Adequate nephroprotection reduces renal complications after hyperthermic intrathoracic chemotherapy.

BACKGROUND AND OBJECTIVES: Hyperthermic intrathoracic chemotherapy (HITOC) is used for the treatment of malignant pleural tumors. Although HITOC proved to be safe, postoperative renal failure due to nephrotoxicity of intrapleural cisplatin remains a concern. METHODS: This single-center study was performed retrospectively in patients who underwent pleural tumor resection and HITOC between September 2008 and December 2018. RESULTS: A total of 84 patients (female n = 33; 39.3%) with malignant pleural tumors underwent surgical cytoreduction with subsequent HITOC (60 minutes; 42°C). During the study period, we gradually increased the dosage of cisplatin (100-150 mg/m2 BSA n = 36; 175 mg/m2 BSA n = 2) and finally added doxorubicin (cisplatin 175 mg/m2 BSA/doxorubicin 65 mg; n = 46). All patients had perioperative fluid balancing. The last 54 (64.3%) patients also received perioperative cytoprotection. Overall 29 patients (34.5%) experienced renal insufficiency. Despite higher cisplatin concentrations, patients with cytoprotection showed significantly lower postoperative serum creatinine levels after 1 week (P = .006) and at discharge (P = .020). Also, they showed less intermediate and severe renal insufficiencies (5.6% vs 13.3%). CONCLUSIONS: Adequate perioperative fluid management and cytoprotection seem to be effective in protecting renal function. This allows the administration of higher intracavitary cisplatin doses without raising the rate of renal insufficiencies.

Hernia diafragmatica en pediatria / Diaphragmatic hernia in pediatrics

Resumen La hernia diafragmática (HD) consiste en un trastorno en el desarrollo del músculo diafragmático, produciéndose el paso de contenido abdominal a la cavidad torácica. Las principales son hernia de Bochdalek, Morgagni y Hiatal.1 Malformación congénita que afecta a 1 de cada 2 200 recién nacidos. Está asociada a elevada morbimortalidad, principalmente por hipoplasia pulmonar e hipertensión.2 La ecografía prenatal determina el diagnóstico, pronóstico y terapia. La cirugía consiste en cerrar el defecto, siendo el objetivo del tratamiento mantener un adecuado intercambio gaseoso, evitar o minimizar la hipoplasia y la hipertensión pulmonar.1 Las hernias diafragmáticas presentes en el momento del nacimiento se diagnostican fácilmente. En contraste, el diagnóstico de las hernias después del periodo neonatal es muy variable, puede conducir a evaluaciones clínicas y radiológicas erróneas.3

Abstract The diaphragmatic hernia is a disorder in the development of the diaphragm, causing the passage of the abdominal contents into the thoracic cavity. The main ones are Bochdalek, Hiatal and Morgagni hernias1. Congenital malformation that affects 1 in 2 200 newborns. It is associated to high morbidity and mortality mainly due to lung hypoplasia and hypertension.2 Prenatal ultrasound determines the diagnosis, prognosis and therapy. The surgical procedure consists ofthe closure of the defect. The goal of the treatment is to maintain adequate gas exchange, to prevent or minimize hypoplasia and pulmonary hypertension.1 Congenital diaphragmatic hernias present at birth are readily recognized. In contrast, the diagnosis of diaphragmatic hernia after the neonatal period varies considerably owing to misleading clinical and radiologic features.3

Effect of hyperthermic intrathoracic chemotherapy (HITHOC) on the malignant pleural effusion: A systematic review and meta-analysis.

BACKGROUND: Although hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely used to treat malignant ascites or as a preventive strategy for microscopic carcinomatosis following surgical resection of abdominal tumors, application of hyperthermic intrathoracic chemotherapy (HITHOC) in the treatment of malignant pleural effusion is limited. The objective of the current study was to conduct a systematic review and meta-analysis on the application of HITHOC in the palliative treatment of malignant pleural effusion. METHODS: After thorough searching of online databases, total 27 articles were included into qualitative systematic review and 5 of them were used to conduct qualitative meta-analysis. RESULTS: It was found that most of HITHOC was used in combination of cytoreductive surgery (CRS) including pleurectomy/decortication or after surgical resection of primary tumors, which mainly were lung cancer, thymoma or thymic carcinoma, breast cancer, and ovarian cancer. Patients who received HITHOC had significantly longer median survival length compared to the patients without HITHOC (Hedges g = 0.763, P < 0.001). In addition, HITHOC therapy was favored (Hedges g = 0.848, P < 0.001) in terms of median survival length, tumor-free survival rate, with tumor survival rate or Karnofsky performance status (KPS) scale. CONCLUSION: HITHOC is a safe and effective therapy in controlling pleural effusion and increasing patient's survival rate.

