Complex bronchopleural fistulas: a case report.

Bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. Concomitant problems, such as pulmonary infection and respiratory failure, are typically the main contributors to mortality from BPF because of improper contact between the bronchial and pleural cavity. We present the case of a 75-year-old male patient with a history of right upper lobe lung cancer resection who developed complex BPFs. Following appropriate antibiotic therapy and chest tube drainage, we treated the fistulas using endobronchial valve EBV placement and local argon gas spray stimulation. Bronchoscopic treatment is the preferred method for patients who cannot tolerate a second surgery because it can help to maximize their quality of life. Our treatment method may be a useful reference for treating complex BPF.

Pictorial Review of Pleural Disease: Multimodality Imaging and Differential Diagnosis.

The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal pleurae and physiologic pleural fluid. There is a broad spectrum of normal variations and abnormalities in the pleura, including pneumothorax, pleural effusion, and pleural thickening. Pneumothorax is associated with pulmonary diseases and is caused by iatrogenic or traumatic factors. Chest radiography and US help detect pneumothorax with various signs, and CT can also help assess the causes. Pleural effusion occurs in a wide spectrum of diseases, such as heart failure, cirrhosis, asbestos-related diseases, infections, chylothorax, and malignancies. Chest US allows detection of a small pleural effusion and evaluation of echogenicity or septa in pleural effusion. Pleural thickening may manifest as unilateral or bilateral and as focal, multifocal, or diffuse. Various diseases can demonstrate pleural thickening, such as asbestos-related diseases, neoplasms, and systemic diseases. CT, MRI, and fluorodeoxyglucose (FDG) PET/CT can help differentiate between benign and malignant lesions. Knowledge of these features can aid radiologists in suggesting diagnoses and recommending further examinations with other imaging modalities. The authors provide a comprehensive review of the clinical and multimodality imaging findings of pleural diseases and their differential diagnoses. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature.

BACKGROUND: Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion. CASE PRESENTATION: A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy. CONCLUSION: The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation.The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases.In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis.With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward.In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising.In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness.In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. (AU)

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects.

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation. The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases. In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis. With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward. In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising. In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness. In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. In neuromuscular patients, ultrasound is a good predictor of impaired lung function. Currently, in Neuromuscular Disease Units, TU is an indispensable tool. Ultrasound study of the intercostal musculature is also effective in the study of respiratory function, and is widely used in Respiratory Rehabilitation. In Intermediate Care Units, thoracic ultrasound is indispensable for patient management. In these units there are ultrasound protocols for the management of patients with acute dyspnoea that have proven to be very effective.

Recognizing the pleura in asbestos-related pleuropulmonary disease: Known and new manifestations of pleural fibrosis.

Pleural thickening (PT) is a major consequence of exposure to all fiber types of asbestos. In recent decades, it is more prevalent than parenchymal asbestosis. Its manifestations occupy a full clinical and radiographic spectrum. Six major manifestations can be identified: (a) acute pleuritis generally with effusion; (b) diffuse PT or fibrous pleuritis; (c) rounded atelectasis; (d) circumscribed PT or plaques; (e) chronic pleuritic pain; and (f) mesothelioma. Review of the experience of workers and community members in Libby, MT to asbestiform fibers in vermiculite has confirmed the appearance of these previously known benign and malignant asbestos-related diseases as well as a unique pleuropulmonary disease characterized as lamellar PT and associated with progressive decline in pulmonary function and pleuritic pain. Despite previous literature asserting that PT represents a marker for asbestos exposure without significant effect on pulmonary function and physiology, the experience of Libby amphibole (LA) disease, along with other studies, indicates that PT plays a role in declining vital capacity in those with prolonged or unusual exposures such as those arising from LA.

[Indocyanine Green Fluorescence Intraoperative Imaging for Fistula Identification of Pleuroperitoneal Communication by Continuous Ambulatory Peritoneal Dialysis:Report of a Case].

A 64-year-old female with chronic renal failure had been receiving continuous ambulatory peritoneal dialysis (CAPD). She developed acute hydrothorax in the right pleural cavity 1 year after the commencement of CAPD. Scintigraphy revealed a diagnosis of pleuroperitoneal communication, and we performed video-assisted thoracoscopic surgery. We infused a dialysis solution containing indocyanine green (ICG) through CAPD catheter. Near-infrared fluorescence thoracoscopy revealed a fistula that could not be identified by white light. We sutured the fistula covered with a polyglycolic acid sheet and fibrin glue. The CAPD was able to be resumed 8 days after surgery, and there was no recurrence of pleural effusion 10 months since surgery. Identification of the diaphragmatic fistula is important in the treatment of pleuroperitoneal communication. This technique using near-infrared fluorescence thoracoscopy with ICG was useful in identifying the fistula, and it emitted sufficient fluorescence even at low concentration ICG.

Preoperative assessment of pleural adhesions in patients with lung cancer based on quantitative motion analysis with dynamic chest radiography: A retrospective study.

