Adrenaline attenuates the acute lung injury after intratracheal lipopolysaccharide instillation: an experimental study.

Endotoxin is a major cause of endotoxinemia, sepsis, and pneumonia due to gram-negative bacteria. Experimental endotoxin administration via the tracheal route has been extensively used to study the biological and pathophysiologic pathways of inflammation. In particular, experimental endotoxin instillation in the respiratory tree has allowed an extended research with regard to the local response of the lungs to the pathogenic stimulus. This study aims (a) to define early events in the inflammatory cascade and (b) to evaluate the efficacy of adrenaline to ameliorate the acute pulmonary inflammation in vivo after administration of intratracheal lipopolysaccharide (LPS) in an in vivo animal model. Two groups of animals were used for that purpose, a control group (single LPS administration) and a study group (subcutaneous adrenaline infusion following LPS administration). We found that mononuclear recruitment, along with an increased population of CD4+ T lymphocytes, is an early event during the course of LPS-challenged inflammation. In the study group, we determined that adrenaline mediated the lung inflammation in a statistically significant degree. By the use of immunohistochemistry, we identified (1) an increased population of CD4+ T lymphocytes in the inflammatory infiltrate, further endorsing the hypothesis that T-helper lymphocytes, along with macrophages, secrete cytokines which amplify the inflammatory response, and (2) an upregulation of ICAM-1 expression, suggesting an important role in the early pathogenesis of LPS-induced acute lung injury. Our study establishes that systemic adrenaline administration after LPS instillation may ameliorate the inflammatory lung response in vivo.

Incidental finding of lung cancer in a patient with thoracic aortic aneurysm - simultaneous management. A case report.

The simultaneous existence of thoracic aortic aneurysm and lung cancer is a rare finding, especially if the malignancy is primary and does not involve the aortic wall. In this report, we present a case of a typical descending thoracic aneurysm combined with a primary adenocarcinoma of the left lower lobe. The aneurysm was repaired with a Dacron graft without use of extra corporeal circulation and a typical left lower lobectomy was performed. In such cases, aneurysms should be treated primarily with endovascular stents. However, if this is not possible, a combined operation can be performed with good outcome.

Malignant triton tumour of the anterior mediastinum as incidental finding.

A rare case of malignant peripheral nerve sheath tumour with rhabdomyoblastic differentiation (malignant triton tumour) of the anterior mediastinum in a 30-year-old male is reported. The tumour was an incidental finding during the diagnostic work-up following a motor vehicle accident. The patient underwent median sternotomy with a tumour resection performed. Local relapse was suspected one month later, as per the chest CT-scan, and post-operative chemoradiation was applied, which produced a response. Twelve months later the patient is doing well while radiological findings remain invariable. Localization of a triton tumour in the anterior mediastinum is extremely rare, adjuvant treatment is necessary, recurrence frequently occurs and the prognosis is dismal.

Tracheoesophageal fistula managed with tracheal stent through flexible bronchoscopy without fluoroscopy.

Inoperable malignant tracheoesophageal fistula (TEF) is characterised by an extremely poor prognosis. Tracheal or double (tracheal-esophageal) stenting through rigid bronchoscopy has been suggested as a valuable therapeutic option. We report on a patient with a large TEF successfully sealed by deployment of a self-expandable stent through flexible bronchoscopy (FB) without fluoroscopy. Dramatically improved health status permitted him to undergo radiation, attaining further clinical improvement. Four months after stent placement no sequelae were observed. During the fifth month a new fistula developed distally to the stent finally leading to death from septic complication. Palliative management of inoperable malignant TEF by tracheal stent placement through FB without fluoroscopy, is feasible, safe and rewarding leading to important clinical improvement.

Spontaneous pneumothorax: are we missing something?

Most thoracic surgeons overlook the fact that spontaneous pneumothorax is one of the pulmonary complications of connective tissue disorders such as Marfan or Ehlers-Danlos syndromes, and they consider it as primary. In the following report we describe a unique case of spontaneous rupture of the sigmoid secondary to a spontaneous recurrent contralateral pneumothorax in a young patient with undiagnosed Marfan syndrome. The aim of this presentation is to raise a high index of suspicion of every thoracic surgeon to include in his differential diagnosis the connective tissue disorders in any case of spontaneous pneumothorax and if so, to follow further diagnostic procedures to anticipate any other visceral complications.

