Biologic lung volume reduction therapy for advanced homogeneous emphysema.

This report summarises phase 2 trial results of biologic lung volume reduction (BioLVR) for treatment of advanced homogeneous emphysema. BioLVR therapy was administered bronchoscopically to 25 patients with homogeneous emphysema in an open-labelled study. Eight patients received low dose (LD) treatment with 10 mL per site at eight subsegments; 17 received high dose (HD) treatment with 20 mL per site at eight subsegments. Safety was assessed in terms of medical complications during 6-month follow-up. Efficacy was assessed in terms of change from baseline in gas trapping, spirometry, diffusing capacity, exercise capacity, dyspnoea and health-related quality of life. There were no deaths or serious medical complications during the study. A statistically significant reduction in gas trapping was observed at 3-month follow-up among HD patients, but not LD patients. At 6 months, changes from baseline in forced expiratory volume in 1 s (-8.0+/-13.93% versus +13.8+/-20.26%), forced vital capacity (-3.9+/-9.41% versus +9.0+/-13.01%), residual volume/total lung capacity ratio (-1.4+/-13.82% versus -5.4+/-12.14%), dyspnoea scores (-0.4+/-1.27 versus -0.8+/-0.73 units) and St George's Respiratory Questionnaire total domain scores (-4.9+/-8.3 U versus -12.2+/-12.38 units) were better with HD than with LD therapy. BioLVR therapy with 20 mL per site at eight subsegmental sites may be a safe and effective therapy in patients with advanced homogeneous emphysema.

Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients.

BACKGROUND: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. METHODS: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. RESULTS: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. CONCLUSIONS: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.

Hyperthermic pleural perfusion with cisplatin: early clinical experience.

BACKGROUND: The preferred treatment for patients with pleural tumors or tumors with pleural extension has not been determined. Systemic and local modalities were studied, including intrapleural chemotherapy and hyperthermia, which mainly have been investigated separately. The objective of this study was to investigate the feasibility, toxicity and early results of a multimodality treatment consisting of surgery, chemotherapy, and hyperthermia in one session for the treatment of patients with pleural malignancies. METHODS: From November 1994 to September 1998, 26 patients (7 patients with mesothelioma, 11 patients with thymic neoplasms, and 8 patients with other tumors) underwent intraoperative hyperthermic pleural perfusion (HPP). Perfusion was performed with a roller pump and a heat exchanger. Cisplatin was added when the temperature stabilized to a mean of 40.8 degrees C (range, 40.2-41.5 degrees C). Dosages of cisplatin used were 60 mg in 2 patients, 100 mg in 2 patients, 120 mg in 1 patient, 150 mg in 18 patients, and 200 mg in 3 patients. The patients underwent the following associated surgeries: extended extrapleural pneumonectomy in 8 patients, resection of tumor without pleurectomy in 4 patients, resection of tumors with pleurectomy in 10 patients, and exploration and HPP only in 4 patients (thoracotomy in 2 patients and video-assisted thoracoscopy in 2 patients). RESULTS: There were no technical problems during the perfusion period. The systemic temperature rose to a maximum of 38 degrees C. There was no renal or hematologic toxicity, except in one patient who experienced thrombocytopenia. One patient died from complications related to a technical error. Eight patients had complications; the most bothersome were in four patients with empyema (early in two patients and late in two patients). The median postoperative hospital stay was 7 days (range, 2-50 days). Ten patients were alive 28-69 months after surgery. The overall 1-year, 2-year, and 3-year survival rates were 72%, 65%, and 44%, respectively. Complete ipsilateral pleuropulmonary control was achieved in 17 patients (9 patients who are alive and 8 patients who have died). CONCLUSIONS: Intraoperative HPP with cisplatin is feasible, easy to perform, and relatively safe. This method may offer excellent local control for patients with pleural tumors.

Resection and perfusion thermochemotherapy: a new approach for the treatment of thymic malignancies with pleural spread.

