Acute pleuropulmonary complications detected by computed tomography following myocardial revascularization

INTRODUCTION: Pleuropulmonary changes are common following coronary artery bypass grafting surgery performed with a saphenous vein graft, with or without an internal mammary artery. The presence of atelectasis or pleural effusions reflects the thoracic trauma. PURPOSE: To define the postoperative incidence of changes in the lung and in the pleural space and to evaluate the influence of the trauma. METHODS: Thirty patients underwent elective coronary artery bypass grafting surgery (8 saphenous vein grafts and 22 saphenous vein grafts and internal mammary artery grafts with pleurotomy). Chest tubes in the left pleural space were used in all internal mammary artery patients. On the second (day 2) and seventh (day 7) postoperative day, patients underwent a computed tomography, and pleural effusions were rated as follows: grade 0 = no fluid to grade 4 = fluid in more than 75 percent of the hemithorax. Atelectasis was rated as follows: laminar = 1, segmental = 3, and lobar = 10 points. RESULTS: All patients had pleural effusion or atelectasis. Between day 2 and day 7, the number of patients with effusions or atelectasis on the right side decreased (P < 0.05). The incidence of effusions on day 2 in the saphenous vein graft group (87.5 percent) was higher (P < 0.05) than in the internal mammary artery group (52.3 percent). The incidence of atelectasis in the lower right lobe decreased (P < 0.05) from 86.7 percent (day 2) to 26.7 percent (day 7). The degree of atelectasis in both sides did not differ on day 2 (P = 0.42) but did on day 7 (P < 0.0001). There was a decrease in the atelectasis from day 2 to day 7 on the right side (P < 0.001), but not on the left (P = 0.21). On day 2 there was a relationship between atelectasis and effusion on the right (P = 0.04), but not on the left (P = 0.113). CONCLUSION: The present series demonstrates that there is a high incidence of both minimal pleural effusion and atelectasis after coronary artery bypass grafting surgery, which drops on the right side from day 2 to day 7 post surgery. Factors that contribute to the persistence of changes on the left side include the thoracic trauma and the presence of chest tubes and pericardial effusion

Tumor carcinóide: broncotomia como alternativa técnica / Carcinoid tumor: bronchotomy as a technical alternative

Geralmente, o tratamento para tumores carcinóides típicos em brônquio é a ressecçäo pulmonar econômica, com ou sem broncoplastia. Este éum relato de caso de uma paciente com tumor carcinóide típico no brônquio lobar inferior esquerdo, junto à carina lobar. Foi realizada broncotomia longitudinal, ressecçäo do tumor e sutura do brónquio, preservando o parênquima pulmonar. A paciente evoluiu bem e apresenta três anos de pós-operatório sem evidência de recidiva da doença nas broncoscopias de controle

Pulmonary biopsy by video assisted thoracic surgery: experience of 76 cases

VATS (Video Assisted Thoracic Surgery) has been progressively more utilized in General Thoracic Surgical. Among its several applications there is the possibility of performing pulmonary biopsy in diffuse lung diseases previously performed by open thoracotomy. VATS presents some disadvantages such as the use of sophisisticated equipment and includes advantages as the use of minimal incisions, optimal visualization of the lung and better adequate choice of the place to be biopsied. Between June/92 and Febuary/95, 76 pacients were submetted to pulmonary biopsy by VATS. The age ranges from 19 to 72 years (mean 47), 57 percent male. The most common indications for biopsy were interstitial fibrosis and interstitial pneumopathy. Two main techniques were used.In one a stapler was used to simultaneously resect the biopsy specimen and suture the parenchyma. This techniques was utilized in 72 percent of the patients. The second technique employed was and endo-loop suture (Vicryl 1 - Ethicon) to carry out the parechyma suture and was utilized in 24 percent of the patients. In 2 percent of the cases, in which there was good lung ealsticity, it was done through external traction biopsy and parenchyma suturing with 5.0 polypropylene. The biopsy site was chosen with the scope. In one patient (2.2 percent) it was not possible to perform VATS due to adhesions between the lung and the chest wall, therefore an open conventional biopsy was done. The histological diagnosis was obtained in all patients. The results showed interstitial fibrosis, pneumonia (or pulmonary infectious disease), pulmonary hypertension, honeycombing and chronic pneumopathy. There were no complications related to the used methols. Two patients (4.4 percent) died in the postoperative period due to previously existing pathology. In conclusion, VATS has proven to be a good, and minimally invasive method for lung biopsy, permitting the choice of the best place to perform the biopsy with effective histological diagnosis.

