Post-traumatic pleural effusion: Don't forget the chylothorax!

In this case we describe a 58-year-old male with bilateral pleural effusion after a blunt trauma to the back. A pleural puncture revealed a chylothorax. An additional computed tomography scan showed a vertebral fracture at level D8 with rupture of the nearby thoracic duct. Our patient could be treated with a conservative approach. This case highlights the importance of ruling out a chylothorax in any post-traumatic pleural effusion. Despite the low prevalence, we consider it a don't-miss diagnosis given the specific treatment requirements.

Diagnostic value and safety of thoracoscopic pleural biopsies in pleural exudative effusions of unknown origin, including follow-up.

INTRODUCTION: Pleural exudative effusions without diagnosis after initial work up are a frequent problem in any respiratory division. Several ways to obtain pleural biopsy exist. Thoracoscopy is one of the most frequently used. Differential diagnosis mainly exists out of malignant pleuritis, tuberculosis, nonspecific pleuritis and rarely systemic or autoimmune disease. We performed a retrospective data analysis of our almost 10-year period experience, the first Belgian data to be published. METHODS: We performed a retrospective data analysis of all patients with unexplained pleural exudates who underwent diagnostic medical thoracoscopy under general anaesthesia in our respiratory department during the period 2006-2015. We report on diagnoses made, sensitivity and specificity, safety of thoracoscopy and follow-up of patients after thoracoscopy. RESULTS: 131 patients underwent diagnostic medical thoracoscopy during the inclusion period. 44.3% (n=58) of the patients were diagnosed with malignant pleuritis, 45.0% (n=59) with nonspecific pleuritis, 7.6% (n=10) with tuberculous pleuritis and some with other benign conditions. Complications are comparable to other data published. Six months follow-up of patients with non-specific pleuritis reveal 8.5% (n=5) of these patients to have malignant pleuritis, and another 8.5% (n=5) with infectious or other benign conditions. CONCLUSION: Medical thoracoscopy under general anaesthesia for diagnostic work up of pleural exudates of unknown origin generally has a high diagnostic yield. It is generally safe, certainly compared with the information it delivers. During follow-up, minority of patients with nonspecific pleuritis will prove to be malignant in origin, benign or autoimmune disease related.

Effectiveness of thoracoscopic talc pleurodesis in the management of complicated spontaneous pneumothorax.

BACKGROUND: Complicated (recurring or persistent) spontaneous pneumothorax requires intervention either by surgical or nonsurgical pleurodesis or other interventions. As for high-risk patients, aggressive interventions may be associated with morbidity, the safety and effectiveness of less aggressive alternative interventions like thoracoscopic talc pleurodesis (TTP) should be evaluated. METHODS: Data were extracted on patients who had undergone TTP for complicated spontaneous pneumothorax at Interventional Clinic, University Hospital, Brussels, Belgium. The complications, length of hospital stay, and success rate over a 24-month period were studied. RESULTS: A total of 41 TTP procedures were performed for 25 (61%) cases of primary spontaneous pneumothorax and for 16 (39%) cases of secondary spontaneous pneumothorax. Twenty-four cases were first episodes, whereas it was a recurrence in 17. Of 4 patients with blebs/bullae, 2 had recurrence after TTP.No patient had acute respiratory distress syndrome or any other serious complication after TTP. Recurrence rates after TTP in primary and secondary spontaneous pneumothorax were 9.5% and 25% at 24 months, respectively. The mean length of hospital stay after TTP was 3±3.2 days. CONCLUSIONS: TTP is a safe and effective intervention in complicated spontaneous pneumothorax.

Quality of life and patient satisfaction after video-assisted thoracic sympathicolysis for essential hyperhidrosis: a follow-up of 138 patients.

