Recurrent hemoptysis with Penicillium marneffei and Stenotrophomonas maltophilia in Job's syndrome.

Pulmonary infection caused by the opportunistic organisms Penicillium marneffei and Stenotrophomonas maltophilia in patients with Job's syndrome is rare and not well documented. The case of a 30-year-old man with Job's syndrome who developed recurrent pneumonia and lung abscesses caused by P. marneffei and S. maltophilia, complicated by massive hemoptysis, is described. Bronchial artery embolization was successful in controlling the hemoptysis; however, the infection proved fatal despite appropriate antimicrobial therapy. A brief review of the literature on Job's syndrome and its associated infective pulmonary manifestations is also presented.

Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience.

BACKGROUND: Life-threatening massive hemoptysis requires prompt action and thoracic surgical input. Although there are a number of reports regarding each therapeutic modality for medical or surgical treatment, the significance of a multidisciplinary strategy remains undetermined. METHODS: From January 1995 to December 2005, 120 patients were referred to our cardiothoracic center with massive hemoptysis. We retrospectively reviewed and compared the outcomes of a recent 5-year period (2000 to 2005) with those from the previous 5 years (1995 to 1999), as we made major changes in our practice in 2000. We currently try to avoid surgery within 48 hours after onset of active hemoptysis and adopt bronchial artery embolization as a first-line therapy. Treatment decisions are made after discussions among intensive care unit physicians, thoracic surgeons, and interventional radiologists. RESULTS: The former group had 49 patients (57.9 +/- 14.1 years old, 41 males), and the recent group, 71 (62.2 +/- 23.5 years old, 52 males). There were no significant differences for any characteristics studied between the groups. In analyses of short-term complications after surgery, the former had a higher in-hospital mortality rate than the recent group (15% versus 0%). Furthermore, postoperative complications were seen in 8 patients (30%) in the former, whereas those occurred in 3 patients (18%) in the recent group. CONCLUSION: Bronchial artery embolization is an effective therapeutic tool and plays a pivotal role in management of life-threatening massive hemoptysis. Surgery is indicated when bronchial artery embolization is not suitable and can be safely performed in combination with a rigid bronchoscopy or bronchial artery embolization procedure. Our results indicate that a multidisciplinary approach should be adopted for management of life-threatening massive hemoptysis.

Increased inducible nitric oxide synthase in lung carcinoma of smokers.

BACKGROUND: Cigarette smoking is well known to play an important role in the development of lung cancer. Inducible nitric oxide synthase (iNOS) can either promote or inhibit cell proliferation and growth, which makes its role in the development of malignant tumors controversial. The relation between cigarette smoking and iNOS in human lung cancer is unknown. METHODS: The study examined the levels of iNOS/NO in nonsmall-cell lung cancer (NSCLC) tissues of smokers and nonsmokers and in NSCLC cells (NCI-H23) treated by 4-(N-Methyl-N-nitrosamino)-1-(3-pyridyl)-1-butanone (NNK), a potent tobacco-specific carcinogen. RESULTS: The level of iNOS/NO was significantly higher in lung cancer tissues of smokers than that of nonsmokers. Unlike iNOS/NO, the activity of caspase-3 was reduced in the former compared with the latter. The expression of the cleaved caspase-3 was deceased in NCI-H23 cells treated with S-Nitroso-N-acetylpenicillamine (SNAP), an NO donor, whereas treatment with NG-methyl-L-arginine (NMA), an NO inhibitor, caused an increase in cleaved caspase-3. Consistent with the change in caspase-3, SNAP treatment inhibited cell death induced by UCN01, a potent cell death-inducer. NMA treatment greatly enhanced the sensitivity of the cells to UCN01. Further, the cells treated by NNK showed an increase in iNOS protein, accompanied by an elevation of cell proliferation. CONCLUSIONS: The study demonstrates that cigarette smoking promotes the level of iNOS/NO but suppresses the activity of caspase-3, which may lead to the proliferation and growth of lung cancer cells.

Surgical treatment for empyema thoracis: is video-assisted thoracic surgery "better" than thoracotomy?