A reappraisal of the utility of somatostatin receptor scintigraphy in patients with ectopic adrenocorticotropin Cushing's syndrome.

Ectopic ACTH hypersecretion is a rare cause of Cushing's syndrome. Bronchial carcinoids are the most common neoplasms causing the occult ectopic ACTH syndrome (EAS). Localization of these tumors is often difficult. The diagnostic utility of somatostatin receptor scintigraphy (SRS) in EAS has been studied in a limited number of patients with conflicting results. Herein we report our experience with 12 consecutive cases. Histological confirmation was obtained in nine patients, the majority being bronchial carcinoids. Among the seven patients with histologically confirmed bronchial carcinoids, SRS was performed in six patients. In three patients SRS correctly localized a bronchial carcinoid tumor at presentation. In the remaining three it became positive after 8, 22, and 27 months during follow-up. In two patients SRS was positive without any finding in the corresponding conventional imaging study. In two patients positive computed tomography/magnetic resonance imaging preceded SRS localization. There was no false positive SRS. Among three patients with highly suspected EAS, SRS was positive in one. Both patients with EAS due to medullary thyroid carcinoma had focal positive uptake. In summary, in this study a substantial number of patients had positive tumor localization by SRS. Therefore, SRS is a useful tool in the evaluation of patients with EAS.

Mediastinal mass with Dysphagia in an elderly patient.

We report the use of endoscopic techniques for successful diagnosis in a case of atypical esophageal tuberculosis. Tuberculosis of the esophagus is an unusual presentation of this disease, having been estimated to occur in 0.15% of the people who die of tuberculosis. A few cases of possible primary tuberculous esophagitis have been described. This report describes a patient with dysphagia who appeared to have esophageal tuberculosis without HIV and in the absence of other signs of tuberculosis. The patient responded promptly to treatment with tuberculostatics.

Donor lung pretreatment with surfactant in experimental transplantation preserves graft hemodynamics and alveolar morphology.

In experimental lung transplantation, the reduction of endogenous surfactant properties occurs after graft preservation and transplant reperfusion. The aim of this study was to evaluate the efficacy of donor lung pretreatment with exogenous surfactant on graft damage after ischemia and reperfusion. Fourteen (control group A, n = 8; study group B, n= 6) young female white pigs (mean weight 27 +/- 3.5 kg) were used in a newly developed autotransplantation model within situcold ischemia. In study group B, before thoracotomy, 1.5 ml/kg surfactant apoprotein-A-free surfactant was administrated into the left main bronchus via flexible bronchoscopy. Belzer UW solution was used for lung preservation. Cold ischemia was achieved for 3 hr with interlobar lung parenchyma temperature at 8 +/- 1.3 degrees C, and central temperature maintained at 37.20 +/- 0.5 degrees C. Animals were sacrificed after 3 hr of graft reperfusion. At the end of reperfusion, pulmonary vascular resistance index (was 447.80 dyn/sec.cm(5).m(2)(+/-66.8) in group A vs 249.51 in group B (P< 0.001) and serum nitric oxide was adequately preserved. The mean alveolar surface area estimated by computerized morphometry was 5280.84 (4991.1) microm(2)(group A) vs 3997.89 (3284.70) microm(2)(group B;P< 0.005). Histology revealed milder macrophage and lymphocyte infiltration in group B at the end of reperfusion. Pretreatment of donor lung with an surfactant apoprotein-A -free surfactant agent appears to be beneficial in terms of maintaining serum NO and reducing hemodynamic disturbances. Furthermore, alveolar histology and stereomorphology are better preserved.

Primary chest wall tumors: early and long-term results of surgical treatment.

