Segmental Lung Resection Research Articles

Application of three-dimensional printed models with near-infrared fluorescence technology in video-assisted thoracoscopic surgery segmentectomy: a single-center propensity-score matching analysis.

The combination of three-dimensional printing (3DP) technology and near-infrared fluorescence (NIF) technology using indocyanine green (ICG) has demonstrated significant potential in enhancing surgical margin and safety, as well as simplifying segmental resection. However, there is limited literature available on the integrated use of these techniques. The current study assessed the effectiveness and value of integrating 3DP-NIF technologies in the perioperative outcomes of thoracoscopic segmental lung resection. This single-center, retrospective study recruited 165 patients with pulmonary nodules who underwent thoracoscopic segmentectomy. Eligible patients were categorized into two groups: the 3DP-NIF group (71 patients) treated with a combination of 3DP-NIF technology, and the three-dimensional computed tomography bronchography and angiography with modified inflation-deflation (3D-CTBA-ID) group (94 patients). Following rigorous propensity-score matching (PSM) analysis (1:1 ratio), perioperative outcomes between these two approaches were compared. Sixty-six patients were successfully matched in each group. In the 3D-CTBA-ID group, inadequate visualization of segmental planes was noted in 14 cases, compared to only five cases in the 3DP-NIF group (P=0.03). In addition, the 3DP-NIF group demonstrated a shorter time for clear intersegmental boundary line (IBL) presentation {9 [8, 10] vs. 1,860 [1,380, 1,920] s} (P<0.001), and shorter operative time (134.09±34.9 vs. 163.47±49.4 min) (P<0.001), postoperative drainage time (P<0.001), and postoperative hospital stay (P=0.002) compared to the 3D-CTBA-ID group. Furthermore, the incidence of postoperative air leak was higher in the 3D-CTBA-ID group than in the 3DP-NIF group (33.3% vs. 7.6%, P<0.001). The combination of 3DP-NIF technologies served as a reliable technical safeguard, ensuring the safe and efficient execution of thoracoscopic pulmonary segmentectomy.

Clinical Efficacy Analysis of Wedge Resection of Pulmonary in Patients with Small Volume Invasive Lung Adenocarcinoma

With further understanding and research into non-small cell lung cancer with tumours ≤2 cm in maximum diameter, segmental lung resection is able to achieve the same long-term prognosis as lobectomy. However, there are few studies on the prognostic effect of wedge resection on small volume invasive lung adenocarcinoma with an invasion depth of 0.5 to 1.0 cm. Therefore, this study focuses on the clinical efficacy and prognosis of wedge resection in patients with small-volume invasive lung adenocarcinoma. A retrospective analysis of the medical records of 208 patients who underwent surgery in the Department of Thoracic Surgery of the Affiliated Provincial Hospital of Anhui Medical University from February 2016 to December 2017 was made, and the postoperative pathological results confirmed small volume invasive lung adenocarcinoma. According to their surgical methods, they were divided into lobectomy group (n=115), segmentectomy group (n=48) and wedge resection group (n=45). Kaplan-Meier survival curve estimation and Cox proportional risk regression model were used to explore the influence of different surgical methods on the prognosis of patients with small volume invasive lung adenocarcinoma. The wedge resection group had better perioperative outcomes compared with the segmentectomy group and lobectomy group, with statistically significant differences in intraoperative bleeding (P=0.036), postoperative drainage (P<0.001), operative time (P=0.018), postoperative time with tubes (P=0.001), and postoperative complication rate (P=0.006). There were no significant differences when comparing the three groups in terms of survival rate (lobectomy group vs segmentectomy group, P=0.303; lobectomy group vs wedge resection group, P=0.742; and segmentectomy group vs wedge resection group, P=0.278) and recurrence-free survival rate (lobectomy group vs segmentectomy group, P=0.495; lobectomy group vs wedge resection group, P=0.362; segmentectomy group vs wedge resection group, P=0.775). Univariate and multivariate survival analyses showed that consolidation tumor ratio (CTR) was the prognostic factor of overall survival and revurrence-free survival for patients with small-volume invasive lung adenocarcinoma (P<0.05). Wedge resection in patients with small volume invasive lung adenocarcinoma can achieve long-term outcomes similar to segmentectomy and lobectomy. When the CTR≤0.5, wedge resection is preferred in such patients.