OBJECTIVES: Essential hyperhidrosis (EH) is defined as excessive functioning of the sudomotor sweat system. Definitive treatment of choice is video-assisted thoracoscopic sympathetic interruption. Success rates are high, but compensatory hyperhidrosis (CH) remains a troublesome side effect. The aim of this study was to document patient satisfaction and side effects at least 6 months after thoracoscopic sympathicolysis. METHODS: Between 2001 and 2005, 246 patients underwent bilateral ablation of the sympathetic chain at the thoracic level T2, T3, and/or T4. Questionnaires using open questions and scoring systems were sent at least 6 months after procedure and were returned by 138 patients (56%). RESULTS: From the 138 patients (56 males/82 females), 39 suffered from cranial (±facial blushing), 34 from palmar, and 34 from axillary hyperhidrosis. Thirty-one patients were treated for a combination. No conversion to open surgery or deaths occurred. For the whole group, average quality of life was 4.5±2.5 before and 8.4±1.8 after surgery (P<.001). Ninety-one percent were very satisfied (score ≥7) and 80% showed an increased quality of life of ≥2. Compensatory sweating occurred in 76% of the patients, only 6% reported this as disabling. Comparing subgroups, a significant improvement in primary complaint score was found in 90%, 94%, and 91% for the T2, T3, and T4 patients, respectively. In the T4 group, the prevalence of CH was markedly lower (53%) and none of these patients were dissatisfied. CONCLUSION: Thoracoscopic ablation of the sympathetic chain is an effective treatment for EH; CH occurs in the majority of patients, but only rarely impairs postoperative quality of life.

Detecting upper airway obstruction in patients with tracheal stenosis.

We propose a forced oscillation test modality for detecting upper airway obstruction (UAO) as an alternative to spirometric UAO indices in patients with tracheal stenosis. From oscillometry performed at different breathing flow rates, airway resistance at 5 Hz was determined at 0.5 l/s (R), and flow dependence of resistance was computed as the regression slope of resistance vs. flow up to 1 l/s (Delta R/Delta V). It was first verified by measurement in 10 normal subjects and 10 patients with chronic obstructive pulmonary disease that Delta R/Delta V was unaffected by the presence of peripheral airway obstruction and that external orifices (with lumen area down to 28 mm(2)) induced marked increases in R and Delta R/Delta V. Ten patients eligible for tracheal dilatation underwent spirometry and impulse oscillometry before and after intervention. Considering the lumen area of tracheal stenosis in the patients (42 +/- 28 mm(2), represented as the mean +/- SD), the R and Delta R/Delta V increases were of similar magnitude to those predicted by the external orifices. In addition, R (r = -0.68; P = 0.001) and Delta R/Delta V (r = -0.65; P = 0.001) showed better correlations with minimal tracheal lumen than any spirometric UAO index. Delta R/Delta V, but not R, showed a consistent return to normal after intervention in the stenosis patients. We conclude that the forced oscillation test at different breathing flow rates up to 1 l/s provides a measure of UAO, namely flow dependence of resistance Delta R/Delta V, which can signal a critical level of tracheal stenosis and is not confounded by the presence of concomitant peripheral airway obstruction.

Performance of fully covered self-expanding metallic stents in benign airway strictures.

BACKGROUND: Airway stenting has become a common technique in inoperable benign strictures. An ideal stent does not yet exist for these conditions. Recently, fully covered self-expandable metallic stents (SEMS) have been commercialized with potential use in benign airway strictures. OBJECTIVE: We retrospectively reviewed the clinical effectiveness of fully covered SEMS in the management of benign strictures. METHODS: A total of 17 patients received 20 stents: 7 Silmet, 8 Taewoong and 5 Alveolus stents. Ten stents were deployed in a structural postintubation tracheal stenosis. Other indications were multinodular goiter, anastomotic stricture, endobronchial posttuberculosis scar, damaged cartilage and relapsing polychondritis. RESULTS: In our series, the short-term (<12 weeks after stent deployment) complication rate was 75%, requiring stent removal in 60%. Overall, stent migration was observed in 65%, stent fracture in 15%, shriveling of the stent in 10% and granulation formation in 10%. CONCLUSION: The use of fully covered SEMS for the treatment of benign airway strictures is associated with a high short-term complication rate requiring stent removal. We have abandoned in our clinical practice the use of fully covered SEMS for benign airway strictures.

Pneumothorax.

Pneumothorax represents a common clinical problem. An overview of relevant and updated information on epidemiology, pathophysiology, and management of spontaneous (primary and secondary), catamenial, and traumatic (iatrogenic and noniatrogenic) pneumothorax is given.