Video-Assisted-Thoracoscopic-Surgery Pleural Decorticator for Emergency Empyema Surgery.

BACKGROUND/NEED: Pleural empyemas carry a high morbidity and mortality. Some can be managed with medical treatment but most require some form of surgery with the goals to remove the infected material from the pleural space and to help re-expand the collapsed lung. Keyhole surgery by Video Assisted Thoracoscopy Surgery (VATS) is rapidly becoming a common approach to deal with early stage empyemas to avoid larger, more painful thoracotomies that hinder recovery. However, the ability to achieve those aforementioned goals is often hindered by VATS surgery due to the instruments available. METHODOLOGY AND DEVICE DESCRIPTION: We have developed a simple instrument called the "VATS Pleural Debrider" to achieve those goals in empyema surgery that can be used in keyhole surgery. PRELIMINARY RESULTS: We have used this device in over 90 patients with no peri-operative mortality and a low re-operation rate. CURRENT STATUS: Used in routine urgent/emergency pleural empyema surgery across 2 cardiothoracic surgery centres.

[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 rare case of chest wall lipoma growing into the pleural cavity: a case report.

BACKGROUND: Several cases of lipoma in unusual locations in the thorax have been reported. Appropriate surgical treatment depending on the location and shape is often required. CASE PRESENTATION: We herein report an extremely rare case of a chest wall lipoma growing into the pleural cavity. The tumor was successfully removed without damaging the capsule by a combination of direct and thoracoscopic approaches. CONCLUSIONS: Chest wall lipomas growing into pleural cavity can be successfully treated by a combination of direct and thoracoscopic approaches.

Video-assisted thoracic surgery in the primary management of advanced ovarian carcinoma with moderate to large pleural effusions: A Memorial Sloan Kettering Cancer Center Team Ovary Study.

OBJECTIVES: We assessed the utility of video-assisted thoracic surgery (VATS) in defining extent of intrathoracic disease in advanced ovarian carcinoma with moderate-to-large pleural effusions. METHODS: Beginning in 2001, VATS was performed on all patients with suspected advanced ovarian carcinoma and moderate-to-large pleural effusions, evaluating for macroscopic intrathoracic disease. The algorithm recommended primary debulking surgery (PDS) for ≤1 cm, neoadjuvant chemotherapy (NACT)/interval debulking surgery (IDS) for >1 cm intrathoracic disease. We reviewed records of patients undergoing VATS from 10/01-01/19. Differences between treatment groups were tested using standard statistical techniques. RESULTS: One-hundred patients met eligibility criteria (median age, 60; median CA-125 level, 1158 U/mL; medium serum albumin, 3.8 g/dL). Macroscopic pleural disease was found in 70 (70%). After VATS, 50 (50%) underwent attempted PDS (PDS group), 50 (50%) received NACT (NACT/IDS group). Forty-seven (94%) underwent IDS. Median overall survival (OS) for the entire cohort (n = 100) was 44.5 months (95% CI: 37.8-51.7). The PDS group had significantly longer survival than the NACT/IDS group [45.8 (95% CI: 40.5-87.8) vs. 37.4 months (95% CI: 33.3-45.2); p = .016]. On multivariable analysis, macroscopic intrathoracic disease (HR 2.18, 95% CI: 1.14-4.18; p = .019) and age ≥ 65 (HR 1.98, 95% CI: 1.16-3.40; p = .013) were independently associated with elevated death risk. Patients with the best outcome had no macroscopic disease at VATS and underwent PDS (median OS, 87.8 months). CONCLUSIONS: VATS is useful in therapeutic decision-making for PDS vs. NACT/IDS in advanced ovarian cancer with moderate-to-large pleural effusions.

Treatment of persistent air leak with endobronchial valves.

Persistent pulmonary air leaks are usually treated conservatively with prolonged thoracostomy tube drainage. In case this approach fails, surgical revision used to be the only option. This case report describes the successful treatment of a 66-year old patient who developped a pulmonary air leak after cardiothoracic surgery that persisted despite attempted surgical repair and talc pleurodesis. The treatment was successfully completed with endobronchial valves thereby demonstrating that treatment with endobronchial valves doesn't only represent an alternative to surgery, but that it can also be successful in case surgical intervention fails.

