[Efficacy and Safety of Medical Thoracoscopic Bulla Volume Reduction in the Treatment of Chronic Obstructive Pulmonary Disease Combined With Giant Emphysematous Bullae]. / ç»å† ç§‘èƒ¸è ”é•œè‚ºå¤§ç–±å‡å®¹æœ¯æ²»ç–—æ ¢æ€§é˜»å¡žæ€§è‚ºç–¾ç— åˆå¹¶å·¨åž‹è‚ºå¤§ç–±çš„ç–—æ•ˆå’Œå®‰å ¨æ€§ç ”ç©¶.

Objective: To explore the efficacy and safety of medical thoracoscopic bulla volume reduction for the treatment of chronic obstructive pulmonary disease (COPD) combined with giant emphysematous bullae (GEB). Methods: A total of 66 patients with COPD combined with GEB were enrolled in the study. All the subjects received treatment at Zhengzhou Central Hospital affiliated with Zhengzhou University between March 2021 and December 2022. The subjects were divided into two groups, a medical thoracoscope group consisting of 30 cases treated with medical thoracoscopic bulla volume reduction and a surgical thoracoscope group consisting of 36 cases treated by video-assisted thoracoscopic surgery. All patients were followed up before discharge and 3 months and 6 months after discharge. The preoperative and postoperative levels of the pulmonary function, 6-minute walk distance (6MWD), and St. George's Respiratory Questionnaire (SGRQ) scores and differences in postoperative complications were compared between the two groups. The operative duration, postoperative length-of-stay, and surgical costs and hospitalization bills, and the maximum visual analog scale (VAS) pain scores at 24 h after the procedure were assessed. Results: The baseline data of the two groups were comparable, showing no statistically significant difference. The forced expiratory volume in 1 second (FEV1) 6 months after the procedures improved in both the medical thoracoscopy group ([0.78±0.29] L vs. [1.02±0.31] L, P<0.001) and the surgical thoracoscopy group ([0.80±0.21] L vs. [1.03±0.23] L, P<0.001) compared to that before the procedures. Improvements to a certain degree in 6MWT and SGRQ scores were also observed in the two groups at 3 months and 6 months after the procedures (P<0.05). In addition, no statistically significant difference in these indexes was observed during the follow-up period of the patients in the two groups. There was no significant difference in operating time between the two groups. The medical thoracoscopy group had shorter postoperative length-of-stay ([7.3±2.6] d) and 24-hour postoperative VAS pain scores (3.0 [2.0, 3.3]) than the surgical thoracoscopic group did ([10.4±4.3] d and 4.5 [3.0, 5.0], respectively), with the differences being statistically significant (P<0.05). Surgical cost and total hospitalization bills were lower in the medical thoracoscopy group than those in the surgical thoracoscopy group (P<0.05). The complication rate in the medical thoracoscopy group was lower than that in the surgical thoracoscopy group (46.7% vs. 52.8%), but the difference was not statistically significant. Conclusion: Medical thoracoscopic reduction of bulla volume can significantly improve the pulmonary function, quality of life, and exercise tolerance of patients with COPD combined with GEB, and it can reduce postoperative short-term pain and shorten postoperative length-of-stay. The procedure has the advantages of minimal invasiveness, quick recovery, and low costs. Hence extensive clinical application is warranted.

Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae.

PURPOSE: Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB. METHODS: We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP. RESULTS: After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB. CONCLUSIONS: We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.

Cutaneous fistula formation after thyroid nodule rupture: A rare complication after radiofrequency ablation.