Critical analysis of surgical pulmonary chronic embolectomy: actual technique and late results

After the onset of acute pulmonary embolism, in the majority of the cases, lysis occurs whit recanalization of the pulmonary branches. However, in a small but undetermined number of patients with chronic pulmonary embolism, the incomplete resolution of the emboli material may result in severe pulmonary hypertension. The pulmonary thromboendarterectomy is a therapeutic option, specially when there is proximal obstruction and the clinical treatment fails. Many surgical techniques have been used but sternotomy, extracorporeal circulation and hypothermic circulatory arrest presented with the best results insofar. Until January/95, 15 patients with chronic pulmonary embolism were operated on. The pulmonary angiography showed pulmonary embolism in both lungs in 66.7 percent of the cases. Sternotomy was performed in 73.3 percent. Endarterectomy by retrograde traction of the thrombus was used in all the patients. Extracorporeal circulation was utilized in all patients, With median operative times of 124.8 min. In 66.7 percent of the cases hypothermic circulatory arrest with median operative times of 34.2 min. The pulmonary artery pressure was 91/32/55 mm Hg preoperatively and was reduced to 52/15/27 mm Hg in the postoperative period. One hospital death occurred due to coagulapathy and one late deathe as result complications not related to surgery itself were registered. Of the 13 survivors, 1 (7.7 percent) present reobstruction and 12 (92.3 percent) had favorable outcome and are now free of symptoms under oral anticoagulation, up to 165 months. In conclusion, the pulmonary thromboendarterectomy done through a sternotomy under hypotheremic circulatory arrest is a safe procedure for resolution of pulmonary embolism and symptoms and such results are sustained at long term.

Avaliaçäo mediastinal no estadiamento do câncer do pulmäo / Mediastinal evaluation in lung cancer staging

INTRODUÇÄO: A presença da linfonodos mediastinais comprometidos no câncer do pulmäo tem implicaçöes terapêuticas e prognósticas importantes e, por isso, o diagnóstico deve ser o mais presciso possível. OBJETIVO: Determinar um padräo de tamanho para considerar um linfonodo comprometido e avaliar a eficiência da tomografia computadorizada e mediastinoscopia no estadiamento linfático do câncer pulmonar. MÉTODO: Cinqüenta pacientes portadores de câncer pulmonar operável foram submetidos a um protocolo prospectivo. todos foram examinados, submetidos a tomografia computadorizada e mediastinoscopia pré-operatória; a operaçäo consistiu na ressecçäo pulmonar compatível e esvaziamento mediastinal radical. A posiçäo e o tamanho dos linfonodos achados na operaçäo foram comparados com os resultados da tomografia e mediastinoscopia prévias. CONCLUSÖES: O estudo mostrou que exixte relaçäo näo linear entre o tamanho dos linfonodos e o comprometimento linfático. O tamanho dos linfonodos näo é um padräo adequado no nosso meio, já que linfonodos maiores que 3cm têm menos de 30 por cento de possibilidade de ser comprometidos. Isso faz com que a especificidade da tomografia seja baixa (63 por cento). Embora a sensibilidade da mediastinoscopia tambêm seja baixa, sua especificidade é de 100 por cento. Os autores concluem que métodos de estadiamento como a mediastinoscopia deveräo ser criteriosamente indicados quando houver sinais de linfonodos aumentados na tomografia