Ventilator-induced Lung Injury Promotes Inflammation within the Pleural Cavity.

Mechanical ventilation contributes to the morbidity and mortality of patients in intensive care, likely through the exacerbation and dissemination of inflammation. Despite the proximity of the pleural cavity to the lungs and exposure to physical forces, little attention has been paid to its potential as an inflammatory source during ventilation. Here, we investigate the pleural cavity as a novel site of inflammation during ventilator-induced lung injury. Mice were subjected to low or high tidal volume ventilation strategies for up to 3 hours. Ventilation with a high tidal volume significantly increased cytokine and total protein levels in BAL and pleural lavage fluid. In contrast, acid aspiration, explored as an alternative model of injury, only promoted intraalveolar inflammation, with no effect on the pleural space. Resident pleural macrophages demonstrated enhanced activation after injurious ventilation, including upregulated ICAM-1 and IL-1ß expression, and the release of extracellular vesicles. In vivo ventilation and in vitro stretch of pleural mesothelial cells promoted ATP secretion, whereas purinergic receptor inhibition substantially attenuated extracellular vesicles and cytokine levels in the pleural space. Finally, labeled protein rapidly translocated from the pleural cavity into the circulation during high tidal volume ventilation, to a significantly greater extent than that of protein translocation from the alveolar space. Overall, we conclude that injurious ventilation induces pleural cavity inflammation mediated through purinergic pathway signaling and likely enhances the dissemination of mediators into the vasculature. This previously unidentified consequence of mechanical ventilation potentially implicates the pleural space as a focus of research and novel avenue for intervention in critical care.

Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study

ABSTRACT BACKGROUND: There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications. OBJECTIVES: To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber. DESIGN AND SETTING: A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil. METHODS: Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups. RESULTS: Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively. CONCLUSIONS: Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe. REGISTRATION: RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Pleural macrophages translocate to the lung during infection to promote improved influenza outcomes.

Seasonal influenza results in 3 to 5 million cases of severe disease and 250,000 to 500,000 deaths annually. Macrophages have been implicated in both the resolution and progression of the disease, but the drivers of these outcomes are poorly understood. We probed mouse lung transcriptomic datasets using the Digital Cell Quantifier algorithm to predict immune cell subsets that correlated with mild or severe influenza A virus (IAV) infection outcomes. We identified a unique lung macrophage population that transcriptionally resembled small serosal cavity macrophages and whose presence correlated with mild disease. Until now, the study of serosal macrophage translocation in the context of viral infections has been neglected. Here, we show that pleural macrophages (PMs) migrate from the pleural cavity to the lung after infection with IAV. We found that the depletion of PMs increased morbidity and pulmonary inflammation. There were increased proinflammatory cytokines in the pleural cavity and an influx of neutrophils within the lung. Our results show that PMs are recruited to the lung during IAV infection and contribute to recovery from influenza. This study expands our knowledge of PM plasticity and identifies a source of lung macrophages independent of monocyte recruitment and local proliferation.

Empyema necessitans (EN) as a rare complication of tuberculosis - A case report.

INTRODUCTION: Empyema necessitans (EN) is an uncommon condition where an intrathoracic empyema extends into surrounding extra-thoracic tissues. This case report presents a rare instance of tuberculous EN in an immunocompetent individual. PRESENTATION OF CASE: We present a case of a healthy young male with complaints of weight loss and a chest wall swelling, initially treated as a subcutaneous abscess. He had a history of TB contact and initial laboratory tests showed elevated CRP and ESR, with no bacterial growth on initial culture from FNAC sample. Subsequent imaging revealed the presence of pleural empyema. Following surgical intervention, a connection between fluid collection outside the thoracic wall and the pleural cavity was identified. Diagnosis of tuberculous EN was made on results of second culture of the fluid collection. The patient was further treated with anti-tuberculous treatment. DISCUSSION: EN, rare extrapulmonary complication of tuberculosis, is challenging to diagnose due to nonspecific symptoms and paucibacillary nature of extrapulmonary TB. Imaging plays a crucial role in diagnosis. A multidisciplinary approach involving surgery and anti-tuberculous treatment is effective in managing EN. CONCLUSION: This case underscores the scarcity of EN occurrences and emphasizes the potential for latent TB to surface as atypical complications. Accurate diagnosis requires a combination of clinical insight, imaging, and laboratory tests. EN should be considered in individuals with chest wall masses, particularly in TB endemic areas, and those with a history of TB contact. Treatment involves surgical intervention and anti-tuberculous therapy.

