Late complications of collapse therapy for pulmonary tuberculosis.

STUDY OBJECTIVES: Collapse therapy for pulmonary tuberculosis involved placement of various materials to occupy space and keep the lung collapsed. Complications are encountered decades later. PATIENTS AND METHODS: Between 1980 and 1997, we treated 31 patients with a history of pulmonary tuberculosis in whom collapse therapy had been used and who later developed complications related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable pneumothorax was present in 1 patient, and migration of a foreign body with formation of subcutaneous mass occurred in 3 patients. All patients with empyema were treated with antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted. RESULTS: Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and 1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap remained closed. Following extraction of paraffin blocks, infection developed in one patient. During the follow-up period, three patients died, all of unrelated causes. CONCLUSIONS: Delayed complications of collapse therapy for tuberculosis should be treated without delay. Pressure on adjacent structures or their erosion presents danger and mandates immediate extraction; however, there is no need for routine removal of every residual plombe. Further increase in the number of multiple-drug resistant strains may force the return of collapse therapy.

Percutaneous drainage of lung abscess.

Patients with primary lung abscess who do not respond to medical management are usually candidates for a lobectomy. Percutaneous tube drainage, used routinely and with good results before the antibiotic era, has nearly been forgotten. Seven patients with lung abscesses and severe sepsis were in critical condition, not permitting pulmonary resection. They were treated by tube drainage. Prompt clinical recovery occurred in all, with complete resolution of abscesses within 4 to 24 days. When medical therapy of lung abscess fails, tube drainage should be considered in preference to a lobectomy. It is safe and curative and avoids unnecessary loss of functioning lung parenchyma. Lobectomy should be considered in patients who have major life-threatening bleeding or massive pulmonary necrosis.

Empyema and bronchopleural fistula. Experience with open window thoracostomy.

Open window thoracostomy (OWT) was created in 12 patients with empyema and sepsis after conventional therapy with antibiotics and drainage had failed. After creation of OWT all infections subsided within ten days to four months and all fistulae closed within one to four months. Complete obliteration of the empyema cavity by granulation tissue occurred in 11 of 12 patients within one to eight months, depending upon the size of the space. All patients tolerated the procedure well. Creation of OWT has not caused lung collapse in any of the patients due to fibrosis caused by the preceding infection. There was no complication or death. OWT is a safe procedure recommended in all patients with empyema resistant to conventional therapy. It does not need to be restricted to post-pneumonectomy cases. Operative closure of bronchopleural fistulae, a major surgical undertaking with an uncertain outcome, is usually unnecessary.

Foreign bodies in the tracheobronchial tree.

Between 1972 and 1984, we treated 66 patients with foreign bodies (FBs) in the tracheobronhial tree. Twenty-six patients (39.4 percent) were between one and two years old; 52 (78.8 percent) were under age ten. Forty-four FBs (67 percent) were fruit and vegetable seeds and nuts. Soft organic material (meat, cucumber peels) was found in four patients, chicken bones in six, pins and needles in six, other nonorganic materials (toys, stone, broken thermometer) in six. In 55 patients, the FB was removed at bronchoscopy; three patients coughed up the FB shortly after bronchoscopy. Eight patients were operated on because the impacted FB could not be removed at repeat bronchoscopy trials. In this group, the FB was removed through a bronchotomy in two patients, but in six, pulmonary resection was necessary because of severe bronchiectasis (FBs had been impacted from ten months to 12 years). Stiff bronchoscope was used in all patients. In several cases, the flexible bronchoscope was used initially but proved inadequate. There were three complications, two related to hypoxia, but no deaths. Infants and little children should be prevented from reaching peanuts and seeds. When presence of a FB is suspected, and in children with unresolving pneumonic process, early bronchoscopy is mandatory. Expert anesthesia is essential, and hypoxia must be avoided.

Retrosternal goiter.

