A New Approach to Tense End-to-End Anostomosis in Primary Surgical Repair of Esophageal Atresia: Vascularized Pleural Flap.

Background: Esophageal atresia (EA) is the most common congenital malformation of the esophagus. If the distance between the proximal and distal pouches is usually more than 2-3 cm, it is considered as long gap esophageal atresia (LGEA). In our study, it was planned to investigate the effect of the use of vascularized pleural flap (VPF) on postoperative recovery in cases with tense end-to-end anastomosis in the primary repair of LGEA. Methods: The postoperative recovery period data of patients who underwent tense end-to-end anastomosis due to LGEA between 01/01/2016 and 01/12/2020 in our clinic were analyzed retrospectively. Results: Between the specified dates, 37 patients were operated for EA. A tense end-to-end anastomosis was performed in 16 of 37 patients. In 5 of these patients, a VPF was placed on the anastomosis line. In the postoperative follow-up, no anastomotic leakage or anastomotic stenosis was observed in 5 patients who underwent tense anastomosis with VPF. In addition, it was observed that patients who underwent tense anastomosis with VPF were started oral nutrition earlier after surgery compared to patients without VPF. Conclusion: The success of the technique we performed in 5 patients without any complications suggested that this technique could be used as a method in tense anastomoses. It was thought that oral nutrition was initiated early in patients using VPF, since there was no anastomotic leak and the surgeon relied on the presence of the VPF.

Angiectasia of the parietal pleura in a hemodialysis patient with central venous stenosis and bloody pleural effusion: a case report.

Pleural effusion in hospitalized patients with long-term hemodialysis (HD) has been frequently reported. The most common causes of unilateral pleural effusions include hypervolemia, parapneumonic, uremic effusion, and malignancy. In contrast, central venous stenosis (CVS) has rarely been shown to result in pleural effusion. CVS is often diagnosed by percutaneous angiography, yet there are no reports of cases where percutaneous angiography missed CVS and instead intrathoracic endoscopy was performed. Herein, we report a case of CVS with angiectasia of the parietal pleura detected on intrathoracic endoscopy. A 62-year-old man with HD presented with massive unilateral pleural effusion. Although the cause of pleural effusion was suspected to be CVS, percutaneous angiography did not show apparent stenosis, and as a result, other potential causes of bloody effusion were investigated. The intrapleural cavity was assessed using intrathoracic endoscopy, which revealed angiectasia and no malignancy. As these findings might be suggestive of congestive and dilated vessels with venous stenosis or occlusion, 3D-computed tomography (CT) scans were performed instead of percutaneous angiography to determine whether a stenosis or occlusion was present. Brachiocephalic vein stenosis was found near the aortic arch. CVS was treated through ligation of the arteriovenous fistula (AVF), resulting in a dramatic decrease in the left pleural effusion. This case would suggest that CVS should be suspected when angiectasia of the parietal pleura is observed in HD patients. In addition, the benefit of utilizing 3D-CT should be considered when HD patients present with a unilateral hemothorax on the same side as that of the AVF, particularly when on the left side.

[Analysis of endothelial dysfunction in the context of pleural effusions of various origins using skin thermometry]. / Issledovanie endotelial'noi disfunktsii pri plevral'nykh vypotakh razlichnoi etiologii metodom teplovoi kozhnoi termometrii.

OBJECTIVE: To analyze the mechanisms and severity of endothelial dysfunction in patients with pleural effusion of various origins using skin thermometry. MATERIAL AND METHODS: We studied microcirculation in 135 patients with pleural effusions of various origins. Local skin thermometry and computer wavelet analysis were performed in 3-5 days after thoracoscopy with pleural biopsy using Microtest-100WF device with a temperature measuring resolution of 0.001°C. We estimated endothelial, myogenic and neurogenic indices using spectral analysis of skin temperature fluctuations in a range 0.0095-2 Hz. The control group comprised 40 healthy participants aged 23-36 years. RESULTS: Three groups of patients were distinguished depending on the cause of effusion: malignant pleural effusions (n=65, 48.1%); inflammatory pleural effusions (para-pneumonic, post-traumatic, pancreatogenic, tuberculous) (n=58, 43%); transudates (hepatogenic, cardiogenic, and nephrogenic) (n=12, 8.9%). There were no significant differences in vascular tone in response to local heating of the second finger of the hand up to 40°C. Measurements were carried out within 10 min in all groups. Patients with diabetes mellitus and cardiovascular diseases (n=48, 35.6%) had significant decrease of thermal vasodilation index in endothelial range up to 2.93±1.77, in the control group - up to 4.21±2.40 (p=0.041). CONCLUSION: Endothelial dysfunction is a universal non-specific aspect in pathogenesis of various diseases. This process is essential in pleural effusion. Local thermometry and computer wavelet analysis revealed no significant differences between patients with malignant, inflammatory and transudative pleural effusions. Pleural effusions in the context of cardiovascular pathology and/or diabetes mellitus occur due to impaired vasodilatation mechanisms in endothelial range.