OBJECTIVES: A retrospective study of primary chest wall tumors (PCWTs/CWTs) was conducted to review their clinical, radiological and pathological features, as well as the early and long-term results of surgical management. MATERIALS AND METHODS: From 1986 through 1996, 41 patients (18/44% male, 23/56% female, aged 15-78 years) with PCWTs were treated in our department. RESULTS: Twenty-three patients (nine male, 14 female, mean age 36 years) had a benign CWT: enchondroma, five patients; fibrous dysplasia, four patients; neurilemmoma, three patients; osteochondroma, two patients; granular cell tumor, two patients; fibroma, two patients; lipoma, two patients; fibrolipoma, one patient; eosinophilic granuloma, one patient; aneurysmal bone cyst, one patient. Eighteen patients (nine male, nine female, mean age 59 years) had a malignant CWT: plasmacytoma, five patients; chondrosarcoma, two patients; osteosarcoma, two patients; fibrosarcoma, two patients; desmoid tumor, two patients; leiomyosarcoma, one patient; malignant fibrous histiocytoma, one patient; tendon sheath sarcoma, one patient; hemangiosarcoma, one patient; neurinosarcoma, one patient. The ribs were involved in 21 patients, the sternum in five patients, and the soft tissue in 17 patients. Distinction between benign and malignant CWT was not possible using radiographic criteria alone, and diagnosis was always confirmed histologically. Surgical treatment consisted of wide resection in 29 patients (15 benign/14 malignant CWTs), with the use of synthetic mesh in five cases, and excisional or incisional biopsy in 12 patients. There was no perioperative mortality. Two patients with a benign CWT (fibroma, one patient; neurilemmoma, one patient) had a local recurrence at 13 and 26 months after resection, respectively, and underwent wide resection (recurrence rate 8.7%). Follow-up at 3-13 years revealed one non-tumor-related death in patients with benign CWT (overall mortality rate 4.3%) and no other local recurrence. The overall 5- and 10-year survival in patients with malignant CWT was 33.3%. CONCLUSIONS: We believe that all CWTs should be considered malignant until proven otherwise. Wide resection with tumor-free margins is required in order to provide the best chance for cure in both benign and malignant lesions.

Treatment of thoracic outlet syndrome: long-term results.

Thoracic outlet syndrome (TOS) refers to a complex of symptoms in the upper extremity caused by compression of the neural and vascular structures at some point between the interscalene triangle and the inferior border of the axilla. A review of our experience in treating this controversial syndrome is presented. Between 1989 and 1997 a series of 23 patients (5 men, 18 women) were operated on for TOS. The average age of the patients was 26.4 years (range 17-60 years). All patients complained of pain typically in the shoulder and proximal upper extremity with radiation to the neck, and most had paresthesias and numbness in the forearm and hand. Their symptoms had been present for 8 months to 9 years (mean 2.6 years). All were evaluated by history, physical examination, radiographs of the chest and cervical spine, electromyography, and nerve conduction studies; computed tomography, magnetic resonance imaging, angiography, and myelography were conducted selectively. When TOS was suspected, a cooperative concept was utilized employing the aid of the neurologist, orthopedist, and occasionally a cardiologist. The initial treatment was physical therapy for a minimum of 6 weeks. If no relief occurred they underwent surgery. In all patients in the present series the first rib was removed through a transaxillary approach. A cervical rib was also removed in four cases. Postoperatively, they were evaluated by questionnaire and reexamination. Nineteen (82.6%) had complete relief, and four had partial relief of symptoms. Complications included pneumothorax and temporary brachial paralysis in one case each. We concluded that careful selection of patients for surgery can yield satisfactory results, and a coordinated team of thoracic surgeons, neurologists, and physical therapists is important for management of these patients.

Surgical management of idiopathic subglottic tracheal stenosis.

A case of idiopathic subglottic tracheal stenosis in a 50-year-old female is presented. A procedure of single-stage resection of the lesion and end-to-end anastomosis was performed with excellent results 1 year after the operation. The clinical, paraclinical, diagnostic, therapeutic and histopathological aspects of this rare pathologic condition are discussed and the literature on this topic is reviewed.

Management of foreign bodies in the tracheobronchial tree in adults: a 10-year experience.