BACKGROUND: Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer. METHODS: During a 22-year period, we treated 44 patients with intrathoracic multinodular goiter. RESULTS: The goiter was resected in 40 patients; 4 patients were rejected because of prohibitive risk. There were three minor complications and no deaths. CONCLUSIONS: The specific indications for resection include compression of adjacent structures, prevention of future complications, and obtaining a diagnosis. Fine-needle aspiration for diagnosis is not always possible and rarely reliable, and there is no effective medical therapy. Cervical incision is nearly always adequate, with few exceptions, such as very large posterior goiter, mediastinal blood supply, or carcinoma necessitating mediastinal dissection.

Pneumothorax: experience with 1,199 patients.

OBJECTIVE: To study the outcome of pneumothorax managed in a university-affiliated metropolitan medical center. DESIGN: A retrospective review. SETTING: Busy metropolitan medical center. PATIENTS AND METHODS: Records of 1,199 patients with pneumothorax were reviewed and analyzed. RESULTS: Primary spontaneous pneumothorax occurred in 218 patients, secondary spontaneous pneumothorax occurred in 505, traumatic in 403, and iatrogenic in 73. Ninety-six patients with small pneumothorax (8%) were managed by observation, and 1,103 patients (92%) were managed by tube thoracostomy. Drainage of the pleural cavity was continued for 1 to 7 days in 893 patients (81%), 8 to 10 days in 176 patients (16%), and > 10 days in 34 patients (3%). Drainage for > 10 days was classified as persistent pneumothorax. In these 34 patients and in 132 others with a second ipsilateral recurrence (a total of 166 patients), direct pleuroscopy was performed. The pleuroscopy findings and further management are outlined in the algorithm. CONCLUSIONS: Pneumothorax is a common condition affecting all age groups. If the volume of the pneumothorax is > 20% of the pleural space, pleural drainage is indicated. For management of persistent or recurrent pneumothorax, the use of pleuroscopy (direct or video-assisted) is of great value and should be part of routine management.

Diagnostic and therapeutic pleuroscopy. Experience with 127 patients.

Experience with 127 pleuroscopies using the mediastinoscope is reviewed. The most frequent indications were pleural effusion (73 patients), pleural involvement by tumor (14), empyema (14), and recurrent pneumothorax (14). Findings were diagnostic in 119 of 127 patients (93.7 percent). Pleural metastases were found in 63 patients, primary pleural or lung tumor in six, nonspecific or tuberculous empyema in 17, emphysematous blebs in 12 and less common findings in the remainder. Pleuroscopy was usefully employed to determine chest wall penetration by a malignant lung tumor in five patients with severely restricted pulmonary reserve. Positive findings helped to avoid unnecessary thoracotomy. There were two minor complications and no deaths. Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 35 of 39 patients. Talc was also used, with equal success and without complications, in eight patients with recurrent pneumothorax and in two with empyema after evacuation of pus. We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure, simple and well tolerated, with the diagnostic yield of over 90 percent and virtually free of complications. It provides the best way of insufflating talc for pleurodesis.

Talc pleurodesis. Experience with 360 patients.

Talc was used intrapleurally for the creation of pleural adhesions in 360 patients. The indications for use were malignant pleural effusion in 169 patients, benign effusions in 41, recurrent pneumothorax in 122, empyema in 19, and chylothorax in 9. Of 336 patients available for follow-up, excellent results (complete pleurodesis) were achieved in 284 patients (84.5%), fair results in 28 (8.3%), and poor results (no adhesions) in 24 (7.2%). The results were best in empyema (100%) and better in pneumothorax than in pleural effusions. With repeat talc insufflation, the results were improved to excellent in more than 90% of the patients. Talc is the most effective and least expensive agent for creation of pleural adhesions. Its use is simple and easily tolerated by the patients. Because of the carcinogenic effect of asbestos, purified talc that is free of asbestos fibers must be used.

Inflammatory fibrous histiocytoma of the bronchus.

A 33 year-old woman underwent lobectomy of the middle and lower lobes of the right lung because of inflammatory fibrous histiocytoma of the bronchus. To our knowledge, this is the first description of such a tumor originating in the bronchus.

Extralobar sequestration presenting as massive hemothorax.

Pulmonary extralobar sequestration is a rare anomaly, usually diagnosed during the first months of life. A case of extralobar pulmonary sequestration in an adult, manifesting itself as massive hemothorax, is presented.