Acute eosinophilic pneumonia masquerading as multiple pulmonary embolisms.

A 47-year-old previously healthy man was admitted to the hospital with a 5-day history of fever, dry cough, and dyspnoea. Thoracic radiographs and CT scan showed extensive bilateral consolidation predominantly involving the central portions of the upper lung lobes, along with multiple scattered nodules. On taking a thorough history, it was found that the patient had visited a gritty 100-year-old Japanese folk house 1 week ago. An urgent bronchoscopy was performed, and the results were consistent with the findings of acute eosinophilic pneumonia (AEP). The patient's respiratory distress resolved within 10 days without treatment. Hence, even in an AEP case with atypical radiological presentations, careful history taking can lead to a rapid diagnosis.

Microbiological analysis of fluids in postsurgical gastroesophageal intrathoracic leaks obtained by endoscopy: a new way to optimize antibiotic therapy.

BACKGROUND/AIMS: Postsurgical gastroesophageal intrathoracic leakage is a potentially life-threatening condition that is frequently accompanied by mediastinitis and subsequent sepsis. Aspiration of fluids from intrathoracic leaks during endoscopy for microbiological analysis is rarely performed in clinical routine. The aim was to evaluate the role of routine microbiological analysis of intrathoracic leaks via endoscopy and its impact on antibiotic therapy. METHODS: This is a prospective, observational single-center study. Seventeen consecutive patients who presented for endoscopic treatment of intrathoracic leaks were included. Concomitantly, fluids from intrathoracic leaks during endoscopic intervention and blood cultures were obtained and a microbiological analysis was performed. RESULTS: Bacteria and/or fungi were detected by culture of fluid aspirated from intrathoracic leaks in 88% cases, but in none of the blood cultures. In 15 patients, microbial colonization of the leakage was detected despite previous empiric antibiotic therapy; treatment had to be adjusted in all patients according to the observed antibiotic susceptibility profile. CONCLUSIONS: The microbiological colonization of postsurgical gastroesophageal intrathoracic leaks in patients is frequent. Only the direct microbiological analysis of fluids from intrathoracic leaks, but not of blood cultures, is effective for optimizing an antibiotic therapy in such patients.

Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion.

BACKGROUND: Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate. METHODS: We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management. RESULTS: Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics. CONCLUSION: This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Surgical treatment for intra-thoracic migration of acupuncture needles.

The aim of this study was to introduce the experience of diagnosis and treatment for patients with migrated acupuncture needle to pleural cavity and or lung parenchyma. We had treated 5 patients who had acupuncture needles in their thoracic cavity from January 2000 to September 2009. The mean age was 55.8 yr old. All patients suffered from the sequelae of the cerebrovascular accident and had been treated with acupuncture. They had drowsiness and hemiplegic or quadriplegic motor activity. Fever and dyspnea were main symptoms when referred to us. Diagnosis was made by the chest radiography and chest computed tomography which revealed straight metallic materials in their thoracic cavity. The needles were removed via thoracotomy or thoracoscopic procedures. Pleural decortications were also needed in four patients. Thoracoscopic surgery was successfully performed in two patients. After the removal all patients became symptomless. Although we experienced only five patients who have migrated acupuncture needles in thoracic cavity, we suggest that thoracoscopic removal of the needle with or without pleural decortication is the most optimal modality of treatment in those patients.

Surgical Treatment for Intra-Thoracic Migration of Acupuncture Needles

The aim of this study was to introduce the experience of diagnosis and treatment for patients with migrated acupuncture needle to pleural cavity and or lung parenchyma. We had treated 5 patients who had acupuncture needles in their thoracic cavity from January 2000 to September 2009. The mean age was 55.8 yr old. All patients suffered from the sequelae of the cerebrovascular accident and had been treated with acupuncture. They had drowsiness and hemiplegic or quadriplegic motor activity. Fever and dyspnea were main symptoms when referred to us. Diagnosis was made by the chest radiography and chest computed tomography which revealed straight metallic materials in their thoracic cavity. The needles were removed via thoracotomy or thoracoscopic procedures. Pleural decortications were also needed in four patients. Thoracoscopic surgery was successfully performed in two patients. After the removal all patients became symptomless. Although we experienced only five patients who have migrated acupuncture needles in thoracic cavity, we suggest that thoracoscopic removal of the needle with or without pleural decortication is the most optimal modality of treatment in those patients.

