16%) and 279 patients (15.2%), respectively. Operative mortality was 4.8% (upper: 4.5%/lower: 5%; P = 0.62), and significantly higher following extended procedures when compared with standard bilobectomy (4.3 vs 7.5%; P = 0.013). Pulmonary complication rate was 21.1%. Bronchial fistula occurred in 46 patients (2.5%) and pleural space complications in 296 (16.2%). Their respective incidence rates were significantly higher following lower than upper bilobectomy (3.5 vs 0.7%; P < 0.001 and 17.8 vs 13.3%; P = 0.007). At multivariate analysis, extended procedures [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.03-5.31; P = 0.04], ASA scores of 3 or greater (OR, 2.02; 95% CI, 1.33-3.07; P < 0.001) and World Health Organization performance status 2 or greater (OR, 1.47; 95% CI, 1.01-2.13; P = 0.04) were risk predictors of mortality. Female gender (OR, 0.39; 95% CI, 0.19-0.80; P = 0.01), highest body mass index (BMI) values (OR, 0.91; 95% CI, 0.86-0.96; P = 0.001) and recent years of surgery (OR, 0.91; 95% CI, 0.84-0.99; P = 0.02) were protective. Predictors of bronchial fistula were male gender, lowest BMI values, lower bilobectomy and longest operative times. Male gender, lowest BMI values and longest operative times were also predictors of pulmonary complications, together with highest ASA scores and lowest forced expiratory volume in 1 s values. Risks related to lower bilobectomy lie halfway between those reported for lobectomy and pneumonectomy. Additional surgical measures to prevent pleural space complications and bronchial fistula should be encouraged with this operation. In contrast, upper bilobectomy shares more or less the same hazards as lobectomy.

A Novel Tissue-Engineered Approach to Problems of the Postpneumonectomy Space

Transfer of viable tissue flaps and thoracoplasty are effective against pleural space complications after pneumonectomy but highly disfiguring. The aim of this study was to explore the possibility of engineered tissue to treat space complications after pneumonectomy. A left pneumonectomy was performed in mice, and the cavity immediately filled with the cellularized collagen matrices. First, bone marrow derived-mesenchymal stroma cells with luciferase expression were used as donor cells to evaluate cell viability and angiogenesis using bioluminescence imaging. Second, using bone marrow cells from GFP mice, histologic evaluation, immunohistochemistry for von Willebrand Factor, and flow cytometric analysis was performed compared with acellular matrix implants. The effect on bacterial clearance was examined using an empyema model with Staphylococcus aureus expressing luciferase. Embedded cells proliferated within the denatured collagen matrices ex vivo. In vivo, bioluminescent imaging activity could be detected till day 8, and the slope (suggesting rate of perfusion with luciferin) increased with time up to day 6 but decreased after day 7. Although GFP-positive donor cells decreased with time, total cellularity increased. Furthermore, vessels stained by von Willebrand factor were significantly increased. Both cellularized and acellularized matrices showed bacterial clearance in vivo. Cells within collagen matrices survive in the thoracic cavity at early time points. Cellularized matrices quickly lead to neovascularization and recipient cell infiltration. Both cellularized and acellularized matrices show bacterial clearance in vivo. This study indicates the potential feasibility of a novel tissue engineering approach to problems of the postpneumonectomy space.

Pleural complications in lung transplant recipients

Pleural complications occurred in 30 (22%) of 138 patients after 53 single and 91 double lung transplants between September 1986 and February 1993. These were defined for the purpose of this study as pneumothorax persisting beyond the first 14 postoperative days, recurrent pneumothorax, or any other pleural process that necessitated diagnostic or therapeutic intervention. Overall, a higher pleural complication rate was seen in double lung transplantation (25 of 30) than in single lung transplantation (5 of 30) with no differences noted in the frequency among preoperative diagnostic groups (p > 0.05). Pneumothorax was the most frequent complication, affecting 14 of 30 patients, with 6 of 14 cases occurring after transbronchial biopsy. All pneumothoraces in single (n = 4) and double lung transplantation (n = 10) resolved spontaneously or with chest tube thoracostomy. One patient required placement of a Clagett window after open lung biopsy and another required thoracotomy and pleural abrasion after transbronchial biopsy. Parapneumonic effusion was observed in 4 of 30 double lung transplantations with spontaneous resolution in all cases. Empyema affected 7 of 30 patients and occurred exclusively in the double lung transplant group. Sepsis developed in three of the patients with this complication and they subsequently died. The risk of empyema was independent of preoperative diagnosis (p > 0.05). Of interest, all patients with cystic fibrosis (n = 3) with complicating empyema had Pseudomonas cepacia in the pleural fluid. Other miscellaneous complications included subpleural hematoma, chylothorax, and hemothorax. The latter two necessitated thoracic duct and bronchial artery ligation, respectively. In summary, a significant proportion of lung transplant recipients will have pleural space complications. The vast majority of these will resolve spontaneously or with conservative procedures. These complications were not related to preoperative diagnosis nor associated with a significant prolongation of hospital stay (p > 0.05). Empyema is the only pleural space complication associated with increased patient mortality and, as such, is an important clinical marker for those at risk for sepsis and death.

Cryosurgery of respiratory structures. II. Cryonecrosis of the lung.

AbstractThis study was undertaken in dogs and monkeys to assess the sequelae of cryosurgery of the lung. In seven animals, a cryoprobe was repeatedly applied to the entire right middle lobe. In no instance was the probe inserted through the pleura into pulmonary parenchyma, but the pulmonary parenchyma was firmly compressed beneath the probe tip during freezing. This permitted through‐and‐through freezing of the entire right middle lobe and ensured complete cryonecrosis of the entire lobe. In three animals, a portion of the right lower lobe was also frozen by repeatedly applying the probe tip to the midportion of that lobe.All animals survived the procedures, and all resumed normal activity within 24 hours of operation. There were no pleural space complications except for the production of pleural adhesions. All lesions had the features of an acute hemorrhagic infarct, characterized by intense local hemorrhage and complete coagulation necrosis, typical of cryolesions. Subsequently, there was total collapse and fibrosis of underlying pulmonary tissue with areas of hemorrhagic necrosis, hemosiderin in macrocytes, focal calcification, and hyalinization. Serum lactic dehydrogenase values and leukocyte counts promptly increased after cryosurgery; however, all values returned to normal within 14 days, and no significant changes were noted thereafter. Thoracic roentgenograms showed changes consistent with consolidation of the right middle lobe, and by seven weeks, the only roentgeno‐graphic evidence of the cryotreated middle lobe was a small density in the hilus. Histologically, this was a small mass of scarified tissue that sealed the bronchial stump and major vessels at the hilus and consisted of organized fibrosis.