Pleural Pressure Differences Before Removal Are Greater in Patients Who Develop Residual Pneumothorax Post Chest Drain Removal.

Aim of study: We aimed to investigate whether the difference in pleural pressures (ΔP) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The ΔP prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of ΔP for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on ΔP. Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The ΔP in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H2O, p < 0.01). The ΔP in patients who required intervention was also significantly higher (14.8 versus 4.2 cm H2O, p < 0.01). A ΔP cutoff value of 8 cm H2O was predictive of the occurrence of residual pneumothorax (sensitivity 85.6%, specificity 84.6%) and a value of 12 cm H2O was predictive of intervention (sensitivity 84%, specificity 85%). Increasing ΔP was an independent predictor of the occurrence of residual pneumothorax (p = 0.008) on the multivariate logistic regression model. Conclusion: Patients with wide ΔP before chest drain removal may be complicated with residual pneumothorax.

CXCL13 production in B cells via Toll-like receptor/lymphotoxin receptor signaling is involved in lymphoid neogenesis in chronic obstructive pulmonary disease.

RATIONALE: Little is known about what drives the appearance of lymphoid follicles (LFs), which may function as lymphoid organs in chronic obstructive pulmonary disease (COPD). In animal infection models, pulmonary LF formation requires expression of homeostatic chemokines by stromal cells and dendritic cells, partly via lymphotoxin. OBJECTIVES: To study the role of homeostatic chemokines in LF formation in COPD and to identify mechanism(s) responsible for their production. METHODS: Peripheral lung homeostatic chemokine and lymphotoxin expression were visualized by immunostainings and quantified by ELISA/quantitative reverse transcriptase-polymerase chain reaction in patients with COPD with and without LFs. Expression of lymphotoxin and homeostatic chemokine receptors was investigated by flow cytometry. Primary lung cell cultures, followed by ELISA/quantitative reverse transcriptase-polymerase chain reaction/flow cytometry, were performed to identify mechanisms of chemokine expression. Polycarbonate membrane filters were used to assess primary lung cell migration toward lung homogenates. MEASUREMENTS AND MAIN RESULTS: LFs expressed the homeostatic chemokine CXCL13. Total CXCL13 levels correlated with LF density. Lung B cells of patients with COPD were important sources of CXCL13 and lymphotoxin and also expressed their receptors. Cigarette smoke extract, H2O2, and LPS exposure up-regulated B cell-derived CXCL13. The LPS-induced increase in CXCL13 was partly mediated via lymphotoxin. Notably, CXCL13 was required for efficient lung B-cell migration toward COPD lung homogenates and induced lung B cells to up-regulate lymphotoxin, which further promoted CXCL13 production, establishing a positive feedback loop. CONCLUSIONS: LF formation in COPD may be driven by lung B cells via a CXCL13-dependent mechanism that involves toll-like receptor and lymphotoxin receptor signaling.

Variation of the postoperative fluid drainage according to the type of lobectomy.

OBJECTIVES: The pleural membrane of the lower pleural cavity has a greater ability to recycle fluid than the pleural membrane of the upper pleural cavity. During lobectomy, the visceral pleura is removed with the lobe, whereas the parietal pleura is traumatized during manipulation. This study investigates variations of the drainage according to the type of lobectomy and its relation to effusion-related complications. METHODS: Data of upper and lower lobectomy patients were compared with those of wedge resection patients. All patients were suctioned until totally dry before closure, and one chest tube was left in the hemithorax. The amount of fluid drained per day, the duration of drainage, the length of hospital stay and the morbidity were noted. Student's paired t-test and Mann-Whitney U-test were used for comparison; P < 0.05 was defined as statistically significant. RESULTS: Patients after lower lobectomy had more fluid drained when compared with patients after upper lobectomy or wedge resection on the first (636 ± 90, 268 ± 75 and 225 ± 62 ml, respectively; P = 0.002) and second postoperative day (464 ± 94, 237 ± 90 and 220 ± 62 ml, respectively; P = 0.046). The drainage tube was removed earlier in patients with upper lobectomy procedures than in patients with lower lobectomy procedures (4.6 ± 0.9 vs 8.1 ± 1.4 days; P = 0.014). Effusion-related complications developed in lower lobectomies with a higher output from the second postoperative day. CONCLUSIONS: A larger amount of fluid is drained after removal of the lower lobes, possibly because the important fluid-recycling ability of the lower parts of the cavity is malfunctioning. Early drainage tube removal after lower lobectomy may be reconsidered when taking into account the possibility of effusion-related complications.

Isolated sternal fractures treated on an outpatient basis.