BACKGROUND: With innovative treatment options such as radiofrequency ablation (RFA) for thyroid nodules, new complications are being identified. It is important to define and delineate complications in order to counsel patients appropriately about treatment options and their associated risks and benefits. METHODS: A 46-year-old male presented with a left thyroid nodule (6.5 cm). Fine needle aspiration results were benign. He started to develop intermittent dyspnea and underwent one RFA procedure. Approximately 6 days post-RFA, the neck area was raised and red with blister. The skin overlying the blister underwent eventual dehiscence with fluid spillage. Several months later, MRI imaging showed substernal extension with tracheal deviation. RESULTS: A left thyroid lobectomy was performed with cutaneous excision and successful closure of a fistula. CONCLUSIONS: This is the first reported case of a thyroid nodule rupture following RFA which manifested into a thyro-cutaneous fistula and required surgical intervention.

[Recurrence of a Giant Emphysematous Bulla After Bullectomy:Report of a Case].

A 38-year-old male, he was diagnosed with a giant pulmonary bulla occupying 2/3 of the right thoracic cavity on chest computed tomography( CT). The preoperative pulmonary function was unfavorable, so bullectomy of right upper lobe with video-assisted thoracoscopic surgery( VATS) was performed. The outpatient follow-up was completed at 6 months after surgery. However, one year and eleven months postoperatively, the patient returned to the clinic complaining of dyspnea. Chest X-ray and CT showed a recurrence of a giant emphysematous bulla in the right upper lobe. Two years and three months after the initial surgery, the recurrent giant bulla was resected by right upper lobectomy with VATS. About four years after the reoperation, no recurrence of giant pulmonary bulla has been seen. Although there are some reports on surgical treatment and results of giant pulmonary bulla, there are few reports on recurrent cases, so we report this case.

Cardiovascular Collapse after the Induction of Anesthesia Due to the MASS Effect of Unruptured Giant Bullae.

Background and Objectives: Giant bullae rupture easily and cause tension pneumothorax, which can cause problems during general anesthesia. However, the hemodynamic instability that can occur due to the mass effect of an unruptured giant bulla should not be overlooked. Case report: A 43-year-old male patient visited the emergency room with an abdominal wound. There was a giant emphysematous bulla in the left lung. Emergency surgery was decided upon because there was active bleeding according to abdominal CT. After tracheal intubation, the patient's blood pressure and pulse rate dramatically decreased. His blood pressure did not recover despite the use of vasopressors and discontinuation of positive pressure ventilation applied to the lungs. Thus, a bullectomy was immediately performed. The patient's blood pressure and pulse rate were normalized after the bullectomy. Conclusions: If emergency surgery under general anesthesia is required in a patient with a giant emphysematous bulla, it is safe to minimize positive pressure ventilation and remove the giant emphysematous bulla as soon as possible before proceeding with the remainder of the surgery. Tension pneumothorax due to the rupturing of a bulla should be considered first. However, hemodynamic changes might occur due to the mass effect caused by a giant bulla.

COVID-19 and spontaneous pneumothorax: a survival analysis.

INTRODUCTION: COVID-19 Patients may be at risk for involving with spontaneous pneumothorax. However, clinical data are lacking in this regard. In this study, we aimed to investigate the demographic, clinical, and radiological characteristics and survival predictors in COVID-19 patients with pneumothorax. METHODS: This is a retrospectivestudy conducted on COVID-19 patients with pneumothorax that had been hospitalized at hospital. l from December 2021 to March 2022. The chest computed tomography (CT) scan of all patients was reviewed by an experienced pulmonologist in search of pulmonary pneumothorax. Survival analysis was conducted to identify the predictors of survival in patients with COVID-19 and pneumothorax. RESULTS: A total of 67 patients with COVID-19 and pneumothorax were identified. Of these, 40.7% were located in the left lung, 40.7% were in the right lung, and 18.6% were found bilaterally. The most common symptoms in the patient with pneumothorax were dyspnea (65.7%), increased cough severity (53.7%), chest pain (25.4%), and hemoptysis (16.4%). The frequency of pulmonary left and right bullae, pleural effusion, andfungus ball were 22.4%, 22.4%, 22.4%, and 7.5%, respectively. Pneumothorax was managed with chest drain (80.6%), chest drain and surgery (6%), and conservatively (13.4%). The 50-day mortality rate was 52.2% (35 patients). The average survival time for deceased patients was 10.06 (2.17) days. CONCLUSIONS: Our results demonstrated that those with pleural effusion or pulmonary bullae have a lower survival rate. Further studies are required to investigate the incidence and causality relation between COVID-19 and pneumothorax.

