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Lung and pleural injuries are characterized by inflammation, fibrinous transitional matrix deposition, and ultimate scarification. The accumulation of extravascular fibrin is due to concurrently increased local coagulation and decreased fibrinolysis, the latter mainly as a result of increased plasminogen activator inhibitor-1 (PAI-1) expression. Therapeutic targeting of disordered fibrin turnover has long been used for the treatment of pleural disease. Intrapleural fibrinolytic therapy has been found to be variably effective in clinical trials, which likely reflects empiric dosing that does not account for the wide variation in pleural fluid PAI-1 levels in individual patients. The incidence of empyema is increasing, providing a strong rationale to identify more effective, nonsurgical treatment to improve pleural drainage and patient outcomes. Therapeutics designed to resist inhibition by PAI-1 are in development for the treatment of pleural loculation and impaired drainage. The efficacy and safety of these strategies remains to be proven in clinical trial testing. Fibrinolytic therapy administered via the airway has also been proposed for the treatment of acute lung injury, but this approach has not been rigorously validated and is not part of routine clinical management at this time. Challenges to airway delivery of fibrinolysins relate to bioavailability, distribution, and dosing of the interventional agents., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: Titanium plate osteosynthesis (Synthes) is an alternative option for sternal closure. The indications and time point of application are still debated. This study investigated the application and feasibility of this technique after median sternotomy., Methods: Forty-one patients (29 M/12F, mean age 63 ± 17 years) received the plate system for complicated sternal conditions. Indications, intraoperative course and postoperative follow-up were assessed., Results: Sternal deformity was present in 5 % (2/41), sternal fractures in 17 % (7/41), bone defect in 12 % (5/41), wire loosening in 39 % (16/41) and pseudoarthrosis in 27 % (11/41). 54 % (22/41) of patients showed concomitant sternal infection. Two intraoperative complications were noted: mammary artery injury (1 patient), pleural injury (1 patient). At discharge the patients reported no pain (90 %, 37/41) or only occasional discomfort (10 %, 4/41). Postoperative complications were subcutaneous hematoma in 12 % (5/41), seroma in 12 % (5/41) and sternal reinfection in 7 % (3/41). 12 % (5/41) showed occasional discomfort and 7 % (3/41) had persistent pain leading to plate removal., Conclusion: The Titanium Sternal Fixation System is comfortable and easy to use. It can be used to treat a wide spectrum of indications, especially for pseudoarthrosis, an entity which has not yet received sufficient attention., (© Georg Thieme Verlag KG Stuttgart · New York.)

Four days after uncomplicated implantation of a two-chamber pacemaker and a normal postoperative course, a patient was referred to our hospital with left-sided hemothorax and early hemorrhagic shock. Chest X-ray and CT scan were suspicious of a right ventricular lead perforation with additional pericardial and pleural injury. Immediate surgery was performed via a lateral thoracotomy and the perforation was repaired via direct suture. An epimyocardial ventricular lead was implanted simultaneously. The patient made an uneventful recovery.

Purpose: Computed quantification of the extent of pleuropulmonary trauma by CT and comparison with conventional chest x-ray--Impact on therapy and correlation with mechanical ventilation support and clinical outcome., Method: In a prospective trial, 50 patients with clinically suspicious blunt chest trauma were evaluated using CT and conventional chest x-ray. The computed quantification of ventilated lung provided by CT volumetry was correlated with the consecutive artificial respiration parameters and the clinical outcome., Results: We found a high correlation between CT volumetry and artificial ventilation concerning maximal pressures and inspiratory oxygen concentration (FiO2, Goris-Score) (r = 0.89, Pearson). The graduation of thoracic trauma correlated highly with the duration of mechanical ventilation (r = 0.98, Pearson). Especially with regard to atelectases and lung contusions CT is superior compared to conventional chest x-ray; only 32% and 43%, respectively, were identified by conventional chest x-ray., Conclusion: CT allows rapid classification and quantification of pulmonary lesions after thoracic trauma and provides higher sensitivity and reliability. Because of the great correlation with the extent of artificial respiration in respect of duration and pressure, prognosis of the individual patient, as well as a differential therapy, appear possible.

Bronchial brushing under fluoroscopy control is used in the diagnosis of pulmonary lesions which are beyond reach of the bronchoscope. A small nylon or steel brush is passed through a bronchial catheter and tissue material from the lesion is taken for cytologic and bacteriologic studies. The technique described is easy to learn, relatively safe, is well tolerated by patients and gives good diagnostic results.

The effect of the fibrin adhesive on the gas density of pleura-lung-sutures was investigated in 28 male Wistar rats. Standardized pleura-lung-lacerations were closed by additional fibrin adhesive application in combination with fibrinolytic inhibitors. 30 minutes and 5 days after operation the animals were sacrificed and manometric and micromorphological examinations performed. In good histo-compatibility the additional application of the fibrin adhesive proved to be a proper technique in elevating the pressure tolerance of pleura-lung-sutures significantly.

In patients with chest injuries, serial rib fractures and intrathoracic lacerations the indication for primary thoracotomy is usually limited to life-threatening organ ruptures. In our own experience with 18 patients primary thoracotomy offers the chance of immediate closure of lung lacerations, suture of pleural and pericardial tears, ligature of torn intercostal vessels and stabilization of the chest wall by elastic rib clamps "Essener Model". Postoperative respiration, freedom of pain, is restored immediately and therefore complications and duration of high-risk respirator treatment can be reduced.

The different types of vagotomy are highly standardized, but show a typical spectrum of complications, injuries of spleen (1 to 4%) and liver, perforation of the oesophagus (0,5 to 1,0%) intraoperative bleeding, lesions of the pleura (0,5%), necrosis of the lesser curvature of the stomach, chylothorax and chyloperitoneum. The article deals with avoidance and successful treatment of such intraoperative lesions.