A Rare Case of Chylothorax Following a Redo Laparoscopic Nissen Fundoplication.

Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Mechanical etiology, including hiatal hernia, can be resistant to empiric proton pump inhibitor (PPI) trials; Nissen fundoplication is commonly used to treat mechanical GERD. Chylothorax is a rare complication of abdominal surgeries, including anti-reflux procedures. In this case report, a 75-year-old female presented with shortness of breath following a redo laparoscopic Nissen fundoplication. Chest CT pulmonary angiography (CTPA) showed bilateral large pleural effusions that were managed by fluid restriction, repeated thoracocentesis, and chest tube insertion; the pleural fluid analysis was significant for fluid triglycerides high at 232 mg/dL which was diagnostic for chylothorax. The patient was treated conservatively. Appropriate management of chylothorax is crucial to avoid subsequent respiratory failure, immunodeficiency, and malnutrition. Chylomicrons and triglycerides in the pleural fluid can be diagnostic for chylothorax. Treatment of chylothorax includes three main approaches: controlling the cause, conservative treatment, and surgical interventions.

Wedge resection and pleurodesis through single-incision videothoracoscopic transmediastinal approach for bilateral spontaneous pneumothorax.

In general, in cases of bilateral primary pneumothorax, videoassisted thoracoscopic surgery procedures are performed sequentially on both sides. However, there are only a few reported cases of bullectomy through video-assisted thoracoscopic surgery using a transmediastinal approach for bilateral primary spontaneous pneumothorax. A 20-year-old male patient was admitted to our clinic with a right pneumothorax and developed a left pneumothorax four days later while he was under treatment. He underwent bilateral bullectomy and pleurodesis via a singleincision video-assisted thoracoscopic surgery in the supine position. The patient was discharged uneventfully within 72 h after the procedure. In conclusion, bilateral bullectomy and pleurodesis using single-incision transmediastinal access video-assisted thoracoscopic surgery may be good choices that are technically reliable and provide favorable surgical outcomes.

Surgical management of descending necrotizing mediastinitis: strategy for thoracic interference.

BACKGROUND: The present descriptive study shares the overall experience of treating all these patients where different surgical process was adopted depending on the treatment required after carefully evaluating the risk factors and comorbidities. METHODS: The present study was conducted at the Department of Thoracic Surgery, Choray Hospital, Vietnam between the period of 2010 to 2020. We have treated 95 patients altogether in this duration. RESULTS: We were able to save most of the patients by applying thoracotomy and thoracic irrigation for most of the patients based on the observed indications that were identified immediately after the compulsory standard cervicotomy. The indication for thoracic interference was considered when the infection was deeply spread into the mediastinum and cannot get out through cervicotomy, although the most effective method of drainage was applied. CONCLUSION: Our statistical investigation of the patient data suggested the possible association and influence of comorbidity such as diabetes. Therefore, we recommend that in specific cases thoracotomy along with thoracic irrigation and repetitive surgical draining could be a better option to reduce the infection and the mortality rate. TRIAL REGISTRATION: Retrospectively registered.