Bronchial carcinoid tumors: twenty years' experience.

We reviewed 69 patients with documented carcinoid tumors, 67 of whom had resectable disease. Operations included nine pneumonectomies, 31 lobectomies, 12 bilobectomies, five segmental resections, and 10 sleeve resections. Follow-up on 65 patients reveals 40 surviving beyond 5 years and 13 beyond 20 years since resection. There were no operative deaths and only one recurrence (local) that was subsequently successfully resected. Twenty patients had had recurrent unifocal pneumonitis or hemoptysis for up to 5 years prior to diagnosis. Two patients had the carcinoid syndrome. Biopsy was performed on 23 tumors and resulted in "moderate-to-severe" hemorrhage in six cases. Lymphatic spread was present in seven cases. All seven are alive and free of disease, six of whom have been followed from 5 to 24 years. Diseased resection margins were present in two cases, with both surviving 20 years after resection. All 10 sleeve resections were performed more than 5 years ago. We conclude that carcinoid tumors carry a favorable prognosis upon resection, even when intrathoracic lymphatic metastases are present and are resected. Lung-sparing resections including sleeve resections should be utilized. Recurrent pneumonia or hemoptysis or both requires diligent investigation. Biopsy of the tumors may be performed with care.

Neglected lung cancer.

Pulmonary nodules of unknown nature may be cancerous and are best treated by early resection. During the past 20 years we have seen 65 patients in whom asymptomatic pulmonary nodules from 5 to 20 mm in diameter were discovered on routine roentgenograms between 1 and 4 years prior to their referral to surgery. These patients have not been investigated for cancer. Instead, they had been 'observed' or treated with antibiotics while their nodules increased in size. At the time of referral, 29 patients had widespread metastases, 28 had locally invasive State III lung cancer, eight had Stage I or Stage II lesions. Only 16 patients had their tumors resected. Sixteen patients (24.6%) survived 1 year or longer; six patients (9.3%) survived more than 2 years. Early resection of all undiagnosed pulmonary nodules is essential. 'Expectant' or antibiotic treatment of these lesions should be condemned. Educational programs for family physicians are urged.

Gangrene of the lung: treatment in two stages.

BACKGROUND: Pulmonary gangrene is a rare complication of severe lung infection with devitalization of lung parenchyma and secondary infection. If untreated, gangrene of the lung leads to sepsis, multiple-organ failure, and death. Resection of all gangrenous tissue is mandatory and is lifesaving. Pleural empyema commonly accompanies gangrene of the lung; in its presence, dissection of hilar structures for resection can lead to mediastinitis or bronchopleural fistula and should be avoided. METHODS: Three patients with pulmonary gangrene were treated in two stages: immediate fenestration first and then delayed resection of gangrenous lung in a clean field and immediate closure of the pleural window. RESULTS: Two patients underwent pneumonectomy and 1 patient, lobectomy. All patients recovered without complications. CONCLUSIONS: Creation of a pleural window (fenestration) for 1 week enables safe and curative resection of a gangrenous lung or lobe in a clean field and in a patient in stable condition.

Surgical management of tracheal tumors.

BACKGROUND: Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor. METHODS: In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved. RESULTS: One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor. CONCLUSIONS: Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Pleural empyema: 24-year experience.

BACKGROUND: Despite the widespread use of antibiotics, empyema remains a common and serious problem, and its treatment is controversial. METHODS: Our experience in 380 patients with empyema was retrospectively reviewed. RESULTS: The causes of empyema were as follows: pneumonia (n = 308), late complication of tuberculosis (n = 24), trauma (n = 15), pulmonary gangrene (n = 3), retained foreign body (n = 1), and undetermined (n = 29). An exudative state was diagnosed in 273 patients, a fibrinopurulent state in 55, and an organizing state in 52. Pleuroscopy was performed in 107 patients resistant to treatment, and this revealed an expansible lung in 49 patients, a nonexpansible lung in 51, and exceptional findings (foreign body, necrotizing pneumonitis, and perforated esophageal cancer) in 7. Treatment was modified accordingly. Five patients died (mortality, 1.3%). CONCLUSIONS: Pleuroscopy is very helpful in disclosing factors responsible for resistance to treatment and in carrying out thorough pleural toilet. The use of talc in selected patients causes pleurodesis and prevents the reaccumulation of pus. Decortication is the ideal treatment in the organizing stage, enabling complete lung expansion. Fenestration is lifesaving in moribund patients who cannot tolerate decortication.