OBJECTIVE: To report our experience of foreign bodies in the tracheobronchial tree in adults. DESIGN: Retrospective study. SETTING: Teaching hospital, Athens. SUBJECTS: 25 patients referred to the department of thoracic surgery for treatment. INTERVENTIONS: Bronchoscopic extraction in 16, thoracotomy with bronchotomy in 5, and resection in 4. RESULTS: No major complications and no deaths. CONCLUSION: Bronchoscopic extraction is usually possible, but thoracotomy and bronchotomy or resection may be necessary.

Bronchopleural fistula after pneumonectomy: a major challenge.

OBJECTIVE: Bronchopleural fistula (BPF) is a life-threatening complication of pneumonectomy. Its treatment still challenges the thoracic surgeon. We present our 10-year experience in the management of this entity. MATERIAL: From 1986 to 1997, 8 patients with BPF, representing 2.5% of the 315 pneumonectomies performed in the same period, were treated in our Department. All were male, aged 52-74 (mean: 62.5) years. Pneumonectomy (right: 5, left: 3) was undertaken due to lung cancer. BPF occurred within one month postoperatively. RESULTS: No difference in BPF incidence was observed comparing hand suturing and stapling of the bronchial stump. BPF was associated with empyema thoracis (ET) in 5 patients. Methods of management included prolonged chest tube drainage (n = 5), open thoracostomy (n = 3), bronchoscopical injection of fibrin sealant (n = 2), BPF closure through the previous thoracotomy with autologous tissue buttress (n = 2), transternal transpericardial closure of the BPF (n = 1). Two patients died (mortality 25%): one patient treated with chest tube drainage due to myocardial infarction, and the other undergone transternal BPF closure due to sepsis. In the rest 6 patients closure of the BPF was achieved. CONCLUSION: BPF after pneumonectomy continues to be a problem without definite solution at present. Prevention has not been achieved with the use of staples for bronchial stump closure. Small leaks may be scaled endoscopically with fibrin glue. Otherwise, early surgical closure is mandatory, especially when empyema thoracis coexists.

Blunt diaphragmatic rupture.

OBJECTIVE: To identify (1) predictors of outcome in blunt diaphragmatic rupture (BDR), and (2) factors contributing to diagnostic delay. METHODS: We reviewed the charts and radiographs of 41 patients with BDR treated in our Hospital from 1988 to 1997. There were 35 male (85%) and six female, aged 17-71 (mean: 41) years. BDR was left-sided in 24 cases (58%), right-sided in 15 (36%) and bilateral in two (5%). RESULTS: Two groups of patients can be identified: group A (n = 36, 88%) with acute BDR, and group B (n = 5, 12%) with post-traumatic diaphragmatic hernia (TDH). In group A, immediate diagnosis was made in 35 cases (97%), but only in 26 (72%) preoperatively. In one case, a right BDR was missed on initial evaluation but became apparent 2 weeks later. Associated injuries were present in 34 patients (94%) involving: spleen (n = 18), rib fractures (n = 17), liver (n = 14), lung (n = 11), bowel (n = 7), kidney (n = 5) and other fractures (n = 21). Injury Severity Score (ISS) ranged from 9 to 66 (mean: 31). BDR repair was accomplished through a laparotomy in 22 cases, thoracotomy in 10 and laparo-thoracotomy in four. The overall mortality rate was 16.6% (6/36). Both patients with bilateral BDR died. The patients who died were older than the survivors (mean age: 54 vs. 39 years, P<0.05), were more severely injured (mean ISS: 46 vs. 28, P<0.05) and were in shock (100 vs. 23%, P<0.05). In group B with TDH, diagnosis was delayed for 7-16 months after injury. Four patients had non-specific clinical signs and one strangulation of hollow viscera. One patient had undergone surgery during acute injury but BDR was overlooked. Location of TDH was on the left in three cases and on the right in two. Delay in BDR diagnosis was 12.5% (3/24) in patients with left-sided and 20% (3/15) in patients with right-sided lesions (P>0.1). Repair of TDH was achieved through thoracotomy in all cases. No mortality or major morbidity were encountered. CONCLUSIONS: (1) Predictors of BDR mortality are: age, ISS and hemodynamic status of the patient. (2) Delay in diagnosis does not influence the outcome and is not influenced by the side of BDR location. (3) BDR can easily be missed in the absence of other indications for prompt surgery, where a thorough examination of both hemidiaphragms is mandatory. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis.