Pulmonary function protection by single-port thoracoscopic segmental lung resection in elderly patients with IA non-small cell lung cancer: A differential matched analysis.

In patients with stage IA non-small cell lung cancer (NSCLC), uniportal video-assisted thoracic surgery (U-VATS) anatomical segmentectomy removes the lung tumor while preserving lung function as much as possible, and it is therefore an alternative to lobectomy. Patients with stage IA NSCLC receiving U-VATS segmental resection at our institution from September 2017 to June 2019 were compared with patients receiving U-VATS lobectomy. A total of 47 patients received segmentectomy and 209 patients received U-VATS lobectomy in the same period. Propensity score matching was conducted to diminish bias. The final study cohort included 42 patients who received segmentectomy and 42 propensity score matching-matched patients who received lobectomy. Perioperative parameters and postoperative complications, length of hospital stay, postoperative forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) were compared between the 2 groups. Surgery was successfully completed in all patients. The mean follow-up was for 8.2 months. The postoperative complication rate was comparable between the 2 groups: 31.0% in segmentectomy patients versus 35.7% in lobectomy patients (P = .643). At 1 month after surgery, FEV1% and FVC% were not significantly different between the 2 groups (P > .05). At 3 months after surgery, FEV1 and FVC were higher in segmentectomy patients than in lobectomy patients (FEV1, 82.79% ± 6.36% vs 78.55% ± 5.42%; FVC, 81.66% ± 6.09% vs 78.90% ± 5.58%, P < .05). Patients receiving segmentectomy suffer less pain and have better postoperative lung function and higher quality of life.

Application of Three-dimensional Computed Tomography Bronchography and Angiography Combined with Perfusion Area Identification Technique in Uniport Thoracoscopic Complex Segmentectomy

With the extensive application of segmental lung resection in the treatment of early-stage lung cancer, how to complete segmentectomy more accurately and minimally invasively has become a research hotspot. The aim of this study is to explore the application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with perfusion area recognition technique in single-hole thoracoscopic complex segmentectomy. From January 2021 to January 2022, the clinical data of 112 consecutive patients undergoing single-port thoracoscopic complex segmentectomy in the Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University were retrospectively analyzed. The three-dimensional reconstruction combined with perfusion area identification technique was used to perform the operation and the clinical data were analyzed. The average operation time was (141.1±35.4) min; the initial time of intersegmental plane display was (12.5±1.7) s; the maintenance time of intersegmental plane was (114.3±10.9) s; the intersegmental plane was clearly displayed (100%); the amount of bleeding was [10 (10, 20)] mL; the total postoperative drainage volume was (380.5±139.7) mL; the postoperative extubation time was (3.9±1.2) d; and the postoperative hospitalization time was (5.2±1.6) d. Postoperative complications occurred in 8 cases. The advantages of 3D-CTBA combined with perfusion area recognition technique are fast, accurate and safe in identifying intersegmental boundary in single-port thoracoscopic complex segmentectomy, which could provide guidances for accuratding resection of tumors, shortening operation time and reducing surgical complications.