BACKGROUND: Thymoma and thymic carcinoma with pleural spread have a high rate of locoregional recurrence and poor prognosis. Maximal debulking coupled with aggressive local treatment could offer a chance for cure. This study evaluates the early and midterm results of operation and hyperthermic pleural perfusion with cisplatinum for thymic malignancies. METHODS: Fifteen patients (11 men), 20 to 67 years old (10 thymoma, 4 thymic carcinoma, 1 carcinoma in thymic cyst) underwent resection and hyperthermic pleural perfusion between 1995 to 2000. All had pleural spread proven before or intraoperatively. Six of the thymoma cases were recurrent. Current operation included resection without pleurectomy (9 patients), resection with pleurectomy (5), and extrapleural pneumonectomy (1 patient) with intraoperative hyperthermic pleural perfusion in all. Intrapleural temperature reached 40.3 degrees C to 43 degrees C. The total dose of cisplatinum was 150 mg or more in 14 patients. RESULTS: Complete resection (R0) was achieved in 10 patients, subtotal (R1) in 3, and partial (R2) in 2. There was no operative mortality, no hemodynamic or respiratory disturbances during perfusion, and no hematologic, neurologic, or renal complications. Complications consisted of significant bleeding (2 patients), fever (2), and air leak (1 patient). Two patients with thymic carcinoma died after 27 and 34 months, and 1 is alive with no evidence of disease at 54 months. Two patients with thymoma died after 7 and 36 months. Eight are alive after 9 to 70 months. Four patients (all R0) are alive without local recurrence more than 60 months after operation and hyperthermic pleural perfusion. CONCLUSIONS: Operation and thermochemotherpy is feasible and safe in patients with thymic tumors. This method seems to offer excellent local control for patients with stage IV-a thymic malignancies. Midterm results suggest that operation plus hyperthermic pleural perfusion may lengthen survival in stage IV-a thymoma.

Psammomatous melanotic schwannoma: presentation of a rare primary lung tumor.

A 30-year-old nonsmoking man underwent a left lower lobectomy with bronchoplasty for an obstructing lesion of the left lower lobe. Pathology results demonstrated a psammomatous melanotic schwannoma, a rare pigmented neural tumor of which only 25 cases have been reported as originating in the respiratory tract.

Pneumothorax: experience with 1,199 patients.

OBJECTIVE: To study the outcome of pneumothorax managed in a university-affiliated metropolitan medical center. DESIGN: A retrospective review. SETTING: Busy metropolitan medical center. PATIENTS AND METHODS: Records of 1,199 patients with pneumothorax were reviewed and analyzed. RESULTS: Primary spontaneous pneumothorax occurred in 218 patients, secondary spontaneous pneumothorax occurred in 505, traumatic in 403, and iatrogenic in 73. Ninety-six patients with small pneumothorax (8%) were managed by observation, and 1,103 patients (92%) were managed by tube thoracostomy. Drainage of the pleural cavity was continued for 1 to 7 days in 893 patients (81%), 8 to 10 days in 176 patients (16%), and > 10 days in 34 patients (3%). Drainage for > 10 days was classified as persistent pneumothorax. In these 34 patients and in 132 others with a second ipsilateral recurrence (a total of 166 patients), direct pleuroscopy was performed. The pleuroscopy findings and further management are outlined in the algorithm. CONCLUSIONS: Pneumothorax is a common condition affecting all age groups. If the volume of the pneumothorax is > 20% of the pleural space, pleural drainage is indicated. For management of persistent or recurrent pneumothorax, the use of pleuroscopy (direct or video-assisted) is of great value and should be part of routine management.

The place of surgery in the treatment of re-emerging pulmonary tuberculosis.

BACKGROUND: A marked worldwide increase in prevalence of pulmonary tuberculosis occurred during the past 15 years. The reasons for this change include the worldwide epidemic of AIDS, poverty and unprecedented migration of people. METHODS: During the past 12 years, we operated on 57 patients with pulmonary tuberculosis or its sequelae. In 42 patients the disease was active at the time of operation. RESULTS: Two patients died of operative complications; one, of unrelated causes. There were three major non-fatal complications. In 49 patients tuberculosis was eradicated; five patients still have active disease and remain under drug therapy. CONCLUSIONS: High level of clinical awareness is the most important factor in disclosure and early treatment of pulmonary tuberculosis. Indications for operation are strengthened by alcoholism, drug abuse, poverty and other social factors. BCG vaccination of tuberculin-negative children should be considered as a preventive measure.

[Plication of diaphragm for postoperative phrenic nerve injury in infants and young children].