Surgical treatment of echinococcosis by a transthoracic approach: a review of 85 cases.

OBJECTIVE: Human echinococcosis remains a serious health problem for the Mediterranean countries, among them Greece. As there is no effective medical therapy, surgery is still the treatment of choice. MATERIAL AND METHODS: We present our experience in the surgical management of hydatidosis by a transthoracic approach, based on 85 patients (49 male, 36 female, aged 4-86 years) treated during 1986-1996. RESULTS: Twenty-one patients (26.3%) appeared with complications as: hydatidemesis (n = 5), hydropneumothorax (n = 3), cyst infection (n = 3), empyema thoracis (n = 8), cholebronchial (n = 3) and cholebronchopleural fistula (n = 1). The location of the cysts was: 61 in the lungs (right, 29; left, 24; bilateral, eight), 31 on the liver dome, six in the pleural cavity, two in the mediastinum, and one in each of pericardium, chest wall, and right pararenal space. Surgical approach involved a thoracotomy or median sternotomy in all cases. Pulmonary endocystectomy and capitonnage was the procedure of choice in the surgical management. Hepatic cysts were approached through a right thoracophrenotomy and were managed with evacuation of the main and daughter cysts, suture of the diaphragm to the margins of the cyst, and drainage of the cystic and pleural cavities. There was no in-hospital mortality. Major postoperative complications were: empyema thoracis (n = 3), biliary fistula (n = 2), and bronchopleural fistula (n = 1). Five patients presented later with seven recurrences of the disease. CONCLUSION: Transthoracic approach is a good and safe choice in surgical treatment of both the intrathoracic and the (concomitant or not) hydatid cysts on the upper surface of the liver.

Surgical treatment of spontaneous pneumothorax: ten-year experience.

Spontaneous pneumothorax (SP) is commonly observed in young, tall, thin subjects without apparent underlying lung disease and in the elderly with chronic emphysematous lung disease. We present our experience in treating SP during the last decade. From December 1986 to November 1996 a total of 417 consecutive patients with SP were admitted to our department. There were 349 males (83.7%) and 68 females, ranging in age from 14 to 93 years. A right-side SP was detected in 234 cases (56.1%), a left-side SP in 175 (42.0%), and a bilateral SP IN 8 (1.9%). Treatment included observation/aspiration (n = 16, 3.8%), tube thoracostomy (n = 372, 89.2%), multiple tubes (n = 29, 7.0%) blood pleurodesis (n = 13, 3.1%), midsternotomy (n = 3, 0.7%), and minithoracotomy (n = 92, 22.1%). Primary indications for operation were recurrent SP (n = 49) and persistent air leak (n = 46). Blebs or bullae were found in all patients and were ablated by stapling. Pleural abrasion was also performed. All showed good lung expansion postoperatively. Perioperative mortality was zero. The mean hospital stay was 6.5 days. Follow-up of 89 patients who had undergone surgical treatment (93.75) at 1 to 100 months revealed only one recurrence. Tube thoracostomy is still in cases of recurrent SP or persistent air leak. Minithoracotomy is a safe surgical approach with satisfactory cosmetic results.

Radiographic determination of total lung capacity in patients with pneumonectomy.

To determine whether total lung capacity (TLC) can be measured from plain chest radiographs in patients with pneumonectomy, we examined 20 such patients (17 male, 3 female) who had pneumonectomy for lung carcinoma. In 16 patients the right lung was preserved, and in 4 the left. The TLC was measured with the helium dilution method and by planimetry of the anterior and lateral projections of the lung on chest radiographs, summing the anterior and lateral projected areas of the lung to a single value, S. The correlation between S and TLC by helium gas dilution was r = 0.95. Linear fit of TLC to S explained 99.5% of the variance in TLC, with the equation. The side resected did not influence the predictive value (p < 0.001). The interquartile range of the residual error was +/-130 ml, and standard error was 64 ml. Therefore in patients with pneumonectomy, TLC of the preserved lung may be estimated within +/-130 ml by planimetry of the anterior and lateral chest radiographs.