BACKGROUND: Operations for empyema thoracis are conventionally performed by open thoracotomy, whereas the video-assisted thoracic surgery (VATS) approach remains controversial. This study compares the radiologic and functional outcomes of decortication using the two approaches. METHODS: During a 5-year period, 77 consecutive patients underwent decortication for empyema thoracis at two university teaching hospitals. The choice of surgical approach was decided by surgeon preference. Preoperative and postoperative empyema management was the same in all patients. Postoperative radiologic improvements were graded by a radiologist blinded to the approach used. Functional improvements were assessed by a questionnaire-based survey conducted at a mean of 36 months after the surgical procedure. RESULTS: The VATS approach was used in 41 patients and the thoracotomy approach in 36 patients. Patients in the two groups had similar preoperative demographic and clinical features. No patients required conversion from VATS to thoracotomy or reintervention for empyema. Intraoperative blood loss, duration of chest drain, lengths of hospital stay, and postoperative complication rates were all similar in the two groups. The mean operation time in the VATS group was significantly shorter (2.5 versus 3.8 hours, p < 0.001). Decortication using both approaches gave similar degrees of postoperative radiologic and functional improvements. Of the 42 patients available for follow-up, the 21 who received the VATS approach reported significantly less postoperative pain (p = 0.04), greater satisfaction with the wounds (p < 0.0001), and greater satisfaction with the operation overall (p = 0.006). CONCLUSIONS: VATS allows equally effective decortication for empyema as thoracotomy. However, the VATS approach gives less pain and greater patient acceptance.

Video-assisted thoracic surgery for pneumothorax in LAM.

Spontaneous pneumothorax is one of the more common presentations of lymphangioleiomyomatosis; however, recurrences are common which can be challenging to manage particularly in bilateral pneumothorax. We present a case of recurrent bilateral spontaneous pneumothorax associated with lymphangioleiomyomatosis, diagnosed intra-operatively, and confirmed by the resected lung specimen. Video-assisted thoracic surgery bullectomy and mechanical as well as talc pleurodesis was required to prevent further recurrences. The case discusses the unusual clinical course, radiological, operative and pathologic findings of the disease, and management difficulties that are distinct from other causes of spontaneous pneumothorax.

Video-assisted thoracic surgery lobectomy for lung cancer is associated with less immunochemokine disturbances than thoracotomy.

OBJECTIVE: Major surgery is immunosuppressive and could have an impact on postoperative tumor immunosurveillance and recurrence in cancer patients. Low circulating levels of insulin growth factor binding protein (IGFBP)-3 have been linked to advance prostate and the development of colonic cancers. This prospective study examined the early postoperative circulating levels of IGFBP-3, matrix metalloproteinase (MMP)-9, and tissue inhibitor of metalloproteinase (TIMP)-1 in early stage non-small cell lung cancer (NSCLC) patients undergoing major lung resection by VATS versus thoracotomy. METHODS: Forty-two consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 7-month-period. Blood samples were collected preoperatively and postoperatively on days (POD) 1 and 3 for enzyme linked immunosorbent assay determination of IGFBP-3, MMP-9 and TIMP-1 levels in the serum. RESULTS: There were no demographic differences between the two groups. VATS lung resection was associated with lower levels of MMP-9 and TIMP-1 on POD1 (median 628 vs 1311ng/ml, p=0.009; and 131 vs 211ng/ml, p=0.004, respectively) but higher levels of IGFBP-3 on POD3 (1366 vs 1144ng/ml, p=0.02), when compared with the thoracotomy approach. There was no perioperative mortality. CONCLUSIONS: VATS major lung resection for NSCLC is associated with higher circulating levels of IGFBP-3, and lower levels of MMP-9 and TIMP-1, compared to the thoracotomy approach. The clinical relevance of these postoperative changes on tumor biology following lung resection for cancer warrants further investigation.

Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomized controlled trial.