Pleural Pressure Differences Before Removal Are Greater in Patients Who Develop Residual Pneumothorax Post Chest Drain Removal.

Aim of study: We aimed to investigate whether the difference in pleural pressures (ΔP) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The ΔP prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of ΔP for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on ΔP. Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The ΔP in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H2O, p < 0.01). The ΔP in patients who required intervention was also significantly higher (14.8 versus 4.2 cm H2O, p < 0.01). A ΔP cutoff value of 8 cm H2O was predictive of the occurrence of residual pneumothorax (sensitivity 85.6%, specificity 84.6%) and a value of 12 cm H2O was predictive of intervention (sensitivity 84%, specificity 85%). Increasing ΔP was an independent predictor of the occurrence of residual pneumothorax (p = 0.008) on the multivariate logistic regression model. Conclusion: Patients with wide ΔP before chest drain removal may be complicated with residual pneumothorax.

Surgical treatment of hydatidothorax in children: A retrospective study of 19 patients.

OBJECTIVE: The objective of this study was to describe the role of surgical management of ruptured hydatid cysts into the pleural cavity in children. A review of the management of patients with intrapleural rupture of pulmonary hydatid cysts in children at our center was performed. MATERIALS AND METHODS: A retrospective chart review was performed on all children who developed intrapleural rupture of a hydatid cyst in the lung. Patients with intrapleural rupture from other locations (liver, mediastinum, diaphragm, kidney) were excluded. RESULTS: In these 19 patients, there were 11 males and 8 females with a mean age of 9.4 years (range 7-16 years). Different clinical symptoms, biological, and imaging data allowed the diagnosis. The surgical approach consisted of a posterolateral thoracotomy and decortication in all patients. In addition, different procedures were needed for the pulmonary lesion according to the degree of lung destruction. Radical resections were required in four cases, including lobectomies (n = 1) and segmentectomies (n = 3). Conservative treatment was possible in 15 patients (simple capitonnage and bronchial fistula closure). Post-operative complications occurred in 2 cases (10.5%), including one pyothorax with a prolonged air leak and one wound infection. There were no postoperative deaths. There was no recurrence of thoracic hydatid disease in postoperative follow-up ranging from 1 to 3 years (mean: 2 years). CONCLUSION: Intrapleural hydatid cyst rupture may be prevented by early treatment of simple forms to avoid increased morbidity. LEVEL OF EVIDENCE: Level IV.

Management of giant benign fibrous histiocytoma in the spinal region with pleural involvement: A case report.

RATIONALE: Benign fibrous histiocytoma with pleural involvement in spinal region is a highly unusual disease with no standard curative managements yet. The objective of this study is to report an extremely rare case of a giant benign fibrous histiocytoma with pleural involvement in spinal region successfully operated by posterior spinal surgery. The management of these unique cases has yet to be well-documented. PATIENT CONCERNS: A 23-year-old man presented with a 2-month history of continuous and progressive back pain. A giant, expanding lesion of the T7 vertebral and paraspinal region with pleural involvement was identified. DIAGNOSES: Computed tomography scan and magnetic resonance imaging of spine showed expanding lesion of the T7 vertebral and paraspinal region involving the right thoracic cavity, which presented as a solid tumor. Postoperative pathology confirmed the diagnosis of thoracic benign fibrous histiocytoma. INTERVENTIONS: The patient underwent thoracic spinal canal decompression, complete tumor resection, pleural defect repair, and T4 to T10 internal fixation procedure via a posterior approach. OUTCOMES: The patient's symptom improved significantly after the surgery, and the postoperative period was uneventful at the 2-year follow-up visit. There were no complications associated with the operation during the follow-up period. LESSONS: In summary, the tumor's clinical features, imaging results, and pathological characteristics are unique. Combined efforts of specialists from orthopedics, thoracic surgery, neurosurgery, pathology, and medical oncology led to the successful diagnosis and management of this patient. Giant benign fibrous histiocytoma with pleural involvement in spinal region, although rare, should be part of the differential diagnosis when the patient presents with back pain and radiculopathy. We recommend the posterior or 1-stage anterior-posterior combined approach for complete resection of the giant thoracic benign fibrous histiocytoma when the tumor has caused severe symptoms or neurological deficits.