[Giant Bullae Misdiagnosed as Pneumothorax:Report of a Case].

A 46-year-old man was taken to a hospital by ambulance because of sudden onset of dyspnea, and was inserted chest drainage tube with a diagnosis of right-sided tension pneumothorax on chest X-ray. Since the chest drainage was not effective, he was transferred to our institute. Based on chest computed tomography (CT) findings, a diagnosis of giant bullae of the right lung was made, and surgical treatment was performed. Postoperatively, the improvement of respiratory function was confirmed.

Ultrathin Skin Grafting Versus Suction Blister Epidermal Grafting in the Treatment of Resistant Stable Vitiligo: A Self-Controlled Comparative Study.

BACKGROUND: Surgical therapies are effective methods to treat resistant stable vitiligo, with each method having advantages and disadvantages. OBJECTIVE: This study aimed to compare the efficacy and safety of ultrathin skin grafting (UTSG) and suction blister epidermal grafting (SBEG) to treat stable vitiligo. METHODS: A total of 15 patients with 45 vitiligo patches were recruited. Each vitiligo patch was divided in half; 1 half was treated by UTSG, whereas the other half was treated by SBEG. The patients were followed up monthly for 3 months to assess the repigmentation rate, relative melanin index (RMI), and relative erythema index (REI) at different timepoints. RESULTS: Excellent repigmentation was observed in 97.8% of patches that underwent UTSG and 93.3% that underwent SBEG. The RMI and REI at 1, 2, and 3 months after the grafting procedure did not significantly differ between the 2 methods. At the recipient site, incomplete fall-off of the graft occurred in 4.4% of patches that underwent UTSG, whereas a "cobblestone appearance" was observed in 66.7% of patches that underwent SEBG. UTSG caused fewer complications at the donor site than SBEG. CONCLUSION: Compared with SBEG, UTSG is faster and achieves better cosmetic outcomes at the recipient and donor sites.

Clinical Results After Intra-Cavitary Drainage Of Giant Bullae In Patients With Poor Pulmonary Reserves.

BACKGROUND: Giant bullae (GB) are space occupying lesions associated with chronic respiratory symptoms. The aim of this study is to evaluate outcome of intra-cavitary tube drainage procedures (ITDP) in terms of clinical and radiological benefits. METHODS: A prospective study was conducted in The Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi, from February 2021 to April 2022 after ethical approval. Patients above 12 years, with poor reserve and GB underwent clinical, radiological and laboratory assessment before and after ITDPs to document various studied parameters. RESULTS: A total of 48 patients were included; thirty-two (66.7%) were males. Mean age was 46.7±12.14 years. Most common aetiology was COPD (28; 58.3%). GB were ≥10 cm in size in 36 (75%) with right upper lobe involvement in 20 (41.7%). Preoperative dyspnoea score of IV was seen in 41 (85.4%) and chest pain in 42(87.5%) patients. In 34(70.8%) patients, Monaldi procedure and in 14 (29.2%) Brompton technique was used. Dyspnoea score improved from grade IV to II (24/41; p=0.004) along with reduction in pain and cough (p=0.012; p=0.002), respectively. Improvement post operatively in oxygen saturation, forced vital capacity, forced expiratory volume in 1 sec (6.08±1.36%, 0.73±0.516 L and 0.57±0.07 L, respectively, p<0.001) was seen. Partial pressure of oxygen (PaO2) and carbon dioxide improved by 40.6±4.82 (p=0.009) and 13.22±3.62mmHg (p=0.7). Improvement of PaO2 was associated with reduction in the size of bullae (9.33±5.13cm; p=0.006). Radiographical resolution was seen in 41 (87.5%) majorly within 2 months (21; 51.2%). Duration of hospital stay was 4.20±0.92 days with no mortality. Complications were seen in 25 (52.1%) patients. CONCLUSIONS: Intra-cavitary tube drainage procedures allow both clinical and physiological improvement in patients with GB. They allow resolution of bullae in patients with poor reserves and help in expansion of underlying compressed lung, improving both the clinical symptoms and radiological picture.