Cystoperitoneal shunt for a giant intrathoracic meningocele under local anesthesia.

Giant intrathoracic meningoceles are extremely rare, and the standard treatment for giant intrathoracic meningoceles remains controversial. We present the case of a patient with giant intrathoracic meningoceles associated with neurofibromatosis type I. Our patient had poor respiratory function because of the giant intrathoracic meningocele, so we performed a cystoperitoneal shunt under local anesthesia. We describe our cystoperitoneal shunt technique using an adjustable-pressure valve. This simple, minimally invasive treatment is a valuable alternative treatment option in patients at high operative risk, especially those with low respiratory function.

Phrenic nerve stimulation: the Australian experience.

Phrenic nerve stimulation is a technique whereby a nerve stimulator provides electrical stimulation of the phrenic nerve to cause diaphragmatic contraction. The most common indications for this procedure are central alveolar hypoventilation and high quadriplegia. This paper reviews the available data on the 19 patients treated with phrenic nerve stimulation in Australia to date. Of the 19 patients, 14 required pacing due to quadriplegia, one had congenital central hypoventilation syndrome and one had brainstem encephalitis. Information was unavailable for the remaining three patients. Currently, 11 of the pacers are known to be actively implanted, with the total pacing duration ranging from 1 to 21 years (mean 13 years). Eight of the 19 patients had revision surgeries. Four of these were to replace the original I-107 system (which had a 3-5-year life expectancy) with the current I-110 system, which is expected to perform electrically for the patient's lifetime. Three patients had revisions due to mechanical failure. The remaining patients' notes were incomplete. These data suggest that phrenic nerve stimulation can be used instead of mechanical ventilators for long-term ongoing respiratory support.

[Effect of herba schizonepetae volatile oil (STO) on activity of 5-lipoxygenase in rat thoracic cavity leukocytes].

OBJECTIVE: To investigate the effect of herba schizonepetae volatile oil (STO) on the activity of 5-lipoxygenase (5-LO), so as to elucidate its mechanisms of anti-inflammatory action which is related to the arachidonic acid (AA) metabolism. METHOD: Thoracic cavity leukocytes from the pleurisy model rat induced by injecting 1%-carrageenan into the pleural cavity were collected. Then 0. 4 mL cell suspension including 2 x 10(7) cells per millilitre were used as the reaction system in vitro. STO in different concentrations (final concentration 0.011, 0.022, 0.043, 0.087, 0.179, 0.255, 0.364 g x L(-1)), zileuton (final concentration 0.625 x 10(-3) g x L(-1)), and DMSO in the same volume were added into the reaction tube respectively. The reaction tubes were incubated at 37 degrees C for 20 min and CaCl2 (final concentration 2 mmol x L(-1)), MgCl2 (final concentration 0.5 mmol x L(-1)), exogenous AA (final concentration 200 micromol x L(-1)) and A23187 (final concentration 5 micromol x L(-1)) were added in turns during this period. The reaction tubes were mixed and continuously incubated at 37 degrees C for 30 min. After terminating reaction by adding methanol, the metabolites of 5-LO, leukotriene B4 (LTB4) and 5-hydroxy-6, 8, 11, 14-eicosatetraenoic acid (5-HETE), were extracted, separated and detected by means of RP-HPLC. RESULT: Compared with control group, STO significantly inhibited the biosynthesis of LTB4 and 5-HETE at final concentration between 0. 022 g x L(-1) and 0.364 g x L(-1) (P < 0.05 or 0.001) in dose dependence manner, and its IC50 value was 0.124 g x L(-1) and 0.142 g x L(-1) for LTB4 and 5-HETE, respectively. CONCLUSION: STO can inhibited the activity of 5-LO, which is an important enzyme of AA metabolism, in rat thoracic cavity leukocytes in a dose-dependent manner in vitro. It is suggested that the mechanism of anti-inflammatory action of STO is related to its inhibiting the activity of 5-LO and decreasing the level of major inflammatory mediators LTB4.

