Intraoperative surprise evidence of bronchial rent during lung surgery: a case report.

Among multiple causes of tracheobronchial rent, most common is iatrogenic factor. Whenever there is surprise evidence of bronchial wall tear while doing lung surgery, tracheal tube extubation and postoperative management pose a challenge. We report a 16-year-old girl, weighing 27kg, a case of pulmonary Koch's who presented with hydropneumothorax on left side. She had a prolonged course on mechanical ventilation, was gradually weaned off and extubated in intensive care unit (ICU) with implantable cardioverter defibrillator (ICD) in-situ. However, chest X-ray continued to show loss of bronchovascular markings and high-resolution computed tomography (HRCT) thorax revealed multiple cavitatory lesions, hydropneumothorax from upper to lower lobe, ground glass opacities on left side and mediastinal shift towards right side. Hence, she was posted for left lung decortication. Decortication was done using one lung ventilation protocol with 28 Fr left sided double-lumen endobronchial tube (DLT). While checking for leaks before closure, it was noted that exhaled tidal volume was unacceptably low and a rent on left main bronchus of around 2x2 cm with scarred borders was detected. The rent was repaired with tissue patch suturing by the surgeons. After the procedure, DLT was exchanged with endotracheal tube (ETT) no 6. Patient was managed with elective ventilation post-operatively in ICU for 48 hours and extubated uneventfully. A vigilant monitoring of vital parameters and close communication with surgeons is important for detecting and managing any perioperative complication during lung surgery. Elective ventilation could play a significant role for healing a big rent in trachea-bronchial area.

A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema.

Spontaneous hydropneumothorax (HP) and mediastinal emphysema (ME) are infrequently presented complications of pulmonary tuberculosis (TB). A-34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic chest pain. He had no history of any surgery, TB, comorbid disease, or other serious pulmonary diseases. Chest radiography revealed a right-sided HP and parenchymal infiltration. The laboratory results of pleural effusion showed elevated adenosine deaminase levels with the empyema features. Acid-fast bacilli were detected and Mycobacterium tuberculosis without any drug resistance grew in the culture both in the sputum and pleural fluid. A chest tube was inserted immediately. A prolonged airway leak was detected. Hepatotoxicity protocol has been initialized (due to increased hepatic enzymes in the initial presentation) and followed without observing any complications associated with the treatment. On the 25th day of the standard TB treatment protocol, we observed hepatic enzymes in the normal range. Around 40-days of a hospitalization period, he started developing fever and methicillin-resistant Staphylococcus aureus was detected in the pleural fluid culture. We introduced linezolid to the treatment regimen in addition to the antituberculosis protocol. Although spontaneous ME is a benign disease, it might be life-threatening and difficult to manage when complicated with HP and active TB infection. Active TB should be considered a differential diagnosis once ME or HP was detected, and treatment should be started immediately for both diseases.

Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma.

A 75-year-old man with a history of epithelioid mesothelioma and a right-sided indwelling pleural catheter (IPC) presented with a history of a purulent fluid drainage via the IPC. The pleural fluid cultured Klebsiella oxytoca and Enterococcus faecalis He was treated with a course of oral fluoroquinolone followed by uneventful IPC replacement. One and half hours postprocedure, the patient had a witnessed drop in conscious level accompanied by seizure like activity. Acute stroke was suspected and a CT head was performed. CT head revealed multiple serpiginous pockets of air along the cerebral fissure, with features that were highly suggestive of cerebral air embolism and multiple wedge-shaped areas of infarction involving the cerebral hemispheres. Further imaging revealed satisfactory position of the replaced IPC. The patient was admitted to the intensive care unit for high flow oxygen therapy and head down ventilation. However, his condition deteriorated and he died later.

Invasive Pulmonary Aspergillosis with Hydropneumothorax in a Patient Taking High-Dose Glucocorticoids.

BACKGROUND Invasive pulmonary aspergillosis (IPA) is a severe form of the fungal infection with relatively high mortality rates. Risk factors that lead to IPA include immunosuppression through corticosteroid use. IPA complicated by hydropneumothorax is rare and its mechanism of formation is unknown. CASE REPORT A 72-year-old woman recently diagnosed with a right frontal meningioma that was managed with dexamethasone presented with a new 3-day history of nonproductive cough, chest pain, and dyspnea and was managed for pneumonia. The patient failed to improve, prompting a follow-up computed tomography scan, which revealed a right middle lobe cavitary lesion. During the workup of this lesion, the patient's hospital course was complicated by hemoptysis and development of a large right hydropneumothorax that was successfully managed with a chest tube. Despite initial resolution of hydropneumothorax, the patient developed a right apical pneumothorax that gradually worsened. Bronchoscopy culture revealed Aspergillus fumigatus, leading to the diagnosis of IPA, which was managed with intravenous voriconazole. CONCLUSIONS Corticosteroid use with subsequent immunosuppression is a risk factor for developing IPA. Clinicians should include IPA in their differential diagnosis for respiratory infections in patients receiving corticosteroids. Although overall prognosis of IPA is poor, outcomes can be improved with early diagnosis, early empiric initiation of antifungals, and withdrawal of immunosuppressive therapy. IPA complicated by hydropneumothorax is a rare phenomenon with a poorly understood mechanism of formation. Based on our case, we propose a mechanism of hydropneumothorax formation from IPA.

Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection.

BACKGROUND: Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave's syndrome (BS), is rare after chest surgery. CASE PRESENTATION: A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6 h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment. CONCLUSIONS: Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Diffuse epithelioid malignant mesothelioma of the pleura presenting as a hydropneumothorax and vertebral body invasion.

Malignant mesothelioma is an uncommon form of neoplastic transformation of the mesothelial cells that line the serosal surfaces of the body. It most commonly affects the pleura and is often associated with pleural effusions and pleural-based masses. The annual incidence in the United States is only 3300 cases, representing less than 0.3% of all cancers worldwide, although this is likely underestimated. We present a case of diffuse epithelioid malignant pleural mesothelioma in a patient with remote, short-term asbestos exposure complicated by recurrent left-sided hydropneumothoraces and pleural-based invasion of the T12 vertebral body, which represent two rare coexisting complications. This case illustrates the importance of maintaining a broad differential for hydropneumothorax, particularly as the risk factors may be decades removed and the degree of asbestos exposure to induce a malignant mesothelioma may be smaller than has been traditionally thought.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients.

OBJECTIVE: To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi. MATERIALS AND METHODS: Children with renal calculi who underwent PCNL between January 2010 and December 2017 were divided into 2 groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared. Comparison of medians was done using Mann Whitney U test and the means were compared using t test. RESULTS: Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2, respectively after 1 session of PCNL (P = .885). After auxiliary procedures, it increased to 96.0% and 96.6%, respectively (P = .852). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (P = .11) whereas the median pain score was 4 in group 1 and 3 in group 2 (P = .37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). Twenty-nine complications were observed in group 1 while 25 complications were observed in group 2 (P = .088). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1. CONCLUSION: Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone-free rate and complications.

Delayed complications following microwave ablation of lung tumours.

The majority of complications following microwave ablation (MWA) of lung tumours are immediately evident, however, delayed complications do occasionally occur. The radiologist plays a major role in identifying and in guiding the management of these complications. This pictorial essay explores the imaging appejmironce of several potentially life-threatening delayed complications of pulmonary MWA.

Postoperative Pulmonary Complications Following Laparoscopy.

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

Diagnosis and Management of Pleural Transudates. / Diagnóstico y manejo de los trasudados pleurales.

Various clinical trials have been published on the optimal clinical management of patients with pleural exudates, particularly those caused by malignant tumors, while little information is available on the diagnosis and treatment of pleural transudates. The etiology of pleural transudates is wide and heterogeneous, and they can be caused by rare diseases, sometimes constituting a diagnostic challenge. Analysis of the pleural fluid can be a useful procedure for establishing diagnosis. Treatment should target not only the underlying disease, but also management of the pleural effusion itself. In cases refractory to medical treatment, invasive procedures will be necessary, for example therapeutic thoracentesis, pleurodesis with talc, or insertion of an indwelling pleural catheter. Little evidence is currently available and no firm recommendations have been made to establish when to perform an invasive procedure, or to determine the safest, most efficient approach in each case. This article aims to describe the spectrum of diseases that cause pleural transudate, to review the diagnostic contribution of pleural fluid analysis, and to highlight the lack of evidence on the efficacy of invasive procedures in the management and control of pleural effusion in these patients.

What About Having a Hydropneumothorax Every Month?

INTRODUCTION: Endometriosis is a pathological, benign, inflammatory condition characterized by the presence of endometrial glands and stroma outside the uterine cavity, typically in the pelvis. In rare conditions, this estrogen-dependent disease may be extrapelvic, presenting with a variety of symptoms, including Thoracic Endometriosis. METHODS: A 37 year-old woman presented with her third right hydropneumothorax in three months. Her medical history included infertility, an ovarian mass (in study), biliary diskinesia and protein C deficiency. The CT showed a bleb in the right inferior lobe and a pleural effusion. A detailed clinical history revealed a temporal relationship of the hydropneumothoraxes and her menses. RESULTS: She underwent a videothoracoscopy: there were macroscopic tissue alterations all over the parietal and visceral pleura. We performed a biopsy of one of those spots (of the parietal pleura) and an atypical resection of the apex of the apical segment of the right inferior lobe, where the bleb was. A talc pleurodesis was also performed. The patient was discharged at day 1 and is currently under regular follow-up in ambulatory, with no recurrent pneumothoraxes for two months. The histopathology was compatible with a pleural Endometriosis. CONCLUSION: Thoracic endometriosis is a clinical diagnosis, although the histopathologic confirmation is preferred (but not necessary): it should be suspected in reproductive age women who present with hemothorax, pneumothorax, hemoptysis, chest or scapular pain, lung nodules or diaphragmatic rupture perimenstrually, especially right-sided. Most commonly it presents as catamenial pneumothorax and/or hemothorax. Those with high clinical suspicion and/ or imaging supportive of the diagnosis, should undergo an interventional procedure (thoracoscopy), both for diagnose and management. Primary treatment is chest tube drainage. Prevention of recurrence can be medical (hormonal suppression) or surgical (lung resection, pleurectomy, pleurodesis).