Lymphovenous anastomosis for the treatment of persistent congenital chylothorax in a low-birth-weight infant: A case report.

RATIONALE: Chylothorax remains a poorly understood phenomenon, and no optimal treatment or guidelines have been established. This is the first report of treating congenital chylothorax and lymphedema in a low-birth-weight infant by lymphovenous anastomosis (LVA). PATIENT CONCERNS: We report a case of successful LVA for persistent congenital chylothorax and lymphedema resistant to other conservative therapies. DIAGNOSIS: The diagnosis of chylothorax was confirmed by the predominance of lymphocytes in the pleural fluid draining from the chest tube. In addition, the infant developed oliguria and generalized lymphedema. INTERVENTIONS: LVA under local anesthesia combined with light sedation was performed at his medial thighs and left upper arm. OUTCOMES: Although his subcutaneous edema markedly improved, the decrease in chest tube drainage was gradual. No additional treatment was required. LESSONS: LVA is of considerable value as a surgical treatment option in the setting of persistent congenital chylothorax and lymphedema, because LVA is a less invasive procedure.

Prophylactic Opening of the Pleural Cavity for Postoperative Drainage is a Risk Factor for Prolonged Pleural Effusion After a Fontan Operation.

Postoperative prolonged pleural effusion (PPE) remains a confounding problem after a Fontan operation. We aimed to describe the risk factors for PPE after a Fontan operation and to clarify the impact of prophylactic opening of the pleural cavity (POPC) for drainage tube insertion on PPE. We retrospectively reviewed the medical charts of 50 consecutive patients who underwent a Fontan operation at our institution. POPC for postoperative drainage was performed based on each surgeon's preference. Patients were divided into three groups for analysis: group A (n = 12), no opening; group B (n = 14), unilateral opening; and group C (n = 24), bilateral opening. At the time of surgery, the median age of our patient group was 26 months, with a median body weight of 10.5 kg. The volume of pleural effusion tended to be lower in group A than in groups B and C (p = 0.08). The median duration of drainage was significantly shorter (p = 0.03) in group A (3 days) than in group B (4 days) or C (5 days). Overall, 12 patients required chest tube drainage for ≥ 7 days. Multivariate analysis revealed POPC (p = 0.01) and postoperative water balance (p = 0.03) as independent predictors of PPE. POPC and postoperative water balance are risk factors for PPE after a Fontan operation. Therefore, avoiding POPC for postoperative drainage may reduce the risk of postoperative pleural effusion and morbidities associated with PPE after a Fontan operation.

The first experience of the use of hydro-surgical technologies in the treatment of children with pulmatic-pleural complications of destructive pneumonia. / Pervyi opyt primeneniia gidrokhirurgicheskikh tekhnologii v lechenii detei s legochno-plevral'nymi oslozhneniiami destruktivnoi pnevmonii.