Single-antiplatelet regimen in ruptured cerebral blood blister and dissecting aneurysms treated with flow-diverter stent reconstruction.

BACKGROUND: Flow diversion treatment of ruptured cerebral aneurysms remains challenging due to the need for double-antiplatelet therapy. We report our experience with flow-diverter stent (FDS) reconstruction with single-antiplatelet therapy of ruptured cerebral blood blister and dissecting aneurysms. METHODS: In this case series we performed a retrospective analysis of all patients with ruptured cerebral aneurysms who were treated with a phosphoryl-bonded FDS between 2019 and 2022 in a single center. Periprocedurally, all patients received weight-adapted eptifibatide IV and heparin IV. After 6-24 hours, eptifibatide was switched to oral prasugrel as monotherapy. We analyzed the rate of bleeding complications, thromboembolic events, occlusion rate and clinical outcome. RESULTS: Nine patients with subarachnoid hemorrhage were treated, eight within 24 hours of symptom onset. Seven patients were treated with one FDS and two patients received two FDS in a telescopic fashion. Two aneurysms were additionally coil embolized. Fatal re-rupture occurred in one case; eight patients survived and had no adverse events associated with the FDS. Six patients showed complete occlusion of the aneurysm after 3 months (n=2) and 1 year (n=4), respectively. Two patients showed subtotal occlusion of the aneurysm at the last follow-up after 3 months and 6 months, respectively. Favorable clinical outcome was achieved in five patients. CONCLUSIONS: Peri-interventional single-antiplatelet therapy with eptifibatide followed by prasugrel was sufficient to prevent thromboembolic events and reduce re-bleeding using an anti-thrombogenic FDS. FDS with single-antiplatelet therapy might be a viable option for ruptured blood blister and dissecting cerebral aneurysms.

Perioperative Management of Congenital Epidermolysis Bullosa.

Congenital epidermolysis bullosa is a rare disease that causes blister formation in areas susceptible to mechanical stimulation. We present the case of a patient with congenital epidermolysis bullosa simplex who underwent thoracoscopic surgery for pneumothorax. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Crusts developed around the blistered skin, which normalized within 2 months postoperatively. General anesthesia and skin management are critical in thoracoscopic surgery for patients with congenital epidermolysis bullosa simplex.

New mechanism for epithelial ingrowth after small incision lenticule extraction: Vertical epithelial gas breakthrough.

A 41-year-old man underwent SMall Incision Lenticule Extraction (SMILE) to treat myopia in both eyes. The femtosecond procedure was uneventful but a paracentral epithelial blister appeared during the dissection of the anterior plane of the lenticule in the right eye. The posterior surface of the lenticule was dissected without any complication. The surgery of the left eye was uneventful. In the postoperative period, he developed a paracentral epithelial ingrowth in his right eye, exactly underneath the site where the epithelial blister had been noted during the dissection of the lenticule. This induced irregular astigmatism, severely affecting his visual acuity. The decision of surgical treatment was made. After the de-epithelialization of an area of 6mm around the ingrowth, the SMILE incision was opened, and the epithelial ingrowth was dissected and removed from the interface. One month later, uncorrected visual acuity was 20/20, no epithelial ingrowth was observed at the interface, and only the edge of the former ingrowth was barely visible in slit lamp examination. No recurrence was observed. We hypothesize that a vertical epithelial gas breakthrough created a fistula between the interface and the epithelium, forming a pathway for the epithelial cells and giving rise to epithelial ingrowth.