Хірургічне лікування секвестрації легень у дітей

Pulmonary sequestration is a complex malformation of the lungs, which is based on a violation of the development of their bronchopulmonary and vascular components. The multifactorial nature of morphological and functional disorders is clinically manifested by respiratory distress syndrome and heart failure with a threat of a critical outcome for a newborn child, despite the sufficient development of the respiratory system as a whole. Purpose - optimization of diagnosis and treatment of lung sequestration in children based on the study of clinical and diagnostic data, as well as the results of surgical treatment. Materials and methods. The study included 18 patients aged from 8 days to 18 years, including newborns - 6, children from 1 to 12 months - 5, from 1 to 3 years - 3, from 7 to 9 years - 2 and from 15 to 18 years - 2. Median age was 4.5 months. Research methods included evaluation of clinical symptoms, chest X-ray, contrast-enhanced CT, and angiography. Prenatal diagnosis was carried out using ultrasonography and fetal MRI. In all cases, open surgical treatment was used. Results. Intrapulmonary sequestration was diagnosed in 13 (72.2%) patients, extrapulmonary - in 5 (27.8%), p=0.082. Left-sided localization in 11 (61.1%) patients, right-sided localization in 7 (38.9%) patients, р=0.3. Associated malformations had 9 (50%) patients: polycystic (n=4) or hypoplasia (n=2) of the lung, diaphragmatic hernia (n=3), pericardial defect (n=1), thoracic dystopia of the kidney (n=2), Waardenburg syndrome (n=1), ventricular septal defect (n=1), innominate artery tracheal compression (n=1). Symptomatic course was noted in 15 (83.3%) patients, asymptomatic - in 3 (16.7%) cases (p=0.021). Main symptoms were as follows: pulmonary bleeding, hemophthisis, respiratory and hemodynamic disorders, signs of inflammation. Lobectomy (n=8), atypical segmental lung resection (n=4) and transection of aberrant vessels (n=1) were performed for intrapulmonary sequestration, and sequestrectomy (n=4) for extrapulmonary sequestration. In cases of associated diaphragmatic hernia (n=3), simultaneous diaphragmatic plasty was performed, including using a non-free pericardial flap (n=1) or a PTFE patch (n=1), and in case of innominate artery compression of the trachea, aortopexy (n=1). In 17 (94.4%) cases, a positive result of surgical treatment was noted. Postoperative complications (intrathoracic bleeding) and lethality were observed in 1 (5.6%) case. Patients were examined in the long-term period from 2 months to 30 years after surgery. Conclusions. Surgical correction of pulmonary sequestration is appropriate as the diagnosis is made, mainly in the neonatal period. Given the complexity of the pathology, especially in the presence of associated malformations, and the expediency of early correction in the neonatal period, thoracotomy access should be preferred as safer for sequential division of arterial and then venous vessels, and for atypical segmental lung resection or lobectomy, depending on peculiarities of sequester. The presence of associated defects requires simultaneous correction. In the case of associated diaphragmatic hernia, autopericardial defect plastics or a synthetic patch are appropriate as an alternative to simple suturing. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Keywords: congenital malformations of the lungs, lung sequestration, surgical treatment, children.

Small Bowel Metastatic Melanoma: An Emblematic “Coal-Black” Appearance at Videocapsule Endoscopy

A 80-year-old woman underwent vulvar melanoma resection and segmental lung resection for pulmonary metastasis. Immunotherapy with Nivolumab was performed. One year later, the patient was admitted for gastrointestinal (GI) recurrent bleeding and severe anemia. Esophagoastroduodenoscopy and colonoscopy did not show any abnormality, while videocapsule endoscopy (VCE) revealed an irregular and exophytic whitish area with a “coal-black” central depression. Small bowel resection was performed and histological examination revealed S100 protein strongly positive melanoma metastasis. The patient died six months later from disease progression. A “coal-black” appearance of intestinal metastatic melanoma has been described only twice before this report. In one case the patient had been treated by immunotherapy with interferon A and dendritic cell-based vaccination. In our patient, it is presumable that the picture we observed was a consequence of Nivolumab treatment inducing the disappearance of melanocytes in the area surrounding the metastasis with the onset of the central coal-black lesion encircled by whitish tissue. This picture should be emblematic of intestinal metastatic melanoma in subjects treated with immunotherapy showing occult/obscure bleeding.

Simultaneous surgery for concomitant lung cancer and diffuse coronary atherosclerosis

To evaluate the early outcomes of simultaneous surgeries in patients with concomitant lung cancer and coronary artery disease. We retrospectively reviewed 37 consecutive patients who underwent CABG with adjunct endarterectomy (n=21) or long segmental coronary artery reconstruction (n=25) and lung resection between 2003 and 2019. Mean age was 61.4±6.7 (range 58-71) years. Males prevailed (n=32, 86.4%). Median sternotomy was used in all patients. Myocardial revascularization was followed by on-pump lung resection. The most common procedure was lobectomy (94.6%) of the right upper lobe (83.7%). Lymph node dissection was performed in all patients. CPB time was 162±19.3 min, aortic cross-clamping time 71±14.2 min. There was no in-hospital mortality. Incidence of perioperative myocardial infarction was 5.4%. Postoperative complications were atrial fibrillation (n=6, 16.6%), re-exploration for bleeding (n=1, 2.7%), pneumonia (n=2, 5.4%). Mean hospital-stay was 14.4 days (range 11-21). Simultaneous lung resections and coronary artery reconstruction is a safe and reliable surgical method in patients with diffuse coronary atherosclerosis and lung cancer. The developed system of choice, evaluation and surgical treatment of patients with concomitant cardiopulmonary pathology is fundamental for successful treatment of these difficult patients. We need larger randomized studies for certainty.