Electrostimulation for intractable delayed emptying of intrathoracic stomach after esophagectomy.

PURPOSE: The use of the denervated intrathoracic stomach as esophageal substitute can rarely lead to severe delayed gastric emptying. We describe the use of electrostimulation for this condition. DESCRIPTION: Gastric electrical stimulation (GES) is used to treat medically refractory gastroparesis and uses a battery powered neurostimulator connected to the gastric antrum with two electrodes. We implant the electrodes through a right thoracotomy and tunnel them to the right subcostal area where the pacemaker is placed. EVALUATION: Medically refractory gastroparesis developed in 2 male patients, aged 52 and 60 years, who underwent Ivor-Lewis esophagectomies for esophageal adenocarcinoma and were dependant on jejunostomy feedings. These patients initially had endoscopic placement of temporary stimulating electrodes with significant improvement in symptoms and radionucleotide gastric emptying. The patients subsequently underwent implantation of a permanent GES device. Relief of symptoms was persistent with no nausea or vomiting and a decrease of total symptom score (maximum 20) from 12.5 and 16 to 6 and 9, respectively. CONCLUSIONS: Patients with intractable delayed gastric emptying after esophagogastrectomy may benefit from a GES device implanted through a thoracotomy.

Multi-loculated empyemas after acupuncture

There are several reported possible complications of acupuncture including hepatitis, pneumothorax, and cardiac tamponades, but the development of empyema is unusual. All the previously described cases of empyemas were due to acupuncture needles being inadvertently left in the thoracic cavities. We describe a thirty seven years old female patient who developed empyema after multiple acupuncture sessions whose disease course was unique because the empyema developed without an acupuncture needle being left in the thoracic cavity. This case demonstrates that an acupuncture needle being left in the thoracic cavity is not necessary for the development of empyema after acupuncture sessions as previously described.

Effect of herba schizonepetae volatile oil (STO) on activity of 5-lipoxygenase in rat thoracic cavity leukocytes / 中国中药杂志

<p><b>OBJECTIVE</b>To investigate the effect of herba schizonepetae volatile oil (STO) on the activity of 5-lipoxygenase (5-LO), so as to elucidate its mechanisms of anti-inflammatory action which is related to the arachidonic acid (AA) metabolism.</p><p><b>METHOD</b>Thoracic cavity leukocytes from the pleurisy model rat induced by injecting 1%-carrageenan into the pleural cavity were collected. Then 0. 4 mL cell suspension including 2 x 10(7) cells per millilitre were used as the reaction system in vitro. STO in different concentrations (final concentration 0.011, 0.022, 0.043, 0.087, 0.179, 0.255, 0.364 g x L(-1)), zileuton (final concentration 0.625 x 10(-3) g x L(-1)), and DMSO in the same volume were added into the reaction tube respectively. The reaction tubes were incubated at 37 degrees C for 20 min and CaCl2 (final concentration 2 mmol x L(-1)), MgCl2 (final concentration 0.5 mmol x L(-1)), exogenous AA (final concentration 200 micromol x L(-1)) and A23187 (final concentration 5 micromol x L(-1)) were added in turns during this period. The reaction tubes were mixed and continuously incubated at 37 degrees C for 30 min. After terminating reaction by adding methanol, the metabolites of 5-LO, leukotriene B4 (LTB4) and 5-hydroxy-6, 8, 11, 14-eicosatetraenoic acid (5-HETE), were extracted, separated and detected by means of RP-HPLC.</p><p><b>RESULT</b>Compared with control group, STO significantly inhibited the biosynthesis of LTB4 and 5-HETE at final concentration between 0. 022 g x L(-1) and 0.364 g x L(-1) (P < 0.05 or 0.001) in dose dependence manner, and its IC50 value was 0.124 g x L(-1) and 0.142 g x L(-1) for LTB4 and 5-HETE, respectively.</p><p><b>CONCLUSION</b>STO can inhibited the activity of 5-LO, which is an important enzyme of AA metabolism, in rat thoracic cavity leukocytes in a dose-dependent manner in vitro. It is suggested that the mechanism of anti-inflammatory action of STO is related to its inhibiting the activity of 5-LO and decreasing the level of major inflammatory mediators LTB4.</p>

[Usefulness of the thoracoscopic surgery under local anesthesia and irrigation for the patient with Bacillus cereus empyema; report of a case].

