["Disappearance" of retroperitoneal vessels - a case report]. / Die "verschwundenen" Retroperitonealen Gefässe: ein Fallbericht.

We report the ultrasound findings in a case of pneumo-retroperitoneum. The 74-year-old patient was admitted because of severe dyspnoea. Chest X-ray revealed a left-sided pleural effusion, and a drainage was performed. Later on the patient for the first time complained about severe pain in the lower abdomen. Ultrasound of the abdomen was performed. Sonographically, it was remarkably difficult to obtain images of the right kidney and the retroperitoneal vessels, as massive reverberation artifacts in the retroperitoneum were present. Plain radiography of the abdomen revealed free retroperitoneal and intraabdominal gas. At laparotomy a perforated diverticulitis of the sigma was discovered. Postoperative follow-up was uneventful, but the recurrent pleural effusion was later confirmed to be due to a malignant mesothelioma. This article discusses the characteristic sonomorphologic features of pneumo-retroperitoneum and its differential diagnosis. Although free retroperitoneal air is a rare condition, it is crucial for the examiner to be aware of the characteristic sonographic findings in order to initiate appropriate therapy.

Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch.

BACKGROUND: The efficacy of bronchial telescope anastomosis was evaluated retrospectively in patients undergoing sleeve resections with high-caliber mismatch. METHODS: The hospital charts of patients undergoing upper and lower sleeve bilobectomy and lower lobe lobectomy with replantation of the middle lobe or upper lobe into the mainstem bronchus were retrospectively reviewed. Age, sex, side, TNM stage, preoperative forced expiratory volume in 1 second (FEV1 [%]), preoperative risk factors, postoperative course, survival (months), and causes of death were recorded. RESULTS: Fifteen patients suffering from bronchial carcinoma were operated on. In 6 cases FEV1 was less than 2 L (FEV1 49% to 80%, mean 64.3, median 61). Three patients were 70 years and older. There were 7 high-risk cases presenting with coronary heart disease (n = 3), chronic alcoholism (n = 3), cerebrovascular disease (n = 1), and active tuberculosis (n = 1). Local radicality was achieved in all patients but 1, in whom pneumonectomy was contraindicated. There was no postoperative mortality. Early complications consisted of 1 anastomotic dehiscence successfully closed with an intercostal flap and 1 patient with bilateral pneumonia requiring mechanical ventilation for 5 days. One parenchymal fistula led to prolonged drainage; in 1 patient pneumothorax after removal of the chest tube required redrainage. There were no late complications, and no anastomotic stenosis developed. Survival ranged from 12 to 56 months (median 29.8, mean 30, SD 15.7). Seven patients died between 3.9 and 14 months postoperatively (mean 8.5, median 6.9) of intrabronchial local recurrence (n = 1), distant recurrence (n = 3), intrathoracic recurrence (n = 1), and nontumor-related causes (n = 2). CONCLUSIONS: Telescope anastomosis is a safe and efficient technique of bronchial sleeve resection.

Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases.

OBJECTIVES: We sought to analyze the experience with bronchoplastic procedures over a 7-year period and to determine putative prognostic factors for survival. METHODS: From 1991 to 1997, 144 bronchoplastic procedures were performed for non-small cell lung cancer (n = 123), small cell lung cancer (n = 5), carcinoid tumor (n = 10), and metastases of extrathoracic malignant tumors (n = 6). There were 111 sleeve lobectomies, 17 bilobectomies, 4 lobectomies with carinal resection, 8 sleeve pneumonectomies, and 4 bronchotomies without parenchymal resection. Multivariable analysis included risk factors, such as age, sex, type of bronchoplastic procedure (bronchotomy, lobectomy, bilobectomy, or pneumonectomy), additional angioplasty, TNM staging, histology, radicality of resection, respiratory risk (forced expiratory volume in 1 second, percent predicted < 60), cardiovascular risk, and adjuvant therapy. RESULTS: Overall 1- and 3-year survival was 72% and 52%, respectively. The overall 30-day mortality was 8.3% (5.4% for single sleeve lobectomies). Multivariable analysis demonstrated 4 risk factors for survival. High tumor stage, type of bronchoplastic procedure, impaired lung function, and presence of cardiovascular risk were associated with a poor outcome. Univariate analysis showed reduced survival in patients with sleeve pneumonectomies (1-year survival, 25%). CONCLUSIONS: Bronchoplastic procedures for central tumors and sleeve pneumonectomies are associated with poor survival. Careful selection of these patients, as well as of patients with impaired lung function and cardiovascular risk factors, is mandatory.

Videothoracoscopic debridement of the postpneumonectomy space in empyema.

OBJECTIVE: Simple irrigation has proven to be an efficient method to treat postpneumonectomy empyema provided that bronchopleural fistula is not present or successfully closed. However, with this treatment modality, infected material inside the thoracic cavity is not removed and this can be a potential source of empyema recurrence if the patient's immune system is compromised. The removal of the infected material should result in a lower recurrence rate. METHODS: As soon as diagnosis of postpneumonectomy empyema was established, a chest tube drainage was inserted. A concomitant bronchopleural fistula was evaluated bronchoscopically. If the fistula was smaller than 3 mm, bronchoscopic sealing with fibrin glue (Tissucol, Immuno, Vienna) was initiated. Fistulas closed surgically were excluded from this analysis. The thoracic cavity was cleared of infected material by videothoracoscopy and bacteriological samples were taken. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection; WBC and CRP were controlled. RESULTS: Nine patients (five men, four women) between 55 and 72 years (mean 61, SD 6), all initially operated on for malignancy, were successfully treated with this regimen. In three cases a concomitant bronchopleural fistula was successfully closed before videothoracoscopy. The interval between primary operation and empyema was between 7 and 436 days (mean 93, SD 141). There was no postoperative mortality and no procedure related morbidity. Operating time ranged from 45 to 165 min (mean 92.7, SD 36.6), the suction volume (consisting of blood, debris and pus) was 300 to 1000 ml (mean 880, SD 600). Duration of thoracic drainage was 12-38 days (mean 22, SD 9), duration of hospital stay after videothoracoscopy 21-46 days (mean 29, SD 9). During the follow-up period of 204-1163 days (mean 645, SD 407) no recurrence of tumour or empyema was observed. CONCLUSIONS: Videothoracoscopic debridement of the postpneumonectomy space with postoperative antibiotic irrigation of the pleural space is an efficient method to treat postpneumonectomy empyema, provided that a concomitant bronchopleural fistula can be closed successfully. No early empyema or fistula recurrence were observed. However, late recurrence may occur many years after operation, therefore close follow-up is indicated.

Glove perforation rate in open lung surgery.

OBJECTIVE: In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS: Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS: One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS: The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.

BACKGROUND: The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. METHODS: The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. RESULTS: Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment. CONCLUSIONS: Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.