Biliotórax: una entidad rara para un diagnóstico frecuente. Un reporte de caso / Bilothorax: a Rare Entity for a Frequent Diagnosis. A Case Report

Introducción: El biliotórax es una condición infrecuente definida por la presencia de bilis en el espacio pleural. Actualmente, hay alrededor de 70 casos descritos en la litera-tura. Sigue siendo relativamente desconocido, por lo tanto, poco sospechado. Esta entidad suele ser el resultado de una lesión iatrogénica, a menudo secundaria a cirugías o traumatismos del tracto biliar, que conduce a la formación de una fístula pleurobiliar.

Introduction: Bilothorax is a rare condition defined by the presence of bile in the pleural space. Currently, there are around 70 cases described in the literature. It remains relatively unknown and, therefore, little suspected. This entity is usually the result of an iatrogenic injury, often secondary to surgery or trauma to the biliary tract, leading to the formation of a pleurobiliary fistula

Cuidados de enfermagem ao paciente adulto com drenagem torácica: protocolo de scoping review / Nursing care to adult patient with chest drainage: scoping review protocol

OBJETIVO: mapear os cuidados de enfermagem empregados aos pacientes adultos com drenagem torácica internados em terapia intensiva. MÉTODO: scoping review a ser conduzida conforme o Joanna Briggs Institute, com a seguinte questão de pesquisa: "quais são os cuidados de enfermagem indicados aos pacientes adultos com drenagem torácica internados em terapia intensiva?". A busca será desenvolvida em cinco bases de dados: Pubmed, Scopus, Embase, BVS e Web of Science, e os achados serão geridos com o auxílio do software Rayyan. Serão incluídos estudos quantitativos e qualitativos, artigos de revisão, dissertações, teses, diretrizes clínicas e protocolos terapêuticos sobre a temática, incluindo a literatura cinzenta. Será descrito o número total de fontes de evidência encontradas e selecionadas. Através de uma narrativa, será detalhado o processo de decisão da inclusão dos estudos. Os principais achados deverão estar descritos em consonância com o objetivo e os resultados relacionados à questão de pesquisa.

OBJECTIVE: to map nursing care employed to adult patients with chest drainage admitted to intensive care. METHOD: scoping review to be conducted according to the Joanna Briggs Institute, with the following research question: "What are the nursing cares indicated to adult patients with chest drainage admitted to intensive care?". The search will be developed in five databases: Pubmed, Scopus, Embase, BVS and Web of Science, and the findings will be managed with the support of Rayyan software. Quantitative and qualitative studies, review articles, dissertations, theses, clinical guidelines and therapeutic protocols on the subject will be included, including gray literature. The total number of sources of evidence found and selected will be described. Through a narrative, the decision-making process of the inclusion of the studies will be detailed. The main findings must be described in line with the objective and the results related to the research question.

Actualidad en el manejo clínico del derrame pleural maligno: revisión narrativa / Update on the clinical management of malignant pleural effusion: narrative review: A narrative review

Introducción: Cerca del 50 % de los derrames pleurales (DP) es neoplásico. El comportamiento clínico del DP neoplásico es altamente sintomático por el gran volumen y su recidiva temprana. Propósito de la revisión: El objetivo de la revisión es delinear el papel de los diferentes métodos diagnósticos y terapéuticos de DP maligno. Buscamos reportes actualizados en donde se incluye los resultados de mejor supervivencia para los distintos tratamientos actuales. Recientes hallazgos: Los criterios de Light es el método estándar para diferenciar un exudado maligno. La toracocentesis guiada por ultrasonido debe ser usada como método diagnóstico/terapéutico. En pacientes con DP maligno se recomienda el drenaje permanente con el posicionamiento de un tubo de tórax y un sello hidráulico con drenaje cerrado. La pleurodesia con instilación de talco está recomendada en pacientes con DP maligno en busca de disminuir el volumen, las recidivas del DP y el tiempo de hospitalización. Conclusiones: Para el correcto manejo del DP maligno, hay que tomar en cuenta varios aspectos, como identificar la presencia de células malignas mediante estudio citológico y descartar una infección. La ecografía pleural permite definir el volumen del DP y permite decidir drenaje en ese momento, con la posibilidad de inserción de catéter intrapleural, con el objetivo de evaluar la posibilidad de esclerosar las pleuras a través de pleurodesia. Sin embargo, para llegar a esta decisión hay que analizar cada uno de los detalles que podrían tener un papel de importancia para el buen manejo y resolución definitiva o por el contrario decidir el manejo a título paliativo, siempre analizando cada caso con el objetivo de proveer de mejoría de síntomas y mejorar la calidad de vida del paciente.