Symptomatic unilateral idiopathic giant bullous emphysema : a case report.

BACKGROUND: Idiopathic Giant Bullous Emphysema (or Vanishing Lung Syndrome) is a rare condition which is usually associated with male gender, active smoking and underlying emphysematous disease. We present an unusual case of a giant bulla occurring in the absence of these risk factors. CASE PRESENTATION: A 54-year-old woman presented to the respiratory outpatient clinic with gradually worsening left sided chest discomfort, which was most marked during a recent flight. She had no significant dyspnoea or other symptoms. She had a remote 5-pack-year smoking history. Chest X-Ray revealed a large hyperlucent area in the left upper lobe. CT Thorax found this to be an isolated bulla occupying more than one-third of the hemithorax. The remaining lung parenchyma was normal. A diagnosis of Idiopathic Giant Bullous Emphysema was made. The patient was referred for VATS (Video-assisted thoracoscopic surgery) bullectomy which was carried out without complication. Her symptoms resolved completely following the operation. CONCLUSIONS: This is an unusual case of a solitary giant bulla occurring without major risk factors or underlying lung disease. VATS bullectomy was shown to be an effective therapeutic option, allowing re-expansion of compressed lung tissue and complete resolution of symptoms.

Bronchoscopic Treatment of Giant Emphysematous Bullae with Endobronchial Silicone Plugs.

Purpose: Surgical bullectomy is the standard treatment of giant emphysematous bulla (GEB). However, bronchoscopic treatment should be considered as an alternative approach for patients who are unfit for surgical treatment. The study aimed to evaluate the clinical efficacy of endobronchial occlusion for the treatment of GEB using silicone plugs. Methods: This retrospective study recruited four patients with GEB who were unsuitable for surgery. Preoperative planning was performed using high-resolution computed tomography and a virtual bronchoscopic navigation system. Customized silicone plugs were then placed in the target airway via bronchoscopy to cause GEB regression and atelectasis. Results: All procedures were completed successfully in four patients. Three months after the procedures, compared with baseline, increases in the mean forced expiratory volume in 1 s (from 1.20 L/s to 1.33 L/s), forced vital capacity (from 2.63 L to 2.90 L), diffusion lung capacity for carbon monoxide (from 29% to 41% of the predicted value) and 6-minute walking test (from 412 m to 474 m) were observed. Additionally, the mean total lung capacity (from 6.80 L to 6.35 L), residual volume (from 3.97 L to 3.52 L), and St. George's Respiratory Questionnaire scores (from 67 to 45) were all lower than baseline data. Conclusion: Our preliminary results demonstrated that the endobronchial placement of silicone plugs could be a low-cost, safe, and effective choice for the treatment of GEB in surgically unfit patients.

Long-Term Follow-Up of Intralobar Bullae After Endobronchial Valve Treatment for Emphysema.

Endoscopic lung volume reduction using unidirectional endobronchial valves is a new technique in the treatment of patients with severe emphysema. However, the movements of the thoracic structures after endobronchial valves insertion are still unpredictable We report the unusual outcome of six patients after valves insertion in the left upper lobe. They all developed a complete atelectasis of the target lobe, a pneumothorax and sequential genuine bullae in the treated left lung of unknown etiology. The chest CT scan prior to the valves insertion was unremarkable. Three patients developed an air-liquid level in the bullae the day before a bacterial infection of their left lower lobe. The three other patients had an uneventful spontaneous resolution of their bullae at long-term follow-up. Therefore, a conservative attitude should be followed in this particular setting.

Palliative Efficacy of Intrastromal Amniotic Membrane Procedure in Symptomatic Bullous Keratopathy Patients.