AIM: The aim of this study is to investigate the need for admission of patients with isolated sternal fracture (ISF) by prospectively and randomly discharging or admitting them. METHODS: Patients with ISF after the completion of investigations were randomly discharged or admitted. Investigations performed included lateral chest x-ray; chest computed tomography; electrocardiogram; cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such as creatine phosphokinase, myocardial branch of creatine phosphokinase, and troponin I (cardiac specific). These investigations were repeated after 6 hours in the admission and the next day in both groups. RESULTS: Forty-two patients were included in the study. Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and ultrasound were normal in both groups upon presentation and the next day. Creatine phosphokinase and myocardial branch of creatine phosphokinase, although elevated at presentation, were normal the next day and similar in both groups. There was no morbidity, need for surgery, or mortality in both groups during a 6-month follow-up. CONCLUSIONS: Patients with ISF can be discharged safely as soon as investigations are completed. Extensive myocardial assessment is not needed on the posttraumatic period. Myocardial involvement seems unlikely in patients with ISF, who can be treated with oral analgesics.

Nonsteroidal anti-inflammatory drugs alter the human mesothelial pleural permeability via ion cellular transportation by inhibiting prostaglandin synthesis.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in clinical practice as analgesics or anti-inflammatory drugs. Studies have implicated them in participating in permeability throughout various tissues such as the kidneys and lungs. OBJECTIVE: The effect of NSAIDs on the pleural permeability and the underlying mechanisms whereby this effect is mediated were investigated. METHODS: Parietal pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Solutions containing paracetamol, acetylsalicylic acid, diclofenac, lornoxicam, parecoxib and ibuprofen were added in the chambers facing the pleural and the outer-pleural surface. Prostaglandin E(2) was similarly used to investigate prostaglandin synthesis involvement at low and high doses. Amiloride- and ouabain-pretreated specimens were used in order to investigate ion transportation involvement. Transmesothelial resistance (R(TM)) was determined as a permeability indicator. RESULTS: Paracetamol, acetylsalicylic acid, diclofenac, lornoxicam and ibuprofen increased R(TM) on the pleural and outer-pleural surface, inhibited by amiloride and ouabain. Parecoxib had no effect on the R(TM). Prostaglandin decreased R(TM) on the pleural and outer-pleural surface inhibited by amiloride, ouabain and ibuprofen. CONCLUSION: NSAIDs, except parecoxib, induce a rapid decrease of the pleural permeability by inhibiting cellular transportation, an effect that is mediated by prostaglandin synthesis inhibition.

Thymoma and myasthenia gravis: clinical aspects and prognosis.

Myasthenia gravis is present in a significant proportion of patients with thymoma. We investigated particular features of the clinical behavior of thymoma and its relationship to myasthenia in a retrospective study of 79 patients who underwent thymectomy for thymoma during the last 20 years. The presence of myasthenia gravis, Masaoka stage, World Health Organization histotype, myasthenia response, and survival were analyzed. The mean age of the patients was 56.1 ± 12.4 years, and 39 had myasthenia gravis. A significantly higher proportion of patients with myasthenia was found in B2 and B3 histotypes compared to A, AB, and B1. Among myasthenic patients, 33.3% had no response, 50% had a partial response, and 16.7% achieved complete remission. During the follow-up period, 16 (21.1%) patients died. Mean survival was 4.8 ± 1.4 years for patients with no myasthenia response, whereas those with a partial or complete myasthenia response had significantly better survival.

Staphylococcal isolated anterosuperior mediastinal abscess of unknown origin.

Mediastinal abscess is a rare presentation of infections involving the mediastinum. In rare cases, the origin of the infection cannot be identified. We report a case of a 32-year old male who was presented with a mediastinal abscess with an otherwise clear history. The origin of the infection could not be identified despite extensive investigations. The patient was operated through a cervical incision. His postoperative recovery was uneventful. Rare causes of mediastinal infections should not be overlooked from the diagnostic process even if the origin of infection cannot be identified.

Extrathoracic chronic heamatoma presenting as a chest wall tumor 2 years after a blunt thoracic injury.

Chronic expanding heamatomas may present as masses mimicking chest wall tumors. We report the case of a patient who was presented with a giant posterior extrathoracic chest wall tumor. The mass was proven to be a chronic heamatoma possibly developed after a blunt thoracic injury which took place 2 years before presentation and was growing thereafter. Clinicians should have high suspicion of rare entities which mimic tumors and consider any information reported by the patient's history in their diagnostic process.

Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy.