Introduction: Approximately 50% of pleural effusions (PE) are neoplastic. The clinical behavior of neoplastic PE is highly symptomatic due to its large volume and early recurrence. Purpose of review: This review aims to outline the role of the different diagnostic and therapeutic methods of malignant PE. We look for updated reports that include the best survival results for the other current treatments. Recent findings: Light's criteria are the standard to differentiate a malignant exudate. Ultrasound-guided thoracentesis should be used as a diagnostic/therapeutic method. In patients with malignant PE, permanent drainage is recommended with the placement of a chest tube and a hydraulic seal with closed drainage. Pleurodesis with the installation of talc is recommended in patients with malignant PE to reduce volume, PE recurrences, and hospitalization time. Conclusions: For the correct management of malignant PE, several aspects must be considered, such as identifying the presence of malignant cells by cytological study and ruling out infection. Pleural ultrasound allows for defining the volume of the PE. It will enable deciding on drainage at that time, with the possibility of inserting an intrapleural catheter, to evaluate the likelihood of sclerosing the pleurae through pleurodesis. However, to reach this decision, it is necessary to analyze each of the details that could play an essential role in good management and definitive resolution or, on the contrary, decide on palliative management, constantly investigating each case to provide symptom improvement. In addition, improving the patient's quality of life.

Minimally invasive lateral retropleural approach to the thoracolumbar junction - review & experience / Acesso lateral e retropleural minimamente invasivo à junção toracolombar - revisão e experiência / Acceso lateral y retropleural mínimamente invasivo a la junción toracolumbar - revisión y experiencia

ABSTRACT Objective To describe the minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine and its viability in several affections of the region, demonstrating its indications, potential advantages, and necessary precautions, with an emphasis on the local anatomy, especially the diaphragm. Methods After a review of the literature, the initial experience of the Service is reported, comparing it to the published results. The surgical technique used is described with emphasis on the surgical anatomy of the diaphragm. Results The minimally invasive lateral retropleural approach to the thoracolumbar junction with the application of an expandable tubular retractor was described step-by-step in this study, with emphasis on the crucial points of technical execution, such as preoperative planning, access to the retropleural plane, and an orthogonal approach for adequate discectomy and/or corpectomy and subsequent implant placement. It can be used in the treatment of deformities, degenerative diseases, trauma, tumors, and infections and it allows for adequate interbody arthrodesis fusion rates associated with a smaller skin incision and less soft tissue damage, blood loss, and postoperative pain. Thus, it results in better postoperative mobility and a shorter hospital stay, which can also be observed in the data from initial experience of this Service. Conclusions The minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine with the application of an expandable tubular retractor was shown to be promising and safe for the treatment of several spinal diseases despite the complex and challenging local anatomy and it presents advantages over the morbidity rates observed in the traditional approach. Level of evidence IV; Case series.

RESUMO Objetivo Descrever a técnica minimamente invasiva para acesso lateral retropleural à coluna toracolombar e sua viabilidade em diversas afecções da região, demonstrando suas indicações, vantagens em potencial e cuidados necessários, com destaque para a anatomia local, especialmente o diafragma. Métodos Após revisão da literatura, relata-se a experiência inicial do serviço, comparando-a aos resultados publicados. Descreve-se a técnica cirúrgica empregada, com ênfase na anatomia cirúrgica do diafragma. Resultados A técnica de acesso lateral retropleural minimamente invasivo à junção toracolombar, com aplicação de retrator tubular expansível, foi descrita passo a passo neste estudo, com destaque de pontos cruciais de execução técnica, tais como planejamento pré-operatório, acesso ao plano retropleural e abordagem ortogonal para discectomia e/ou corpectomia adequadas e posterior colocação de implante. Ela pode ser usada no tratamento de deformidades, doenças degenerativas, trauma, tumor e infecções e possibilita taxas adequadas de fusão pela artrodese intersomática associada à menor incisão de pele, dano aos tecidos moles, perda sanguínea e dor pós-operatória. Resulta, assim, em melhor mobilidade pós-cirúrgica e menor período de internação hospitalar, o que pode ser observado também nos dados da experiência inicial do Serviço. Conclusões A técnica de acesso lateral retropleural minimamente invasivo à junção toracolombar com aplicação de retrator tubular expansível mostra-se promissora e segura para tratamento de diversas doenças da coluna, apesar da anatomia local complexa e desafiadora e apresenta vantagens diante da morbidade decorrente da abordagem tradicional. Nível de evidência: IV; Série de casos.