Intrathoracic herniation of retrosternal gastric conduit after thoracolaparoscopic esophagectomy causing gastric conduit obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Intrathoracic herniation of gastric conduit (IHGC) is a specific complication following esophagectomy with retrosternal gastric pull-up but is not well recognized. Diagnosis and management are challenging due to the lack of literature reviews. CASE PRESENTATION: We report a 50-year-old man where a reconstructed gastric conduit hernia into the mediastinal pleural cavity after esophagectomy. The patient underwent minimally invasive esophagectomy with cervical anastomosis for middle esophageal carcinoma followed by retrosternal reconstruction; during the tunneling phase, the mediastinal pleura was injured. Subsequently, the patient developed progressive dysphagia postoperatively, and chest CT scans revealed that the dilating gastric tube had moved into the mediastinal pleural cavity. CLINICAL DISCUSSION: After ruling out the pyloric stenosis by endoscopy, our diagnosis was severe gastric outlet obstruction due to gastric conduit herniation. We performed laparoscopic surgery to mobilize and straighten the redundant gastric conduit. No recurrence occurred throughout the follow-up for one year. CONCLUSION: IHGC can cause gastric conduit obstruction, which requires reoperation to repair. The laparoscopic approach is an appropriate strategy with the advantages of being less invasive and effective in mobilizing and straightening the gastric conduit. To prevent mediastinal pleural injury - which affects the continuation of the reconstructions, the surgeon should use blunt dissection with direct observation during the route creation.

Pleural appendages: Description, incidence and relations with body mass index

BACKGROUND AND AIMS: Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients. PATIENTS AND METHODS: Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI>30) and non-obese (BMI<30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant. RESULTS: Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured <5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458). CONCLUSIONS: Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.

Efficacy of sternocleidomastoid muscle flap in reducing anastomotic mediastinal/pleural cavity leak.

BACKGROUND: Anastomotic mediastinal/pleural cavity leak (AMPCL) is a life-threatening postoperative complication after esophagectomy. The objective of this study was to find a safe and effective surgical method to reduce the incidence of AMPCL. METHODS: A total of 223 patients who underwent surgery in Fujian Medical University Union Hospital from May 2020 to October 2021 were enrolled in this study. Data for preoperative and postoperative test indices, postoperative complications, perioperative treatment were collected. After using 1:1 propensity score matching (PSM) to match two cohort (caliper = 0.1), the relationship between various factors and the incidence of AMPCL were analyzed. RESULTS: 209 patients were included for further analysis in the end. There were 95 patients in the sternocleidomastoid muscle flap embedding group (intervention group) and 114 in the routine operation group (control group). There was a significant difference in mean age between two groups. Gender, age, body mass index, diabetes, American society of anesthesiologists score, preoperative neoadjuvant therapy, pathological stage were included in performing 1:1 PSM, and there were no significant differences between two groups. Median operative time was significantly less in intervention group. Anastomotic leak (AL) did not present significant difference between two groups (8 [8.6] vs. 13 [14.0], p = 0.247), however, the AMPCL in intervention group was significantly lower than control group (0 [0] vs. 6 [6.5], p = 0.029). CONCLUSIONS: The sternocleidomastoid muscle flap embedding could significantly reduce the incidence of AMPCL. This additional procedure is safe, and effective without increase in the occurrence of postoperative complications and hospital expenses.

Extrapleural harvesting of the internal thoracic artery - impact on early postoperative results and pulmonary function.

INTRODUCTION: The internal thoracic artery (ITA) has proven to be the best graft for surgical myocardial revascularization, especially in the configuration left ITA (LITA) to the anterior descending branch of left coronary artery (LAD). Its harvesting is usually accompanied by pleurotomy, followed by drainage tube placement into the pleural cavity, using the so called intrapleural method. Extrapleural technique for LITA harvesting is also practiced in many cardiac surgery centers and with this technique the pleura is left intact.

Pleural involvement in cryptococcal infection.

Pleural involvement of cryptococcal infection is uncommon and is more commonly observed in immunocompromised hosts than in immunocompetent ones. Pleural involvement in cryptococcal infections can manifest with or without pleural effusion. The presence of Cryptococcus spp. in the effusion or pleura is required for the diagnosis of cryptococcal pleural infection, which is commonly determined by pleural biopsy, fluid culture, and/or detection of cryptococcal antigen in the pleura or pleural fluid.

Diffuse Large B-cell Lymphoma Presenting as a Primary Pleural Mass: A Case Report and Literature Review.

