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Copyright of Saúde Coletiva is the property of MPM Comunicacao and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Tension pneumothorax, a major preventable cause of battlefield death, often arises from chest trauma and is treated by needle decompression to release trapped air from the pleural cavity. Surgical simulation mannequins are often employed to train medical personnel to perform this procedure properly. Accurate reproduction of the mechanical behavior of the parietal pleura, especially in response to needle penetration, is essential to maximize the fidelity of these surgical simulators. To date, however, the design of pleura-simulating material has been largely empirical and based on subjective practitioner feel rather than on the tissue properties, which have remained unknown. In this study, we performed uniaxial extension tests on samples of cadaveric human parietal pleura. We found that the pleura was highly nonlinear and mildly anisotropic, being roughly twice as stiff in the direction parallel to the ribs vs. perpendicular to the ribs (large-strain modulus = 20.44 vs. 11.49 MPa). We also did not find significant correlations for most pleural properties with age or BMI, but it must be recognized that the age range (59 ± 9.5 yrs) and BMI range (31 ± 5.3) of the donors in our study was not what one might expect from combatants, and there could be differences for younger, lighter individuals. We found a significantly higher low-strain modulus in the diabetic donors (0.213 vs. 0.100 MPa), consistent with the general tendency of tissue to stiffen in diabetes. The nonlinearity and tensile strength should be considered in material design and selection for future surgical simulators. [ABSTRACT FROM AUTHOR]

Objectives: The stair-climbing test as measured in meters or number of steps has been proposed to predict the risk of postoperative complications. The study objective was to determine whether the stair-climbing time can predict the risk of postoperative complications. Methods: Patients aged more than 18 years with a recommendation of thoracotomy for lung resection were included in the study. Spirometry was performed according to the criteria by the American Thoracic Society. The stair-climbing test was performed on shaded stairs with a total of 12.16 m in height, and the stair-climbing time in seconds elapsed during the climb of the total height was measured. The accuracy test was applied to obtain stair-climbing time predictive values, and the receiver operating characteristic curve was calculated. Variables were tested for association with postoperative cardiopulmonary complications using the Student t test for independent populations, the Mann–Whitney test, and the chi-square or Fisher exact test. Logistic regression analysis was performed. Results: Ninety-eight patients were evaluated. Of these, 27 showed postoperative complications. Differences were found between the groups for age and attributes obtained from the stair-climbing test. The cutoff point for stair-climbing time obtained from the receiver operating characteristic curve was 37.5 seconds. No differences were found between the groups for forced expiratory volume in 1 second. In the logistic regression, stair-climbing time was the only variable associated with postoperative complications, suggesting that the risk of postoperative complications increases with increased stair-climbing time. Conclusions: The only variable showing association with complications, according to multivariate analysis, was stair-climbing time. [ABSTRACT FROM AUTHOR]

Background: We compared the surgical outcomes in patients with clinical N0 and pathologic N2 (cN0-pN2) non–small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy and open thoracotomy to evaluate the role of VATS lobectomy for cN0-pN2 disease. Methods: Between March 2006 and August 2011, 1,456 patients with clinical N0 NSCLC disease underwent lobectomy with systematic node dissection (SND) at Shanghai Chest Hospital. Of those patients, 157 were shown to have cN0-pN2 NSCLC. Of those, 67 patients underwent VATS lobectomy, and 90 patients underwent open lobectomy. SND was performed in all 157 patients. Clinicopathologic factors, local recurrence rates, and survival rates were compared. Results: The two groups were similar in age, sex, and pulmonary function. The VATS approach was associated with significantly shorter chest tube duration and postoperative stay than was the thoracotomy approach. Operative mortality, morbidity, and recurrence did not differ between the two groups. There was no significant difference between the two types of operation in numbers of total lymph nodes removed (17.4 ± 6.1 in the VATS group vs 18.1 ± 7.2 in the open group, p = 0.78) and mediastinal lymph nodes removed (11.7 ± 5.6 in the VATS group vs 12.0 ± 5.1 in the open group, p = 0.84). Similarly, the two groups were not significantly different with regard to stations of total lymph nodes removed (7.6 ± 1.9 in the VATS group vs 7.8 ± 2.3 in the open group, p = 0.81) and mediastinal lymph nodes removed (4.5 ± 1.1 in the VATS group vs 4.7 ± 1.3 in the open group, p = 0.71). The rates of overall survival and disease-free 5-year survival were not significantly different between the two groups. Conclusions: The clinical outcomes of thoracoscopic lobectomy were comparable to those of thoracotomy for patients with cN0-pN2 NSCLC. Single-station N2 is a good prognostic factor for disease-free survival in these patients. [Copyright &y& Elsevier]