Persons working capacity after pulmonary tuberculosissurgery

Objective — to analyze the level of disability and incapacity for workresulting from surgical interven­tions for pulmonary tuberculosis.Materials and methods. The analysis of the results of surgical treatment of 343 patients with pulmonary tuberculosis was performed. The following types of surgical interventions were performed in the patient: lobectomy, segmental resection of the lungs, thoracoplasty, thoracoplasty in combination with resection methods, pleurectomy, pneumonectomy.Results and discussion. Because of the intervention 98 (28.6 %) patients experienced a decrease or loss of capacity to work, followed by the appointment of a disability group. Among them 33 got II, and 65 — III disability groups. After lobectomy, disability was diagnosed in 37 (10.8 %) patients, after segmental lung resection — in 16 (4.7 %), thoracoplasty — in 34 (9.9 %), thoracoplasty with segmental resection or lobectomy — in 2 (0.6 %), pleurectomy — 2 (0.6 %), pneumonectomy — 7 (2.0 %) patients. Pneumonectomy has led to disability in 100 % of cases, thoracoplasty — 73.9 %, segmental resection — 21.1 %, lobectomy — 24.5 %, pleurectomy — 9.1 %, thoracoplasty in combination with lobectomy or segmental resection — in 4,9 % of cases. After the carried operation 77 (78.5 %) people were not worked, 15 (15.4 %) were worked 6 (6.1 %) were studying.Conclusions. As a result of surgery treatment for pulmonary tuberculosis, a total loss of capacity to work with the appointment of the II group of disability was 9.6 % of operated, partial loss of capacity to work (group III) — in 19.0 % of patients. Simultaneous surgical interventions give better results than resection as regards the rehabilitation.

Pulmonary sequestration in children. postnatal course, diagnosis and surgical treatment

The aim — to optimize the diagnostic and treatment of pulmonary sequestration in children on the basis of clinical and diagnostic data and treatment results study.Materials and methods. The study included 14 patients aged 8 days to 17 years, 3 of which were newborns, 4 — from 1 to 12 months, 3 — from 1 to 3 years, 2 — 7­8 years, and 2 — 15 — 17 years old. There were 8 (57.1 %) boys and 6 (42.9 %) girls. Postnatal diagnosis was based on contrast computed tomography or angiography. In all cases the surgical treatment was performed. In 5 cases, the diagnosis of pulmonary sequestration was established intraoperatively during the surgery for mediastinal tumor, congenital diaphragmatic hernia or polycystic lung.Results and discussion. Ten (71.4 %) patients had intralobar sequestration and another 4 (28.6 %), extralobar one (p = 0.099), left­side localization was in 9 (64.3 %) cases, right­side in 5 (35.7 %). Associated malformations were found in 7 (50.0 %) patients and included polycystic lung (n = 3), lung hypoplasia (n = 2), diaphragmatic hernia (n = 2), pericardial defect (n = 1), thoracic dystopia of kidney (n = 1), Waardenburg syndrome (n = 1). Twelve (85.7 %) patients had a symptomatic disease presented with respiratory or hemodynamic disorders, signs of inflammation and hemophtysis. Lobectomy (n = 4), segmental lung resection (n = 4) or division of aberrant vessels (n = 2) were used in cases of intralobar disease depending on the extent of lesion while sequesterectomy (n = 4) was performed in extralobar sequestration. Simultaneous diaphragmoplasty, including that with use of bounded autopericardial flap (n = 1) was performed in 2 cases of associated diaphragmatic hernia. There were no postoperative complications and mortality. Late follow­up examination within the period from 4 to 22 years after the operation showed positive results in all 100 % of cases.Conclusions. Pulmonary sequestration, since the diagnosis is established, is subject to compulsory surgical correction, the effectiveness of which reaches 100 %. Correction of intralobar sequestration consists of lobectomy or segmental resection of the lungs, in the case of extralobar disease sequesterectomy is indicated. Associated congenital diaphragmatic hernia can be effectively corrected by diaphragmoplasty, including that with use of autopericardium.