OBJECTIVE: Studies in other surgical specialties have suggested that pre-emptive wound infiltration using a local anesthetic may reduce post-operative pain. We report the first randomized trial to assess the use of pre-emptive local anesthesia in video-assisted thoracic surgery (VATS). METHOD: Thirty-one consecutive patients undergoing bilateral needlescopic VATS sympathectomy for palmar hyperhidrosis were studied prospectively. Each patient acted as their own control. For each patient, one side was randomized to receive 10ml 0.5% bupivicaine injected to the port sites before incision, and the contralateral control side to receive 10ml saline. Pain severity on a visual analog scale (VAS) was recorded for each chest side at 4h, 1 day and 7 days following surgery. All patients were blinded to the results of randomization throughout the study. RESULTS: Follow up was complete for all patients. At 7 days after surgery, wound pain was significantly reduced by pre-emptive local anesthesia, with 10 (62.5%) of the 16 patients having residual pain reporting less pain on the pre-treated side (p=0.039). There was a trend for reduced pain on the pre-treated side at the other time points. Pain reduction by pre-emptive local anesthesia was not correlated with any demographic or clinical variable. Chest wall paresthesia distinct from localized wound pain was noted by six patients (19.4%), but was not reduced by pre-emptive local anesthesia. Overall, the post-operative discomforts felt by the patients after needlescopic VATS were mild, and did not cause significant functional disturbances. CONCLUSION: Pre-emptive wound infiltration with a local anesthetic may reduce post-operative wound pain in needlescopic VATS procedures.

Video-assisted thoracic surgery for early stage lung cancer - can short-term immunological advantages improve long-term survival?

The development of video-assisted thoracic surgery (VATS) in the past decade has changed the way many pulmonary conditions are being treated. VATS has gained popularity among clinicians due to faster recovery following surgery, less postoperative pain and better cosmesis. It is well known that surgical trauma can induce a systemic inflammatory response and affect postoperative systemic immunity. Minimal access VATS has been shown to be associated with a reduced postoperative systemic inflammatory response. Recent evidence suggests VATS is also associated with better cellular immunity, and produces less immunochemokine disturbance following surgery, when compared with the thoracotomy approach. Circulating natural killer (NK) cell numbers and levels of insulin growth factor binding protein (IGFBP) are found to be higher, and plasma levels of matrix metalloproteinases are lower following VATS than that after thoracotomy. Maintenance of immune function with VATS may have important clinical implications in lung cancer surgery.

Bronchiolitis obliterans following lung transplantation.

Bronchiolitis obliterans syndrome (BOS) is the main and late chronic complication after lung transplantation. It remains a major impediment to long-term outcome. Unfortunately, the survival rate of lung transplant recipients lags behind that of other organ transplant recipients, and BOS accounts for more than 30% of all mortality after the third year following lung transplantation. Most recent studies suggest that immune injury is the main pathogenic event in small airway obliteration and the development of BOS. Early detection of BOS is possible as well as essential because prompt initiation of treatment may halt the progress of the disease and the development of chronic graft failure. Current treatment of BOS is disappointing despite advances in surgical techniques and improvements in immunosuppressive therapies. Therefore, a clear understanding of the pathogenesis of BOS plays a major role in the search for new and effective therapeutic strategies for better long-term survival and quality of life after lung transplantation.

Bronchoscopic management of airway obstruction in pediatric endobronchial tuberculosis.

The present report describes a case of severe airway obstruction caused by endobronchial tuberculosis in an 11-year-old girl who was successfully treated by bronchoscopic balloon dilation. This case illustrates the insidious presentation and the increasingly important role of bronchoscopic intervention in the management of endobronchial tuberculosis. In addition, a brief literature review of the condition in the pediatric age group is included.

Video-assisted thoracic surgery pulmonary resection for lung cancer in patients with poor lung function.

BACKGROUND: The aim of this study is to evaluate the early outcome of patients with poor lung function who underwent video-assisted thoracic surgery (VATS) pulmonary resection for primary non-small cell lung carcinoma. METHODS: We reviewed retrospectively the records of patients with lung cancer undergoing VATS lung resection over a period of 5 years. Twenty-five patients with preoperative poor lung function defined as forced expiratory volume in 1 second less than 0.8 L or the percentage predicted value for forced expiratory volume in 1 second less than 50% were identified. Thirteen patients underwent VATS lobectomies and 12 VATS wedge resections. Data were analyzed with respect to demographics, risk factors, and early postoperative outcome and survival. RESULTS: There were 8 cases of morbidities (29%) and no surgical mortality. Five of these 8 patients had respiratory-related complications after surgery. A deterioration in pulmonary performance as indicated by the Eastern Cooperative Oncology Group (ECOG) score was seen in 7 patients (28%), with only 1 patient having an ECOG score greater than 2. No patient required home oxygen supplementation beyond the third month postoperatively. After a median follow-up period of 15.1 months (range, 1 to 24), 5 patients died. Only 1 patient (4%) died of a respiratory complication (pneumonia 6 weeks after surgery). The other 4 deaths were due to recurrent or metastatic disease. The actuarial survival rates at 1 and 2 years were 80% and 69%, respectively. CONCLUSIONS: Video-assisted thoracic surgery pulmonary resection for cancer in patients with poor lung function can achieve acceptable functional and oncologic outcome.