The use of talc for pleurodesis in the treatment of resistant empyema.

The use of talc in the infected pleural space has not been reported previously. Five patients who had empyema of the pleura in the fibrinopurulent stage and did not respond to treatment with tube drainage and antibiotics were treated by talc insufflation to stimulate pleural adhesions. Pleurodesis was achieved in all 5 patients, with complete recovery from empyema. No untoward effects were observed. These results suggest that talc pleurodesis may be an acceptable solution to the problem of empyema resistant to other methods of treatment.

Pleuroscopy in patients with pleural effusion and pleural masses.

We performed diagnostic pleuroscopy in 66 patients with pleural effusion and in 14 with pleural masses. The findings were diagnostic in 76 patients (95%). Pleural metastases were found in 63 patients, primary pleural or lung tumor in 5, and less common findings in the remainder. Only 1 minor complication occurred, and there were no deaths. Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 31 of 35 patients. Talc also was used with equal success and without complications in management of recurrent pneumothorax. We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure. It is simple and well tolerated, has a diagnostic yield of 95%, and is virtually free from complications. It provides the best way of insufflating talc for pleurodesis.

Diagnosis of breast lesions by fine needle aspiration biopsy.

The authors performed 480 fine needle aspiration biopsies (FNAB) of breast masses for cytologic diagnosis in 464 patients. Parallel surgical biopsy with histologic examination was carried out in 163 patients; the results were identical in 161. Two hundred eight of 297 benign lesions and 83 of 96 malignant tumors were diagnosed positively by FNAB. In 87 instances FNAB was not diagnostic but excluded malignancy, while in 87 others, the cytologic specimen was inadequate for diagnosis. There was one false-positive and one false-negative result. There were virtually no complications. FNAB of breast masses is a simple and reliable method, easy to carry out in ambulatory patients.

Fine-needle aspiration biopsy in diagnosis of pulmonary masses.

Fine-needle aspiration biopsy (FNAB) is a diagnostic method indicated in patients with pulmonary lesions that cannot be reached with a bronchoscope and when cytologic examinations of the sputum are persistently negative. Cells are aspirated under fluoroscopic control and stained using the Papanicolaou method for cytologic examination. Results are available within hours, and the material can be used for other studies. Between 1975 and 1984, the authors performed 845 FNABs in 342 patients. Diagnosis was established in 306 patients, or 89.5 per cent. Malignant neoplasm was diagnosed in 284 instances, benign disease in 22. In 176 patients with malignant tumors, the diagnosis was based on FNAB exclusively. In 108 patients who were operated on, the results of FNAB matched histology in 97 per cent. The aspiration specimen was inadequate in 36 patients, most of whom had diffuse lung disease. The incidence of complications was extremely low. FNAB is safe and reliable. It is recommended for use in clinical workup of undiagnosed pulmonary masses. FNAB enables rational planning of treatment when other diagnostic methods fail. The authors do not recommend FNAB for use in cases of diffuse pulmonary disease.

Traumatic perforations of the esophagus.

Over the past 15 years nine patients with traumatic mechanical perforations of the esophagus have been treated. Seven perforations were iatrogenic, two were accidental. One patient treated conservatively did well. Two patients were operated on without delay. Their hospitalization was short and they had no complications. Six patients were referred to surgery after a delay ranging from 5 days to 17 days from the time of perforation. Their hospitalization ranged from 9 to 113 days, averaging 62.7 days. Complications were common and two patients died. In order to assure survival of patients with esophageal perforation, early aggressive treatment is essential in nearly all instances. In an occasional patient with a small and clean perforation at the esophageal inlet, conservative treatment may be justified.