Objectives: To evaluate the palliative efficacy of the intrastromal human amniotic membrane (hAM) surgery technique in patients with symptomatic bullous keratopathy and limited visual potential. Materials and Methods: The study was carried out retrospectively by reviewing the medical data of 10 patients with poor visual prognosis who underwent intrastromal hAM surgery due to bullous keratopathy-related severe pain. Visual acuity, surgical indication, epithelization time, preoperative and postoperative pain scores, as well as anterior segment optical coherence tomography images and anterior segment photographs were obtained from the medical records. Results: Ten patients (6 females/4 males) were included in the study. Nine patients underwent surgery for pseudophakic bullous keratopathy and glaucoma, and 1 patient due to graft failure and glaucoma. The mean time for corneal epithelization was 27.10±13.05 days (range, 10-50), while the mean follow-up time was 37.5±1.6 months (range, 36-39.2). Subjective pain score improved in all patients after surgery. Suture-induced keratitis occurred during follow-up in one patient and was controlled with medical treatment. Conclusion: Intrastromal amniotic membrane surgery may be an alternative to keratoplasty for pain palliation in patients with limited visual prognosis after corneal transplantation when donor tissue is scarce. With this method, hAM remains on the ocular surface longer, and superficial stromal excision is believed to provide a more regular ocular surface and extend the asymptomatic period.

Characteristics of Snakebite-Related Infection in French Guiana.

Wound infection is frequently reported following snakebite (SB). This study is retrospective. It was conducted in the emergency department and the Intensive Care Unit (ICU) of Cayenne General Hospital between 1 January 2016 and 31 July 2021. We included 172 consecutive patients hospitalized for SB envenoming. All patients were monitored for wound infection. Sixty-three patients received antibiotics at admission (36.6%). The main antibiotic used was amoxicillin-clavulanate (92.1%). Wound infection was recorded in 55 cases (32%). It was 19% in grade 1, 35% in grade 2, and 53% in grade 3. It included abscess (69.1%), necrotizing fasciitis (16.4%), and cellulitis (21.8%). The time from SB to wound infection was 6 days (IQR: 3-8). The main isolated microorganisms were A. hydrophila and M. morganii (37.5% and 18.8% of isolated organisms). Surgery was required in 48 patients (28.1%), and a necrosectomy was performed on 16 of them (33.3%). The independent factors associated with snakebite-associated infection were necrosis (p < 0.001, OR 13.15, 95% CI: 4.04-42.84), thrombocytopenia (p = 0.002, OR: 3.37, 95% CI: 1.59-7.16), and rhabdomyolysis (p = 0.046, OR: 2.29, 95% CI: 1.02-5.19). In conclusion, wound infection following SB is frequent, mainly in grade 2 and 3 envenomed patients, especially those with necrosis, thrombocytopenia, and rhabdomyolysis. The main involved bacteria are A. hydrophila and M. morganii.

Expeditious Resolution of Giant Bullae with Endobronchial Valves and Percutaneous Catheter Insertion.

As bullae contribute to decreased lung function in chronic obstructive pulmonary disease (COPD) patients, effective decompression of large bullae is important. Bronchoscopic lung volume reduction via endobronchial one-way valves is less invasive and has a lower mortality rate than lung volume reduction surgery. We report the case of a 48-year-old male who presented with giant bullae that were expeditiously resolved with endobronchial valves and percutaneous catheter insertion. Three days later, imaging revealed marked decreases in the extent of bullae and atelectasis of the contralateral lung without any complications, including air leakage or pneumothorax. Combination of endobronchial valves and percutaneous catheter insertion might be helpful to accelerate the release of large bullae and to achieve improved lung function and higher levels of physical activity in patients with COPD.

Unexpected Histopathological Diagnosis of Placental Transmogrification of the Lung after Bullectomy for Recurrent Spontaneous Pneumothorax: A Case Report and Literature Review.

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.