Analysis of middle- and long-term efficacy of thoracoscope-assisted segmental resection of the lung on non-small cell lung cancer in the early stage.

We investigated the short- and long-term efficacy of thoracoscope-assisted segmental resection of lung of non-small cell lung cancer (NSCLC). We selected a total of 94 patients with lung cancer in the early stage who were admitted to The First People's Hospital of Xuzhou for treatment between March 2011 and February 2012. Patients were divided randomly into either the control group (n=47) or the observation group (n=47). In the observation group, patients received thoracoscope-assisted segmental resection of lung, while in the control group, the conventional thoracic surgery was performed for treatment. After surgeries, we observed the incidence rate of complications among the two groups, and enzyme-linked immunosorbent assay (ELISA) was adopted to detect levels of inflammatory factors. We also compared the cardiac and pulmonary functions, the levels of immunoglobulins and subgroups of T lymphocytes in the peripheral blood of the patients. In addition, all patients attended a 5-year follow-up to determine the recurrence and survival rate. Compared to the control group, patients in the observation group had significantly less intra-operative bleeding volume, a shorter duration of surgery, and suffered slighter pain after surgery (P<0.05). After surgery, the incidence rate of complications in the observation group was significantly lower than that in the control group (P<0.05). After surgeries, patients in both groups experienced a remarkable improvement in cardiac and pulmonary functions, and the improvement in the observation group was superior to that of the control group (P<0.05). During the 5-year follow-up, the survival rate of the observation group is significantly higher than that in thecontrol group, and patients in the observation group experienced a lower recurrence rate than those in the control group (P<0.05). Thus, thoracoscope-assisted segmental resection of lung is of great significance in clinical practice.

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.

Trends and New Evidence in the Management of Acute and Chronic Post-Thoracotomy Pain-An Overview of the Literature from 2005 to 2015.

IN ADDITION TO being a major stressor, thoracotomies are associated with moderate-to-severe pain, impairment of respiratory function, protracted recovery, and the potential for the development of chronic pain. Of all surgical procedures, thoracotomies may create the greatest demand for postoperative analgesia. Even after less-invasive techniques, such as videoand robotic-assisted thoracoscopic surgery, postoperative pain is of considerable concern. Uncontrolled post-thoracotomy pain has important implications for a patient’s recovery and can add significant morbidity and increase healthcare costs. Absence of adequate post-thoracotomy analgesia in patients undergoing lung surgery may be associated with delayed postoperative extubation. Cywinski et al conducted a logistic regression analysis on 2,068 patients who underwent open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection and found that the absence of thoracic epidural analgesia (TEA) was a significant predictor of delayed extubation. Based on the authors’ review of the relevant literature, in the past decade no single paradigm shift in the treatment of postthoracotomy pain has been reported. Cumulatively, however, a recent body of evidence now supports an expanded armamentarium of pharmacologic and procedural interventions and an improved understanding concerning the etiology of thoracotomy pain. The aim of this review was to report on many of these numerous incremental findings by providing a concise overview and discussion of recent relevant evidence, which, in aggregate, could contribute to improved clinical outcomes.

Absence of both fissures in a right lung: a case report

AbstractThe right lung has two fissures which separate the lung into three lobes. They are the oblique fissure and the horizontal fissure and the lobes are superior, middle and the inferior lobes respectively arranged from the apex of the lung to the base. In the present case, during routine dissection the right lung was observed to have complete absence of both oblique fissure and horizontal fissure and there was no lobar pattern. The lung pleural membrane was continuous from the apex to the base. Hilum structures were arranged normally. Left lung was completely normal with no variation. Variation of anatomy of lung fissures is important in case of diagnosis of lung pathologies and in the modality of treatment for segmental resection of lung.

Radical resection of upper right lung under thoracoscopic guidance.

In recent years, thoracoscopic lobectomy has been rapidly developing and applied in China with an ever growing list of indications as the resectable range has been evolving from the peripheral type to the central type, from a diameter less than 3 cm to greater than 5 cm, and from lobectomy to pneumonectomy and segmental lung resection. This technique has become a routine option in our department. This video shows one case of thoracoscopic lobectomy with lymph node dissection for upper right lung cancer of 6 cm in diameter.