The case was 54-year-old male with some risks such as chronic heart failure, atrial fibrillation, and liver chirrhosis. He was admitted because of severe back pain and diagnosed as empyema by preoperative thoracentesis. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned as much as possible and 3 of chest tubes were replaced. The final diagnosis was Bacillus cereus pyothorax by bacterial cultures of pleural effusion. Intrathoracic cavity was cleaned with physiological saline solution. The patient made favorable progress and recovered. Thoracoscopic surgery under local anesthesia with thoracic irrigation was so effective and safe methods to control the infection.

Measuring thoracic excursion: reliability of the cloth tape measure technique.

OBJECTIVE: To assess the reliability of using a cloth tape measure to determine thoracic respiratory excursion as a measurement of chest expansion or mobility. METHODS: Physicians and residents experienced in osteopathic manipulative treatment measured thoracic excursion with a cloth tape measure held around the circumference of healthy male subjects' chests at two levels. Upper thoracic excursion measurements were taken at the level of the fifth thoracic spinous process and the third intercostal space at the midclavicular line. Lower thoracic excursion measurements were taken at the level of the 10th thoracic spinous process and the xiphoid process. At peak inhalation and exhalation, three examiners measured thoracic excursion at both levels. In the first session (n=5), examiners measured the same subject inhalation and exhalation. In the second session (n=4), examiners measured separate respiratory cycles. For each session, interexaminer intraclass correlation coefficients (ICCs) were calculated for thoracic excursion, inhalation, and exhalation in the upper and lower positions using a two-way random-effects analysis of variance model. RESULTS: Intraclass correlation coefficients for thoracic excursion ranged from 0.81 to 0.91 (95% confidence interval, 0.69-0.99) at both measurement levels in both sessions. When inhalation and exhalation were considered separately, interexaminer ICCs were 0.99 and greater. Standard deviations for measurements of each subject's thoracic excursion at both levels ranged from 0.5 cm to 0.8 cm with a mean of 0.6 cm. CONCLUSION: The method of using a tape measure to assess thoracic excursion was highly reliable in men, resulting in ICCs of substantial reliability. The SDs at each level of measurement indicate that this method may be most useful in measuring changes in thoracic excursion that are expected to be 0.6 cm or greater.

Hyperthermia combined with intra-thoracic chemotherapy and radiotherapy for malignant pleural mesothelioma.

BACKGROUND: Prognosis for patients with malignant pleural mesothelioma (MPM) remains poor and such patients require intensive treatment. Few studies have examined hyperthermia for MPM. The present study investigated the feasibility of hyperthermia combined with weekly chemo-radiotherapy for patients with MPM and estimated the efficacy of this regimen. METHODS: A total of 11 patients (median patient age was 67 and all had pleural effusion) with MPM were enrolled in this study. The treatment regimen comprised of weekly thermo-radiotherapy with intra-thoracic chemotherapy 2-5 times at initiation of treatment. Hyperthermia was performed once per week for approximately 60 min. Hemithorax external radiotherapy was administered once weekly on the same day as hyperthermia and just before thermochemotherapy. Median total radiation dose was 6 Gy (range, 2-10 Gy). Chemotherapy was administered into the thoracic cavity through a tube. Chemotherapeutic agents administered were CDDP for seven patients, carboplatinum (CBDCA) for three patients and both CDDP and CBDCA for one patient. Dose of CDDP was 50 mg/body and dose of CBDCA was 200-300 mg m-2. Response rate and median survival time (MST) and palliative effect were investigated. RESULTS: Complete response was not achieved in any of the 11 patients. Partial response was achieved in three of 11 patients (27.3%), SD in six patients (54.5%) and PD in two patients (18.2%). There was no correlational relationship between thermal parameters and response. MST was 27.1 months. Pleural fluid decreased in all patients after therapy, while all patients displayed improved performance status and could be discharged from hospital. Patients with partial response had a relatively longer survival time than SD or PD. All patients underwent the complete course of treatment and only one of 11 patients developed grade 4 thrombocytopenia. CONCLUSION: It was therefore concluded that hyperthermia combined with intra-thoracic chemotherapy using cisplatinum or carboplatinum may be tolerable. This approach appears effective and more acceptable for patients with MPM with pleural effusion than other multi-modality therapy.