Drainage and endoscopic methods of sanitation of the pleural cavity do not always allow to achieve effective debridement of pathological contents. AIM: To development and introduction into clinical practice of hydrosurgical technologies for debridement of the pleural cavity. MATERIAL AND METHODS: From 423 children with acute community-acquired pneumonia 88 (20.80%) children destructive pneumonia were diagnosed. Of the 88 patients with destructive pneumonia, 28 patients did not have pleural complications and were excluded from the study. 60 patients were divided into 2 groups depending on the method of surgical treatment. In the first group (n=30), two additional subgroups were formed: IA group (main n=15) - they carried out drainage and washing the pleural cavity with saline; IB group (control n=15) - only drainage of the pleural cavity. The second group (n=30) were also divided into 2 subgroups; Group IIA (main n=15) children operated according to the method of video-assisted thoracoscopic sanitations of the pleural cavity developed by us using hydrosurgical technologies; Group IIB (control n=15) - children are operated on by the method of traditional video-assisted thoracoscopic sanitations of the pleural cavity. A prospective, non-randomized, single-center study was conducted to evaluate the effectiveness of various treatments. The treatment plan was determined on the basis of a combination of anamnesis, clinical and instrumental studies and laboratory parameters. RESULTS: All studied in the comparison groups were homogeneous by sex, weight and height. The results of applying the Kruskal-Wallis test revealed statistically significant differences between the groups for the periods of relief of the intoxication syndrome (p<0.001) and the periods of relief of the pain syndrome (p=0.012) in favor of the main group. Summarizing all analyzing the parameters in the comparison groups allowed us to prove the advantage of the proposed treatment methods over the treatment methods used in the control groups. CONCLUSION: Hydrosurgical methods of treatment demonstrate obvious clinical and economic efficacy, which leads to the rapid reexpantion of the affected lung.

Left lateral intercostal region versus subxiphoid position for pleural drain during elective coronary artery bypass graft surgery: randomized clinical trial.

BACKGROUND: The pleural drain insertion site after coronary artery bypass graft (CABG) surgery may alter lung function, especially respiratory muscle strength. The main objective of this study was to compare the effectiveness and safety of use of the left lateral intercostal region versus the subxiphoid position for pleural drainage during elective CABG surgery using extracorporeal circulation (ECC). DESIGN AND SETTING: Randomized trial conducted in a tertiary-level hospital in Porto Alegre, Brazil. METHODS: 48 patients were assigned to group 1 (pleural drain in the left lateral intercostal region) or group 2 (pleural drain in the subxiphoid position). Respiratory muscle strength was measured in terms of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), in cmH2O, by means of manovacuometry preoperatively, 24 and 72 hours after drain removal and before discharge from hospital. Painand dyspnea scales, presence of infections, pleural effusion and atelectasis, duration of drain use, drainage volumes and surgical reinterventions were also evaluated. RESULTS: After adjustments, there were no significant differences between the groups at the end of the study (before discharge), in predicted percentages either for MIP (delta group 1: -17.21% versus delta group 2: -22.26%; P = 0.09) or for MEP (delta group 1: -9.38% versus delta group 2: -13.13%; P = 0.17). Therewere no differences between the groups in relation to other outcomes. CONCLUSION: There was no difference in maximal respiratory pressures in relation to the pleural drain insertion site among patients who underwent CABG surgery using ECC. TRIAL REGISTRATION: ReBEc V1111.1159.4447.

Trasplante pulmonar bilateral en un paciente con una restricción severa de la cavidad pleural derecha / Bilateral Lung Transplantation in a Patient With Severe Right Pleural Cavity Restriction

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Left lateral intercostal region versus subxiphoid position for pleural drain during elective coronary artery bypass graft surgery: randomized clinical trial

ABSTRACT BACKGROUND: The pleural drain insertion site after coronary artery bypass graft (CABG) surgery may alter lung function, especially respiratory muscle strength. The main objective of this study was to compare the effectiveness and safety of use of the left lateral intercostal region versus the subxiphoid position for pleural drainage during elective CABG surgery using extracorporeal circulation (ECC). DESIGN AND SETTING: Randomized trial conducted in a tertiary-level hospital in Porto Alegre, Brazil. METHODS: 48 patients were assigned to group 1 (pleural drain in the left lateral intercostal region) or group 2 (pleural drain in the subxiphoid position). Respiratory muscle strength was measured in terms of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), in cmH2O, by means of manovacuometry preoperatively, 24 and 72 hours after drain removal and before discharge from hospital. Painand dyspnea scales, presence of infections, pleural effusion and atelectasis, duration of drain use, drainage volumes and surgical reinterventions were also evaluated. RESULTS: After adjustments, there were no significant differences between the groups at the end of the study (before discharge), in predicted percentages either for MIP (delta group 1: -17.21% versus delta group 2: -22.26%; P = 0.09) or for MEP (delta group 1: -9.38% versus delta group 2: -13.13%; P = 0.17). Therewere no differences between the groups in relation to other outcomes. CONCLUSION: There was no difference in maximal respiratory pressures in relation to the pleural drain insertion site among patients who underwent CABG surgery using ECC. TRIAL REGISTRATION: ReBEc V1111.1159.4447.