RATIONALE: Controlled mechanical ventilation (CMV) results in atrophy of the human diaphragm. The autophagy-lysosome pathway (ALP) contributes to skeletal muscle proteolysis, but its contribution to diaphragmatic protein degradation in mechanically ventilated patients is unknown. OBJECTIVES: To evaluate the autophagy pathway responses to CMV in the diaphragm and limb muscles of humans and to identify the roles of FOXO transcription factors in these responses. METHODS: Muscle biopsies were obtained from nine control subjects and nine brain-dead organ donors. Subjects were mechanically ventilated for 2 to 4 hours and 15 to 276 hours, respectively. Activation of the ubiquitin-proteasome system was detected by measuring mRNA expressions of Atrogin-1, MURF1, and protein expressions of UBC2, UBC4, and the α subunits of the 20S proteasome (MCP231). Activation of the ALP was detected by electron microscopy and by measuring the expressions of several autophagy-related genes. Total carbonyl content and HNE-protein adduct formation were measured to assess oxidative stress. Total AKT, phosphorylated and total FOXO1, and FOXO3A protein levels were also measured. MEASUREMENTS AND MAIN RESULTS: Prolonged CMV triggered activation of the ALP as measured by the appearance of autophagosomes in the diaphragm and increased expressions of autophagy-related genes, as compared with controls. Induction of autophagy was associated with increased protein oxidation and enhanced expression of the FOXO1 gene, but not the FOXO3A gene. CMV also triggered the inhibition of both AKT expression and FOXO1 phosphorylation. CONCLUSIONS: We propose that prolonged CMV causes diaphragm disuse, which, in turn, leads to activation of the ALP through oxidative stress and the induction of the FOXO1 transcription factor.

Numerical abnormalities of chromosome 9 and p16CDKN2A gene deletion detected by FISH in non-small cell lung cancer.

BACKGROUND: Lung cancer is one of the most common types of cancer worldwide and its pathogenesis is closely associated with various environmental exposures and gene alterations. The identification of genetic changes is a useful strategy toward understanding tumourigenesis and specific genetic associations. Since the tumor suppressor gene p16 located at 9p21 chromosomal region might have an important role in lung carcinogenesis, the aim of the present study was to investigate p16 gene alterations and numerical aberrations of chromosome 9 in non-small cell lung cancer. MATERIALS AND METHODS: Nineteen cases of non-small cell lung cancer (11 squamous cell carcinomas, 6 adenocarcinomas and 2 large cell carcinomas) were investigated by fluorescence in situ hybridization (FISH) technique using a DNA p16 probe and alpha-satellite probe specific for chromosome 9. RESULTS: Polysomy 9 was found in 13 cases (6/11 squamous cell carcinomas, 5/6 adenocarcinomas and 2/2 large cell carcinomas). p16 gene alterations were found in 16 cases. Among them, deletion of p16 gene was found in 15 cases (8/11 squamous cell carcinomas, 5/6 adenocarcinomas and 2/2 large cell carcinomas). In six cases with p16 gene deletion, homozygous deletion was observed. CONCLUSION: Numerical aberrations of chromosome 9 and p16 gene deletion are common findings in all subtypes of non-small cell lung cancer. Despite suggesting the p16 gene in the 9p chromosomal region plays a role in lung carcinogenesis, the presence of other oncogenes reflected by polysomy 9 participating in the neoplastic process cannot be excluded. Data of the present study also suggest, that there might not be a fundamental relationship between genetic changes and histological subtype of non-small cell lung cancer.

Low incidence of bronchopleural fistula after pneumonectomy for lung cancer.

Bronchopleural fistula (BPF) after pneumonectomy for NSCLC remains a highly morbid complication. We examined possible factors including the surgical techniques associated with BPF development. From 221 pneumonectomies for NSCLC, bronchial stump closure was mechanically performed in 192 patients and manually in the remaining 29. In all right-sided pneumonectomies mechanical closure was performed with associated stump coverage. In 114/130 left-sided procedures where mechanical closure was selected, bronchial stump remained uncovered. In the remaining 16 left-sided cases where manual stump closure was selectively performed, the stump was covered utilizing various tissues. Risk factors were classified into preoperative, intra-operative and postoperative. Five patients (2.3%) developed BPF. Univariate analysis revealed peri-operative transfusion, respiratory infection at the time of presentation, neoadjuvant therapy, right-sided pneumonectomy, manual type of bronchial closure, days of postoperative hospitalization and mechanical ventilation as significant risk factors for BPF development. Multivariate analysis followed revealing preoperative respiratory infection and right pneumonectomy as the only independent risk factors. In our series, a selected stump coverage policy showed a low incidence of BPF development. Mechanical stapling was superior to manual closure, although not as an independent factor. Early recognition of possible risk factors associated with fistula development is of paramount importance.

Postlaparoscopic iatrogenic pseudoaneurysms of the arteries of the peritoneal and retroperitoneal space: case report and review of the literature.