Background: Radical pleurectomy (RP) for mesothelioma is often considered either technically unfeasible or an operation limited to patients who would not tolerate a pneumonectomy. The purpose of this study was to review our experience using RP and intraoperative photodynamic therapy (PDT) for mesothelioma. Methods: Thirty-eight patients (42–81 years) underwent RP-PDT. Thirty five of 38 (92%) patients also received systemic therapy. Standard statistical techniques were used for analysis. Results: Thirty seven of 38 (97%) patients had stage III/IV cancer (according to the American Joint Committee on Cancer [AJCC manual 7th Edition, 2010]) and 7/38 (18%) patients had nonepithelial subtypes. Macroscopic complete resection was achieved in 37/38 (97%) patients. There was 1 postoperative mortality (stroke). At a median follow-up of 34.4 months, the median survival was 31.7 months for all 38 patients, 41.2 months for the 31/38 (82%) patients with epithelial subtypes, and 6.8 months for the 7/38 (18%) patients with nonepithelial subtypes. Median progression-free survival (PFS) was 9.6, 15.1, and 4.8 months, respectively. The median survival and PFS for the 20/31 (64%) patients with N2 epithelial disease were 31.7 and 15.1 months, respectively. Conclusions: It was possible to achieve a macroscopic complete resection using lung-sparing surgery in 97% of these patients with stage III/IV disease. The survival we observed with this approach was unusually long for the patients with the epithelial subtype but, interestingly, the PFS was not. The reason for this prolonged survival despite recurrence is not clear but is potentially related to preservation of the lung or some PDT-induced effect, or both. We conclude that the results of this lung-sparing approach are safe, encouraging, and warrant further investigation. [Copyright &y& Elsevier]

Copyright of Contributions of Macedonian Academy of Sciences & Arts is the property of Macedonian Academy of Sciences & Arts (MANU) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: This study was designed to assess the use of the intrathoracic vacuum-assisted management of persistent and infected pleural spaces. Description: Five patients with a persistent and infected pleural space after pulmonary resection underwent intrathoracic vacuum-assisted management to reduce the duration and frequency of dressing changes and to accelerate the formation of granulation tissue and the obliteration of the pleural space. Three patients also underwent a pleural space filling procedure. Evaluation: Resolution of the infection or complete obliteration of the pleural space, or both, was in all patients achieved using fewer dressing changes than with traditional methods. No major complications related to the vacuum-assisted management were reported. Conclusions: The use of intrathoracic vacuum-assisted management of a persistent and infected pleural space after lung resection may reduce the duration and frequency of dressing changes necessary to allow spontaneous chest closure or a space filling procedure. Its use may decrease patient discomfort and contribute to a faster resolution of the infectious process. [Copyright &y& Elsevier]

The article offers information on omentum harvest for intrathoracic use. It mentions that the greater omentum has long been used to treat pleural space problems because of its size and abundant blood supply. In addition, the omentum has been shown to have angiogenic factors that enhances neovascularization to the tissue that is being repaired and it also has specific immunologic properties that increase local lymphocyte counts. Several photographs of the surgical procedures are presented.

