Thoracoplasty-Current View on Indication and Technique.

Thoracoplasty was invented for removing cavities between thoracic wall and remnant lung or mediastinum. It was initially used in cases of tuberculosis or unspecific infections, while currently it is used mainly for space problems after lobectomy/pneumonectomy.This article presents an overview of the historical and current techniques of this surgical procedure.Nowadays, thoracoplasty is rarely performed due to the low incidence of diseases for which this method is necessary. Therefore, this method has even been discredited. Furthermore, certain technical aspects of the thoracoplasty are not very well known because of the infrequent application of this procedure.Unfortunately, a look into the literature of thoracoplasty is not always usefull due to the biased views of advocates of different techniques such as Schede's thoracoplasty, Heller's Jalousie-Plastik, Alexander's extramusculoperiosteal thoracoplasty, Bjork's osteoplastic thoracoplasty, etc.Not to forget, there has always been a lack of research on the relevance and on the several techniques of thoracoplasty.The point is precise indication and correct execution of thoracoplasty as a final therapeutic option, which allows a safe and definitive solution of the space problem even in complex cases, without creating serious functional and cosmetic impairment for the patient.The main types of thoracoplasty are described in this article. Although the core principle of this operation remains unchanged, modern techniques are often cosmetically more considerable and less destructive, compared with techniques that were used in the past.

Efficacy and safety of topical application of human fibrinogen/thrombin-coated collagen patch (TachoComb) for treatment of air leakage after standard lobectomy.

OBJECTIVES: Persisting air leakage after pulmonary resection remains a significant problem. The aim of the study was to evaluate the incidence of air leakage after standard lobectomy and test the efficacy and safety of TachoComb (TC). METHODS: A total of 189 patients undergoing lobectomy were enrolled in a multi-centre, open, randomised, and prospective study to test the efficacy and safety of TachoComb (TC) for air leakage treatment. Air leakage was assessed by water submersion test, and scored as grades 0 if no, 1 if countable, 2 if a stream of and 3 if coalescent bubbles have been observed. Any sites with grade 3 air leakage received further stapling or limited suturing until grade 0, 1 or 2 was obtained. Treatment of air leakage was done with TC or suturing according to randomisation. Air leakage was assessed by further submersion tests. Postoperative air leakage was assessed using the Pleur-Evac system. RESULTS: Overall incidence of air leakage 48+/-6 h after surgery was 34% for TC and 37% for standard treatment (P=0.76). The reduction of intra-operative air leak intensity in the subgroup with grades 1-2 was significantly higher for the TC group (P=0.015). Postoperative air leakage intensity in the subgroup with air leakage grades 1-2 was lower for TC than standard treatment (P=0.047). The mean duration of postoperative air leakage in the subgroup with grades 1-2 was shorter for the TC group than for standard treatment, i.e. 1.9+/-1.4 vs. 2.7+/-2.2 days (P=0.015). CONCLUSIONS: TC could be proven as well-tolerated and safe. In the subgroup of patients with established air leakage, TC showed superior potential in reduction of intra-operative air leakage as well as in reduction of intensity and duration of postoperative air leakage.

Tracheobronchial injuries. Conservative treatment.

UNLABELLED: Tracheal lacerations are iatrogenic, localized, low impact injuries with longitudinal tears (in about 1:20,000 intubations). In contrast traumatic tracheobronchial ruptures are high velocity injuries with horizontal transections. Between 1986 and 2002, we treated 27 tracheobronchial injuries (8 bronchial 3 of them iatrogenic, 19 tracheal 17 of them iatrogenic (+1 horizontal rupture+1 tracheoesophageal stabbing)). Extension of the tears 5-12 cm. All bronchial ruptures, the tracheal rupture as well as six iatrogenic tracheal tears have been managed operatively. All the other underwent conservative treatment. INDICATIONS: (1) critically ill patients, (2) delay in diagnosis >72 h, and (3) refusal of operation. It consists in endotracheal intubation for 5-9 days. This way we prevent pressure peaks as well as retention achieving a continuous control. Conservative group: 12/13 patients survived, neither stenosis nor megatrachea. Operative group: 1 patient died (MOF), 1 postoperative stenosis (Montgomery tube for 2 months). Tracheobronchial ruptures have to be operated. Lacerations show frequently discrete clinical signs, but typical X-rays. They can be dealt with conservatively in the majority of cases as well as operatively. According to our experience, conservative treatment is safe and shows a mortality as low or lower than operative procedures.