Analgesic effect of electroacupuncture in postthoracotomy pain: a prospective randomized trial.

BACKGROUND: The role of electroacupuncture in postthoracotomy pain control is uncertain. We conducted a pilot study to evaluate the role of electroacupuncture in the management of early postthoracotomy wound pain. METHODS: A total of 27 patients with operable non-small cell lung carcinoma who received thoracotomy were recruited and randomized to receive either electroacupuncture or sham acupuncture in addition to routine oral analgesics and patient-controlled intravenous analgesia for postoperative pain control. All patients received acupuncture twice daily with visual analog pain score recorded for the first 7 postoperative days. Specific chest acupoints (LI 4, GB 34, GB 36, and TE 8) were targeted. Patient-controlled analgesia was used for the first 3 postoperative days in all patients, and the cumulative dosage used was recorded. RESULTS: Two patients were excluded after randomization because of complications unrelated to acupuncture. Interventions and data collection were completed for the remaining 25 patients (13 in the electroacupuncture group; 12 in the sham acupuncture group). There was a trend for lower visual analog scale pain scores in the electro-acupuncture group between postoperative days 2 and 6, although this did not reach statistical significance. The cumulative dose of patient-controlled analgesia morphine used on postoperative day 2 was significantly lower in the electroacupuncture group (7.5 +/- 5 mg versus 15.6 +/- 12 mg; p < 0.05). Such delay of onset of pain control may be related to the frequency of electroacupuncture used. CONCLUSIONS: Electroacupuncture may reduce narcotic analgesic usage in the early postoperative period. A prospective randomized controlled trial using different electroacupuncture frequency is warranted to verify this benefit.

The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients.

OBJECTIVE: The pain following thoracic surgery and trauma is often refractory to conventional analgesic strategies. However, it shares key characteristics with neuropathic pain which gabapentin, an anticonvulsant, has been proven to effectively treat. To our knowledge, this is the first prospective study assessing the use of gabapentin in cardiothoracic surgery patients. METHODS: Gabapentin was prescribed to 60 consecutive out-patients with refractory pain persisting at four weeks or more after thoracic surgery or trauma. Follow-up of 45 patients (75%) was performed for a median of 21 months (range: 12-28), and clinical data collected prospectively. The mean age of these patients was 51.6 years (range 22-83). Of these 45 patients, 22 had received video-assisted thoracic surgery (VATS), 8 had received thoracotomy, 3 had received median sternotomy, and 12 were treated for blunt chest trauma. RESULTS: The mean duration of pre-treatment refractory pain was 5.76 months (range 1-62). The mean duration of gabapentin use was 21.9 weeks (range 1-68). No deaths or major complications were encountered. Minor side effects-mostly somnolence and dizziness-occurred in 18 patients (40.0%), causing 3 patients (6.7%) to discontinue gabapentin. Overall, 33 patients (73.3%) noted reduction of pain. Chest wall paresthesia distinguishable from wound pain was relieved in 24 (75.0%) of 32 affected patients. Severe initial pain was significantly correlated with pain relief using gabapentin (p=0.009). No other demographical or clinical variable correlated with benefit or side effects. Satisfaction with gabapentin use was expressed by 40 patients (88.9%). Side effects were not a source of dissatisfaction in any patient. CONCLUSIONS: Gabapentin appears safe and well tolerated when used for persistent post-operative and post-traumatic pain in thoracic surgery patients, although minor side effects do occur. Gabapentin may relieve refractory chest wall pain in some of these patients, particularly those with more severe pain. Further studies are warranted to define the role of gabapentin in cardiothoracic surgical practice.

Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.