Computed tomography angiography for presence of systemic-to-pulmonary artery shunt in transpleural systemic arterial supply.

PURPOSE: To investigate radiographic indications and relevant clinical symptoms of retrograde systemic-to-pulmonary artery shunt (RSPAS). METHODS: Forty-six consecutive patients, with transpleural systemic arterial supply to the lung confirmed by surgery or conventional angiography, underwent chest computed tomography angiography (CTA). Patients with the finding of RSPAS in CT scans were compared with those among whom no retrograde systemic-to-pulmonary artery shunt (NRSPAS) was present. Differences in clinical features, distribution and diameters of systemic supplying arteries between RSPAS and NRSPAS were assessed. RESULTS: RSPAS in twenty patients (8 left and 12 right) and NRSPAS in 26 patients (14 left and 12 right) were detected at CTA. Hemoptysis and sputum were more frequent in RSPAS (85 % and 60 %, respectively) than in NRSPAS (46 % and 31 %, respectively) (P < 0.05). Single systemic supplying artery was more common in NRSPAS (65 %) while multiple systemic arteries were more frequent in RSPAS (65 %) (P < 0.05). The mean diameter of systemic arteries (6.13 ±â€¯0.57 mm) in RSPAS was significantly larger than that (4.26 ±â€¯0.55 mm) in NRSPAS (P < 0.0001). The anatomic location of systemic arteries crossing the thickened pleura distributed more intensively in apical and costal pleura in RSPAS than that in NRSPAS (P < 0.05). The distribution of systemic arteries adjacent to left or right lung was not statistically significant between RSPAS and NRSPAS. CONCLUSION: Radiographic features of RSPAS are different from NRSPAS. RSPAS may include enlarged and multiple systemic supplying arteries. And that may suggest greater risk of hemoptysis.

Spontaneous bilateral haemothorax as presentation of primary pleural epithelioid haemangioendothelioma.

Pleural epithelioid haemangioendothelioma (EHE) is a rare tumour that originates in the vascular endothelium with an intermediate degree of malignancy between haemangioma and angiosarcoma. Smoking and asbestos exposure are unproven risk factors and diagnosis is usually confirmed by thoracoscopy, since pleural fluid (PF) cytology is often not conclusive. Immunohistochemistry can also help to confirm the diagnosis. We report an 85-year-old patient with bilateral pleural EHE diagnosed by thoracoscopy, who debuted with a spontaneous bilateral haemothorax, the second described so far, and we conducted a thorough review of the literature to describe the clinical, radiological and prognostic features, as well as the PF, of this rare tumour.

Vascular-penetration defect detected in parietal pleura of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax (PSP) is one of the most frequent diseases that thoracic surgeons handle, but the aetiology is not really known. We prospectively examined intraoperative images and collected the data of PSP patients who received bullectomy and mechanical pleurodesis with the thoracoscope at the Department of Thoracic Surgery at our hospital. Vascular-penetration defects (VPDs) were 2-6 mm vessel-converged holes that we found on the apex of the parietal pleura of PSP patients exclusively. The VPDs were solely located in the apex of the parietal pleura on the chest wall above the first rib. As many as up to four in number could be present. The VPDs were sometimes complementary to blebs and were not found in any of the other thoracoscopic surgeries for diseases other than PSP. We postulate that the presence of VPDs may be a contributing factor to the formation of a subgroup of emphysematous-like changes and the recurrence of PSP.

[Pleural lymphatics and effusions]. / Lymphatiques pleuraux et épanchements.