RESUMEN Objetivo Describir la técnica mínimamente invasiva para acceso lateral retropleural a la columna toracolumbar y su viabilidad en diversas afecciones de la región, demostrando sus indicaciones, ventajas en potencial y cuidados necesarios, destacando la anatomía local, especialmente el diafragma. Métodos Después de revisión de la literatura, se relata la experiencia del Servicio, comparándola a los resultados publicados. Se describe la técnica quirúrgica empleada, con énfasis en la anatomía quirúrgica del diafragma. Resultados La técnica de acceso lateral retropleural mínimamente invasivo a la junción toracolumbar, con aplicación de retractor tubular expansible, fue descrita paso a paso en este estudio, con destaque de puntos cruciales de ejecución técnica, tales como planificación preoperatoria, acceso al plano retropleural y abordaje ortogonal para discectomía y/o corpectomía adecuadas y posterior colocación de implante. La misma puede ser usada en el tratamiento de deformidades, enfermedades degenerativas, trauma, tumor e infecciones y posibilita tasas adecuadas de fusión por artrodesis intersomática asociada a la menor incisión de piel, daño a los tejidos blandos, pérdida sanguínea y dolor postoperatorio. Resulta, así, en mejor movilidad postquirúrgica y menor período de internación hospitalaria, lo que puede ser observado también en los datos de la experiencia inicial del Servicio. Conclusiones La técnica de acceso lateral retropleural mínimamente invasivo a la junción toracolumbar con aplicación de retractor tubular expansible se muestra prometedora y segura para tratamiento de diversas enfermedades de la columna, a pesar de la anatomía local compleja y difícil, y presenta ventajas delante de la morbilidad del abordaje tradicional. Nivel de evidencia IV; Serie de casos.

Primer separador retráctil de pulmón para facilitar la disección extrapleural de la arteria torácica interna / First retractable lung spreader to facilitate extrapleural dissection of the internal thoracic artery

RESUMEN La disección de la arteria torácica interna es uno de los procedimientos más definitorios de la cirugía de revascularización miocárdica, pues se ha demostrado que la calidad de vida y la evolución a corto y largo plazo de los pacientes dependerán de las características morfológicas del injerto. Hace más de 25 años se propuso la utilización de un separador pulmonar maleable para facilitar la disección de la arteria torácica interna, especialmente su segmento proximal, pero nunca se ha fabricado ese dispositivo. Se presenta un separador pulmonar manufacturado a partir de dispositivos en desuso, empleados en cirugía coronaria. Se comentan y discuten las principales ventajas demostradas durante más de tres años en cerca de un centenar de pacientes.

ABSTRACT Internal thoracic artery dissection is one of the most defining procedures of coronary artery bypass grafting, as it has been demonstrated that the quality of life and short-long term outcome of patients will depend on the morphological characteristics of the graft. More than 25 years ago, the use of a malleable lung spreader was proposed to facilitate the internal thoracic artery dissection especially its proximal segment, but that device has never been manufactured. A lung spreader, assembled from disused devices, used in coronary artery revascularization is presented. The main advantages confirmed over more than three years in nearly a hundred patients are discussed and commented upon.

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.

Incarcerated Hiatal Hernia with Perforation after Laparoscopic Total Gastrectomy with Roux-en-Y Reconstruction: a Case Report

The occurrence of hiatal hernia after total gastrectomy with Roux-en-Y reconstruction is rare. We report the case of a 76-year-old man who presented with dyspnea, vomiting, and fever around 8 days after total gastrectomy with Roux-en-Y reconstruction. Abdominal computed tomography revealed a hiatal hernia containing part of the small intestine in the left thoracic cavity. Emergent reduction and repair of the hiatal hernia were performed later. Operative findings revealed that the Roux limb was incarcerated in the left pleural cavity. Esophagojejunostomy leakage, perforation of the small intestine with transient ischemic change, and pyothorax were also found. Thus, feeding jejunostomy, thoracoscopic decortication, and diversion T-tube esophagostomy were performed. Considering that the main cause of hiatal hernia is blunt dissection with division of the phrenoesophageal membrane, approximating the crus with 1 or 2 figure-8 sutures, according to the size of the defect, to prevent the incidence of hiatal hernia after total gastrectomy may be performed.

Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists / 결핵및호흡기질환

Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity (“water seal”) drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.

Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion / Posicionamento intrapleural, guiado por ultrassonografia, de cateteres pleurais: influência na expansão pulmonar imediata e na pleurodese em pacientes com derrame pleural maligno recorrente

ABSTRACT Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

RESUMO Objetivo: Avaliar o papel do posicionamento intrapleural do cateter pleural na expansão pulmonar precoce e no sucesso da pleurodese em pacientes com derrame pleural maligno recorrente (DPMR). Métodos: Trata-se de um estudo retrospectivo aninhado em um estudo prospectivo de coorte maior com pacientes com DPMR recrutados em um hospital-escola universitário terciário entre junho de 2009 e setembro de 2014. Os pacientes foram submetidos a inserção de cateter pleural e, em seguida, pleurodese à beira do leito. A TC de tórax foi realizada duas vezes: imediatamente antes da pleurodese (TCi) e 30 dias após a pleurodese (TC30). Com base na TCi, a posição do cateter foi classificada em posterolateral, anterior, fissural e subpulmonar. Usamos o volume pleural na TCi para estimar a expansão pulmonar precoce e a diferença entre os volumes pleurais na TC30 e na TCi a fim de avaliar o sucesso radiológico da pleurodese. Considerou-se que a pleurodese teve êxito clínico quando não foi necessário realizar nenhum outro procedimento pleural. Resultados: Dos 131 pacientes elegíveis do estudo original, 85 foram incluídos neste estudo aninhado (64 mulheres; média de idade: 60,74 anos). A posição da ponta do cateter foi subpulmonar em 35 pacientes (41%), anterior em 23 (27%), posterolateral em 17 (20%) e fissural em 10 (12%). Não houve diferenças significativas entre os grupos quanto à expansão pulmonar precoce (mediana da cavidade pleural residual = 377 ml; intervalo interquartil: 171-722 ml; p = 0,645), sucesso radiológico da pleurodese (mediana do volume = 33 ml; intervalo interquartil: −225 a 257 ml; p = 0,923) e sucesso clínico da pleurodese (85,8%; p = 0,676). Conclusões: Nossos resultados sugerem que a posição da ponta do cateter pleural não influencia nem a expansão pulmonar precoce nem o sucesso da pleurodese à beira do leito em pacientes com DPMR.

Medical Thoracoscopy in Pleural Disease: Experience from a One-Center Study / 결핵및호흡기질환

BACKGROUND: Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital. METHODS: Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data. RESULTS: From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT). CONCLUSION: MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.

Delayed Iatrogenic Diaphragmatic Hernia after Left Lower Lobectomy

A 66-year-old patient undergoing regular follow-up at Samsung Medical Center after left lower lobectomy visited the emergency department around 9 months postoperatively because of nausea and vomiting after routine esophagogastroduodenoscopy at a local clinic. Abdominal computed tomography showed the stomach herniating into the left thoracic cavity. We explored the pleural cavity via video-assisted thoracic surgery (VATS). Adhesiolysis around the herniated stomach and laparotomic reduction under video assistance were successfully performed. The diaphragmatic defect was repaired via VATS. The postoperative course was uneventful, and he was discharged with resolved digestive tract symptoms.

Squamous Cell Carcinoma Arising from the Pleural Cavity After Pneumonectomy for Chronic Empyema

Malignant tumors associated with chronic empyema have been reported in the literature, and a majority of these tumors are lymphomas. Epithelial tumors originating from the post-pneumonectomy space in patients with chronic empyema are extremely rare. Here, we present the cases of 2 patients with squamous cell carcinoma arising from the pleural cavity after pneumonectomy for chronic empyema.