PURPOSE: Preoperative assessment of pleural adhesion is crucial for appropriate surgical planning. This study aimed to quantitatively evaluate the usefulness of motion analysis using dynamic chest radiography (DCR) for assessing pleural adhesions. METHODS: Sequential chest radiographs of 146 lung cancer patients with or without pleural adhesions (n = 25/121) were obtained using a DCR system during respiration (registration number: 1729). The local motion vector was measured, and the percentage of poor motion area to the maximum expiration lung area (%lung area with poor motion) was calculated. Subsequently, percentage values ≥49.0% were considered to indicate pleural adhesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the prediction performance. The percentage of lung area with poor motion was compared between patients with and without pleural adhesions (p < 0.05). RESULTS: DCR-based motion analysis correctly predicted pleural adhesions in 21 out of 25 patients, with 47 false-positive results (sensitivity, 84.0%; specificity, 61.2%; PPV, 30.9%; NPV, 94.9%). The lung with pleural adhesions showed a significantly greater %lung area with poor motion than the opposite lung in the same patient, similar to the cancerous lung in patients without pleural adhesions. CONCLUSION: On DCR-based motion analysis, pleural adhesions could be indicated by an increase in the percentage of lung area with poor motion. Although the proposed method cannot identify the exact location of pleural adhesions, information regarding the presence or absence of pleural adhesions provided by DCR would help surgeons prepare for challenging surgeries and obtain informed consent from patients.

Apéndices pleurales: descripción, incidencia y relación con el índice de masa corporal / Pleural appendages: Description, incidence and relations with body mass index

Antecedentes y objetivo Los apéndices pleurales son grasa extrapleural que cuelga de la pared torácica. Han sido descritos mediante videotoracoscopia, pero no se conocen exactamente ni el aspecto ni la frecuencia con que se observan apéndices pleurales en tomografía computarizada (TC) ni tampoco si están relacionados con la cantidad de grasa del paciente. Pretendemos describir el aspecto y conocer la prevalencia de los apéndices pleurales observados en TC, así como saber si su presencia, tamaño y número es mayor en pacientes obesos que en no obesos. Pacientes y métodos Se han revisado retrospectivamente las imágenes axiales de tomografía computarizada de 226 pacientes con neumotórax. Fueron excluidos del estudio los pacientes con antecedentes de enfermedad pleural, cirugía torácica o neumotórax pequeños. Se dividió a los pacientes en dos grupos según el índice de masa corporal (IMC): obesos (IMC?≥?30) y no obesos (IMC<30). Se recogieron el número y tamaño de apéndices pleurales en cada paciente. Se emplearon una prueba de χ2 y el test exacto de Fisher para evaluar las diferencias entre los dos grupos. Un valor de p<0,05 se consideró significativo. Resultados 101 pacientes presentaron estudios de TC válidos. Se identificaron apéndices pleurales en 50 de los 101 pacientes (49,5%). La mayoría se presentan de forma solitaria (n=31), en el seno cardiofrénico (n=27) y tienen un tamaño inferior a 5cm (n=39). No hubo diferencia significativa entre los pacientes obesos y los no obesos en relación con la presencia o ausencia (p=0,315), número (p=0,458) y tamaño (p=0,458) de apéndices pleurales. Conclusiones Los apéndices pleurales se observan en el 49,5% de los pacientes con neumotórax estudiados con TC en este estudio. No hubo diferencia significativa entre los pacientes obesos y los no obesos respecto a la presencia, número y tamaño de apéndices pleurales (AU)

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

Pleural Plaques and the Role of Exposure to Mineral Particles in the Asbestos Post-exposure Survey.

BACKGROUND: Previous studies have inconsistently reported associations between refractory ceramic fibers (RCFs) or mineral wool fibers (MWFs) and the presence of pleural plaques. All these studies were based on chest radiographs, known to be associated with a poor sensitivity for the diagnosis of pleural plaques. RESEARCH QUESTION: Does the risk of pleural plaques increase with cumulative exposure to RCFs, MWFs, and silica? If the risk does increase, do these dose-response relationships depend on the co-exposure to asbestos or, conversely, are the dose-response relationships for asbestos modified by co-exposure to RCFs, MWFs, and silica? STUDY DESIGN AND METHODS: Volunteer workers were invited to participate in a CT scan screening program for asbestos-related diseases in France. Asbestos exposure was assessed by industrial hygienists, and exposure to RCFs, MWFs, and silica was determined by using job-exposure matrices. A cumulative exposure index (CEI) was then calculated for each subject and separately for each of the four mineral particle exposures. All available CT scans were submitted to randomized double reading by a panel of radiologists. RESULTS: In this cohort of 5,457 subjects, significant dose-response relationships were determined after adjustment for asbestos exposure between CEI to RCF or MWF and the risk of PPs (ORs of 1.29 [95% CI, 1.00-1.67] and 1.84 [95% CI, 1.49-2.27] for the highest CEI quartile, respectively). Significant interactions were found between asbestos on one hand and MWF or RCF on the other. INTERPRETATION: This study suggests the existence of a significant association between exposure to RCFs and MWFs and the presence of pleural plaques in a large population previously exposed to asbestos and screened by using CT scans.

Asbestos-associated pulmonary disease.

PURPOSE OF REVIEW: Exposure to asbestos can cause both benign and malignant, pulmonary and pleural diseases. In the current era of low asbestos exposure, it is critical to be aware of complications from asbestos exposure; as they often arise after decades of exposure, asbestos-related pulmonary complications include asbestosis, pleural plaques, diffuse pleural thickening, benign asbestos-related pleural effusions and malignant pleural mesothelioma. RECENT FINDINGS: Multiple recent studies are featured in this review, including a study evaluating imaging characteristics of asbestos with other fibrotic lung diseases, a study that quantified pleural plaques on computed tomography imaging and its impact on pulmonary function, a study that examined the risk of lung cancer with pleural plaques among two large cohorts and a review of nonasbestos causes of malignant mesothelioma. SUMMARY: Asbestos-related pulmonary and pleural diseases continue to cause significant morbidity and mortality. This review summarizes the current advances in this field and highlights areas that need additional research.