The pleural lymphatic system has a great absorption capacity. Its most known function is fluid resorption. The pleura which cover the lungs (visceral pleura), the mediastinum, diaphragm and thoracic wall (parietal pleura) are formed by a mesothelial cell layer (mesothelium). This permeable layer is in direct contact with the vascular endothelium. The mesothelium is based over a connective tissue (interstitium) containing the blood and lymphatic vessels. The primary lymphatic vessels drain interstitium but are also in direct contact with pleural space by the stoma or openings, situated in the lower parts of parietal pleura, i.e: diaphragm, over lower ribs and mediastinum but not existing in the adjacent visceral pleura. In addition, a part of interstitial pulmonary fluid entered in the pleural cavity by passing the visceral pleura would be absorbed by these openings. The resorption process is active and directly related to the function of smooth muscles of lymphatic vessels. Besides resorption, we must emphasize that this "pumping" activity is permanent and the origin of negative pressure (the pleural void) in pleural cavity, a unique property. The other resorbed elements are molecules, bacterial and cellular debris, cells, red blood and cancer cells.

Detection of pleural lymph flow using indocyanine green fluorescence imaging in non-small cell lung cancer surgery: a preliminary study.

PURPOSE: Lymphatic spread of lung carcinoma to the mediastinum is a key determinant of prognosis. The lymph flow often carries metastases from the pulmonary segment directly into the mediastinal lymph nodes, without passing through the hilar nodes. This phenomenon is termed as "skip metastasis." This study investigated the subpleural lymphatic flow to the mediastinum using indocyanine green (ICG) with a near-infrared fluorescence imaging system. METHODS: Seventeen patients with lung cancer were enrolled in this study. A 0.3 ml sample of solution containing the fluorescent dye ICG (5 mg/ml) was injected into subpleural sites near the primary tumor. Fluorescence imaging was used to monitor the flow of ICG-containing lymph from the injection site for 5 min. The relationship between the anatomical segment of the primary tumor and the lymphatic flow was assessed. RESULTS: The lymphatic vessels draining from the injection site were revealed by the bright ICG fluorescence in 14 of the patients (82.4 %). A direct lymphatic flow to the mediastinum was confirmed in 3 of those 14 (21.4 %). CONCLUSIONS: These findings confirm the direct flow of lymph to the mediastinum without passage through the hilum pulmonis intraoperatively. These preliminary results may provide a valuable clue for further investigations of the mechanisms underlying skip metastasis.

[Pleuritis in yellow nail syndrome]. / Pleurabefunde beim Yellow-Nail-Syndrom.

A 76-year-old man presented clinically with coughing and shortness of breath and was diagnosed radiologically to have massive pleural effusion as a combined feature of yellow nail syndrome. A lung biopsy was taken and revealed histologically: chronic non-specific inflammation in the pleuropulmonary border, intrapleural edema with eightfold pleural thickening in comparison to normal, angiogenesis in both the nutritive and functional intrapleural blood vessels, no abnormalities of lymphatic vessels with normal topographical distribution as detected by immunohistochemistry for antibody D2-40, granulomatous chronic foreign body reaction as a consequence of pleural effusion therapy by talcum pleurodesis.The histopathological findings of chronic non-specific pleuritis with angiogenesis and increased permeability of blood vessels led to massive intrapleural edema with pleural effusion. Abnormalities of lymphatic vessels could not be confirmed. Considering the features of this disease, they are probably secondary to chronic r infectious or immunological inflammation or paraneoplastic complications with angiogenesis (in about 19%).

Suitability of the pericardiophrenic veins for phrenic nerve stimulation: an anatomic study.