Mediastinal Pancreatic Pseudocysts

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Serosal Cavities Contain Two Populations of Innate-like integrin α4highCD4+ T Cells, Integrin α4β1+α6β1+α4β7− and α4β1+α6β1−α4β7+ Cells

We previously reported peritoneal innate-like integrin α4 (CD49d)highCD4+ T cells that provided help for B-1a cells. Here we analyzed the expression of various integrin chains on the peritoneal and pleural integrin α4highCD4+ T cells and investigated the functional heterogeneity of the subpopulations based on the integrin expression. Pleural cavity contained a lower ratio of integrin α4highCD4+ T cells to integrin α4lowCD4+ T cells than peritoneal cavity, but the pleural integrin α4highCD4+ T cells have the same characteristics of the peritoneal integrin α4highCD4+ T cells. Most of integrin α4highCD4+ T cells were integrin β1highβ7−, but a minor population of integrin α4highCD4+ T cells was integrin β1+β7+. Interestingly, the integrin α4highβ1highβ7− CD4+ T cells expressed high levels of integrin α4β1 and α6β1, whereas integrin α4highβ1+β7+ CD4+ T cells expressed high levels of integrin α4β1 and α4β7, suggesting an alternative expression of integrin α6β1 or α4β7 in combination with α4β1 in respective major and minor populations of integrin α4highCD4+ T cells. The minor population, integrin α4highβ1+β7+ CD4+ T cells, were different from the integrin α4highβ1highβ7− CD4+ T cells in that they secreted a smaller amount of Th1 cytokines upon stimulation and expressed lower levels of Th1-related chemokine receptors CCR5 and CXCR3 than the integrin α4highβ1 highβ7− CD4+ T cells. In summary, the innate-like integrin α4highCD4+ T cells could be divided into 2 populations, integrin α4β1+α6β1+α4β7− and α4β1+α6β1−α4β7+ cells. The functional significance of serosal integrin α4β7+ CD4+ T cells needed to be investigated especially in view of mucosal immunity.

Ventana torácica y anestesia local en la supuración pleural / Thoracic window and local anesthesia in pleural suppuration

Introducción: la colección purulenta en la cavidad pleural es causa de complicaciones, por procesos infecciosos pulmonares, y de alta mortalidad. Con frecuencia se trata de enfermos con deterioro del estado general, situación que se agrava en enfermos de edades geriátricas. Objetivo: mostrar la experiencia en el uso de la toracostomía con resección costal y anestesia local en el Hospital Universitario Manuel Fajardo para la atención de enfermos con empiema pleural. Métodos: se estudiaron 24 pacientes con empiema pleural atendidos desde enero de 1998 hasta octubre de 2015, con edad avanzada y estado físico precario en el Hospital Universitario Manuel Fajardo a los que se les realizó una ventana pleurocutánea con anestesia local. Resultados: La edad promedio fue de edad 72 años; 75 por ciento presentó enfermedades asociadas. La relación hombre/mujer fue de 3 a 1. La causa más frecuente fue el derrame paraneumónico infestado, 100 por ciento tuvo antecedentes de pleurostomía. Hubo cultivo negativo en 20,8 por ciento pacientes. Los gérmenes más frecuentes fueron el estreptococo, estafilococo y gérmenes gramnegativos. Las costillas resecadas fueron los arcos costales anteriores sexto y séptimo y el tiempo promedio de cierre de las ventanas fue de 8 meses, sin mortalidad quirúrgica. Conclusión: la ventana torácica pleurocutánea es un procedimiento quirúrgico de baja mortalidad, ideal para solucionar una cavidad pleural tabicada con gran utilidad en enfermos de edades geriátricas y con estado físico precario, por la factibilidad de realizarla con anestesia local(AU)

Introduction: pleural cavity purulent collection causes high mortality and complications in lung infections processes. It often comes to patients with deterioration of general condition, a situation muchworsened in patients of geriatric age. Objective: to show the experience in using costal thoracostomy and local anesthesia in care for elderly patients with pleural empyema and poor physical condition. Methods: study carried out in 24 patients with pleural empyema, advanced age and poor physical condition cared for from January 1998 to October 2015 at Comandante Manuel Fajardo University Hospital and who also underwent pleurocutaneous window with local anesthesia. Results: average age was 72 years. The male/female ratio was 3 to 1. 75 percent of the patients presented associated diseases. The most frequent cause was infested parapneumonic effusion. There was pleurostomy history in 100 percent of the cases, negative culture in 20.8 percent, while the most common germs were streptococcus, staphylococcus and gram-negative bacteria. The resected ribs were the sixth and seventh previous costal arches. El average windows closing time was 8 months. There was no surgical mortality. Conclusion: pleurocutaneous thoracic window is a surgical procedure with low mortality, ideal to settle a pleural cavity tabicada with great utility in patients at geriatric age and in precarious physical condition, from the feasibility of being performing under local anesthesia(AU)