Primary pleural lymphoma is a rare type of lymphoma that accounts for only ​​0.3% of all non-Hodgkin's lymphomas. The rarity and nonspecific clinical presentation of primary pleural lymphomas pose a diagnostic challenge for clinicians. We present an atypical case of primary pleural lymphoma in an elderly patient without any associated pleuro-pulmonary disease, immunosuppression, or history of lymphoma. To our knowledge, this is one of the first described cases of a primary pleural lymphoma with such a presentation.

Large Pleural Lipoma Manifesting With Chronic Shoulder Pain.

Musculoskeletal symptoms related to orthopedic conditions are highly prevalent worldwide and are a leading cause of morbidity. However, non-orthopedic conditions may also present with musculoskeletal symptoms. For example, shoulder pain may be caused by gastrointestinal, hepatobiliary, cardiac, and neurological pathologies. We report the case of a 32-year-old man who presented to the orthopedic clinic with a complaint of left shoulder pain for the past three months. He described the pain as sharp in nature. The pain was constant and was not related to the shoulder movements. It was not associated with morning stiffness. He had no history of preceding trauma. On examination, both shoulders were symmetrical with no evidence of deformities. Palpation over the shoulder region did not elicit any tenderness. The range of motion in both the active and passive movements was intact. The Neer and Jobe tests were negative. Also, the sensory examination was intact, and laboratory findings were normal. The patient underwent a plain frontal radiograph of the chest, which revealed a large well-circumscribed lobulated mass lesion in the left hemithorax, arising from the pleural lining. A thoracic CT scan was then performed to provide further characterization of the mass lesion and it re-demonstrated the mass as having homogeneous fat-attenuation with thin septations, probably representing pleural lipoma. The tumor was successfully resected via open thoracotomy. The patient's symptoms resolved and he had no recurrence after one year of follow-up. Pleural lipoma is a very rare benign mesenchymal tumor. The case highlights the importance of considering non-orthopedic conditions in the differential diagnosis of shoulder pain in patients with normal physical examination findings. A CT scan is vital to make the diagnosis and can show the accurate anatomic relations with respect to the tumor for surgical planning.

Better effect of intrapleural perfusion with hyperthermic chemotherapy by video-assisted thoracoscopic surgery for malignant pleural effusion treatment compared to normothermic chemoperfusion of the pleural cavity.

OBJECTIVE: The aim of this study was to assess the efficacy and safety of intrapleural perfusion with hyperthermic chemotherapy (IPHC) in treating malignant pleural effusion (MPE) compared to normothermic chemoperfusion of the pleural cavity (NCPC), and to investigate the better treatment to control MPE. METHODS: Malignant pleural effusion patients were enrolled in the study and treated with NCPC or IPHC under video-assisted thoracoscopic surgery (VATS). The chest drainage duration, clinical characteristics, and recurrence time of pleural effusion of patients were collected for statistical analysis. The chi-squared test and the Fisher's exact test were applied to compare the distribution differences in categorical variables. Progression-free survival (PFS) was estimated by the Kaplan-Meier method and was compared by the log-rank test. The survival analysis was performed using the Cox proportional hazards method. RESULTS: A total of 37 MPE patients were enrolled in this study. Twenty-seven patients received NCPC and 10 patients received IPHC under VATS. Significant differences were found in pathological types (p = 0.011), chest drainage duration (p = 0.005), and remission rate (p = 0.009) between two different treatment groups. The chest drainage duration of IPHC under VATS was shorter than the NCPC group (t = 2.969, p = 0.005). The remission rate of MPE in IPHC group was better than the NCPC one (OR = 0.031, 95% CI: 0.002-0.507, p = 0.015). The result of the Kaplan-Meier method showed that IPHC group could significantly prolong the PFS of patients with MPE compared to NCPC group (log-rank p = 0.002). Univariate cox regression analysis showed that patients with MPE in the IPHC group presented significant longer PFS than the NCPC group (HR = 0.264, 95% CI: 0.098-0.713, p = 0.009). Multivariate cox regression analysis further verified this conclusion (HR = 0.268, 95% CI: 0.096-0.753, p = 0.012). CONCLUSION: Compared to the NCPC, the IPHC under VATS presents a better control effect on MPE, shorter tube placement time, and longer complete remission time. For this reason, we recommend IPHC under VATS as the first-line treatment for patients with MPE those who can tolerate minimally invasive surgery.