OBJECTIVE: The objective of this study was to assess the potential of the pericardiophrenic veins (PPVs) as conduits for transvenous stimulation of the phrenic nerves. Modulating respiration with transvenous phrenic nerve stimulation via the PPVs might reduce or eliminate the adverse effects of central sleep apnea in heart failure. METHODS: Forty-eight fixed cadavers were dissected to study the anatomic characteristics of the PPVs and related neurovascular structures. RESULTS: The right PPV, found in only 1 of 35 cadavers, was <0.5 mm diameter. The left PPV, located in all 48 cadavers, drained into the left brachiocephalic vein (BCV) directly or into the BCV via the superior intercostal vein (SICV). Mean ± SD SICV trunk diameter was 4 ± 2 mm. Mean ± SD left PPV diameter was 2 ± 1 mm. The length between the point of separation of the left PPV from the phrenic nerve to its junction with the BCV or SICV trunk ranged from 6 to 40 mm. The angle of approach, defined as the angle formed by the intersection of the longitudinal axis of the BCV and the longitudinal axis of the PPV or SICV trunk, and which represents the angle that would need to be navigated when inserting a stimulation lead into the PPV using a peripheral cannulation approach, was 99 ± 28 degrees. Valves were identified in 54% of left PPVs. CONCLUSIONS: Because of its extremely small size, the right PPV appears unsuitable for transvenous phrenic nerve stimulation. In contrast, the left PPV may be accessible via the left BCV using standard transvenous catheterization techniques; however, the small caliber of the left PPV and the frequent presence of valves within it might pose challenges in navigating the vessel to achieve transvenous phrenic nerve stimulation.

Microscopic anatomy of the pleura.

This article describes the anatomy of the pleura, which is made up of five layers. Blood supply and lymphatics are described, as are pleural fluid, mesothelial cells, and Kampmeier foci.

Multidetector CT imaging of pleura: comparison of two contrast infusion protocols.

OBJECTIVES: Imaging of the pleura by multidetector CT (MDCT) can be challenging. There is no clear evidence or guidelines on contrast infusion parameters for imaging pleura. We compared two contrast protocols for assessing pleural pathology on MDCT. METHODS: This was a prospective study in which consecutive patients with MDCT for suspected pleural disease on chest radiograph were randomised into two groups. The first group received 150 ml of intravenous contrast at a rate of 2.5 ml s(-1) and the second group received 100 ml at 2 ml s(-1). Images were acquired after a 60 s delay. Hounsfield units of the pleura, thoracic aorta, main pulmonary artery, portal vein and superior mesenteric artery were measured and analysed by two independent readers. RESULTS: 40 patients (20 in each group) who had pleural enhancement on MDCT were included for final analysis. The mean pleural enhancement value was 83 HU (Group A) vs 59 HU (Group B) (p = 0.0004). The mean aortic enhancement was 241 HU (A) vs 141 HU (B) (p<0.0001); main pulmonary artery enhancement was 208 HU (A) vs 139 HU (B) (p<0.0002); portal venous enhancement was 169 HU (A) vs 115 HU (B) (p<0.0001); and the superior mesenteric artery enhancement was 215 HU (A) vs 128 HU (B) (p<0.0001). CONCLUSION: Enhancement of the pleura and major vessels was significantly higher in the group receiving more contrast at a greater infusion rate. This technique of a single scan through the entire pleural surface with a delayed acquisition is promising. When pleural disease is suspected, contrast infusion protocols should be modified to achieve the best results and clinicians should be encouraged to specifically request a "pleural CT".

Identification of MPO-positive capillaries of the pleura by immunohistochemistry in MPO-ANCA associated vasculitis.

We present a case of a middle-aged woman with myeloperoxidase anti-neutrophil cytoplasmic autoantibody (MPO-ANCA)-associated vasculitis that demonstrated immunohistochemically positive MPO capillaries of the pleura. The patient initially presented with proteinuria and microscopic hematuria at the age of 38. Acute progressive glomerulonephritis and pulmonary hemorrhage occurred 4 years later, and a high serum titer of MPO-ANCA was detected therefore a diagnosis of microscopic polyangiitis was made. Steroid-pulse therapy was performed and the pulmonary shadow improved, but the renal failure did not improve, thus, hemodialysis was initiated. Thereafter, an 18-year asymptomatic phase followed, but high serum levels of MPO-ANCA persisted during this period. Chronic pulmonary hemorrhage was discovered at the age of 60, and video-assisted thoracoscopic surgery was performed. Resected tissue revealed diffuse aloveolar hemorrhage accompanied by marked hemosiderin deposition, whereas MPO-immunopositive capillaries were identified only in the pleura. To our knowledge, this is the first report demonstrating MPO-positive capillaries in a disease other than glomerulonephritis. Judging from this unique case, MPO-positive endothelial cells may appear only during the hyperacute stage before hemorrhage, and may diminish thereafter, thus, may be associated with the trigger of microscopic polyangiitis.