Background: Three-dimensional computed tomographic angiography (3D-CT angio) allows selective access to peripheral segments. Superselective segmentectomy (SSS) was applied to the surgical management of indeterminate small and deep pulmonary nodules. Methods: Thirty patients with indeterminate pulmonary nodules less than 25 mm in diameter and located deeper than 20mm from the pleural surface were enrolled in this study between 2002 and 2009. All patients underwent exploratory thoracotomy. The SSS with a surgical margin from the nodule larger than the nodule diameter or 20 mm was directed toward the target pulmonary arteries by 3D-CT angio using a multidetector-row CT scanner. The SSS was evaluated for resected area, surgical margin, regional lymph nodes, morbidity, lung function, and survival rate. Results: Three patients received SSS at the daughter segment, 23 patients that at the subsegment, and the remaining four underwent miscellaneous SSS without major complications. Twenty patients exhibited early lung cancer, one patient stage IIA lung cancer, and the remaining nine patients had metastatic or benign tumors. Five patients with primary cancer subsequently underwent standard lobectomy. The remaining 16 patients with early lung cancer did not undergo lobectomy because of their major comorbidities or refusal of a second thoracotomy. The surgical margins were free of disease in all patients. The actual and disease-free five-year survival rates were 100% for the lung cancer patients, excluding those who subsequently underwent lobectomy. The lung function after SSS was well preserved. Conclusions: Superselective segmentectomy is an applicable optional strategy for the surgical management of indeterminate small and deep pulmonary nodules. [Copyright &y& Elsevier]

Background: Recurrent thoracic empyema in the presence of residual lung tissue can be treated with an open window thoracostomy (OWT). Vacuum-assisted closure (VAC) of these large thoracic defects is a novel option. Methods: Nineteen patients with residual lung tissue received an OWT for treatment of recurrent thoracic empyema. In this retrospective case series, 8 patients (aged 58 ± 20 years, all male) were treated conventionally, and 11 patients (aged 53 ± 17 years, 8 male) were treated with VAC. Results: The application of the VAC system resulted in rapid debridement of the thoracic cavity and reexpansion of the residual lung tissue. The duration of OWT and VAC therapy was 39 ± 17 and 31 ± 19 days, respectively. All 11 patients were amenable for subsequent closure using pedicled muscular flaps. In 2 patients, VAC therapy alone resulted in complete closure of the OWT. The average duration of follow-up was 46 ± 19 months. All patients, except 1, have recovered well. One patient died of nonpulmonary causes. In the non-VAC group (n = 8), the OWT was managed conventionally by application of saline-soaked gauzes. In 2 patients, the OWT was eventually closed using pedicled muscular flaps (after 75 and 440 days, respectively). Four patients died of OWT-related complications (1 bleeding, 3 recurrent infections) during follow-up; 1 patient died of a cause unrelated to OWT. The average duration of OWT was 933 ± 1,422 days. Conclusions: When compared with conventional management of OWT, VAC therapy accelerates wound healing and improves reexpansion of residual lung tissue in patients with OWT after empyema, allowing rapid surgical closure. [Copyright &y& Elsevier]

Abstract: Purpose: Chylothorax after congenital diaphragmatic hernia (CDH) repair contributes significantly to morbidity. Our aim was to identify factors contributing to chylothorax and effective treatment strategies. Methods: We reviewed 171 patients with CDH from 1997 to 2008 and analyzed hernia characteristics, extracorporeal membrane oxygenation (ECMO) use, operative details, and treatment approaches for chylothorax. Results: Ten (7%) patients developed chylothorax; all were left sided. Using univariate analysis, prenatal diagnosis, ECMO use, and patch repair were associated with development of chylothorax. Logistic regression analysis showed that patch repair was the only variable predictive of chylothorax (P = .028; confidence interval, 0.032-0.823). Although survival was not affected, patients with chylothorax had a significant increase in ventilator days and length of stay (t = 3.57; P = .000; t = 2.74; P = .007). All received thoracostomy and total parenteral nutrition. Six patients received octreotide, 5 of whom required pleurectomy because of failed medical management; the remaining patient died of overwhelming sepsis. Conclusions: The incidence of chylothorax at our institution was relatively low. Patch repair was associated with the formation of chylothorax. Morbidity was substantial, but survival was not significantly affected. Total parenteral nutrition and thoracostomy were appropriate initial treatments. Octreotide was not an effective adjunct. Refractory cases were successfully treated with pleurectomy. [Copyright &y& Elsevier]