Rare Cavitary MAC Lung Disease Causing a Serious Broncho-Pleural Air Leak in an Immune Competent Patient

Mycobacterium avium - intracellulare complex (MAC) is a non-tuberculous mycobacterium that can cause a variety of pathologies in both immune-competent and immune-deficient individuals. In this paper, I present a rare and unique case of severe MAC cavitary pulmonary disease complicated by a serious broncho-pleural air leak and persistent hydropneumothorax in a patient with normal immunity. His successful recovery took a lengthy antibiotic course and a segmental lung resection with pleural decortication. A brief discussion about MAC lung disease follows this presentation. J Med Cases • 2013;4(12):825-827 doi: http://dx.doi.org/10.4021/jmc1578w

Congenital emphysema in children: Segmental lung resection as an alternative to lobectomy

BackgroundCongenital emphysema is a rare lung malformation characterized by overinflation of lung segments or lobe, together with ventilation and lung perfusion disorders. The lesion frequently causes respiratory distress in infants and may require urgent surgery. The pathogenesis is still controversial, and the usual treatment recommended is a lobectomy. AimThe aims of the study were to clarify the pathogenesis and relationship to vascular abnormalities and to assess the safety and efficacy of lung-sparing segmental resections. Materials and MethodsRetrospective review of hospital records, chest radiograph, digital subtraction angiography, and contrast-enhanced chest CT were used for diagnosis. ResultsForty-three (median age 4months, range 10days to 10years) children were diagnosed with congenital emphysema. Most were <1year of age at presentation (n=33; 77%). The predominant side affected was the left (n=24; 56%), and of these all but one had segmental (not lobar) lesions. Most of these then underwent segmental lung resection (S1–S3) with preservation of the uninvolved lingual (S4–5) segments preserved. A standard lobectomy was used in right-sided lesions. There was a high incidence of vascular abnormalities in association with the emphysematous segments, which may be important in its etiology. One child, referred in extremis and died before surgery could be undertaken. Otherwise, early and late results of surgery were rated as good or excellent in all patients. Longer-term follow-up of the preserved left lingual segments did not suggest any recurrence of emphysema. ConclusionSegmental resection in cases of left-sided congenital emphysema appears effective and merits further use as a lung-sparing operation.

Rare Cavitary MAC Lung Disease Causing a Serious Broncho-Pleural Air Leak in an Immune Competent Patient

Mycobacterium avium-intracellulare complex (MAC) is a non-tuberculous mycobacterium that can cause a variety of pathologies in both immune-competent and immune-deficient individuals. In this paper, I present a rare and unique case of severe MAC cavitary pulmonary disease complicated by a serious broncho-pleural air leak and persistent hydropneumothorax in a patient with normal immunity. His successful recovery took a lengthy antibiotic course and a segmental lung resection with pleural decortication. A brief discussion about MAC lung disease follows this presentation. J Med Cases. 2013;4(12):825-827 doi: https://doi.org/10.4021/jmc1578w

Predictors of Prolonged Postoperative Endotracheal Intubation in Patients Undergoing Thoracotomy for Lung Resection

The aim of this study was to identify predictors of delayed endotracheal extubation defined as the need for postoperative ventilatory support after open thoracotomy for lung resection. An observational cohort investigation. A tertiary referral center. The study population consisted of 2,068 patients who had open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection between January 1996 and December 2005. Not applicable. Preoperative and intraoperative variables were collected concurrently with the patient's care. Risk factors were identified using logistic regression with stepwise variable selection procedure on 1,000 bootstrap resamples, and a bagging algorithm was used to summarize the results. Intraoperative red blood cell transfusion, higher preoperative serum creatinine level, absence of a thoracic epidural catheter, more extensive surgical resection, and lower preoperative FEV(1) were associated with an increased risk of delayed extubation after lung resection. Most predictors of delayed postoperative extubation (ie, red blood cell transfusion, higher preoperative serum creatinine, lower preoperative FEV(1), and more extensive lung resection) are difficult to modify in the perioperative period and probably represent greater severity of underlying lung disease and more advanced comorbid conditions. However, thoracic epidural anesthesia and analgesia is a modifiable factor that was associated with reduced odds for postoperative ventilatory support. Thus, the use of epidural analgesia may reduce the need for post-thoracotomy mechanical ventilation.