The pleural curtain of the camel (Camelus dromedarius).

The visceral pleura of the camel (Camelus dromedarius) possesses a fibrous curtain of pleural threads or extensions along its basal margins, which extends into the pleural cavity of the costophrenic recesses. These threads are lined by mesothelium and have a core or stroma, which is largely collagenous. Small threads are avascular and nearly acellular. In larger proximal threads, blood vessels in the stroma are often arranged in a branching network, with irregular endothelia surrounded by several incomplete basal laminae. Lymphocytes and other inflammatory cell types aggregate in the stroma near blood vessels. The threads are lined by typical mesothelium except in patches close to the main pleural surface. These patches consist of layers of loosely applied cells with numerous cellular processes and features suggestive of phagocytosis. The position of the pleural curtain in the costophrenic recess and the presence of possibly phagocytotic cells suggest that the pleural curtain stirs, samples, and cleans the pleural fluid. The pleural curtain appears to be a feature of camelids and has also been seen in giraffes.

[Prophylaxis of pleurectomy complications].

Basing on the literature and the observations of their own data analysis, the authors suggest, that pleurectomy constitutes a reconstructive-restoration operation. Nevertheless, this procedure, due to its complexity and traumatism, not infrequently is complicated by various intraoperative complications, in particular, the life threatening--in 1.1% observations and dangerous for health--in 13.8%. The methods of prevention and overcoming of possible complications are determined.

Narrow band imaging applied to pleuroscopy for the assessment of vascular patterns of the pleura.

BACKGROUND: Narrow band imaging (NBI), which enhances blood vessels, is a new endoscopic technology for diagnosing malignancies, but it has not been investigated for pleuroscopy. OBJECTIVES: To evaluate the efficacy of NBI applied to pleuroscopy for detecting malignant lesions by assessing vascular patterns of the pleura. METHODS: From May 2006 to September 2008, 45 patients with undiagnosed pleural ef-fusion underwent pleuroscopy using a pleura-videoscope with white light (WL) and NBI under local anesthesia. For this prospective study, 73 biopsy specimens were obtained from sites where images under both WL and NBI were recorded and classified regarding vascular patterns. RESULTS: Of the 73 lesions, WL showed blood vessels in 32 lesions, and NBI in 52 lesions (WL vs. NBI; p = 0.0014). The accuracy, sensitivity and specificity in the detection of irregular vascular patterns, e.g. blood vessels with irregular caliber or punctate vessels indicating malignant lesions, were 60.3, 76.5 and 55.4% in WL, and 80.8, 85.3 and 76.9% in NBI, respectively, resulting in a significant increase in NBI (p = 0.0106 for accuracy and p = 0.0494 for specificity). For flat lesions, NBI revealed a higher accuracy rate (90.6%) in the detection of irregular vascular patterns indicating malignant lesions. CONCLUSION: Our study demonstrated that NBI applied to pleuroscopy displayed blood vessels significantly better than WL. NBI was useful to detect irregular vascular patterns suggesting malignant lesions, especially for flat lesions. Therefore, NBI was considered useful in the selection of optimal biopsy sites by assessing vascular patterns.

High vascular pressure-induced lung injury requires P450 epoxygenase-dependent activation of TRPV4.

High vascular pressure targets the lung septal network, causing acute lung injury. While calcium entry in septal endothelium has been implicated, the channel involved is not known. This study tested the hypothesis that the vanilloid transient receptor potential channel, TRPV4, is a critical participant in the permeability response to high vascular pressure. Isolated lungs from TRPV4(+/+) or TRPV4(-/-) mice were studied at baseline or during high pressure challenge. Permeability was assessed via the filtration coefficient. Endothelial calcium transients were assessed using epifluorescence microscopy of the lung subpleural network. Light microscopy and point counting were used to determine the alveolar fluid volume fraction, a measure of alveolar flooding. Baseline permeability, calcium intensity, and alveolar flooding were no different in TRPV4(+/+) versus TRPV4(-/-) lungs. In TRPV4(+/+) lungs, the high pressure-induced permeability response was significantly attenuated by low calcium perfusate, the TRPV antagonist ruthenium red, the phospholipase A(2) inhibitor methyl arachidonyl fluorophosphonate, or the P450 epoxygenase inhibitor propargyloxyphenyl hexanoic acid. Similarly, the high pressure-induced calcium transient in TRPV4(+/+) lungs was attenuated with ruthenium red or the epoxygenase inhibitor. High vascular pressure increased the alveolar fluid volume fraction compared with control. In lungs from TRPV4(-/-) mice, permeability, calcium intensity, and alveolar fluid volume fraction were not increased. These data support a role for P450-derived epoxyeicosatrienoic acid-dependent regulation of calcium entry via TRPV4 in the permeability response to high vascular pressure.