Paralysis of the diaphragm may cause life-threatening respiratory distress in infants and young children because of paradoxical motion of the affected diaphragm and contralateral shift of the mediastinum during expiration. Phrenic nerve injury (PNI) may follow chest operations. 10 children with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm. Ages ranged from 14 days to 5 years. 9 had PNI after operations for congenital heart disease and 1 after resection of an intraspinal cervical lipoma. The right side was affected in 7, the left in 3. Indication for surgery was inability to wean from mechanical ventilation, which had ranged from 11 to 152 days (median 35). 8 underwent plication via a thoracic approach and 2 via an abdominal approach. There were no complications directly related to the operation. The interval from plication to weaning from mechanical ventilation ranged from 2 to 140 days (median 4). 1 patient died 2 hours after plication due to severe heart failure and 2 after prolonged hospitalization due to sepsis and multi-organ failure. 6 were extubated 2-8 days (median 4) after plication and 1 only after 40 days. Early diaphragmatic plication is simple and avoids more serious surgery. While effective in ventilator-dependent infants and young children, it should not be used in those with multi-organ failure. Early plication may prevent the complications of prolonged mechanical ventilation.

Surgical management of tracheal tumors.

BACKGROUND: Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor. METHODS: In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved. RESULTS: One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor. CONCLUSIONS: Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Gangrene of the lung: treatment in two stages.

BACKGROUND: Pulmonary gangrene is a rare complication of severe lung infection with devitalization of lung parenchyma and secondary infection. If untreated, gangrene of the lung leads to sepsis, multiple-organ failure, and death. Resection of all gangrenous tissue is mandatory and is lifesaving. Pleural empyema commonly accompanies gangrene of the lung; in its presence, dissection of hilar structures for resection can lead to mediastinitis or bronchopleural fistula and should be avoided. METHODS: Three patients with pulmonary gangrene were treated in two stages: immediate fenestration first and then delayed resection of gangrenous lung in a clean field and immediate closure of the pleural window. RESULTS: Two patients underwent pneumonectomy and 1 patient, lobectomy. All patients recovered without complications. CONCLUSIONS: Creation of a pleural window (fenestration) for 1 week enables safe and curative resection of a gangrenous lung or lobe in a clean field and in a patient in stable condition.

Pleural empyema: 24-year experience.

BACKGROUND: Despite the widespread use of antibiotics, empyema remains a common and serious problem, and its treatment is controversial. METHODS: Our experience in 380 patients with empyema was retrospectively reviewed. RESULTS: The causes of empyema were as follows: pneumonia (n = 308), late complication of tuberculosis (n = 24), trauma (n = 15), pulmonary gangrene (n = 3), retained foreign body (n = 1), and undetermined (n = 29). An exudative state was diagnosed in 273 patients, a fibrinopurulent state in 55, and an organizing state in 52. Pleuroscopy was performed in 107 patients resistant to treatment, and this revealed an expansible lung in 49 patients, a nonexpansible lung in 51, and exceptional findings (foreign body, necrotizing pneumonitis, and perforated esophageal cancer) in 7. Treatment was modified accordingly. Five patients died (mortality, 1.3%). CONCLUSIONS: Pleuroscopy is very helpful in disclosing factors responsible for resistance to treatment and in carrying out thorough pleural toilet. The use of talc in selected patients causes pleurodesis and prevents the reaccumulation of pus. Decortication is the ideal treatment in the organizing stage, enabling complete lung expansion. Fenestration is lifesaving in moribund patients who cannot tolerate decortication.

Pleuroscopy: therapeutic applications.

Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.

Symptomatic diaphragmatic hernia: surgical treatment.

Seventy-eight cases of symptomatic diaphragmatic hernia are reported--55 hiatal (42 sliding, 9 rolling, 4 intrathoracic stomach), 19 diaphragmatic hernias proper (12 Bochdalek, 7 Morgagni) and four diaphragmatic eventrations. Pulmonary function was compromised by massive herniation in ten cases. Four hernias were incarcerated. Surgery was performed in 76 cases, as emergency in ten. Two patients were rejected because of poor pulmonary function. One patient died and three hernias recurred. The results were satisfactory in 72 cases. In sliding hiatus hernia, gastro-oesphageal reflux is the main problem and investigations should include oesophagoscopy, fluoroscopy and manometry, with treatment directed at prevention of reflux. Surgical treatment, if indicated, is usually fundoplication and dilatation of strictures. In rolling hiatus hernia and all types of diaphragmatic hernia proper, the hernia per se is the main problem, with risk of incarceration. Surgery is always indicated and should comprise reduction of hernia contents, excision of the sac and closure of diaphragmatic rift.