Objective: A complete surgical resection is the cornerstone of therapy of thymic tumors. Unfortunately, there is no standard treatment for pleural recurrence. This article describes our overall experience with the surgical treatment of pleural implants in patients who previously underwent resection of a thymoma. Material and Methods: From January 1980 to June 2006, 20 patients previously operated on for a thymoma were operated on for the surgical resection of pleural implants. Patients with the initial Masaoka stage IVA were excluded from our analysis. Our sample comprised 10 male and 10 female patients (12–65 years old). The surgical approach to the resection of the thymoma was as follows: video-assissted thoracic surgery in 2 patients, sternotomy in 13 patients, thoracotomy in 2 patients, and sternothoracotomy in 3 patients. The initial Masaoka stage of the thymoma was IIA in 2 patients, IIB in 7 patients, and III in 11 patients. Results: The interval between resection of the thymoma and pleural implants ranged from 11 to 156 (median 60) months. Fifteen patients had a thymus-related syndrome (in 13 patients it resulted myasthenia gravis), and in 11 patients it improved or remitted after treatment of the pleural recurrence. All the resections were performed through a posterolateral thoracotomy. Three patients underwent an iterative resection of new pleural implants. At the latest follow-up, 10 patients are still alive (8 disease-free) and 10 have died (9 of a relapse and 1 of the complications of red cell aplasia). From the pleural recurrence resection, the overall 5- and 10-year survivals are 43.1% and 25.8%, respectively. Conclusions: Repeat operation on patients with thymoma pleural recurrences is feasible and safe. It can produce satisfactory results in terms of overall survival and paraneoplastic syndrome control. Moreover, the multimodality treatment could improve the results of surgical treatment. [Copyright &y& Elsevier]

Summary: Purpose of the study: This aim of this study was to evaluate the initial experience of pectus deformity repair using the pectus less invasive extrapleural repair (PLIER) procedure. Methods: PLIER is an open procedure which involves a small midline chest incision, with exposure of the xiphoid which is raised to create a retrosternal space. The costal cartilages are excised to free the sternum and metal struts are implanted to stabilise the reconstructed chest wall. Main findings: Corrections were performed on 35 patients [25 pectus excavatum (PE) and 10 pectus carinatum (PC)] with a median age of 15.2 years (range 13–19 years). The mean size of the incision was 7.5cm (range 7–10.5cm). The mean operation time was 85min (75–115min). There were no intraoperative complications. The follow-up period ranged from 6 months to 2 years. Conclusions: The initial experience with the PLIER procedure demonstrates that it is suitable for the correction of PE and PC. The advantage of PLIER procedure is that it can be performed through small incisions in a short time with minimal loss of blood. Excellent aesthetic results after the procedure indicate the need to offer this method of surgical correction to low risk children. [Copyright &y& Elsevier]

An 80-year-old woman had an asymptomatic chest wall tumor. She had undergone thoracotomy to treat a benign lesion 11 years previously. Chest computed tomography revealed a convex lens–shaped mass 7 cm in diameter in the chest wall. Positron emission tomography demonstrated mild accumulation of F-deoxyglucose. We performed an exploratory thoracotomy; however, no mass lesion was found. Therefore, we thought that the soft tissue of the back was drawn into the pleural cavity through the widened intercostal space during the previous thoracotomy. We simply aligned the ribs using heavy surgical sutures. The patient has experienced good recovery, with no recurrence since the surgery. [ABSTRACT FROM AUTHOR]

A 64-year-old man was diagnosed with complex empyema after a second course of palliative chemotherapy for metastatic lung cancer. Because of the poor general condition of the patient, the decision was made to proceed with vacuum-assisted closure (VAC) therapy of the empyema without Eloesser or Clagett open-window thoracostomy (OWT). Installation and changing of the VAC sponge were performed using the ALEXIS Wound Protector/Retractor (Applied Medical, Rancho Santa Margarita, CA), a flexible polymer membrane tube. After 10 days of VAC treatment, the pleural cavity was sterile and was closed with single stitches. Chemotherapy was resumed 1 week later. [Copyright &y& Elsevier]