The "Raven Sign": A case of apical left lung herniation into the superior right hemithorax detected on 99mTc-MAA lung perfusion scintigraphy in a pediatric patient with pulmonary tuberculosis

Lung hernia is a rare finding described as the protrusion of lung tissue outside the pleural cavity. Lung perfusion scintigraphy is used for pre-operative assessment of high-risk patients prior to pneumonectomy This case report presents a case of an apical left lung hernia detected in a lung perfusion scan prior to elective pneumonectomy in a seven-year-old girl with pulmonary tuberculosis destroyed right lung and compensatory left lung hyperinflation.

Videotoracoscop í a con bloqueo loco regional en pacientes complejos para manejo del derrame pleura / Videothoracoscopy under local antesthesia in complex patients for management of pleural effusion

Introducción: La videotoracoscopía con anestesia local es un método mínimamente invasivo que permite la visualización directa de la cavidad pleural así como toma de muestras para biopsia y realización de intervenciones terapéuticas en pleura.1,2,3. Objetivo: Demostrar la utilidad de la realización de videotoracoscopía con anestesia local en pacientes con derrame pleural neoplásico que presentan elevada morbimortalidad quirúrgica. Material y Método: En el periodo comprendido entre Marzo 2012 a Marzo 2015, se evaluaron 23 pacientes que se les realizo Videotoracoscopia por derrame neoplásico, de las cuales 8 fueron con anestesia local. Resultados: Se analizaron en el Sector de Cirugía Tórax del Hospital Aeronáutico Central 23 videotoracoscopía, desde Marzo 2012 a Marzo 2015 de las cuales 8 (34.78%) fueron realizadas con anestesia loco regional. La edad promedio de los pacientes fue de 81,5 años. Además del antecedente neoplásico, todos fueron evaluados por anestesia como ASA IV. Todos presentaban derrame pleural que afectaba por lo menos 2/3 del hemitórax, favoreciendo así el colapso pasivo pulmonar. La evolución posoperatoria fue satisfactoria, sin morbimortalidad. El promedio de tiempo de drenaje pleural fue de 6 días. Conclusiones: La videotoracoscopia bajo anestesia local es una variante que debería tenerse en cuenta para pacientes complejos con elevada morbimortalidad.

Introduction: VATS under local anesthesia is a minimally invasive method that allows direct visualization of the pleural cavity and biopsy sampling and production of therapeutic interventions in pleura.1,2,3 Objective: To demonstrate the usefulness of performing VATS under local anesthesia in patients with neoplastic pleural effusion presented high surgical mortality and morbidity. Material and Methods: In the period from March 2012 to March 2015, 23 patients who underwent Videothoracoscopy by malignant effusion, of which 8 were evaluated under local anesthesia. Results: We analyzed in Sector Thoracic Surgery Central Hospital Aeronautic videothoracoscopy 23, from March 2012 to March 2015 of which 8 (34.78%) were performed with locoregional anesthesia. The average age of patients was 81.5 years. In addition to neoplastic history, all were evaluated by ASA IV anesthesia. All had pleural effusion affecting at least 2/3 of the hemithorax, favoring passive lung collapse. The postoperative course was satisfactory without morbidity and mortality. The average time of pleural drainage was 6 days. Conclusions: VATS under local anesthesia is a variant that should be considered for patients with high morbidity and mortality complex.

The "Raven Sign": A case of apical left lung herniation into the superior right hemithorax detected on 99mTc-MAA lung perfusion scintigraphy in a pediatric patient with pulmonary tuberculosis

Lung hernia is a rare finding described as the protrusion of lung tissue outside the pleural cavity. Lung perfusion scintigraphy is used for pre-operative assessment of high-risk patients prior to pneumonectomy This case report presents a case of an apical left lung hernia detected in a lung perfusion scan prior to elective pneumonectomy in a seven-year-old girl with pulmonary tuberculosis destroyed right lung and compensatory left lung hyperinflation.

A "Vanishing", Tuberculous, Pericardial Effusion

We present an iatrogenic, pleuro-pericardial connection resulting from pericardiocentesis of a large, tuberculous, pericardial effusion. Recognition of this situation is paramount when one is unable to aspirate pericardial fluid after a successful, initial puncture. Such knowledge will help prevent myocardial or coronary artery injury with further attempts at aspiration.