Long-Term Outcomes After Thoracoamniotic Shunt for Pleural Effusions With Secondary Hydrops.

BACKGROUND: Congenital pleural effusion is a rare condition with an incidence of approximately one per 15,000 pregnancies. The development of secondary hydrops is a poor prognostic indicator and such cases can be managed with a thoracoamniotic shunt (TAS). Our objective is to describe postnatal outcomes in survivors after TAS placement for congenital pleural effusions. MATERIALS AND METHODS: A retrospective study of all cases with fetal pleural effusions treated between 2006 and 2016. Patients with dominant unilateral or bilateral pleural effusions complicated by secondary hydrops fetalis received TAS placement. The results are reported as median (range). RESULTS: A total of 29 patients with pleural effusion with secondary hydrops underwent TAS placement. The gestational age at the initial TAS placement was 27.6 (20.3-36.9) wk. Before delivery, hydrops resolved in 17 (58.6%) patients. The delivery gestational age was 35.7 (25.4-41.0) wk and the overall survival rate was 72.4%. Among the 21 survivors, 19 (90.5%) required admission to the neonatal intensive care unit for 15 (5-64) d. All 21 survivors had postnatal resolution of the pleural effusions. All 21 children were long-term survivors, with a median age of survivorship of 3 y 3 mo (9 mo-7 y 6 mo) at the time of last reported follow-up. CONCLUSIONS: Thoracoamniotic shunting in fetuses with a dominant pleural effusion(s) and secondary hydrops resulted in a 72% survival rate. Nearly all survivors required admission to the neonatal intensive care unit. However, a majority did not have significant long-term morbidity.

Multiple intercostal neurilemmomas in a Chinese woman.

Neurilemmomas are rare tumors of neural crest cell origin that occur most commonly in the head and neck region. Intercostal neurilemmomas are extremely rare and are mostly seen as solitary tumors in the posterior mediastinum. Only one case report of multiple intercostal neurilemmomas has been documented previously. In this article, we report a case of multiple intercostal neurilemmomas in a 54-year-old woman who had initially presented with progressive dull left chest pain over a 1-year period. A computed tomography scan revealed three tumors in the left thoracic cavity which were distributed as a string of beads along the third intercostal nerve. Histological and immunohistochemical testing confirmed a diagnosis of neurilemmomas. The patient underwent successful radical excision of the tumors through a thoracotomy approach, and her postoperative course was uneventful. Following the operation, she had no evidence of recurrences.

[Thoracoscopic pulmonary resection for metastatic lesion without pleural drainage: initial experience]. / Torakoskopicheskie rezektsii legkogo pri metastaticheskom porazhenii bez ustanovki plevral'nogo drenazha: nachal'nyi opyt.

AIM: To analyze the possibility of thoracoscopic pulmonary resection for metastatic lesion without pleural drainage. MATERIAL AND METHODS: There were 10 patients aged 53.8 years. Most of patients had solitary lung injury within 3 cm from the visceral pleura on the average. Surgical treatment was performed in standard fashion: hardware atypical pulmonary resection within healthy tissues. Pleural cavity was drained with 24 Fr tube. After that lung was inflated under visual control. Since wounds were closured residual air was evacuated by active aspiration and drainage tube was removed. Control chest X-ray was performed in 2 hours and 1 day after surgery. RESULTS: The technique was successful in all patients. Mean surgery time was 52 minutes. There was no blood loss in all patients. Pneumo- and/or hydrothorax were absent according to control chest X-ray in postoperative period. Mean length of postoperative hospital-stay was 3 days (median 2 days). There were no cases of repeated hospitalization.