Cardiothoracic Surgery after Heart and Heart-Lung Transplantation

We sought to examine our management and the outcomes of cardiothoracic procedures after heart and heart lung transplantation. We performed a retrospective review of cardiothoracic surgical procedures carried out between 1990 and 2004 in patients who had previously undergone heart or heart-lung transplantation at our institution. Twenty-one out of 340 patients (6.2 %) were identified. Cardiothoracic surgery was performed 44.4 +/- 33 months (range 1 - 115 months) after transplantation. Predominant types of surgery were coronary artery bypass grafting due to allograft vasculopathy (n = 5), aortic surgery due to acute dissection (n = 3), biventricular assist device implantation due to acute rejection (n = 1), tricuspid valve repair (n = 1), multiple cardiac surgical procedures including coronary artery bypass grafting, retransplantation, and tricuspid valve replacement (n = 2), explantation of a functionless heterotopic transplanted heart (n = 1). Lung surgery was performed in six patients due to pneumonia (n = 2), primary lung carcinoma (n = 3), lung torsion following heart-lung transplantation (n = 1). All patients underwent either lobectomy or segmental lung resection. Single lung retransplantation (n = 2) after prior heart-lung transplantation due to bronchiolitis obliterans was performed. In one patient a pneumonectomy (n = 1) due to severe chronic rejection of the contralateral lung was performed. Six subsequent deaths after cardiothoracic procedures were recorded after 1, 4, 78, 163, 205, and 730 days, respectively. Causes of death were advanced carcinoma (n = 1), multi-organ failure due to sepsis (n = 2), sudden heart death (n = 2), and advanced heart failure (n = 1). Fifteen out of 21 patients having undergone cardiothoracic procedures (71.4 %) survived the observation period of 56.6 +/- 34 months (range 1 - 114). Reasons for cardiothoracic procedures after prior heart or heart-lung transplantation were allograft vasculopathy, aortic dissections years after transplantation, chronic rejection, and either lung infections or malignancies. Surgical repair can be performed with an acceptable operative risk and good long-term survival rates.

The volume-staffing-outcome relationship: A population-based study of moderate-risk cancer surgery

6025 Background: Patients (pts) are referred to high-volume (Hi Vol) hospitals (hosps) for high-risk cancer surgery (pancreatectomy, esophagectomy) because peri-operative mortality is significantly lower at such hosps. For moderate-risk procedures (mortality 1%–5%), the benefit of Hi Vol hosps is significant, but modest. The value of referral for these common procedures is unclear, but alternatives are lacking. We hypothesized that, independent of procedure volume, hosps with high staff-to-bed ratios would have lower mortality after moderate-risk cancer surgery. Methods: We studied inpatient claims of pts who underwent 3 moderate risk procedures (segmental or wedge resection of lung, 646 lung ca pts; partial or total cystectomy, 1510 bladder ca pts; partial colectomy, 14,948 colon ca pts) between 1/99 and 12/01 in all Texas hosps, except federal. We studied the relationship between inpatient mortality and hosp staffing, using a random effects logit model to account for clustering of pts within hosps. Staffing factors included registered nurse (RN)-, total nursing staff-, and respiratory therapist-to-occupied bed ratios. We adjusted for confounding pt factors (age > 75 yrs, African-American race, Hispanic ethnicity, low income, male sex, chronic comorbidity, metastases, cancer site) and hosp factors (teaching status, rural location, for-profit ownership, total annual surgeries). Results: 17,104 pts were treated at 273 hosps. 51% were male, 37% were >75 yrs, 11% were African-American, and 13%, Hispanic. Inpatient mortality was 4% for segmental lung resection, 2.2% for cystectomy, and 3.2% for partial colectomy. After adjusting for confounding, treatment at a Hi Vol hosp (OR=0.74; p = 0.001) and a high RN-to-bed ratio (OR=0.80; p = 0.02) predicted significantly lower inpatient mortality. These findings were consistent overall and for each procedure individually. Total nurse and respiratory therapist staffing did not predict mortality. Conclusions: A high RN-to-bed ratio is a significant predictor of low peri-operative mortality after moderate risk procedures. Increasing RN staffing could improve outcomes in low vol centers. No significant financial relationships to disclose.