Primary pleural hemangiopericytoma-like tumor: an unusual localized fibrous tumor of the pleura (2007: 4b).

In this report, the case of a 65-year-old woman with cough and dyspnoea is described. The chest radiographs showed a sharply demarcated mass located in the left paravertebral hemithorax and a left pleural effusion. Computed tomography after intravenous contrast material showed a heterogeneous, mainly cystic mass with peripheral enhancement and enhancing intratumoral foci and septa. Magnetic resonance imaging confirmed the location and enhancement pattern of the lesion. Histology following the surgical excision of the tumor showed a localized fibrous tumor of the pleura and specifically the hemangiopericytoma-like type.

The short-term administration of Ketoprofen does not decrease the effect of Pleurodesis induced by talc or Doxycycline in rabbits.

OBJECTIVE: To determine whether the concomitant administration of ketoprofen, a non-steroidal anti-inflammatory drug (NSAID) has any effect on the pleurodesis induced by talc or doxycycline in rabbits. METHODS: Four groups of seven New Zealand rabbits were assigned to receive the following treatments: 400mg/kg of talc intrapleurally only (group 1), 400mg/kg of talc plus 1mg/kg of ketoprofen intramuscularly (group 2), 10mg/kg of doxycycline intrapleurally only (group 3) and 10mg/kg of doxycycline plus 1mg/kg of ketoprofen intramuscularly (group 4). Intramuscular administration of ketoprofen began 4h before the intrapleural administration of the sclerosing agents, followed by twice daily administrations for 1 week. Pleural fluid was collected 24, 48 and 72h after intrapleural injections. Pleurodesis was evaluated macroscopically and microscopically after 14 days. RESULTS: The concomitant use of ketoprofen at 1mg/kg does not decrease the WBC, LDH, and protein in pleural fluid at 24h following intrapleural injection of talc or doxycycline. There were no significant differences in the macroscopic pleurodesis scores, the degree of microscopic pleural fibrosis, the thickness of the pleura or the percent of the pleura occupied with angiogenesis. CONCLUSIONS: The study shows that the short-term systemic administration of NSAIDs does not affect the efficacy of pleurodesis induced by talc or doxycycline in rabbits.

KATP channels are an important component of the shear-sensing mechanism in the pulmonary microvasculature.

OBJECTIVE: To investigate the role of a KATP channel in sensing shear, specifically its cessation, in the endothelial cells of the pulmonary microvasculature. METHODS: Endothelial cells isolated from the pulmonary microvasculature of wild-type and KATP channel knockout (KIR6.2-/-) mice were either statically cultured (non-flow-adapted) or kept under flow (flow-adapted) and the KIR currents in these cells were monitored by whole-cell patch-clamp technique during flow and its cessation. Membrane potential changes, generation of reactive oxygen species (ROS), and Ca2+ influx with flow cessation were evaluated by the use of fluorescent dyes. Lungs isolated from wild-type mice were imaged to visualize ROS generation in the subpleural endothelium. RESULTS: By patch-clamp analysis, reduction in the KIR current with cessation of flow occurred only in wild-type cells that were flow-adapted and not in flow-adapted KIR6.2-/- cells. Similar observations were made using changes in bisoxonol fluorescence as an index of cell membrane potential. Generation of ROS and Ca2+ influx that follow membrane depolarization were significantly lower in statically cultured and in KIR6.2-/- cells as compared to flow-adapted wild-type cells. Imaging of subpleural endothelial cells of the whole lung showed that the KATP antagonist glyburide caused the production of ROS in the absence of flow cessation. CONCLUSIONS: The responses to stop of flow (viz. membrane depolarization, KIR currents, ROS, Ca2+) were significantly altered with knockout of KATP channels, which indicates that this channel is an important component of the pulmonary endothelial response to abrupt loss of shear stress.