BACKGROUND AND AIMS: Laparoscopic surgery procedures are associated with a low percentage of cases of iatrogenic traumatic laceration of the arteries of the peritoneal and retroperitoneal space. These lesions rarely lead to pseudoaneurysm formation. In 1 case, we performed a meta-analytic review of the literature on postlaparoscopic iatrogenic pseudoaneurysms focusing on specific parameters: (1) artery involved, (2) type of laparoscopic operation, (3) time interval between the laparoscopic operation and the final diagnosis of the pseudoaneurysm, (4) clinical presentation, (5) diagnostic tools used, (6) mode of treatment applied, and (7) clinical outcome. MATERIALS AND METHODS: We searched Medline for pseudoaneurysms developing as complications of laparoscopic procedures. The search terms used were "iatrogenic pseudoaneurysm," "complications after laparoscopic procedures," "traumatic arterial laceration," "pseudoaneurysm formation," and "postoperative hematoma" in various combinations. RESULTS AND CONCLUSIONS: A total of 66 cases were retrieved. Postlaparoscopic iatrogenic pseudoaneurysms are late manifestations of arterial complications developing during routine laparoscopy. There are 66 reported cases of this type of complication in the literature. The majority occurs in the arteries of the operation field of the respective laparoscopic procedure. Distal vessels are involved less frequently. They usually present after a mean period of approximately 6 weeks. The hepatic and renal arteries are usually affected. The clinical picture includes upper and lower gastrointestinal bleeding, diffuse or localized abdominal pain, hematuria, and drain bleeding.

Simultaneous bilateral carotid endarterectomy under local anesthesia.

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.

Surgical treatment of coronary subclavian steal syndrome.

The internal mammary artery is the conduit of choice for cardiac revascularization. Atherosclerotic disease of the coronary arteries may simultaneously involve the subclavian artery. Proximal stenosis in the left subclavian artery may result in recurrent myocardial ischemia in patients with a patent left internal mammary artery (LIMA), due to coronary steal syndrome through the LIMA.

The effectiveness of an extracellular low-potassium solution in 24-hour lung graft preservation.

BACKGROUND: The transplanted lung suffers ischemia-reperfusion injury and many efforts have been made to improve preservation. The aim of this study was to compare the effectiveness of intracellular high-potassium Belzer solution versus extracellular Celsior in 24-hour lung preservation. MATERIAL/METHODS: Sixteen pigs weighing 25.1-28.1 kg underwent single, left-lung allotransplantation. Sixteen other pigs were donors of the left lung. Heart and lungs were retrieved from the donors using single-flush perfusion by a randomly selected solution that was also used for cold storage (4 degrees C) for 24 hrs. Biopsies were taken from the right lung before storage, after the preservation, and finally three hours following transplantation. The observation period lasted three hours following transplantation. RESULTS: Pulmonary artery pressure and pulmonary vascular resistance were significantly higher in the Belzer group (p<0.05), while the pO2/FiO2 ratio was much higher in the Celsior group (p<0.05). Compliance was reduced approximately equally in both groups. Histology showed less edema, atelectasis, and hemorrhagic infiltration in the Celsior group than in the Belzer group, which developed more interstitial thickening and presented more leukocyte infiltration and desquamation of alveoli cells. CONCLUSIONS: According to hemodynamic, respiratory, and histological data, the extra-cellular solution Celsior offers improved prolonged preservation compared with Belzer.

In situ cooling in a lung hilar clamping model of ischemia-reperfusion injury.

Experimental models for studying transplantation have up to now been unable to isolate reperfusion injury with minimal surgical manipulation and without the interference of graft rejection. Six pigs were subjected to left hilum preparation only (control group), and eight pigs were subjected to left hilum preparation plus in situ cooling ischemia and reperfusion of the lung (experimental group). The hilum was dissected free from other tissues in both groups. Lung preservation was achieved by antegrade flush perfusion via the left pulmonary artery. Pulmonary veins were clamped at the left atrium and a vent was created. The left main bronchus was clamped. Lung temperature was maintained at 4 degrees -8 degrees C, while core temperature was kept at 38 degrees C. After 3 hrs of cold ischemia the clamps were removed and the lung was reperfused. Elevated pulmonary vascular resistance and local and systemic aspects of ischemia-reperfusion syndrome were consistently reproduced. This large-animal model of in situ unilateral lung cold ischemia with warm reperfusion proved to be very reliable in reproducing all aspects of ischemia-reperfusion injury. It excludes the interference of rejection and extensive surgical manipulation. We therefore propose its use in experimental studies investigating pharmaceutical or cooling modifications affecting lung ischemia-reperfusion outcomes.