STUDY OBJECTIVES: Minimal-access thymectomy has become increasingly popular as surgical treatment for patients with nonthymomatous myasthenia gravis (NTMG) because of its comparable efficacy, safety, and lesser degree of tissue trauma compared with conventional open surgery. We reviewed and analyzed our data on video-assisted thoracic surgery (VATS) thymectomy and present the clinical outcomes according to the Myasthenia Gravis Foundation of America classification. DESIGN: A retrospective review of VATS thymectomy for NTMG in a university hospital over a 12-year period. Data were collected from the medical records and supplemented with telephone surveys. The impact of surgery and other variables potentially affecting complete stable remission (CSR) were calculated using Kaplan-Meier survival curves; comparisons between survival curves was performed using the log-rank test. RESULTS: A total of 38 consecutive patients underwent VATS thymectomy for NTMG. Median postoperative stay was 3 days. Pathologic examination revealed thymic hyperplasia in 61.1% of cases, normal thymus in 22.2%, and thymic atrophy in 16.6%. There was no perioperative mortality; complications occurred in four patients. After a median follow-up of 69 months, 91.6% of patients experienced improvement, with crude CSR achieved in 22.2%. Kaplan-Meier survival curve demonstrated a 75% CSR rate at 10-year follow-up. On univariate analysis, only disease duration < or = 12 months (p = 0.03) was associated with a statistically significant improvement in CSR. CONCLUSIONS: VATS thymectomy for NTMG results in symptomatic improvement in the vast majority of patients, with a high rate of CSR. The procedure is associated with low morbidity and no perioperative mortality. Future studies on thymectomy for myasthenia gravis should be reported in a standardized manner to allow accurate comparisons between results in the absence of randomized prospective trials.

Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer.

Major surgery is immunosuppressive, and this could have an impact on postoperative tumor immunosurveillance and, therefore, long-term survival in cancer patients. Video-assisted thoracic surgery (VATS) lung resection is a new alternative surgical approach to thoracotomy for patients with early lung cancer. This is a pilot study to examine the postoperative changes in leukocytes, lymphocyte subsets, B cells, T cells, and natural killer (NK) cells in non-small-cell lung cancer (NSCLC) patients undergoing lung resection with VATS versus thoracotomy approaches. Twenty-one consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 3-month period. Blood samples were collected preoperatively and at postoperative days (POD) 1, 3, and 7 for flow cytometry determination of total leucocytes, B cells, NK cells, lymphocytes, total T cells, and T4 and T8 cell numbers. There were no demographic differences between the two groups. Compared with the preoperative values, significantly increased total white cell numbers were detected at POD 1, 3, and 7 in all patients. At POD 1, although T8 cells and NK cells were reduced in both groups, total T cell, T4 cell, and lymphocyte numbers were significantly reduced only in the thoracotomy group. At POD 7, NK cell numbers were significantly lower in the thoracotomy group than that in the VATS group. No significant intra- or intergroup differences were seen with B cells. No significant differences in survival or disease-free survival were found between the two groups. Thus, VATS major lung resection for NSCLC is associated with less, as well as quicker recovery from, postoperative immunosuppression compared with the thoracotomy approach. The clinical relevance of better preserved cellular immunity in the early postoperative period warrants confirmation from large randomized trials.

Post-pneumonectomy empyema: current management strategies.

Post-pneumonectomy empyema is an uncommon but potentially life-threatening complication. It has a strong association with bronchopleural fistula, which acts as a continued source of infection into the thoracic cavity. Numerous risk factors have been identified and strategies formulated to minimize its occurrence. When bronchopleural fistula occurs, its treatment depends on several factors including extent of dehiscence, degree of pleural contamination and general condition of the patient. Early diagnosis and assessment with appropriate investigations, and aggressive therapeutic strategies are paramount in controlling sepsis, facilitating closure of fistula, and sterilization of the closed pleural space. Recent success with repeat debridement has made routine space obliteration not mandatory in management. The development of minimal-access interventions including video-assisted thoracic surgery, endoscopic application of tissue glue and stenting may be additional tools to complement conventional surgery in post-pneumonectomy empyema management.

Alveolar capillary dysplasia with congenital misalignment of pulmonary vessels.

Alveolar capillary dysplasia with misalignment of pulmonary vessels is an uncommon congenital cause of persistent pulmonary hypertension of the newborn. It is universally fatal, and diagnosis is entirely dependent upon surgical lung biopsy. We present a case of alveolar capillary dysplasia with misalignment of pulmonary vessels occurring in a full-term neonate, emphasizing that early involvement of the thoracic surgeon for a histological diagnosis allows expensive and ineffective treatments to be avoided.