[Postoperative drainage of the pleural cavity with aspiration of the contents by high-tech mobile devices]. / Posleoperatsionnoe drenirovanie plevral'noi polosti s aspiratsiei soderzhimogo vysokotekhnologichnymi mobil'nymi apparatami.

Postoperative drainage of pleural cavity is currently a common component of treatment of patients with surgical diseases of thoracic organs. Peculiarities of suctioning (aspiration parameters, passive drainage or active aspiration, the degree of discharge in the device-pleural cavity system, as well as the possibility of early patient activation, no need to «attach¼ him to the electric stationary suction) remain topical and continue to be discussed. New devices - aspirators, including mobile ones with digital control and rarefaction control component, appear in the market. MATERIAL AND METHODS: Between May and September 2021, 65 patients aged from 23 to 88 years with various oncological and non-oncological diseases of the thoracic cavity followed by drainage underwent resection operations with a volume less than pneumonectomy or lung decortication for empyema, parietal pleurectomy for recurrent pneumothorax. Six patients (4 after pneumonectomy and one with postoperative complications (1 after retoracotomy for hemothorax and 1 after laparoscopic cholecystectomy for acute destructive cholecystitis in the immediate postoperative period) were excluded from the study. The patients were divided into 2 groups. The first group consisted of 22 patients in whom in the early postoperative period we used continuous active pleural content aspiration with the help of high-tech mobile devices Atmos. The second group included 37 patients in whom we used drainage by means of medical suction of Lavrinovich or Visma-Planar design (Belarus). RESULTS AND CONCLUSION: Soft drainage by modern systems of pleural cavity content evacuation provides the best conditions for stopping air leakage from the lung tissue as well as for preventing pneumothorax when transporting a patient from the operating room and around the clinic for examination. The early activation of the patient with the connected mobile digital aspirator not only promotes the Fast-track surgery concept but also the ERAS program, i.e. accelerated rehabilitation, as recommended by the European Society of Thoracic Surgeons (ESTS). These designs also have advantages over stationary devices, such as subjective factors based on the relative ease of operation of mobile systems in their use, accessibility not only for medical staff, but also for the patient himself.

A multidirectional two-tube method for chemical pleurodesis could improve distribution of the sclerosing agent within the pleural cavity - A pilot study.

INTRODUCTION: Malignant pleural effusion (MPE) affects approximately 200,000 people in the United States per annum. Chemical pleurodesis is a recommended first line treatment in the management of MPE, however, success rates as low as 43% has been reported. A bedside chemical pleurodesis can cost up to $11,224 and an estimated inpatient annual expenditure of more than $5 billion in the US alone. This study aims to assess the distribution of the talc slurry within the pleural space using human cadaveric models and to determine the force required to push the talc slurry though a 14 Fr chest tube. MATERIALS AND METHODS: The force required to administer the talc slurry through a 14 Fr chest tube was tested using a Zwick/Roelle Z005 mechanical tester, using a porcine thoracic biomodel. Talc slurry distribution within the pleural cavity was assessed by direct visualisation following administration to the human cadaveric models using single and multidirectional two-tube methods. RESULTS: Maximum force required to push the talc slurry through a 14 Fr chest tube was 11.36 N ± 2.79 N. Distribution of the talc slurry within the pleural cavity was found to be poor with a single tube method. Multidirectional two-tube method of administration showed more even distribution. CONCLUSION: The experimental multidirectional two-tube method results in wider distribution of the talc slurry within the pleural cavity and could further improve success rate of the talc pleurodesis.

Extrapleural fat: description, incidence, and relation with body mass index. / Apéndices pleurales: descripción, incidencia y relación con el índice de masa corporal.

BACKGROUND AND AIMS: Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients. PATIENTS AND METHODS: Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI > 30) and non-obese (BMI < 30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant. RESULTS: Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured < 5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458). CONCLUSIONS: Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.